tails of a mouse asthmatologist

Cuccidati

2010-12-16T15:28:00.007-05:00

What can I say, packing, our recent move, unpacking, the Holidays, it's been a busy time. Not to mention all my work related events keeping me away from doing stuff that is more or less a guilty pleasure.

We did break in our new home by having our families up for Thanksgiving. I took the entire week off and during one of my shopping excursions I came across a 'Fig and Ginger Jam'. Seeing this reminded me of one of my favorite Christmas cookies that my Grandmother used to make. The cookies are called Cuccidati, and they are a traditional Italian (actually Sicilian) Christmas cookie made with figs and dates.

It's been a long time since I have had these cookies, as my Grandmother passed away many years ago, and although my Father loved to bake he really wasn't into baking cookies. So I called my Aunt to see if she had the recipe, which of course she did. Unfortunately for me the recipe was for >250 cookies!! I don't think I ever realized how hard my Grandmother worked preparing all the cookies that she made for the Holidays.

I decided that I needed to make these cookies for our Thanksgiving in our new home.

The cookie filling is a mixture of figs, dates, raisins, nuts, orange, honey, spices (cinnamon, nutmeg and cloves) sometimes brandy is added, sometimes pineapple and other subtleties. Back in the day my Grandmother chopped all of the ingredients by hand.

Anyway, I did some online searching and found many variations as to the filling as well as the presentation of this cookie. In the end, I thought that I would modify my Grandmothers recipe a bit and adjust the filling based on my own taste. I stuck to the basic ingredients but also used dried cherries instead of pineapple, I used almonds but not walnuts, I left out the candied fruit altogether and decided to add a little rum to the mixture. Of course I used a food processor to chop everything. Once the filling is made it has to sit in the refrigerator for at least 8 hours, though mine stayed in for a day or 2.

Making the dough, refrigerating that, rolling it out, filling and cutting the cookies also turned out to be somewhat labor intensive and I began to wonder if I should have given this decision more thought.

In the end, the cookies were not exactly like my Grandmothers, they ended up being a bit larger, the dough was different in that I used butter instead of Crisco, (I think butter makes almost anything better), and I had a little trouble with the consistency of the frosting early on. All-in all, they were pretty good and brought back memories of my Grandmothers cookies and Holidays spent with my Family.

I decided to make another batch for Christmas.

Smoke less, Breathe more

2010-09-17T10:37:00.005-04:00

Agree or disagree with smoking bans, the fact is that more and more data are being accumulated showing that smoking bans may actually be saving lives. In addition, it may be an impetus for some smokers to contact a quit line.

A recent study in the New England Journal of Medicine, found a significant reduction in children admitted to teh hospital with asthma exacerbations after smoking bans were implemented.

USA today also reported that, "Since the law took effect, doctors also have found fewer breathing problems among waiters, bartenders and other pub employees, says Pell, of the University of Glasgow in Scotland. Studies in the USA have shown that heart attacks decline immediately after cities implement smoking bans."

This article was also covered by Bloomberg and MedPage Today.

Additionally, their is some circumstantial evidence that the implementation of these laws along with State funded smoking cessation programs, and perhaps higher taxes on cigarettes, has reduced the rates of smokers. In Cuyahoga County, the smoking rate went from 20.7 percent in 2005 to 15 percent in 2009, according to the state's Behavior Risk Factor Surveillance Survey. The overall state rate went from 22.4 to 20.3 percent in the same time period. According to a recent article by The Plain Dealer.

On the flip side I have not seen any data published on the health effects of people smoking outside of bars and restaurants in the winter time.

Is the term 'Green Landscaping' redundant?

2010-08-25T15:35:00.011-04:00

Green landscaping? What does that mean? Up until recently I didn't know of such a thing.

Our builder recommended a landscape architect who also does landscape design for our County parks. I learned a lot from this experience.

Much like any 'Green' design a major component when designing a Green landscape, is to limit the impact the landscaping has on the rest of the environment. This is accomplished in several ways.

First, the vast majority (~95%) of the plants and trees we are planting are native to our region. By doing this we not only reduce the likelihood of bringing disease into the area but we are also selecting vegetation that is well adapted to the environment. Because we have a lot of deer in our area we have selected some plants that are not necessarily native to our area but do well in our climate and do not attract deer, such as Hostas.

Second, our land backs up to a wooded area, instead of a lawn that runs right up to the area we are planting Meadow field, so there is a transition from lawn, to meadow, to trees. This has the additional benefit in that it limits the size of the grass lawn, reducing some of the water runoff (see below).

Third, one of the biggest impact lawns, homes, driveways, and patios have is that they increase water runoff. In our area, 80% of the homes are not linked to a sewer system, so we utilize a septic tank for our indoor water waste. This also means that rain water that enters the drainage pipes in the street flows directly to a nearby river, increasing erosion. This has been such a problem that our county sewer district is starting to assess fees on all homes as sort of an erosion impact fee. One of the ways we can reduce this fee is by reducing the amount of water that flows off our land. To accomplish this we have incorporated the following design elements in our landscaping.

1) We have tried to limit the lawn space, especially in the back of the house.
-most people, me included, still think a lawn is a great place to play, and ofcourse have a picnic. So we have not eliminated the lawn altogether. But we have a large meadow field in the back and front of the house to limit some lawn space.
2) We have incorporated bioswales and rain gardens on the property lines and near our rainbox. Many properties are sloped to encourage water to drain away from the house, which is fine, but the water then ends up in the sewer system and, in our case, out to the rivers. By planting vegetation that is able to tolerate a 'wetland edge' you can allow some water to collect in the area thus limiting runoff.
3) Our patio area will be made with permeable pavers, which allow for movement of water in and around the pavers, also limiting water runoff.

Finally, we have designed a landscape to conserve water. In our area of the country most people don't think of water conservation because it is relatively abundant. However, that is not the case everywhere.
-We are not putting a sprinkler system in for the lawn, certainly this has the added benefit of saving us money.
-The grass seed we are planting is relatively drought resistant. Of course during the first few years it will be necessary to water the lawn until it is established, but by not cutting the grass to short during the summer months and allowing the root system to develop, it will not need as much water in the long run and will be more resistant to dry spells during the summer months.
-In the Southwest corner of our house we have a rainbox collection system. This will be used to water our vegetable garden as well as the landscaping around the house. The landscaping surrounding the box will also be a rain garden and overflow from the rainbox will be used to water this area.

For more information:
University of Minnesota has a website, Sustainable Urban Landscape Information Series.
University of Missouri has a fact sheet on how to manage and control storm water runoff.
An article on the effects of water runoff in the Cleveland Metroparks.

The Cost of Going Green

2010-06-21T15:05:00.003-04:00

View from South West corner

As I have alluded to in several of my previous posts, not only are we building a "Green Home", but our home will also be on the Green Home Tour this fall, prior to our moving in. When I inform people that we are building a Green Home, they often ask, "Oh, are you using wind or solar power?"

I guess the idea of "Green" means different things to different people and no wonder, the term is being used by everyone and everything lately. I have said this many times on my blog, I have a moderate belief system. I believe in balance. Balance in life, in politics, in work, in Religion, and with Family. I despise most extremism as it only serves to create conflict.

How does this relate to our new home? Well, it means that I have no plans of "going off the grid". Essentially, what it means to me is that we have he technology to build more energy efficient homes, there are methods available to diminish the impact a home has on disrupting the environment, there are vendors and manufacturers you can choose that do the same, so why not do it. While some of these improvements come at an additional up front cost, many do not. Additionally, a good portion of the up front costs can be recouped in energy savings over the life of the home.

Regardless of whether or not you believe or do not believe in climate change, why wouldn’t you change things in your life that diminish the impact you have on your environment? There are blogs I have read, news reports, and radio talk shows, where all they do is argue about climate change. What a waste of time and dare I say energy. Seriously, what is so wrong with deceasing our dependence on foreign oil? What is wrong with developing solar or wind power? What is wrong with recycling? What is wrong with building cars that are more fuel-efficient? What is wrong with reducing our energy usage? There are many reasons other than climate change to pursue these goals.

Additionally, going green is not just about energy savings but also about efficient design and construction. Our goal is to have our home LEED certified. LEED stands for Leadership in Energy Efficiency and Design and is a third party certification program and the nationally accepted benchmark for the design, construction, and operation of high performance green buildings. Developed by the U.S. Green Building Council in 2000 through a consensus based process, LEED serves as a tool for buildings of all types and sizes.

So, here are some of the things we have done to make our home 'Green'. Or in other words, here are things we have done to diminish the impact that our home has on the environment, to reduce our carbon foot print, to limit waste, to enhance sustainability. Some things may seem obvious, while others may not.

DESIGN: Our home footprint is compact.
IMPACT: Less disruption to the surrounding land, fewer building materials needed.
COST: Less expensive to build a house with a compact footprint and fewer corners. Fewer materials means less cost.

DESIGN: To increase space we built up instead of out.
IMPACT: Less disruption to the surrounding land.
COST: Less expensive to build a two story house than a similar square footage home as a Ranch design.

DESIGN: North/South facing home with limited windows on the East/West side of house.
IMPACT: Limited passive heating of home in Summer. During Winter months, the lower path of the sun will provide passive heat via South facing windows. (as noted in a previous post, this was an issue we had with the Architectural Review Board)
COST: Savings by reducing overall number of windows on East/West of house and through energy savings.

DESIGN: The windows we do have are Energy efficient.
IMPACT: Reduced passive heating and cooling, means energy savings
COST: Neutral.

