Shoulder Meniscoid Plica?

I have seen this many times in the past but it is usually not accompanied by static subluxation of the GH joint.  There is a large fibrous meniscoid lesion in the anterior shoulder that appears to be capsular or synovial based on signal characteristics.

 

shoulder meniscoid axial

Ax PD FatSat: These images are slowed down on the slices of interest.

 

Gallery – I apologize for the seizure inducing poly-animation.  Click on a sequence to view individually.

Shoulder plicae are alluded to in some articles:  Superior plica of the shoulder joint: Case reports

 

 

Masticator Space Infection

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Patient presented with trismus following dental extraction. Tiny masticator space abscesses following a right third maxillary molar extraction. Infectious myositis with asymmetric swelling of the right muscles of mastication. The abscess tunnels dorsal to the anterior aspect of the temporomandibular joint. Good demonstration of spread patterns in the spaces of the face and neck.

 

 

Adult Small Bowel Intussusception

Demonstration of adult small bowel intussusception. Typically these are transient and asymptomatic incidental findings on CT. Clinicians can become alarmed at the mention of intussusception however most of them spontaneously resolve and result from vigorous peristalsis rather than a lead point.

This patient however has postoperative changes of Roux-en-Y gastric bypass and on prior CT, angulated loops of bowel were present in the location of the intussusception making it very likely that the postoperative adhesions acted as a lead point. Another more unusual finding is the dilation of proximal small bowel indicating obstruction associated with the intussusception.ezgif.com-gif-maker(2)

Parotid sialadenitis

Demonstration of both the inflammatory changes of the right parotid gland and the anatomy of the vessels and ducts associated with the parotid gland.

 

In this animation, I have paused the animation to demonstrate the parotid papilla, parotid duct and the transverse facial artery marked by arrows.

The asymmetric parotid inflammatory change is highlighted by the white boxes, with edema and phlegmon of the right parotid gland with enlarged cervical and parotid lymph nodes which is markedly asymmetric when compared to the left on these coronal reconstructions.

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Revised Fleischner Guidelines

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Exec Summary:

  • The smallest breakpoint is now 6 mm.
  • The guidance table now separates into risk factors rather than nodule size and multiplicity of nodules.
  • Distinction between solid and sub solid nodules.
  • Guidelines should only be applied the age > than 35. Outside of this age range, follow-up should be tailored to the patient.
  • For solid nodules, the minimum threshold size for routine follow-up has been increased, and fewer follow-up examinations are recommended for stable nodules.
  • For subsolid nodules, a longer period is recommended before initial follow-up, and the total length of follow-up has been extended to 5 years.
  • These guidelines apply to incidental nodules, which can be managed according to the specific recommendations.
  • These guidelines do not apply to patients younger than 35 years, immunocompromised patients, or patients with cancer.
  • For lung cancer screening, adherence to the existing American College of Radiology Lung CT Screening Reporting and Data System (Lung-RADS) guidelines is recommended.

The Fleischner Society Guidelines have been a godsend for the management of incidental pulmonary nodules.  This area has plagued radiology and IMHO serves as a useful barometer for both radiologists and practices. If a practice uses arbitrary follow-up for pulmonary nodules rather than guidelines, in my experience, there are probably other failings.

More advanced practices not only include the recommendation and description of the nodules but also include the reference and optimally, the guideline table in the report to help the clinicians decide how to manage the patient since clinical information relevant to follow-up is usually not available to the radiologist (pertinent risk factors are frequently not given).

Source Ref: Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017, Heber MacMahon et al., Radiology 2017 284:1, 228-243.

SPN2017 pdf reference

And a really pretty infographic from Mass Gen!


This is a juicy article with lots of nuggets:

Perifissural Nodules

Finally!  Some data driven guidance on subpleural/intrapulmonary nodes.  Yay!

Perifissural nodule is a term used to describe small solid nodules that are commonly seen on CT images adjacent to pleural fissures and that are thought to represent intrapulmonary lymph nodes. Similar nodules can occur in other locations, usually adjacent to a pleural surface. Typically, these are triangular or oval on transverse images, and they have a flat or lentiform configuration in sagittal or coronal reconstructions and a fine linear septal extension to the pleura. When small nodules have a perifissural or other juxtapleural location and a morphology consistent with an intrapulmonary lymph node, follow-up CT is not recommended, even if the average dimension exceeds 6 mm. In one study of patients in the NELSON Lung Cancer Screening Trial, 20% of nodules were classified as perifissural, and 16% of these grew during the study; however, none were malignant (94). However, perifissural or juxtapleural location does not in itself reliably indicate benignancy, and the specific nodule morphology must be considered (95, 96). A spiculated border, displacement of the adjacent fissure, or a history of cancer increase the possibility of malignancy, and a follow-up examination in 6–12 months should be considered in these patients.

Incidentally Detected Lung Nodules on Incomplete Thoracic CT Scans

Lung nodules are commonly encountered in the portions of the lungs that are included on CT scans of the neck, heart, and abdomen, and the question often arises as to whether a complete thoracic CT examination should be performed in such instances.

For most small nodules (<6 mm), we do not recommend any further investigation on the basis of the estimated low risk of malignancy (6,7). For intermediate-size (6–8-mm) nodules, we recommend follow-up CT of the complete chest after an appropriate interval (3–12 months depending on clinical risk) to confirm stability and to evaluate additional findings. If nodule stability can be demonstrated on the basis of retrospective comparison with a previous study, that may suffice. In the case of a large or very suspicious nodule, we recommend proceeding with a complete thoracic CT examination for further evaluation.

