MRI for Diagnosis of Mycetoma or Madura Foot

MRI for Diagnosis of Mycetoma or Madura Foot â€Å"Dot in Circle† sign — a unique attribute of mycetoma foot on MRI: a report of two cases Aggarwal A, Gupta M, Patel B N, Patel S B Abstract Mycetoma or Madura Foot is a chronic localized granulomatous disease characterized by exuberant granulomatous tissue formation involving the subcutaneous plane. It is most common in tropical countries. Diagnosis has been traditionally done by microbiological culture and histopathological tissue diagnosis but these are often difficult to obtain and frequently inconclusive. MRI has recently emerged as a promising technique for early and prompt diagnosis of Mycetoma with the description of a highly specific sign called as â€Å"Dot in Circle† sign. We hereby present 2 cases showing this characteristic â€Å"Dot in circle† sign on MRI and thereby establishing the diagnosis of Madura Foot. Patient 1 A 52-year-old male farmer by occupation presented with a painless swelling involving the left foot, which had been operated on elsewhere two times. Previous reports of surgery were not available. Examination revealed a non tender, large swelling involving whole of the left foot and the ankle joint. It was associated with numerous chronic discharging sinuses. (Fig 1) General examination was unremarkable and the soft tissue was normal. Rotuine blood and biochemical investigations were also unremarkable. Plain radiograph revealed a soft tissue mass in the left foot with advanced bony destruction mainly involving the tarsal, metatarsals and phalanges without any calcification. MRI scan was performed to evaluate the disease further. MRI showed a soft tissue mass lesion, diffuse hyperintensity involving subcutaneous tissue, muscles, and intermuscular fascial planes. There were also multiple focal fluid collections seen in the fascial plane with ulceration of overlying skin. The mass demons trated characteristically conglomerate areas of multiple, inconspicuous, small 3–4 mm oval to round hyperintense lesions, which were separated by a low-signal-intensity rim in the subcutaneous plane of the dorsum of the foot. The centre of few of these lesions showed a small hypointense focus, resulting in the dot-in-circle sign (Figs. 2, 3). The underlying bones showed cortical erosions mainly involving the tarsal, metatarsals and phalanges. On the basis of the above clinical and radiological findings, a diagnosis of mycetoma foot was put forward. A biopsy was performed to confirm the diagnosis which revealed granulomatous inflammation and presence of eumycetoma (Fig. 4). Patient 2 A 37 year old male, complained of mass in the left foot for the past 2 years. Examination revealed multiple numerous discharging sinuses with skin ulcerations. The discharging sinuses did not contain any grains which is usually pathognomonic of Madura mycosis. Plain frontal radiograph of the left foot shows soft tissue mass with severe destruction of the bone along with a palisade type of periosteal reaction mainly involving the tarsals and metatarsals (Figs. 5). The patient underwent MRI for evaluation and extent of the disease. Similarly, the lesion showed marked inflammatory changes in the left foot with cortical erosion, with micro-abscesses formation. The characteristic dot in circle sign (Figs. 6) was described and diagnosis of mycetoma foot was made. The patient underwent an excision biopsy. Histopathology showed eumycetoma. Images Figure 2. T2-weighted axial MR cut sections  of the left foot shows extensive inflammatory  changes. Multiple hyperintense lesions which were small and round in shape and separated by tissue of low signal intensity  are noted. Some of these lesions (arrows) show a  central small focus of hypointensity, resulting in the characteristic  dot-in-circle sign. Figure 3 T2-weighted fat-saturated coronal MR image of  the left foot shows multiple microabscesses separated by  a low-intensity matrix seen posteriolaterally. Marked inflammatory changes with multiple fluid collections are noted in the fascial plane. Figure 4 Haematoxylin and Eosin( HE) : Fungal organisms  surrounded by granulation tissue. Figure 6 T2-weighted axial MR image  of the left foot shows extensive inflammatory  changes with cortical erosion. Multiple small spherical  hyper-intense lesions