DESIGN: We built our home using Insulated Concrete Forms.
IMPACT: Highly energy efficient. Sustainable, in that the home can last 200+ years, whereas a traditional wood framed home has an average life expectancy of 80-85 years. Saves lumber. Structure is impervious to rot, decay, and insects. Improved indoor air quality.
COST: Increase overall cost of 7-15% of total cost of house. However, can be recouped on energy savings, reduced maintenance, and reduced cost to insure.

DESIGN: Geothermal Heating and Cooling.
IMPACT: Zero emissions,renewable energy, and more efficient.
COST: About 3x as expensive as a dual fuel system. However, with the current tax incentive the net cost is decreased to 2x that of a duel fuel system. Additional savings in heating and cooling costs will add to tax benefit.

DESIGN: Tankless water heating system.
IMPACT: Reduced energy usage.
COST: Anywhwere from 1.5-3x more than a traditional water heater. However, some of the cost will be recouped on energy savings.

DESIGN: PEX tubing using a manifold homerun design, instead of copper tubing.
IMPACT: Recyclable tubing (while it can not be re-used, it can be recycled into other products). Less heat transfer than copper, thus conserves energy. No solder required. Manifold homerun design conserves water.
COST: Significantly less than copper plumbing.

DESIGN: Energy Star Appliances.
IMPACT: Reduced energy consumption
COST: Neutral up front cost with a long-term net energy savings.

DESIGN: use of CFLs in select locations, such as garage, closets, laundry room, and outdoors. Until CFLs or LED light design improves we have decided to use traditional lighting in living areas, but they will be attached to dimmers.
IMPACT: Reduced energy consumption.
COST: Higher initial expense for CFLs but net savings over the life of the bulb.

DESIGN: Purchase tile with recycled content and from a US manufacturer working to improve its own sustainability.
IMPACT: Limits environmental impact during manufacturing process. Use of recycled products.
COST: Neutral

DESIGN: Purchase wood flooring from a US manufacturer harvesting trees from certified sustainable forests.
IMPACT: Limits environmental impact during manufacturing process.
COST: Neutral.

DESIGN: The use of a Truss framed roof rather than traditional hand framed roof.
IMPACT: Less wood needed, less time to install, and from a structural standpoint is typically stronger than a hand framed roof.
COST: Less wood used fewer tress and lower cost, in addition less time needed to install also reduces labor costs.

So, those are some of the things we are doing related to the building of our home. Many of these things I learned about for the first time during the building process and were a surprise to me. Certainly this is not an exhaustive list and there are many other ways to build a sustainable and Green home, this is just one example.

NEXT: Is the term 'Green Landscaping' redundant?

So Far, So Good.

2010-06-08T09:56:00.005-04:00

After the initial shock, which occurred when we heard about the additional cost to build our home when our Suburbs Architectural Review Board added their 2 cents, I mean $7,500 worth, we were hoping that things would run a bit smoother.

I am happy to report, (as I find some wood to knock on), that so far things have been pretty good. Our builder has done an amazing job of laying out an appropriate budget for us based on our discussions and has been very good at helping Boo Wife and I stay on budget. They will inform us about cost saving options and what is worth a little extra and what may not be worth a little extra.

In addition, because our home will be in the Green Home Tour this Fall, our builder brought in an Interior Designer to help us with some of our selections, mainly tile and flooring, as well as paint colors.

It was quite fun, educational, and a little serendipitous as well. Turns out that there was a Homeshow we went to a couple of years ago in which Boo Wife really loved the design and color scheme of the bedrooms. Well, this is the designer who is now helping us.

The fun and educational part was that we had already picked most of our tile, so it was interesting to see the choices that our designer picked and the reasons why. I would show her the tile we picked, and she would then explain why she picked a particular tile and how the color scheme works better. I liken Interior Designers to Wine connoisseurs, the designers can see colors that I cannot, while the wine connoisseur can taste things that I am unable to. The cool thing is, that they were all tiles that we really liked. She told us that she already had a good idea of our color preferences based on our cabinets, and the selections we had already made. We left the store even more excited than the first time, although I think it affected our own confidence for making future selections.

That's not all! A couple of weeks later we received a call from our builder. We will have to go back to the tile store for a third time and re-select all of our tiles. Sounds bad but it is actually going to be very good! The Tile store wants to advertise during the home tour but has asked us to pick a "Greener" product. Turns out that there are several tile manufacturers that use recycled content in their tiles, in addition their manufacturing plants are decreasing waste and improving energy efficiency. Crossville is one of those manufacturers. I am not sure if this is the tile we are going to choose from, but the store does carry this brand.

To be quite honest I really didn't know about this aspect of the tile industry. I knew that the wood flooring company we chose only harvested wood from certified sustainable forests, which is one of the reasons we chose Mullican, that and it is a USA based company, and perhaps just as important, the cost was actually below our allotted budget.

Hopefully, things will continue to go smoothly...knock, knock, knock.

Our Big Dig, the cost of living in the Burbs

2010-05-07T11:08:00.011-04:00

So, they say that if you build a house you should budget at least 10% of the total estimated costs for overages. Some of these come from your own selection process.
"a 36 inch dual fuel range cost how much more!"
"Really, choosing a slightly different stainless steel sink changes the cost from $200 to $600!"

Anyway, sometimes the cost doesn't seem so much and you think its worth it, but the problem is that all those costs add up.

Other times though, the cost is truly unexpected.

As I mentioned in my previous post, our builder had to submit our home plans to the "Architectural Board of Review" of the Suburb we were moving to. They meet the first and 3rd Tuesday of each month, and not only review the design but also the exterior choices, brick, stone, siding etc. Well, they apparently had some suggestions for us. In retrospect it probably would have been wiser for us to go there with the builder but, at the time, we didn't think it would be a problem. In addition to their exterior suggestions there were also a couple of their own building codes they were going to enforce that cost us even more.

1) The builder planned on digging a 5 foot basement and then grading the rest of the house with the dirt. We liked this idea ourselves as it made it possible to put slightly larger windows in the basement. Unfortunately, this is not allowed. The basement had to be dug an additional 3-4 feet and the dirt had to be hauled away. Additional cost $4,500.
2) Our State building code requires one layer of Ice Guard that lines the area where the wall meets the roof. Our Suburb said that we need 2 layers of ice gaurd. I guess they believe the adage, if one is good then two must be even better. Additional cost $850.
3) The review board also 'requested' that the roof on our dining room bay window be copper rather than the shingles which is what we were originally planning. Additional cost $1,500. Sure it looks nicer and is probably worth the additional cost, but it all adds up.
4) Finally, they thought we didn't have enough windows on the West side of our house. Really? The area we are moving, unbeknowst to us prior to our buying there, was all about 'going green'. They even had a neat little slogan to promote it. So WHY would they suggest putting 4 more windows on the WEST side of a house. The point of building an energy efficient home is to conserve energy, right? Having a North/South facing house is more energy efficient in that most of the windows are not exposed to direct sunlight, that is the whole idea of limiting the windows on the East and West side. As a compromise our builder was able to talk them down to adding only two additional windows instead of four. Additional cost $650.

All totaled, the Review Board cost us an additional $7,500, even before we started to break ground. My hope is/was that the rest of the build will go a lot smoother.

NEXT: So far, so good.

Our Big Dig, Getting started.

2010-05-04T15:50:00.009-04:00

We sold our old home and began settling into our rental. We were still not entirely ready to build though. We've been working hard to save our money to pay off the land loan which will be our down payment on the construction loan. Meanwhile Boo wife and I had a lot of decisions to make regarding the overall construction of the house and selections. During these next few months as we met with the builders we are asked if we would consider letting the house be used as a model for a while. Sure, were open to that, not yet realizing what this will mean. As the winter holidays approach we are more focused on family and little happens with regards to the new house.

As the new year rolls in we are still in the 'saving money' mode and I am just starting to keep a closer eye on the mortgage rates. Finally, as January is coming to a close we hear more from the builder, they seem more anxious to get things started at this point. At first I am not sure why but as things progress I begin to understand. Though I don't know all the details it turns out that our builder has been given permission to market the remaining sublots where we bought. In addition, there is a planned 'Green Home Tour' for September 2010 and since we have decided to build our house using Insulated Concrete Forms our builder wanted to use our home as their model.

This is advantageous for our builder and for us. Easier for them to market the land if they have a product to show. Since we are familiar with the quality of their work, if they end up building other homes on the lots then it would only enhance the value of our home. Plus, being a model home provides us with a few additional perks as well. The only down side is that we would have to delay our move in date by a few weeks.

In mid February I contact a loan officer to start the preliminary paper work for a loan pre-approval. Several more meeting ensue, some more changes in our plans, a whole lot of paperwork, some more selections, appraisals etc. The builders are in the process of obtaining all the permits. In addition they have to submit the plans and elevation design to the architectural board of review. Yes, the Suburb we chose, much like the Suburb we live in currently, reviews all new builds to make sure that it meets with their approval. I am not sure how common this is elsewhere, but I know that the Suburb we currently live in actually limits the exterior color choices of many of the homes, so as to keep them appropriate for the time period that they were built.

On March 4, 2010 Boo Wife and I sign all the paper work for the land title and the construction loan. On March 8th all the paper work has been filed. March 10th there is still alot of snow on the ground here, but as luck would have it a warm and wet spell ensues and when the bull dozers and diggers arrive to dig out the driveway and start the foundation all the snow is gone. One of the most exciting moments for me was when Brad called me on my way home from work that week and asked, "Are you ready to build a house?"

NEXT: Our Big Dig, the cost of living in the Burbs.

