Medical Imaging

Introduction

Medical imaging is done on walk-in basis, but with prior appointment from the referral clinic (eg ORL Clinic), and requires overnight patient fasting. A minimum 5 hours fasting is required if a patient has eaten or taken breakfast and was unaware of the prerequisite fasting prior to scanning or imaging. Imaging requires that the patient change into a hospital gown without any metal parts (no bras, no hooks etc) before commencing scanning/imaging. A butterfly needle is inserted in the left hand for administration of media. Media are injected for baseline. Another media is injected to overcome hypersensitivity (if any - eg allergic reactions to certain foods/alahan kepada makanan such as sefood (prawns), sinus/resdung, other). Scanning is performed once the basic media and hypoallergens are injected. Iodinated contrast media are then injected for image contrast after the basic scan is performed.

MRI versus CT Scan

For MRI, the time taken to do a whole body scan is approximately 20 minutes. For CT Scan, it takes less than 20 minutes. CT Scan of 2 legs below knee for an adult male on wheelchair takes 5 minutes; no change of clothes is required if the patient is wearing a singlet and kain pelekat. CT Scan from vertex to upper abdomen takes 13 minutes in total for a 57-year old woman, from changing clothes, positioning the torso and head, adjusting head under the red beam, water calibration for baseline, first scanning, injecting contrast media, re-scanning, and change of clothes and removing the butterfly port. MRI uses powerful magnets and there is no x-ray radiation involved. MRI is considered relatively safe. CT Scan involves high dose x-ray radiation (similar to sudden exposure to x-ray radiation coming from an atomic bomb). CT Scan is relatively unsafe compared to MRI, but is mostly performed today compared to MRI, which is time-consuming.

When to install a butterfly port and when to remove it?
The butterfly port can be installed after registration at CT Scan counter and be left intact for 5 hours. The patient returns and CT Scan begins with changing into the blue hospital gown. The tie strings are criss-crossed and tied in front. After scanning, it is better to change into normal clothes first and then remove the butterfly port. Strong pressure must be applied on the insertion site when the butterfly port is removed as blood will start to gush out. If the patient requests to remove the butterfly port first before changing clothes, it is better to advise the patient on this blood matter. Even if the patient has the butterfly port removed, it will bleed and the patient will forget this while changing and walking around until a considerable amount of blood fills the cotton swab and surgical tape and feels blood gushing out. Apply a little bit more pressure on the sampling site will stop bleeding. Of course, there are dried blood marks that will need to be washed.

Muslim patients

For Muslim patients, it is advisable to have CT Scan done early in the morning after overnight fasting. For patients who have eaten on the day of CT Scanning, an additional 5 hours fasting is required (eg 7.30 am - 12.30 pm). This means if a patient ate breakfast at 7.30 am and came for CT Scan that morning, he has to wait till past 12.30 pm, even up to 1 pm before a CT Scan can be done. CT Scan takes less than 20 minutes at most if a significant amount of adjusting needs to be done before CT Scan can commence. By the time a patient completes the CT Scan, it is almost time for Azan Zohor and Solat Zohor. Blood marks must be carefully washed before ablution (Wudhu') can be performed by the patient if he want to follow the congregational prayer or perform it solo.

Number of CT Scan Patients

Hospital USM (HUSM) at Kubang Kerian in Kelantan, Malaysia, has 17 patients daily on appointment basis as ordered by referring clinicians. However, up to 20 or more patients may be referred to the CT Scan unit. Most are bed-ridden and some are on wheelchairs.

CT Scan Facilities

There is only one Siemens SOMATOM Definition AS CT Scanner at HUSM. I feel there should be another one.

The staff rotate daily between the main Radiology Unit and the CT Scan unit. Four to 5 staff attend to a patient for CT scanning. One staff I asked, has worked for 15 years at the CT Scan unit.

The present CT Scan room has quite narrow doors, just wide enough for modern hospital beds to be wheeled in; they should make them wider in modern hospitals. There were severe scratch marks on the prep room wall, indicating how narrow the passage from the entrance door to the scanning room is.