separated by tissue of low signal intensity  are noted. Some of these lesions show a  small foci of hypointensity centrally, resulting in the  dot-in-circle sign. Note the presence of multiple  microabscess. Discussion Madurai Mycosis is a chronic granulomatous disease caused by 2 group of organisms, the Eumyces which are also called as true fungi or eumycetoma, and the Actinomyces, which are the filamentous form also called as Actinomycetales or actinomycetoma. The disease was first described in the Madurai district in the state of Tamil Nadu, hence the eponym Madura foot. The infective organisms are normal inhabitants of the soil and cause infection by direct implantation into the skin, most commonly the foot in individuals walking bare foot. Patients classically present with multiple subcutaneous nodules which are characteristically painless. These may give rise to fistulae formation, often associated with a purulent discharge. The disease progresses slowly and over long term leads to abscess formation, sinus tracts, osteomyelitis, and fistula formation ultimately resulting in severe deformity and disability if treatment is not provided [4] . Histologically the disease is characterized by formation of so called ‘‘grains’’, which are found embedded in the abscesses. These grains are nothing but aggregates of the organism and are surrounded by extensive granulation tissue. Initially there is soft tissue swelling with induration which later progresses to form multiple discharging sinus with or without bone involvement. [5] Radiological investigations play a significant role in arriving at the diagnosis swiftly especially since tissue cultures are seldom diagnostic. Radiographs may be normal early in the disease process but later show varying degree of soft tissue swelling with destruction of the bone in form of sclerosis, cavity formation and classical palisade type of periosteal reaction. This is followed by expansion of the bone with scalloping of the cortex or osteoporosis. This condition mimics bacterial osteomyelitis but in mycetoma the bones are usually detsroyed from the outside, giving rise to characteristic â€Å"Moth eaten appearance†. [2] The â€Å"Dot in circle† sign has emerged has a highly specific sign for the diagnosis of this condition and is based on the understanding of the pathogenesis of the disease process. It reflects the unique pathological feature of mycetoma and consists of multiple small round hyperintense lesions of size measuring around 3-5 mm surrounded by a hypointense rim. The small hyperintense lesions represent the granulation tissue and the surrounding hypointense rim represents the intervening stroma having fibrous septations. The low-signal intensity dot in the centre is due to the presence of fungal grains which causes a susceptibility effect on MRI. This is a unique appearance and is easily recognisable in mycetoma. [1] This sign was proposed by Sarris et al. in 2003 on T2-weighted, STIR, and T1-weighted fat-saturated gadolinium enhanced images. Conclusion We conclude by saying that mycetoma is a severe debilitating disease with high morbidity. Until now the diagnosis of the disease was limited to clinical picture supplemented by biopsy and microbiological culture which were difficult to obtain and proved to be inconclusive in many cases. MRI has emerged as an excellent investigation in mycetoma and helps to arrive at the diagnosis much earlier in the course of disease thereby further helping in reducing the morbidity and rate of complications. Awareness of this characteristic sign is important in view of the scarcity of reports that describe it in the literature and with increasing use of MRI in the evaluation of soft tissue tumours. [3] Ref: S, Betty M, Manipadam MT, Cherian VM, Poonnoose PM, Oommen AT, et al. The â€Å"dot-in-circle† sign A characteristic MRI finding in mycetoma foot: A report of three cases.Br J Radiol.2009;82:662–5. Mycetoma revisited. Incidence of various radiographic signs. Abd El-Bagi ME, Fahal AH Saudi Med J. 2009 Apr; 30(4):529-33. Kumar J, Kumar A, Sethy P, Gupta S. The dot-in-circle sign of mycetoma on MRI.Diagn Interv Radiol.2007;13:193–5. Lewall DB, Ofole S, Bendl B. Mycetoma. Skeletal Radiol 1985; 14:257–262. Magana M. Mycetoma, some clinical and histopathological features.Turk J Dermatopathol.1994;3:94.