Selling our Home (The Good, The Bad, and The Ugly)

2010-04-21T14:20:00.015-04:00

Once Boo wife and I decided to buy the land and build we also decided that it would be best for us, from a financial standpoint, to sell our condo before we started to build. It was, and still is, a tough housing market and as always, Condo's seem to take an especially hard hit during times like this. However, it would be very tough for us to pay 2 mortgages if we started building and we weren't able to sell our condo.

Our Realtor suggested we get someone to help us 'stage our home'. For those of you unfamiliar with home staging you can find more info here. I really have to give Boo Wife a lot of credit here as she took the suggestions to heart and really changed the whole feel of the house with just a few simple additions and a lot of de-cluttering. She also kept the house in shape for all the showings and open house events we had.

Unfortunately, for us, we knew we were going to take a loss on the condo but we were anxious to sell so we priced it accordingly.

The first few months there seemed to be some interest but most of the people wanted to rent the condo with an option to buy. Unfortunately this is NOT where I wanted to be, I just didn't want to take the chance. As the summer wore on the news became more and more depressing. Some condos in our development had been on the market for over one year, those that did sell were sold substantially below their original cost. It was also difficult to live the 'minimalist approach' necessary to stage a home. This was even more difficult with a one year old child, who was almost ready to start walking, and a 60 lb Labrador Retriever who sheds like there is no tomorrow, oh and lets not forget the cat. The constant cleaning, vacuuming, and picking up was keeping us both busy.

Towards the end of August we had our first 'serious' offer. I have serious in quotes because the buyer was low balling the hell out of me AND the buyer wanted us out of the condo at the end of August. So, we had about a week to finalize a deal, find movers, find a new place to live, and pack up our Condo!? Seriously?! I am still not sure what his plan was since in order to sell we the would also need a local inspection, a bank appraisal, and his own inspection.

Anyway, we went back and forth for a few days and finally agreed on a selling price and that we would be out of the Condo and close at the end of September. Boo wife found a great rental in a great neighborhood close by that was pet friendly. No easy task as some of the house rentals on the market were in pretty nasty shape. Once again I have to give Boo Wife a lot of credit as she did a lot of the footwork in finding a rental as well as the bulk of the packing. We also had at least three trips to the Goodwill, donating clothes and misc items. Some things we were able to give to friends and family. Bottom line, we were out of our Condo and in our rental by mid September.

As we approached the last week in September I had made all the calls to the utility companies for final readings and am getting ready to close when I get a call from our Realtor that the 'buyer' wants to delay closing until the end of October. Seriously!? WTF. His Realtor was saying how busy he was, job, travel, personal issues, etc.

So now here I am in the exact situation I didn't want to be in. Responsible for our rental payment AND my mortgage payment AND double utilities. To make matters even more frustrating I was getting calls twice a week because he was bringing in contractors and decorators into the Condo. Not that I had a problem with that per se but when we would go back there would always be several lights and fans left on, and I'm still paying the electric bill. I really wanted to charge the 'buyer' some sort of rent each time he went in but I kept hearing things like, "oh don't piss him off because he'll walk away from the deal".

The problem was that at one point I was so pissed with all the antics that I was actually willing to forgo the sale and move back. This was especially true after we found out that the reason the closing date changed was not related to work, or travel, but rather he had not turned in some simple paperwork to his loan officer.

Things get even uglier as the end of October rolls around and I haven't heard form the Title Company about when the closing time is. As it happens they have not received some of the paper work they need due to some oversight as well. As my stomach continues to ball up and I take my extra proton pump inhibitor I begin to wonder if the Condo wouldn't have been such a bad place to raise a family.

Our closing day, Monday October 26, 2009 comes and goes without a word. I come into work the next day and get a call from the Title Co at 9:30 am telling me that the paperwork will be signed at a location 45 minutes away at 11:30am. Both me and Boo Wife are at work, which leaves me one hour and 15 minutes to change my entire work schedule, contact my wife and have her change her entire work schedule and make the drive to sign the paper work. Unfortunately there was no way we could do this. Oh, no problem, said the 'nice' lady at the Title agency, we can have an agent come to your home tonight to sign the paper work. "Oh!", great I thought, "Lets do that".

"Yes, that will be a $150.00 charge that you will have to pay when he comes out". She stated nonchalantly.

Arrggghhh! So the closing date I had previously set aside is canceled, through no fault of my own. Then, they give me a total of 75 minutes to change mine and my wife's entire work schedule to drive to a location 45 minutes away and I get charged for this!?!

Now, I am at the point where I just want to get all this over and done with. Nobody at this POS Title Company really cares at this point and they just ignore my calls and e-mails. If you ever have any dealings or are asked to deal with Title Source based out of Michigan, I would suggest that you avoid them at all costs.

The only satisfying part of this whole adventure, and I know how spiteful this sounds, but I couldn't help but laugh a little inside when I heard this. Our contract stated that the buyer could not take possession of the property until the Title was transferred. Apparently in Michigan, the signing of the paperwork is enough and the POS Title company did not file the paperwork even after they had it. This led to a lot of frantic calls from the buyer to the POS Title Company, who finally filed the paperwork on Friday afternoon. Friday night I dropped of the key, checked the place one last time, turned out all the lights and left my Condo for good.

So, in summary,

The Good:
-we sold our condo in about 4 months.
-we were one step closer to getting a new house built.
-we have great neighbors and a small yard at our temporary home.

The Bad:
-sold at about 18% below my original cost.
-lost another month of mortgage and utility payments because the buyer, who originally wanted to be in the condo in August, was to 'busy' to get his paper work in.

The Ugly:
-Don't ever deal with Title Source.

Finding a Builder Part II

2010-04-13T15:36:00.007-04:00

The day after Boo wife and I had our first tour of the 1950's Cape Cod house on a quiet cul de sac we decided to contact a builder to have them take a look at the house, give us some ideas as to what might be done and maybe some rough estimates as to costs. The business card I received 6 months ago from the builder we met at the home show was sitting on my desk. I typed in their web address and did a quick BBB check to see if anything was grossly afoul. Superficially things looked OK.

I sent an e-mail stating our situation, that we had met at the Homearama and we were interested in a remodel/new construction and wondered if they would be able to meet to discuss, I also stated I would be happy to pay a consultant fee if needed.

The e-mail back to me was simple, even though it sounded like a sales pitch I sensed sincerity in the words. To summarize the e-mail: "Our business is about families and building relationships. We'd be happy to meet you and take a look at the land and home. There is no cost involved."

So we met Alan and his associate Brad, at the 1950's Cape Cod and had a nice conversation about options and building. It turns out that Alan lived in the neighborhood and builds most of his homes and remodels in this area. He has lived here for many years and was an early adopter of green technology in home building.

Truth be told Boo wife and I didn't do a lot of comparison shopping when it came to choosing a builder. This is very atypical for me, as I am usually the one reading Consumer Reports when it comes time to buy almost anything. Then once I find the best whatever, I start looking to find the best price. You would think with a project like this I would have taken more time, but sometimes you have to trust your instinct and besides, at the time, there really weren't many established, reputable builders in our area using the technology these guys were.

As I mentioned in a previous post we didn't get the 1950's Cape Cod, but Brad and Alan came out on a cold and snowy day in mid March to meet my Father-in-Law and me so we could take a look at and walk the five 1.5 acre lots up for sale.

Turns out it would be another 12 months before we even started building. During that time we met with Alan or Brad on numerous occasions discussing almost every aspect and details, crunching numbers, going through initial selections, and getting estimates etc. The only time they asked for any money was after the second round of blueprint changes, and that was because the architect was asking for a payment for work already done.

They worked with us for these 12 months with only a verbal commitment from Boo Wife and I and without a signed contract. Is this typical of all builders? I don't know the answer to that question, but I do know that these guys did it.

NEXT: Selling our Home (The Good, The Bad, and The Ugly)

Finding a Builder

2010-04-12T14:35:00.015-04:00

Turns out that finding a builder wasn't as hard for us as one might think. Back in October of 2008, several months before Boo wife and I thought seriously about moving, we went to a Homearama here in town. Now you might ask, if we weren't thinking about moving why go to a Homearama. Well, it wasn't the first one we went to. Boo wife and I would often go to Home shows and events such as this just to look, and get ideas, and see what's out there. This particular event had 7 homes, from 7 different builders, all in one location.

It was a sunny and warm October weekend and so we packed up Anthony, who was 4 months old at the time, and took the relatively short drive out to the show. It was very interesting to view all the different architectural styles of the homes. Some I liked, some I didn't, but I remember entering one home where the info on the spec sheet stated that the 6,800 sq ft home was guaranteed to heat and cool for less that $90/month. Seriously?!, at the time I was paying more, on average, per month for my 2,000 sq ft Condo. The exterior of this home was nice but not my favorite of the bunch but, I really liked the floor plan and overall layout of the home so I decided to talk to the builder to get some more information.

Turns out that they built this home in under 6 months for this show and it was built using Insulated Concrete Forms (ICF) and also utilized Geothermal heating/cooling. He told me about some of the advantages of building with ICF, and of course I asked several questions about design, limitations, and cost. Anyway we talked about a variety of things for the next 10-15 minutes. I took his card and put it in my pocket, never thinking that I would be contacting him less than 6 months later.

NEXT: Finding a Builder Part II

Serendipity

2010-04-07T08:45:00.011-04:00

So we ended up losing our bid on the 1950's Cape Cod in a cul-de-sac neighborhood. However, during the whole process I was informed that I would need to obtain a land loan since we were planning on tearing down the house. I called my bank but they don't do land loans. So once again I called my Father-in-Law who informed me that he would check with some of his friends and associates. As it turned out, one of the people he checked with had some land on the market and wondered if we would be interested in it.