Abbreviations

CT: computed tomography --> the machines are named SOMATOM
MRI: magnetic resonance imaging --> the machines are named MAGNETOM
MDCT: multi detector computed tomography
DECT: dual energy CT
VA: virtual autopsy
U/S: ultrasound

MCBI: megavoltage cone beam imaging
MAGAT: methacrylic acid, gelatin, and tetrakis
MAGIC: methacrylic acid, gelatin, copper sulphate, ascorbic acid, hydroquinone, and water
MAGAS: methacrylic acid, gelatine, and ascorbic acid
PAGAT: polyacrylamide, gelatin, and tetrakis
PAGAS: polyacrylamide and ascorbic acid

BANG: bisacrylamide, nitrogen, gelatin

MC: Monte Carlo simulation
NIPAM: N-isopropylacrylamide
HU: Hounsfield unit
LAC: linear attenuation coefficient
CTDI: CT dose index

Case studies & write-ups

1. Clinical specials/specialties
2. Anatomic region
3. Systems
4. Clinical software (s/w) applications (apps) and benefits
5. S/w version
6. Technologies & innovations, and gantry electronics (insulated with extra silicon)
7. Recommended protocol

Imaging priorities

1. First line imaging: x-ray, U/S, CT
2. Second line procedure: MRI

Applications of clinical imaging

1. Oncology
2. Neurology
3. Cardiology
4. Acute Care
5. Forensic Pathology (uses MDCT & MRI)

DECT

1. DECT is Dual Energy CT
2. It has 2 x-ray sources running simultaneously at different energy levels (80 kV & 140 kV)
3. Can obtain additional information about the elementary chemical composition (C, H, O, N, P, Cl) of the scanned material (gelatin, Tetrakis, methacrylic, water)
4. Assign colours according to the value differences between 80 kV and 140 kV, to obtain colour-mapped dual energy image
5. Can differentiate between calcifications and iodine contrast for stenosis, soft plaques, etc
6. Can use this technique for direct subtraction of bone from the CT raw data; MC code; reconstruction algorithm
7. No need to do post processing
8. Better visualize blood clots in vessels, bleeding in soft tissues
9. Do classification of different tissue types --> identify tendons and cartilage

Hospital scanner

1. Siemens SOMATOM Definition AS CT scanner
2. Siemens Primus linear accelerator (linac)

Siemens CT Scanners: SOMATOM at rear and Primus in foreground

Introductory topics

1. Diffusion problem
2. Single spin echo
3. Multiple spin echo
4. Basic principles of FT-Raman
5. DICOM
6. CERN
7. LAC

Research topics

1. CT based MAGAT gel dosimetry system
2. 3D dose verification in radiotherapy
3. Personalized radiation therapy

External links:
http://en.wikipedia.org/wiki/Medical_imaging
https://en.wikipedia.org/wiki/Magnetic_resonance_imaging
http://en.wikipedia.org/wiki/Computed_Tomography
https://en.wikipedia.org/wiki/CT_scan
http://medicalphysicsweb.org/cws/channel/research
http://www.micropos.se/

Google search for Siemens SOMATOM Definition AS:
https://www.google.com/?gws_rd=ssl#q=Siemens+SOMATOM+Definition+AS

Slowed Ageing

Source: Discovery Channel on ASTRO, 1 January 2014 at 9am (Southeast Asia: Malaysia)
http://en.wikipedia.org/wiki/Discovery_Channel

"Living with a child who never seems to grow old"

Case 1
Gabby Williams (6 yo)
Normal chromosome but bizarre features, lies down only, lives like a 1-yo
Sequence entire genetic code/genome and find out which had affected her development
Which genes control development and ageing, and development of ageing?

Case 2
Nicky Freeman (40 yo)
Slowed aging and blind, walks and eats by himself, lives like a 10-yo
Do MRI scan
What causes lack of growth?
Pituitary gland: it is posterior and not in its normal position - mal development of the pituitary. A normal pituitary is bigger and in a different position.
His brain was damaged in the early stage of development.
Is his condition genetic? No
Do chromosome analysis - but he is a normal male
Damage to his pituitary is the main cause of his slowed aging
He can walk off his mother's lap and walk over to his doctor, Dr Richard Walker
His condition is not genetic
He had never touched snow so his family took him to the snowy mountains
He was brought to see the Williams family (to meet Gabby Williams)
Nicky loved horses so they arranged for him to ride a horse

Takla Makan Desert Tocharians: White Mummies of China's Silk Road

Taken from YouTube. 30 December 2013.