Psychology of Adolescence Essay

BoysTown is a registered charity and a national organization for youth welfare in Australia. It focuses on helping disadvantaged youths who are at risk of social exclusion to enhance their quality of life (â€Å"Youth social†). It recognizes several causes of social exclusion among disadvantaged youths that need to be addressed, which include single parenthood, low self-esteem, physical and mental health problems, substance abuse, lack of work experience, functional illiteracy, and underdeveloped personal and vocational skills (â€Å"Youth social†). BoysTown also recognizes that most of the disadvantage youths came from families who have a history of intergenerational unemployment and welfare dependency and from Indigenous backgrounds (â€Å"Youth social†). BoysTown offers several social inclusion programs to help disadvantage youths to improve their life. The programs include Kids Helpline, Youth Programs, Indigenous community development, Family programs, and Intermediate labor markets. The key attribute of these programs is that they emphasized sustainable outcomes while they rely on safe strategies for working with youths who are at risk of social exclusion (â€Å"Youth social†). BoysTown’s Kids Helpline is a national telephone and web-based counseling program that provides services for more than 60,000 children and youths across the country. The Youth programs offer personal development, training and employment assistance to more than 3,500 youths in communities. BoysTown is collaborating with key stakeholders to work on a social inclusion project with four remote Indigenous communities in the East Kimberleys (â€Å"Youth social†). It also provides parenting programs and family refuges such as home-based support and training to make way for the transition of disadvantaged youths to the wider world (â€Å"Youth social†). The organization also operates various social enterprises and transitional employment programs in order to provide 400 youths per year with paid work and on-the-job training. There are various indicators that demonstrate the degree of social exclusion suffered by families and children, which include low-birth-weight babies, permanent exclusion from school, the number of children living in unemployed households, teenage pregnancy, low academic achievement, and the number of children aged 10-16 who are in young offender institutions (Pierson, 2002). The indicators of social exclusion at the level of community include overcrowded housing, a high percentage of households without a bank account, poor community participation, and high levels of burglaries (Pierson, 2002). The key forces that increases the likelihood of social exclusion are poverty and low income, lack of social supports and networks, lack of access to the labor market, the impact of the local neighborhood, and exclusion from services (Pierson, 2002). Pierson (2002) suggests ways to address social exclusion, which include maximizing income and securing basic resources; improving social networks and supports; collaborating in partnership with local organizations and agencies; developing channels of effective participation for users, local residents, and their organizations; and concentrating on whole neighborhoods. Socially excluded youths have a significant cost impact on society in terms of publicly-funded health services, justice system and social security costs, and the impact of decreased individual earning capacity, lost productivity, and decreased tax revenue (â€Å"Youth social†). The Australian government is investing in developing the capability of the not-for-profit organization to provide more holistic, community-based strategies to respond to social exclusion, especially among young people (â€Å"Youth social†). Models of intervention must be multi-dimensional and aimed at providing young people with a comprehensive range of support over an extended period of time (â€Å"Youth social†). They should also be based on a holistic approach in order for young people to overpower personal barriers; improve their strengths, health, well-being, life and interpersonal skills; develop their self-esteem and the ability to learn; and succeed in shifting to independent living, training or work, and further education (â€Å"Youth social†). BoysTown’s Youth programs are effective in helping youths who are at risk of social exclusion because they incorporate individual assessment, counseling, and support, life skills training, personal development and mentoring; vocational skills training, employment assistance; and post-placement support (â€Å"Youth social†). Young people must be provided assistance into paid employment by giving advice, training and other help that they need to make them more employable (Kemp, 2005). Focusing on individual agency such as young people’s attributes, qualifications, decision-making, and behavior allows young people to successfully transition from welfare to work (Kemp, 2005). The Kids Helpline at BoysTown is similar to a mentoring program that helps disadvantaged young people to tackle social exclusion. Mentoring consists of an informal educative role and personal support and encouragement (Pierson, 2002). Mentor acts as a trusted counselor or guide (Pierson, 2002). The goal of a mentoring or counseling program is to connect two individuals in a one to one voluntary relationship, with one individual being more experienced than the other and with the hope that their knowledge and skills will be transferred (Pierson, 2002). The key features of a mentoring relationship include a voluntary arrangement as required by the individual being mentored and can be ended by either party at any time, interpersonal skills of mentors to manage and monitor the relationship, and the understanding of both mentored and mentors about the boundaries and objective of the relationship (Pierson, 2002). Colley (2003) mentions the popularity of mentoring with policy-makers because it addresses their concerns such as the moralization of social exclusion. The author adds that the solution to social exclusion of young people depends on their re-engagement