Now, in all honesty, we knew about the land before we put the bid on the 1950's Cape Cod, but we decided that bidding on this house would be the best initial option. Of course, shortly after we realized it wasn't going to happen we decided to re-visit the offer.

It was an area a few miles from the 1950's Cape Cod we bid on. There were 5 lots, all about 1.5 acres, all of which backed up to a 46 acre park. None of the lots had been sold as of yet, and the seller was willing to drop the price and offer us an additional incentive.

POSITIVES:
-1.5 acres instead of 1
-Land was flat and cleared, nothing to tear down.
-Good schools.
-Buffer of trees in far back and a 46 acre park with play area, soccer, baseball fields, volleyball court, pitching green, and 1.5 miles of walking trails.
-Did I mention there was also a sledding hill?!
-Price seemed like a good deal.
-We would have a real yard. (Abby would love it)

NEUTRAL:
-Taxes slightly higher than where we were looking but less than where we are currently.
-Septic system instead of sewer. (same as where we were looking)

NEGATIVES:
-On a busier street.
-Farther and slower drive into work.
-No sidewalks.

Boo Wife and I thought about it and one weekend we went out to the park with Anthony and Abby and walked around. Maybe because the sun was out, maybe because it was a nice walk with the family after a long winter, maybe it just felt right.

We bought the land.

NEXT: Finding a Builder.

A Day Late and a Dollar Short

2010-03-31T16:29:00.010-04:00

Our next step was to find some place to build. Finding a home on the Internet is pretty easy, just go to any Realtor website, type in your criteria and you get listings from almost every single Realtor in the area. Some offer the option to search for land but I realized later that not all land listings are on these sites. So when I couldn’t find any land for sale in the areas we were interested in building, or when the land I found exceeded what I was willing to pay (read: was overpriced and I couldn’t afford) we started looking at other options. The option to buy and remodel was still on the table though for the reasons outlined previously it wasn’t our top choice. The second option was to tear down an old house in disrepair and rebuild.

One day I came across a home on a one-acre lot that was bank owned, a casualty of the real estate crash. It was a Cape Cod style house built in the 1950’s on a quiet cul-de-Sac and had already been on the market for over a year. So on a rainy weekend we called the agent on the listing who seemed a little put off that we were calling. He wondered why we didn’t have an agent of our own to take us through and told us that the house is in pretty bad shape. So we ended up calling my Father-in-law, who works in commercial real estate. He was able to get the information and lock code to enter the house and take us through.

It was a nice flat lot, the home had a nice slate roof, but it was in significant disrepair. Tiny postage stamp of a kitchen, a three season room with a leaky roof and a small pond of algae on the floor. A narrow, spiral staircase leading up to the second floor bedrooms made me wonder how any furniture would even make it to the second floor. A 'refinished' basement with a roof so low even I had to duck. It was perfect! We talked about it and a week later went through one more time and decided to put a bid on the house.

My father-in-law handled all the paperwork and one evening we got together, gave him a 'good faith' deposit and signed on the straight line. We decided to bid on the lower side with the rationale being that we were placing the bid on the land given that the home itself was in such poor shape.

Well, as fate would have it, the day before our bid came in, someone else bid on the house and his or her bid was a whole lot closer to the actual asking price than ours. Needless to say we were a bit disappointed but we had a set limit on what we wanted to pay and knew we were not going to get this property.

Boo Wife and I drove past the house not too long ago and it looks like the home was remodeled and people are living there again. In a way I’m glad, tearing down a house looks so cool on TV but it’s kind of sad when you think about it. Anyway, most of the time things happen for a reason...Right?

NEXT: Serendipity

Building a Home

2010-03-18T21:58:00.011-04:00

Before we even decided to have children Boo Wife was telling me that we would need a new home. It was hard for me to argue, although I often did, both my parents seemed to side with Boo Wife. Our condo with no real backyard and no real place to play outside was never going to be acceptable. I bought the place shortly after I moved here and at the time I was still single. It seemed like a good idea to have a place where I didn’t have to worry about mowing a lawn or shoveling the snow.

After Anthony was born, we sat back and thought a lot about what to do. The housing market had crashed so there were a lot of homes on the market in our area. In the areas we were interested in living, most of the homes were built in the 1920’s and 30’s thru the 1950’s. Now I have nothing against older homes. I love the architecture and the details that went into many of these homes and I envy the people that can go into an older home and remodel and fix up. Sadly, I am not one of those people.

There were several factors that made us decide to consider building, despite the bargains to be had and the potential loss to be incurred when selling our own home.
1). I think one of the key factors for me was energy efficiency. I love the old houses, I hate the drafts and inefficiencies of old houses. Sure we could remodel and re-insulate and buy a more efficient HVAC, and replace windows, (although the charm of many of the houses in our area are the leaded windows that decorate them). But as I already stated, I am not a good ‘fixer-upper’.
2). Older homes typically have small closets; small tucked away kitchens, and narrow hallways. The homes built in t he 1950’s tended to have lower ceilings as well. More remodeling, see all of the above.
3). If we were planning to raise our family here then why settle for someone else’s idea of a good floor plan. Boo Wife and I had some very specific ideas for our floor plan. Boo Wife wanted all the bedrooms on the second floor. If all the bedrooms were on the second floor then we wanted the laundry to be on the second floor. We wanted closet space off the garage entry for our coats, shoes, dog leashes, etc. I wanted an office off the same entry to drop off all the mail so it wouldn’t accumulate on our counters, as has been the case in the last 3 places I have lived. Boo wife did not like the vast openness of our Condo and preferred what she called a more ‘homey’ home. We both wanted a kitchen that had a lot of counter space and opened up to the family room. I have always wanted to have a walk-in-pantry, just for the added convenience and storage. We also wanted a formal Dining room, primarily so that we could have our family over for the Holidays.
4.) As an Italian I also wanted a second kitchen in the basement, but nobody else seemed to like that idea so it was nixed.

While this may not be everybody’s idea of the perfect floor plan it was what we thought would work best for us.

The problem was that we needed a place to build.

NEXT: A day late and a dollar short.

The Cost Conundrum

2010-03-01T15:37:00.004-05:00

“The greatest threat to America’s fiscal health is not Social Security, it’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.”

I have a tough time trying to understand the shortsightedness of many of our politicians. I'm not sure throwing a 10 foot rope to someone who is drowning 50 feet from the shore is a good thing.

This article isn't new, but it is very interesting reading and provides a unique look at the high cost of healthcare.

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

Dead leaves and the dirty ground

2010-02-24T15:15:00.002-05:00

Kudos

2010-01-22T11:35:00.003-05:00

Many Thanks to Paul Levy over at Running a Hospital and the CEO of Beth Israel Deaconess Medical Center in Boston for posting this. So much fear about health care reform and so many seem to want to maintain a status quo that will end up costing us much more. While the current reform is not perfect, we need to start somewhere.

Ruby Tuesday

2010-01-05T10:41:00.006-05:00

Check out all the Ruby Tuesday photos over at Work of the Poet. There are over 100 participants.

Today I have continued with the Lomo theme and modified an old pic I had of a door, taken in Medina, Ohio. Click on the pic to enlarge, and Happy Ruby Tuesday!

Pseudo Lomography tails

2009-12-18T14:23:00.011-05:00

I found this site, Digital Photography School, a while back and one day while perusing it came across a post on how to make a digital photo look like a Lomo photograph. Before I go any further, I just want to apologize if any Lomo purists come across this post, as there seems to be an almost cult following in this regard.

Briefly, a Lomo was/is an inexpensive 35 mm, compact, point and shoot camera from Russia sold in the early 1980's. The pictures were often fuzzy and had a characteristic vignette due to poor lens quality. The Lomography motto, "Don't think, just shoot". At some point, photographers did something called cross processing, in which they would shoot color slide film (E6) but process it as if it were color negative film (C41). This resulted in bold often over saturated colors and sometimes very freaky results.

The top photo is one I took last year that was digitally altered, to appear as a Lomograph, using Adobe Photoshop as detailed in the link provided above. Below is the original photo. Needless to say I had to try it out on other photos and the bottom two shots are the Lomo version and original of our Yellow Lab, Abby. It gives each photo a very different feel and turned an otherwise bland Old Red Mill, into a photo with some depth and texture, which is something I really like in a photograph.

There is an entire website and blog devoted to Lomography with examples from the real camera and you can also order a camera if you would like to give it a try. I encourage you to check it out, and also check out the photos, some are truly incredible.

Food tails

2009-12-14T09:58:00.005-05:00

I am not sure how many parents think about when to introduce certain foods and how long to avoid allergenic foods such as fish and peanuts. I do know that if you perform a search of when to introduce peanuts in a children's diet there are thousands of hits. As an allergist, married to a woman with allergies and asthma, I occasionally perseverate on this very question. The problem is that there really is no good data.

A recent article in the journal Pediatrics, found that late introduction of solid foods was associated with increased risk of allergic sensitization to food and inhalant allergens. A review and summary of the article can be found here. The BIG caveat is that the children in this study had an HLA-conferred susceptibility to type-1 diabetes. Thus, it is unclear if this study is generalizable.

In the past the American Academy of Pediatrics recommended delaying the introduction highly allergic foods such as peanuts until 3 years old in children with a family history of food allergy or with a family history of asthma or allergies. In 2000 they also advised breastfeeding mothers not to eat peanuts. The AAP now says that current evidence does not support peanut restriction during pregnancy or breastfeeding, and that there is no convincing evidence that delaying peanut-containing foods beyond 4 to 6 months of age will reduce the risk of peanut allergy.