Partial Thoracic CT Scans for Nodule Follow-up

We do not recommend use of partial thoracic scans for practical reasons, including the need for a technologist or radiologist to determine the appropriate range of the scan from a scout image and the possible detection of unanticipated abnormal findings that would require complete examination of the thorax to properly evaluate.

Apical Scarring

Some degree of pleural and subpleural apical scarring is extremely common, and these scars may have a nodular appearance, especially when viewed on transverse images. Certain features are suggestive of a scar, including a pleural-based configuration, an elongated shape, straight or concave margins, and the presence of similar adjacent opacities. Review on coronal or sagittal reconstructed images can be helpful in the characterization of such findings. Similar considerations apply to subpleural opacities in other locations, including the costophrenic angles, where focal scarring is also common.

Home Assistant on Orange Pi Zero

NOTICE:  DUE TO CHRONIC STABILITY PROBLEMS, I DO NOT RECOMMEND USING STANDARD ARMBIAN ON OPZero.  DIET PI RESOLVES STABILITY ISSUES.  NEW BLOG POST WILL BE FORTHCOMING.

 

 

Guide here: https://home-assistant.io/blog/2017/05/13/home-assistant-on-orange-pi-zero/

Phase 1

Important: Have your router set the IP for the Orange Pi before you configure it. Manual configuration has broken the entire thing several times.

  1. Download Armbian for pi zero
  2. Download Etcher
  3. Extract Armbian and use etcher to burn image to microSD card (I used 2GB which may be too small)
  4. Insert mSD and plug into network.
  5. Check router for IP after giving time to boot.

Phase 2

Save a profile to putty:

  • include: keepalive 10 as per this post and enlarge the font if you are old like me and don’t like craning your neck to watch terminal output.

  • Putty to SSH into PiZero with root:1234

Change root password and create a user so you don’t have to use root.

sudo apt-get update

sudo apt-get upgrade

(directory locked and had to reboot first).   This step takes a while to download and install packages.


Phase 3

next install python and its packages:
sudo apt-get install python3-dev python3-pip python3-venv


Now execute the following:
ha@orangepizero:~$ pyvenv-3.5 homeassistant

ha@orangepizero:~$ cd homeassistant && source bin/activate


(homeassistant) ha@orangepizero:~/homeassistant$ pip3 install --upgrade pip


(homeassistant) ha@orangepizero:~/homeassistant$ pip3 install homeassistant


(homeassistant) ha@orangepizero:~/homeassistant$ hass

USE pyenv-3.4 if in dietpi

aiohttp takes quite a while to install so go get coffee or something. First loading hass also takes a while and appears to hang at several points.  That’s okay. Just give it some time.

Make sure to upgrade pip3 from the venv once it’s initiated.  Not doing that will cause a raft of errors.

There can be problems with venv so if needed, just destroy it with

sudo rm -rf homeassistant

Whoop! Dare it is!

Capture

I then restored by configs from the .homeassistant directory.

This threw errors for pylutron-caseta (because it wasn’t installed yet) and mqtt because mosquitto wasn’t installed yet.


Tackling mosquitto as a broker:

sudo apt-get install mosquitto

apt-get install mosquitto-clients

Gotta have both to monitor the messages using:

mosquitto_sub -h 127.0.0.1 -t “home-assistant/”


There is also a known issue with installation of pylutron-caseta (click for forum link).

To solve this one:

sudo apt-get install build-essential libssl-dev libffi-dev python-dev

Until you do that, you won’t get anywhere installing pylutron-caseta.

Also, be aware that pynacl take an extremely long time to install due to it only using one of the 4 cores for compilation.  There is a bug and fix enroute for this at the time of writing.

sudo -H pip3 install pylutron-caseta

This eventually installs in the venv after a reboot.  I also installed paho-mqtt through pip but am unsure if it is needed at all.

There are some super useful aliases which you’ll want to edit the .bashrc to add:


alias config='nano ~/.homeassistant/configuration.yaml'

alias checkconfig='hass --script check_config'


alias venv='cd ~/homeassistant && source bin/activate'


alias hasslog='nano ~/.homeassistant/home-assistant.log'


alias customize='nano ~/.homeassistant/customize.yaml'


alias restart='sudo systemctl restart home-assistant@ha'


alias status='sudo systemctl status home-assistant@ha'


alias stop='sudo systemctl stop home-assistant@ha'


alias start='sudo systemctl start home-assistant@ha'


alias secrets='nano ~/.homeassistant/secrets.yaml'

Don’t forget to enable HASS autostart.

file location:

/etc/systemd/system/home-assistant@ha.service

[Unit]
Description=Home Assistant
After=network.target

[Service]
Type=simple
User=%i

## The line below needs modification based on file location

ExecStart=/srv/homeassistant/bin/hass -c “/home/homeassistant/.homeassistant”

[Install]
WantedBy=multi-user.target


Install Armbian Monitor to use web interface for stats

sudo armbianmonitor r

Port: 8888


Samba

Setup here 


To Do list:

  1. Shell script automate backups of config files to github.  cron job.
  2. Backup to image using easus and win32 Disk Imager
    1. Test restored backups to secondary card
    2. Try restoring to disparate size card
  3.  Automate shell script complete disk image backups.
  4.  change units of some sensors so they don’t all get graphed together
    1. Particularly the DarkSky API sensor.
  5.  Automatically enter the venv from login/boot