with the labor market and/or formal learning routes. The key role of mentoring is to provide a way for the re-engagement by changing young people’s values, beliefs, attitudes, and behavior to engage their personal commitment to become employable (Colley, 2003). Mentoring helps young people in terms of empowering them, discussing aspirations, and making them more realistic about their view of work (Colley, 2003). It is also important to assist young people to attain skills in areas such as confidence building, problem solving, improvement of interpersonal skills, punctuality, and team working in order to enhance their personal effectiveness in the workplace (Colley, 2003). Moreover, mentoring is also important to help disadvantaged young people develop social networks and capital (Colley, 2003). It is necessary to create initiatives that involve young people not only in making decisions that affect them individually or on particular services but also in making decisions that influence their communities collectively (Pierson, 2002). Organizations led by young people play an important role in defining services and provide practical support for young persons (Pierson, 2002). The aim of the Indigenous community development at BoysTown is to help young people to re-engage in learning; increase community involvement in formal education and training; enhance access to sustainable mainstream employment opportunities; and develop training and work opportunities through community-based social business enterprises (â€Å"Youth social†). According to Pierson (2002), adolescent support teams have emerged rapidly during the early 1990s. The author adds that the aim of adolescent support teams is to divert youths from the care system and offer short-term preventive service that assists families prevent problems in relationships that might result to homelessness. The approach used by the adolescent support teams is preventive and based on time-limited, task-focused work (Pierson, 2002). Most of the work of the adolescent support teams involves negotiation and mediation between young people and parents (Pierson, 2002). BoysTown enterprises are involved in several community infrastructure development, asset maintenance, and urban renewal projects in disadvantaged areas (â€Å"Youth social†). Enterprise-based intermediate labor markets are effective in minimizing crime and anti-social behavior and in helping young people who are socially excluded to engage again with the labor market (â€Å"Youth social†). According to Aiken (2007), social enterprises are considered mission-driven organizations with a commitment to a specific disadvantaged group. The author adds that placement agencies function as intermediaries in searching and training people to move into work in the mainstream labor market. Social enterprises have often focused on the needs of socially excluded client groups (Aiken, 2007). Aiken (2007) mentions that the origin of social and community enterprises can be found in the mutual and cooperative sector in Great Britain. The author adds that the emergence of this movement has resulted to an important pattern which has focused on the economic development of poorer communities, including the importance of maintaining paid work. Intermediate Labor Market organizations focus on short-term training and employment with the goal of trainees transitioning into paid work in other organizations (Aiken, 2007). They may be working with disadvantaged people and will have a tendency to be reliant on some degree of public sector contracting. References Aiken, M. (2007). What is the role of social enterprise in finding, creating and maintaining employment? for disadvantaged groups? Retrieved June 14, 2009, from http://www. parracity. nsw. gov. au/__data/assets/pdf_file/0003/22575/Cabinet_Office Colley, Helen (2003). Mentoring for social inclusion: A critical approach to nurturing mentor relationships. New York, NY: Routledge. Kemp, P. A. (2005) Young people and unemployment: From welfare to workfare. In M. Barry (Ed. ), Youth policy and social inclusion: critical debates with young people (pp. 139-156). New York, NY: Routledge. Pierson, J. (2002). Tackling social exclusion. New York, NY: Routledge. Youth social exclusion: A global concern. Retrieved June 14, 2009, from http://www. boystown. com. au/downloads/rep/BT-Youth-Social-Exclusion. pdf

Computer Testing

1. Answer the Following Questionsa. How is vsftpd more secure than other FTP server? vsftpd is more secure than other FTP servers because it does not run root privileges making it more difficult to compromise the system directly.b. What is the difference between passive and active FTP? The difference between a passive and an active FTP connection is the that in passive mode, the client initiates the connection to the server (on port 20 by default). In active mode, the server initiates the connection, having no default port.c. Why is ASCII transfer sometimes necessary? ASCII transfer is sometimes necessary in order to performs conversion between different code sets.d. If you want vsftpd to run in standalone mode, what do you need to set in vsftpd.conf? Set the listen parameter to YES in the vsftpd.conf filee. A user tries to log in, provides a user name, and gets denied. What settings would cause this and how? Setting /etc/vsftpd/ftpusers lists users that are not allowed to log in on the FTP serverf. What is a directive that has an opened and closed tag instead of being a single word called? Directive that has an opened and closed tag instead of being a single word is a containerg. What is the ability to respond to multiple IPs or names as if the server were multiple servers called? Virtual Hosting2. You can create virtual hosts by host names or IP addresses. Explain the basics of how each type works. IP-based virtual hosts use the address of the connection to decide the correct virtual host to connect to. In order for name-based virtual hosting to work, the server depends on the client to deliver the hostname as part of the HTTP headers. Many different hosts can  share the same IP address using this method.