The topic came up again yesterday because Boo Wife made a 'no bake' peanut butter cookie covered in chocolate and graham crackers. She tells me that they are supposed to be sandwiched between some marshmallow fluff, kinda' making them into a S'more. But, they taste good even without the marshmallow. Father-in-Law almost gave Anthony a taste yesterday until we jumped in and said no, because of the peanuts.

Anthony loves food and he loves sweets, but most of his sweets have been in the form of fruits, one of his first words and still a favorite food is 'nana' or banana. He also loves blueberries, pineapple, kiwi, strawberries, apple, mango, and the list goes on.

Should I give him a taste of these delectable peanutty treats? I'm tempted, but then there would be less for me ;)

Finally, if you do have a food allergy, a great source for information and news can be found at the Food Allergy and Anaphylaxis Network website.

A Tail of Tools

2009-12-02T10:04:00.006-05:00

As I mentioned in some older posts, in college my second major was in Anthropology. It was an area I never really knew about until I was exposed to an entry level course during summer school between my Sophomore and Junior year.

Anthropology, according to Merriam-Webster, is the the science of human beings. Essentially, it is the study of human beings and their ancestors through time and space and in relation to physical character, environmental and social relations, and culture.

I was fortunate enough to have been able to take a class taught by a visiting Professor, Colin Turnbull. Dr. Turnbull was a world-renowned Anthropologist known best for his work with the Mbuti pygmy tribe in Africa. He was a kind, down to Earth person, and a great Teacher, but I digress.

For many years Anthropologists attempted to define humans and for many years that definition included the use of tools. The thought being, that humans were the only species capable of using tools. While it is known that some species of birds can use tools, such as the Woodpecker Finch, their use is quite inflexible and can not be applied effectively in new situations.

In 1960, Jane Goodall observed Chimpanzees making tools to "fish" for termites. Since then there have been many other observations of both primate and non-primate use of tools. The discovery was so important that her biography was titled, appropriately enough, "Jane Goodall: The Woman Who Redefined Man"

Which brings me to a somewhat less serious anectdote. A couple of weekends ago, Anthony was spotted using a tool. He knows we get his water from the refrigerator dispenser and apparently wanted some. His 'word' for water is "Ahhh", because when we take a big drink we put down the glass and go "Ahhh." Boo Wife was cleaning up after his morning breakfast and he pointed to the wooden spatula on the counter. Boo Wife handed it to him, and he promptly ran over to the fridge and used the spatula to activate the water dispenser. Of course, since he had no glass, most of the water ended up on his shirt. Little did he care about such a trivial matter, playing with water was so much more fun.
As such, I am happy to say, that based on standards prior to 1960, Anthony is human ;)

Happy Thanksgiving

2009-11-25T10:17:00.006-05:00

Boo wife and I were driving through Auburn Township in Geauga County a little while back when we ran across these two guys, or girls, I can't tell. Anyway, it was the first time I have actually seen a wild turkey in the wild and not on a bottle of Bourbon.

Of course, I shot them, with my camera.

As an aside, as a kid one of our neighbors would go turkey hunting around this time of year. I remember one year hanging out with him has he plucked the feathers and removed the buckshot from the bird and kept thinking to myself, what happens if you come across some buckshot while your eating this?

Hope everyone has a great Thanksgiving and I hope, even more, that you all have alot to be thankful for. I know I do.

Potpourri

2009-11-23T13:10:00.006-05:00

It was a sad, fun, nice, relaxing weekend, one of the nicer weekends I’ve had in a long time. It started Friday evening when we took Manisha out to dinner. Manisha has been working in my lab for a couple of years but I have known her and her husband for quite some time now. Unfortunately, for me, she and her husband are leaving, so we took her to L’Albatros for her going away dinner. This was sad, but also fun, she will be missed tremendously and we all wish her the best.

I am new at food photography so the pic is not that great. I enjoyed the chopped salad with bleu cheese, a lot of different flavors with chicken confit, a combination of romaine and radicchio lettuce, and sundried tomatoes. The bleu cheese was nice but not overpowering. For my entrée I had the cassoulet, which consisted of white beans and carrots, with duck, two-types of sausage, pork belly, and lamb. It was not a traditional cassoulet, but was termed ‘deconstructed’; I have also seen it referred to as ‘Haute cuisine’ version of cassoulet, as the meats were not cooked with the beans. Overall the dish was a little salty for my taste. However, the duck was very good as was the house made sausage and pork belly. The lamb was a little over cooked. Other members of our group seemed to enjoy their meals and 3 people ordered the special that evening which was beef tongue, it seemed to be a winner as their plates were empty. The service was excellent and overall I would give it ‘3.5 tails out of 5’, and feel as though it deserves another visit.

Saturday morning I woke up early to take Anthony to get his haircut; it was getting a little too long. We came home for some breakfast and hung out until the afternoon when he was taken to his Grandma’s for the night, Thanks Grandma! Boo wife and I went to a ‘post wedding’ reception downtown at Sammy’s. Good friends, good food, drinks, and dancing. The Bottom Line Band was awesome and we had a great time.

We slept in Sunday morning and then went out for breakfast before heading to pick up Anthony. We hung out with family for a while before heading home. Anthony and I caught the end of some bad football while Boo Wife went out to meet some of her friends for dinner. After Anthony went to bed we settled in for the Season finale of The Next iron Chef.

Ruby Tuesday

2009-11-17T10:42:00.004-05:00

Although there was a little bit of red, ok probably more pink, in my previous post on Aspergilloma, here is my submission for Ruby Tuesday. Please join Mary the Teach to check out more Ruby Tuesday Pics.

Click on the picture to enlarge.

Shot with Nikon D80, 135mm, ISO 200, 1/800 sec, f5.6

A Fungus Among Us

2009-11-13T08:46:00.018-05:00

There aren't many things that look like this on a chest X-ray or a CT scan. What the first image is showing is known as the Cresent's sign or Monod's sign. A solid mass surrounded by a radiolucent crescent. The mass represents a mycetoma or fungus ball. Sometimes they will be freely mobile and repeating a Chest X-ray with the patient in the decubitus position will show that the mass has moved.

We were consulted to see this gentleman who had an underlying leukemia and was recovering from his chemotherapy. He was admitted with new onset fever and chills, the chest X-ray revealed multiple infiltrates and the CT scan you see. Anyone of a number of fungi can cause a mycetoma, but more often than not this picture is almost classic for an aspergilloma.
Further review of the CT scan revealed that the anterior segment of the Right Upper Lobe (RUL) bronchus led into one of the fungus balls. We were asked to perform a bronchoscopy to determine if indeed this was Aspergillus. The image below shows the takeoff of the anterior segment of the RUL, seen at about 8 o'clock. You can already see the black gray of the fungus sitting in the area.
As we moved in for a closer look we can see the fungus ball even better.
Finally, we 'popped' into the segment for a close up of the mycetoma.
Cultures grew out Aspergillus niger and the patient was treated with IV antifungals. Since Aspergillus is an angoinvasive fungus, meaning it is capable of invading the vascular bed, some patients present with hemoptysis (coughing up blood). It can be so severe that some patients die by drowning in their own blood. Patients presenting this way are either taken directly to surgery to remove the aspergilloma or for bronchial artery embolization.

Aspergillus was first described and named by Micheli in 1729. The similarity in appearance between its fruiting heads and the brush used for sprinkling holy water (aspergillum) probably suggested the name.Photo credit Jasper Juinen/Getty images

Photo Credit

In 1952 Hinson described the first case of Allergic Bronchopulmonary Aspergillosis (a very different disease than the mycetoma) but, more importantly he was the first to note that Aspergillus can cause at least three types of disease in humans. 1) Saprophytic, 2) Allergic, and 3) Septicemic or Pyemic.

It is also important to note that Aspergillus is a ubiquitous mold representing between 0.1 and 22% of the total air spores sampled. Underlying disease, host immunity, and the organisms virulence all play role in the development of disease in humans. There are 250 species of Aspergillus, but only a few are human pathogens. Most people go through life never being bothered by this fungus.

One of the most interesting historical aspects of Aspergillus is the following; in 1890 Dieulafoy, Chantemesse, and Widal were the first to describe the disease in pigeon-crammers and they called it maladie des graveurs. The pigeon-crammers of Paris performed 'gavage' by taking a mouthful of grain and water and spitting it into the mouth of a pigeon. Each man fed about 2,000 pigeons a day and it was well known among them that they would succumb to a chronic pulmonary disease.

Last I saw of this patients records he had recovered from chemo, the aspergilloma was treated and resolved, and he was Cancer free.

References:
-NIH/Medline plus on Pulmonary Aspergilloma
-Review of all forms of aspergillus infections
-Pulmonary Aspergillosis: A clinical update
-Broncho-pulmonary Aspergillosis: A review and a report of eight new cases. K.F.W. Hinson, AJ. Moon, and N.S. Plummer. Thorax 1952;7;317-333.

Ruby Tuesday

2009-11-10T08:55:00.003-05:00

Here is my Ruby Tuesday post. Stop by and see Mary the Teach over at Work of the Poet for all of today's submissions. There are over 100 participants, from all over the world, all with great photos. Have fun.

I took this photograph this summer at University Circles, Parade the Circle festivities.
Nikon D80, Shutter 1/80, f5.6, ISO 200, focal length 105mm.

Dona Nobis Pacem

2009-11-05T01:00:00.005-05:00

An idea, started by Mimi, over at Mimi writes.