Published on 22 Sep 2013
White Mummies in China▕ March of the Titans

Perfectly preserved 3000-year-old mummies have been unearthed in a remote Chinese desert, shedding new light on the contact between the East and West in the ancient world. But these don't appear to be the ancestors of the modern-day Chinese people, they have long, blonde hair and blue eyes. New evidence of the lost civilization of the Tocharians along the Silk Road offers more clues to this mystery from the past.

The Tocharians: the Great Lost White migration to China.

The Chinese civilization always contained stories of blue-eyed and blonde-haired leaders who were the originators of Buddhism and who were the first leaders and organizers of Chinese society. These stories were always regarded as pure legend until the 1977 discovery of the graveyards of the Tocharians in the Takla Makan desert in China. The Tocharian mummies - naturally preserved in the dry desert sands are unequivocally clear Nordic racial types. The graveyards lie near the ruins of the great Tocharian cities, built along the famous Silk Route. It is beyond doubt that Whites settled in China, and the Chinese legends of White influence on that civilization may yet have some basis in fact

Song: General Lü

General Lü,
The valiant-hearted,
Riding alone on Scarlet Hare,
Out of the gates of Ch'in,
To weep at Gold Grain Mound
By funeral trees.

Inscrutable that vaulted azure,
Arching over earth,
This is the way the world wags
In our Nine Provinces.
Gleaming ore from Scarlet Hill!
Hero of our time!
Green-eyed general, you well know
The will of Heaven!

After years of controversy and political intrigue,the research, which the Chinese government has attempted to postpone, archaeologists using genetic testing have proven that Caucasians roamed China's Tarim Basin 1,000 years before East Asian people arrived. 2004 study carried out by Jilin University also finding that the mummies DNA had white European genes, further proving that the earliest settlers of Western China were not East Asians but European.

The research, which the Chinese government has appeared to have delayed making public out of concerns of fueling Uighur Muslim separatism in its western-most Xinjiang region, is based on a cache of ancient dried-out corpses that have been found around the Tarim Basin in recent decades.

"It is unfortunate that the issue has been so politicized because it has created a lot of difficulties," Victor Mair, a specialist in the ancient corpses and co-author of "Mummies of the Tarim Basin", told AFP.

"It would be better for everyone to approach this from a purely scientific and historical perspective."

The discoveries in the 1980s of the undisturbed 4,000-year-old "Beauty of Loulan" and the younger 3,000-year-old body of the "Charchan Man" are legendary in world archaeological circles for the fine state of their preservation and for the wealth of knowledge they bring to modern research.

In historic and scientific circles the discoveries along the ancient Silk Road were on a par with finding the Egyptian mummies.

But China's concern over its rule in restive Xinjiang has widely been perceived as impeding faster research into them and greater publicity of the findings.

The desiccated corpses, which avoided natural decomposition due to the dry atmosphere and alkaline soils in the Tarim Basin, have not only given scientists a look into their physical biologies, but their clothes, tools and burial rituals have given historians a glimpse into life in the Bronze Age.

Mair, who played a pivotal role in bringing the discoveries to Western scholars in the 1990s, has worked tirelessly to get Chinese approval to take samples out of China for definitive genetic testing.

"I spent six months in Sweden last year doing nothing but gen. res.," Mair said from his home in the United States where he teaches at the University of Pennsylvania.

"My research has shown that in the second millennium BC, the oldest mummies, like the Loulan Beauty, were the earliest settlers in the Tarim Basin.

"From the evidence available, we have found that during the first 1,000 years after the Loulan Beauty, the only settlers in the Tarim Basin were Caucasoid."

East Asian peoples only began showing up in the eastern portions of the Tarim Basin about 3,000 years ago, Mair said, while the Uighur peoples arrived after the collapse of the Orkon Uighur Kingdom, largely based in modern day Mongolia, around the year 842.

"Modern DNA and ancient DNA show that Uighurs, Kazaks, Krygyzs, the peoples of Central Asia are all mixed Caucasian and East Asian. The modern and ancient DNA tell the same story," he said.

Source:
March of the Titans. Nova: White Mummies in China
http://www.youtube.com/watch?v=_MACE-NWjqM