Measure Words in Mandarin Chinese

Measure words are very important in Chinese grammar as they are needed before every noun. There are more than a hundred Mandarin Chinese measure words, and the only way to learn them is by memorizing them. Whenever you learn a new noun, you should also learn its measure word. Here is a list of the most commonly used measure words in Chinese to kick start your growing vocabulary. What Is a Measure Word? Measure words are familiar to English-speakers as a way to classify the type of object being discussed. For example, you would say a â€Å"loaf† of bread or a â€Å"stick† of gum. Mandarin Chinese also uses measure words for types of objects, but there are many more measure words in Chinese. Measure words in Chinese can refer to the shape of the object, the type of container it comes in, or are simply arbitrary. The main difference between English (and other Western languages) and Mandarin Chinese is that Mandarin Chinese requires a measure word for every noun. In English we can say, â€Å"three cars,† but in Mandarin Chinese, we need to say â€Å"three (measure word) cars.† For example, the measure word for car is  Ã¨ ¼â€º (traditional form) / è ¾â€  (simplified form) and the character for ​car is è »Å  / è ½ ¦. Thus, you would say  Ã¦Ë†â€˜Ã¦Å"‰ä ¸â€°Ã¨ ¼â€ºÃ¨ »Å  / 我æÅ"‰ä ¸â€°Ã¨ ¾â€ Ã¨ ½ ¦, which translates to I have three cars. Generic Measure Word There is one â€Å"generic† measure word which can be used when the actual measure word is not known. The measure word 個 / ä ¸ ª (gà ¨) is a measure word for people, but it is frequently used for many types of things. The generic measure word can be used when referring to items like apples, bread, and light bulbs even when there are other, more appropriate measure words for these objects. Common Measure Words Here are some of the most common measure words encountered by students of Mandarin Chinese. Class Measure Word (pinyin) Measure word (traditional Chinese Characters) Measure word (simplified Chinese Characters) People gà ¨ or wà ¨i 個 or ä ½  ä ¸ ª or ä ½  Books bÄ›n æÅ" ¬ æÅ" ¬ Vehicles lià  ng è ¼â€º è ¾â€  Portions fà ¨n ä » ½ ä » ½ flat objects (tables, paper) zhÄ ng Ã¥ ¼ µ Ã¥ ¼   Long round objects (pens, pencils) zhÄ « æ” ¯ æ” ¯ Letters and Mail fÄ“ng Ã¥ °  Ã¥ °  Rooms jiÄ n éâ€"“ éâ€" ´ Clothing Jià  n or tà  o ä » ¶ or Ã¥ ¥â€" ä » ¶ or Ã¥ ¥â€" Written Sentences jà ¹ Ã¥  ¥ Ã¥  ¥ Trees kÄ“ æ £ µ æ £ µ Bottles pà ­ng ç“ ¶ ç“ ¶ periodicals qÄ « æÅ"Ÿ æÅ"Ÿ Doors and windows shà  n 扇 扇 Buildings dà ²ng æ £Å¸ æ  â€¹ Heavy objects (machines and appliances) tà ¡i Ã¥  ° Ã¥  °