The BlogBlast for Peace idea is simple: To have as many people put globes like the one above on blogs around the world and Blog for PEACE.

There are various globes on Mimi's blog that you can customize yourself. Mine once again is a very simple cut and paste job but some are more elaborate. You can see all the Peace Globes in the Peace Globe Gallery.

Ruby Tuesday

2009-11-03T13:47:00.005-05:00

Happy Ruby Tuesday courtesy of Mary the Teach over at Work of the Poet, head over there to see all the great submissions. It has been a long time since I submitted anything but here is a recent pic of Anthony playing at the local park with some red in the jacket, some red rope, and chain.

Happy Halloween to Fall

2009-10-30T10:04:00.004-04:00

Last year we had a beautiful Fall. This year has been a little cooler, a bit windier, and more gray. These pics were taken last year at Lakeview Cemetery in Cleveland. The first pics is one of the many interesting gravestones in this cemetery. Sometimes referred to as the Haserot Angel, named for Francis Haserot and his family who are buried there. This is also sometimes referred to as "Angel of Death Victorious". The Fall season provided a nice background and contrasts nicely with the Bronze sculpture.

This gravestone was sculpted by Herman Matzen in 1924, who is also buried in the Lakeview cemetery among his other works of art including the Burke Chapel and the White Memorial. The Angel is actually holding a torch which has been turned upside down and extinguished. Time has discolored his bronze skin giving the appearance of dark tears streaming from his eyes. Other notable people buried in Lakeview Cemetery include President James Garfield, John Davison Rockefeller, and Elliot Ness.
These next two pics are obviously the same, the top pic is the original. I love the overlap of colors from the variety of trees in this pic. Green, yellow, red, and orange. It really was a spectacular fall.

I modified the one below by using spot color and playing with the intensity in Picasa. A very different feel, I think it gives the photo more contrast and depth.
Happy Halloween to all. Our neighbors tell us to expect upwards of 100 kids tomorrow so I doubt I'll be posting anything this weekend.

Been a Long Time

2009-10-28T09:58:00.010-04:00

Been a long, but not so lonely, time.

Away from the blog for quite a while. I think overall it was just a lack of enthusiasm, a bit overwhelmed at work, too much happening at home, and just needed to take a little break.

I am constantly amazed at the steady output of quality posts from many of the bloggers on my blog roll. Which I tried to update a bit. For fun I recommend you check out Photoshop Disasters. Hilarious, funny, and often awkward, I think the title speaks for itself.

With regards to my last post way back in March. If you are interested in reading more about Pulmonary Calcinosis you can find a great review here. (Better late than never?)

Anthony is now 16 months old. He started walking in August and although he still wants to be picked up now and again he loves his new found mobility. The above picture was him being a little fussy at our new location. We moved about a month ago, which is another long and often frustrating story but are settling into our 'new' temporary digs.

Boo wife is doing well. She lost her job this summer which was both good and bad. Good, because she was able to spend some time with Anthony as well as do a lot of the work in getting our house ready for sale. Bad because of the lost income. But, she started a new job last month and is enjoying it.

So, I guess we'll see how this goes again. I have a few new pics, an interesting case or two, and probably some random rants that are waiting to be released. So to my one or two readers, if your still out there, sorry for the absence.

Interesting CT scan

2009-03-27T16:22:00.004-04:00

Here is an interesting case I saw when I was on service a month ago. I haven't seen a case like this since my fellowship training. A gentlemen in his 50's with end stage renal disease on hemodialysis for 25 years presents with increasing dyspnea on exertion.

Why I'm Hating Digital Photography

2009-03-18T09:28:00.006-04:00

Photo Credit

As a follow up to my last post during which I reflected back on the days when I lugged around my 35mm Nikon FE SLR. I remember getting my 'Popular Photography' magazine and every once-in-a-while Canon or Nikon would come out with a new model. All in all though the advancements were'nt enough to make me even think of buying a new camera. In addition, I knew I could never afford the "professional models" like the Nikon F4. The reason I bought the N60 some 15 years later was that it had autofocus lenses and a built in motor drive.

Then, technology made its way into the long held tradition of film photography. Oh, there were many naysayers. "It's just a fad.". "It can never replace the creative control you have with film." "The quality will never be as good as Kodachrome or Ektachrome." Blah, Blah, Blah!

But all that has changed, and now every time you buy a new camera it is outdated in 6 months. Just like my computer, just like cell phones, just like iPODs, just like my GPS.

Check out the "HOT NEW" digital cameras of 2009 Ladies and Gentlemen. But don't weep that your camera can't shoot underwater or be frozen in an ice block and survive to shoot another day. Or that your 8 megapixel Elph is now a clunky bulky camera when sitting next to the new 12 megapixel camera with a 12x xoom lens that fits neatly in that little 5th pocket in your jeans. Just go out and shoot something (with the camera you have) and ignore the hype, like me ;)

Why I'm Loving Digital Photography

2009-03-10T11:07:00.013-04:00

I remember my younger days taking photography classes in High School and even signing up for a summer school program. I had a part time job, but even so, buying film and processing was a significant cost. By taking classes I could process my film and print pictures with minimal cost. We did have to buy or own film and paper, but the chemicals and equipment were free to use. During college I still enjoyed taking pictures and loved to experiment with different settings, often taking multiple shots of a single scene. The problem was that my father, who often paid for my film processing, always wanted to see the pictures. Imagine his surprise when perhaps 2 or 3 pics of our family vacation actually included people and the rest were multiple shots of various 'scenery'. Attempts to explain my situation were futile. For a little while I set up a black and white darkroom in our basement but handling and storing the chemicals became an issue, and although it was less expensive overall, the chemicals and photo paper were not cheap. During my training in Nashville I would shoot a lot of pics and often just have the local pro photo shop make a contact print so I could review the images and pick the ones I liked to have printed.

I delayed purchasing my own 35mm type digital camera for a variety of reasons but as you may already know, the Nikon D80 was my Christmas present in 2007. Since then I have been having a lot of fun taking as many pictures as I want and not worrying about whether they will turn out or not. I've been able to experiment with different lighting and exposures. I can snap 100's of pics and only keep one and even the pics that don't look good can sometimes be made to look good. Take, for example, the B&W picture I posted of Anthony last month. The original shot is posted below.

I was just getting set up to take some pics of his bath and fired of the first shot. After I took it, and saw it, I realized that I hadn't adjusted the settings from previous photos I was taking. I kept the pic anyway and was about to delete it one day when I decided to play around in iPHOTO with it. By adjusting the exposure and color balance I was able to get a shot that looked like the one below. A little bit better, but I couldn't get the color balance right.

However, once I converted it to black and white and adjusted the exposure a little more we get the result below. I shot a bunch of pics that evening while Boo Wife was giving Anthony his bath, but the one I thought I was going to delete, ended up being the one I liked the most. The other side bar, and I'm not sure if you can make it out on the lower quality image I uploaded, but the adjustments gave the pic a slightly grainy appearance reminiscent of a high speed black and white film image. Which, to me at least, is the coolest thing.

Baby You Can Drive My Car, just don't let it idle.

2009-02-19T11:36:00.003-05:00

In a story related to my post on 2/17. New York City is limiting vehicles' idling time in school zones in an attempt to reduce childhood asthma rates.

The AP (2/19, Kugler) reports that a newly passed measure aims to reduce the "fumes from idling taxicabs and delivery trucks" in New York City school zones in an effort to reduce "the city's high child asthma rates." According to the city health department, "asthma is the most common cause of hospitalization for children 14 years and younger, and is a leading cause of missed school days in the nation's largest school district." The legislation "cuts the allowed idling time from three minutes to one minute around schools," which is "the toughest such law in the United States." It also "gives more city agencies the power to issue violations," while requiring "an annual violations report so officials can track enforcement." Notably, there "is no federal anti-idling law, but about 30 states and dozens of municipalities have their own measures."

Baby You Can Drive My Car

2009-02-17T08:26:00.006-05:00

Study suggests traffic pollution may cause genetic changes that increase asthma risk.

Interesting study released which reveals a direct interaction of the environment on genes. There is a large amount of data reporting that people living near high traffic areas are not only at increased risk of developing asthma but also increased risk of asthma exacerbations. This study provides a possible explanation for the former.

HealthDay (2/16, Preidt) reported, "Traffic pollution may cause genetic changes in the womb that increase a child's risk of developing asthma, say US researchers who studied umbilical cord blood from New York City children." Researchers from the University of Cincinnati and Columbia University "found evidence of a possible new biomarker -- an epigenetic alteration in the gene ACSL3 -- associated with prenatal exposure to polycyclic aromatic hydrocarbons (PAHs), which are created as byproducts of incomplete combustion of carbon-containing fuels such as gasoline." The findings are published in the February 16th issue of the journal PLoS One. The authors say that the research yields "a potential clue for predicting environmentally-related asthma in children, particularly those born to mothers who live in high-traffic areas."

UPI (2/17) reports that senior author Shuk-mei Ho of the University of Cincinnati said, "Our data support the concept that environmental exposures can interact with genes during key developmental periods to trigger disease onset later in life, and that tissues are being reprogrammed to become abnormal later."

BBC News (2/15) reports, "Although the finding needs to be confirmed in larger studies, researchers say changes in the ACSL3 gene may be help early diagnosis of pollution-related asthma," yet "more work is needed to unpick the role of the gene in asthma.

Additional References:

2) Residential traffic and childrens respiratory health

Back From Blog Break

2009-02-16T09:38:00.010-05:00

I've been on a bit of a blog break, not only in writing my own but also in keeping up with others, but I'm back now. Let's see, Happy Holidays, Happy New Year, Happy Chinese New Year, Happy Valentines Day, and Happy Presidents Day. The pic at the top is a gift courtesy of my Mother-In-Law. She found a heart shaped potato chip and gave it to us.

The rest of this post is just a series of brief updates/snippets.

FAMILY:
-Anthony is 8 months old now. He says 'momma' and 'dada'. He occasionally does some 'ma scatching'. Not sure if I spelled that correctly, but ma scatching are those sometimes annoying noises people make when they are eating, ya' know, the smacking, moshing kinda sounds.
-Eating is not a problem, he'll eat anything.
-Sleeping is still occassionally a problem, although he has intermittently slept through the night. Overall it seems to be getting better though.
-He has one tooth in and another is on its way.

-Boo Wife is amazing, as usual. Although she recently joined Facebook and has been attached to her laptop. (Ofcourse I can't say anything since I am addicted to my Xbox 360 and Tiger Woods 09.

-There hasn't been a day that has gone by that I haven't thought about and missed my Father.

-Abby is back to her old self again. Even in the dead of winter she'll take a dip in some water if its around. Not sure how or why she does it but, she seems to love it.

LOCAL:
-What a long, cold, snowy, Winter it has been. 'nuff said.
-Our institution has put a freeze on all pay raises and new hires so that they won't have to lay off workers. Good idea!

US and WORLD:
-Phelps, c'mon, he's 23. How many 23 y/o haven't taken a hit from a bong. BTW if my son ever reads this "Anthony, you can smoke pot as soon as you win 14 Gold Medals for your Country."
-All of a sudden the Republicans are fiscal conservatives?
-Watched 'House of Cards' on CNBC recently. Very interesting and informative show detailing the current financial meltdown. To use a catch phrase from the Campaign trail, The Greed stretched from Wall Street to Main Street and every where in between.
-The Economic stimulus bill also included 10 billion dollars for the NIH, Hooray!.
-The increase in the number of Pirates should help Global warming.

Back it up please

2008-12-19T16:58:00.001-05:00

A random helpful tip that many have probably heard but not everyone acts on.

I've visited several blogs recently in which the owners have had hard drive failures and ended up paying several hundred dollars to recover data and more importantly images that they have stored and not backed up.

I am a big fan of the digital camera, you can literally take thousands of images and 'throw away' the ones you don't like or that don't turn out. Alternatively, even some bad images can be manipulated in an editing program to look not so bad. The down side is that we store them on devices that are prone to failure and/or need replacement every few years or so. The cost of external hard drives have dropped dramatically and they are easy to use, so if you don't already have one, put one on YOUR Christmas list or take the time to back up your photos on some other media like DVD. While nothing is absolutely permanent, in the digital world, having a plan B is always helpful.

Of course here at work we back up all our data onto servers and I don't have to worry about it too much. But even with that I have my hard drive partitioned into three separate drives all with their own operating system onto which I back up my main hard drive at least once a month. In addition, I have an external hard drive attached to my computer and back up onto that as well.

On my home computer I now have well over 5,000 photo's that I have accumulated since my very first digital camera I bought back in 2002. In fact, in just the past year I've taken over 1,800 pictures and over 700 pictures of Anthony in the past 6 months, that's more than 100 pics a month, yeesh! They are stored primarily on my home Desktop computer but I also link my camera to my laptop and store them there as well. In addition, I have an external hard drive which I back up every time I load new pictures onto my desktop. If this sounds like someone who has been the victim of a hard drive failure before, you are absolutely correct. It has also happened to Boo wife, she didn't lose everything because I backed up a lot of her data onto her iPOD one day without her even knowing it. (She has an 80GB iPOD but was only using 15 GB for music). She was also lucky in that her work IT department offers "one free fix" a year and they were able to restore most of her hard drive. BUT, not everyone is this lucky.

I was the victim of "Oh, I'll get to it eventually" or "Nothing's going to happen to my hard drive". Think of all your work and memories you have stored on a fallible electronic device and think of how you would feel if you lost all of that.

So back up your hard drive, if you have an iPOD with extra space use that, otherwise splurge on an external hard drive. Now go! Do it now before you forget! Shoo! Stop procrastinating!

BACK UP! BACK UP! BACK UP!

Photo Tails

2008-12-17T14:42:00.015-05:00

So Mother-in-Law has been wondering why we haven't gotten any 'Professional' photos of Anthony yet. We were planning on a family portrait this past weekend but canceled due to time constraints and other planned activities. There are a lot of web sites and blogs devoted specifically to photography or promoting a photography studio and the quality is certainly very good.

I am certainly not a professional photographer and photographing people has always been the hardest for me. For me the big issue is lighting, and background. You really need the right light to get good people shots as well as a nice, neutral or otherwise complimentary backdrop. Now I'm not talking about the average vacation shot or family events etc. But if you really want a portrait quality shot you absolutely need good lighting and background. So I've perused many of these sights to get some ideas, paying special attention to these two features of the shot.

This past weekend happened to be a fairly bright day here in the typically gray North/Midwest. Additionally, I was in charge of taking care of Anthony, while Boo wife prepared for a little pot luck she was having for the Undergrad students who work in the lab with her. So I grabbed my camera and Anthony and set up a 'little studio' in his room. Anthony's room has a large glass door that leads out onto a patio and in the mid morning the light is bright but not direct. I also brought out my old Vivitar Flash that I bought back in High School (yes it is over 25 years old now), although I don't have a slave or extension I used the bounce feature to direct the flash off the ceiling to provide additional indirect light. I experimented alot with the white balance features and played with various exposures. For the backdrop I used the beautiful quilt made and sent to Anthony by Dr. Ramona bates over at Suture for a Living. Which I wrote about here and Ramona wrote about here.

Anyway, here are a few of the pics I took that day, other than cropping I haven't adjusted anything, although a couple could use a little tweaking in the exposure compensation. The first two were shot with the flash and exposure was 1/60 f6.3 and iso 200. The last two were shot only with natural light and the exposure was 1/20 f4.5 and iso 200.

Sick, Ill, and Injured

2008-12-10T13:25:00.007-05:00

Anthony is now on his third day care cold. Boo wife and I are both getting over our second. Anthony developed a fever of 103.1 Sunday evening so it was obvious we were going to have to keep him home from daycare on Monday. It's funny they don't want your kid if he/she is sick but most of the time they get their illness from being there in the first place. As luck would have it he was scheduled for his 6 month "well-visit" on Monday anyway. I decided to stay home and take care of him. He did OK for the most part, fever controlled with some Tylenol. I took him to the Pediatrician where he weighed in at 7.8 kg and 67.3 cm in length, keeping him around the 50th percentile for both weight and height. We had to temporarily hold off on the vaccinations due to his fever, so we need to reschedule him in a week or so. Anthony has been fed mostly breast milk and some formula for the past 6 months. We recently started feeding him some rice cereal and got the go ahead to add some veggies to his diet as he tolerates. He seems to enjoy eating from a spoon.
Tuesday, Boo Wife stayed home with Anthony as he still had a fever but peak was only 102.0. Unfortunately Boo wife is feeling a bit ill herself, I still have a residual cough from the last daycare cold and am hoping this particular virus will spare me, but only time will tell. Again, Anthony did well at home but it turns out Abby, our dog, didn't fair as well. She came home from playing with her doggie pals and had a pretty bad tear on her left paw pad. Boo Wife called telling me there was blood all over our floor and she was going to take her to see our Vet. Labs have a pretty high pain tolerance, I think that is why they are so good around kids, because when Anthony tries to grab her ear or tug on her fur Abby just turns and licks him. Not surprisingly Abby didn't seem at all phased by the injury. Luckily it didn't need any sutures, althought to be quite honest I am not sure if they could or would suture a paw pad. They did clean it out for us and gave us some pain pills and a course of antibiotics, just to be sure it doesn't get infected. That's the easy part, Abby would probably take the pills straight if I gave them to her but usually I put them in a little peanut butter. The hard part will be limiting her activity for the next few weeks! Here is Abby looking a little sad with her paw bandaged up.
Ofcourse to make matters worse it has been snowy and rainy here so they cut the bottom off of a liter bag of lactated ringers and put a gauze tie around it so we could use it to protect her bandages when we take her outside. The bottom still drags a little when she walks although she seems to be learning to lift her leg a little higher to compensate. The bigger problem is she can't take stairs as well and it took a little coaxing to get her up the steps after our morning bathroom break.

Tagged

2008-12-05T12:21:00.004-05:00

I was tagged by Jill D. over at Watson McGee Danford's Blog

Shows I Watch
1. The Office
2. Chuck
3. How I met your mother
4. 30 Rock
5. Any losing football team, The Bills, the Browns
6. Any Sabres hockey game, although I rarely get to see them here
7. Meet the Press, although it is not the same without Tim Russert
8. Terminator: The Sarah Connor Chronicles

8 Favorite Restaurants, in no particular order.
1. Moxi’s (Cleveland, OH)
2. The Left Bank (Buffalo, NY)
3. Scala’s Bistro (San Francisco, CA)
4. Taza Lebanese Grill (Cleveland, OH)
5. Zola’s (Nashville, TN)
6. Lola’s (Cleveland, OH)
7. Duff’s (Buffalo, NY)
8. Ted’s Hot Dogs (Buffalo, NY)

Things that happened today (over the past 24 hours roughly noon 12/4 to noon 12/5)
-Gave a talk at Vanderbilt University
-Met with old friends and colleagues at Vanderbilt.
-Took cab to airport
-Had a slice of spinach cheese pizza at Famiglia in Nashville airport while waiting for my flight back to home.
-Arrived home around 11:00 pm, Boo wife and Anthony were both sound asleep, took a little peek in his room anyway.
-Much needed sleep from 11:30 till 6am.
-Fed Anthony his bottle.
-Got ready and took Anthony to daycare. Sister Ann in daycare told me what a delight he is to have and take care of, made me smile as I drove in to work.
-Back to work, catching up on e-mails, writing letters of recommendation, finishing clinical evaluations, meeting with my lab personnel to discuss upcoming plans, review data, plan next experiments, prepare a manuscript for submission, lunch and working on this meme.

Things I look forward to:
1. The present and the future. Life is one big surprise anyway.

Things on my Wish list:
1. What do you wish for when you already have everything you could wish for. A great family, great friends, and good health.

Whoever reads this and wishes to participate, please consider yourself tagged.

Blog Plug, for a good cause

2008-12-01T13:36:00.005-05:00

Photo Credit

Please stop by Dr. Ramona Bate's Blog over at 'Suture for a Living' and check out the "silent" charity auction to aid the Childhood Brain Tumor Foundation.

Ramona has a beautiful quilt up for auction (see photo above) and the rules are posted on her blog. Alternatively, if you'd like to donate to the foundation directly you can go here.

All that wheezes is not Asthma

2008-11-25T13:24:00.006-05:00

I've been meaning to write about this since the news came out about 2 weeks ago but have just found the time to get around to it. A recent study in the Canadian Medical Journal found that asthma was misdiagnosed in as many as 1/3 of Canadians. Based on the patients I see in my clinic I doubt that a similar study in the US would perform any better.

"When participants were retested using clinical guidelines, 30 per cent had no evidence of the chronic disease, the researchers found."

The bottom line is that many of these patients are diagnosed based on history alone, told they have a chronic disease, are given medications, and never have any assessment of their lung function. Spirometry is important for both the diagnosis and treatment of asthma and is a relatively simple non-invasive test that provides a great deal of information. A spirometry test measures the rate and volume of airflow during the patient's exhalation, before and after using an inhaler.

According to the NHLBI Guidlines for the diagnosis and management of asthma, spirometry is recommended at the initial assessment, after treatment has stabilized and at least every 1 to 2 years.

The other reason I feel that spiromtery is vitally important in the diagnosis and management of asthma comes from this article back in 2002 which showed that up to 25% of asthmatics have an altered perception of dyspnea (POD). I see this very often in my clinic, especially in younger patients. They come in with a past history of asthma that may be getting a little worse. When we measure their lung function it turns out their FEV1 (forced expiratory volume in 1 second, a measure of airway obstruction) is 50 or 60% of what it should be. Many patients with this degree of obstruction would be very symptomatic, but for some reason these patients don't notice too much trouble. Unfortunately, these patients are the ones at higher risk for ED visits, hospitalization, near fatal and fatal asthma. There were 29 patients with a low POD in this study, during the two year follow up there were 32 ED visits, 22 hospitalizations, 13 cases of near fatal asthma and 6 deaths in this group. Pretty astonishing numbers if you ask me!

So if you have a diagnosis of asthma but have NEVER had a measure of your lung function, ask your doctor to get one. If it is normal and you are not responding well to therapy then it may also be a good idea to have a Methacholine challenge, which is a very good test to rule in or rule out the diagnosis of asthma.

REFERENCES:
-CMAJ • November 18, 2008; 179 (11)
-CBC news
-eScience news
-NHLBI Guidlines for the diagnosis and management of asthma
-The risk of hospitalization and near-fatal and fatal asthma in relation to the perception of dyspnea. Chest 2002 Feb;121(2):329-33.

Lion Tails

2008-11-07T12:47:00.011-05:00

Above and below are a series of pics I took at the Buffalo Zoo this past summer. Take a look at the top one first. If I posted only this photo it appears as though the lioness is going to bite her 'rock mate'. Below is the actual series of pics as it happened.
"Awwk, what a boring day."
"Getting a little sleepy, Awww!"
"Soooo tired."

"Well maybe I can stay awake by grooming my friend."
"Dude, what the heck are you looking at?"

Don't forget to click on the pic to make them larger and feel free to suggest other captions.

Dona Nobis Pacem

2008-11-06T00:01:00.000-05:00

Get Out & Vote

2008-11-04T10:13:00.004-05:00

Boo Wife, Anthony and I made it to our polling location around 7AM today and the line was already out the door. We left at 8:45AM, most of the people in line were in a good mood and things ran rather smoothly despite the long wait. The volunteers were saying that they have never seen so many people so early. It was nice to see the American people taking an active interest in politics again. Boo Wife and I have never had to wait in line before to vote. This occurred despite the fact that, at least according to the news last night, about 20-24% of people in our County voted early. By the time we left the line was no longer out the door but still longer than it usually is. People were just able to get inside but I estimated their wait to be around 45 minutes or so based on our experience.

So make a difference yourself and GET OUT AND VOTE, if you haven't done so already.

Once again my favorite volunteer was there and after I scanned my ballot he gave me a sticker and said "Thanks for voting, You're a great American".

I'm a Winner!

2008-11-01T10:00:00.001-04:00

Many Thanks to Roger at Idaho Photo and the Judges over at Creative Photography, I'm one of the winners in the October contest for this entry. Click the title above to check out the other winners this past month, or check out their links below.
Patti of Late Bloomer Boomer
Enigma of Meandering Through My Gray Matter
Tish of CrAzY Working Mom
Gattina of Keyhole Pictures
Ralph of Airhead 55
Michelle of Creative Treasures
Ivory of Distorted Vision
Bond of Big Leather Couch
Sanni of Life Through a Lens
Cynthia Nichols of Kaleidoscope
Linda of Are We There Ye t

Paraneoplastic syndromes

2008-10-29T08:00:00.001-04:00

Paraneoplastic disorders (or syndromes) are a group of rare degenerative disorders that are triggered by a person's immune system response to a neoplasm, or cancerous tumor. Neurologic paraneoplastic syndromes are believed to occur when cancer-fighting antibodies or white blood cells known as T cells mistakenly attack normal cells in the nervous system.

We often read about them in Medical school and they are bound to show up as questions on our boards but how many times do we actually see a patient with a paraneoplastic disorder?

Incidence - Paraneoplastic disorders (PND) are more frequent than previously considered, with an incidence that varies with the neurologic syndrome and type of tumor. The more common syndromes are Lambert-Eaton myasthenic syndrome (LEMS), which affects approximately 3 percent of patients with small-cell lung cancer (SCLC), and myasthenia gravis, which affects 15 percent of all patients with thymoma. For other solid tumors, the incidence of paraneoplastic neurologic syndromes is far less than 1 percent in most tumors.

We saw a patient a short while back who was admitted with a diagnosis of Multiple Sclerosis exacerbation. She reportedly has had MS for 3 years based on previous w/u, which was a little vague, but a review of her symtpoms and progression made this diagnosis seem less likely. A routine admission Chest X-ray revealed a fullness in the hilum and a subsequent CT scan revealed mediastinal adenopathy, including a 26 x 20 mm high right paratracheal node, somewhat lobular 33 x 22 mm left prevascular node, ovoid shaped 35 x 23 mm subcarinal lymph node as well as confluence right hilar adenopathy measuring up to 39 x 24 mm. This right hilar adenopathy encases the bronchus intermedius and right interlobar pulmonary artery. No left hilar or axillary adenopathy.

We were consulted to perform a diagnostic bronchoscopy. We used a 19 g Wang needle to sample the subcarinal lymph node. Inspection of the remainder of the airways also revealed an area of external compression as we passed the scope down the bronchus intermedius (see picture, lump at 10 o'clock). We sampled this area with a 22 g needle. The cytology report was positive for Small Cell Undifferentiated carcinoma in both the subcarinal node and the right hilar node.

Paraneoplastic disorders typically affect middle-aged to older persons and are most common in persons with lung, ovarian, lymphatic, or breast cancer. Neurologic symptoms generally develop over a period of days to weeks and usually occur prior to tumor detection, which can complicate diagnosis. These symptoms may include difficulty in walking and/or swallowing, loss of muscle tone, loss of fine motor coordination, slurred speech, memory loss, vision problems, sleep disturbances, dementia, seizures, sensory loss in the limbs, and vertigo.

Treatment involves treating the underlying malignancy as well as efforts to decrease the autoimmune response either with steroids, high-dose intravenous immunoglobulin, or irradiation. Plasmapheresis, a process that cleanses antibodies from the blood, may ease symptoms in patients with paraneoplastic disorders that affect the peripheral nervous system. Speech and physical therapy may help patients regain some functions.

REFERENCES:
1) National Institute of Neurological Disorders and Stroke
2) Mayo Clinic
3) eMedicine
4) Up To Date online 16.2 'Overview of Paraneoplastic Syndromes of the Nervous System'.

ADDENDUM: (10/29/08 11:30 AM)
This patient's paraneoplastic antibody panel came back positive for ANNA-1 (antineuronal nuclear autoantibodies). This autoantibody is associated with a sensory neuronopathy, and small cell lung cancer accounts for 90% of cases. In addition, neurologic dysfunction precedes the diagnosis of cancer in over 90% of cases.

Ruby Tuesday

2008-10-28T10:32:00.004-04:00

Happy Ruby Tuesday courtesy of Mary the Teach over at Work of the Poet. this is the playground area at the Buffalo Zoo.

Creative Photography Contest #14 week 4

2008-10-27T14:58:00.007-04:00

I’ve been remiss in submitting entries in the Creative Photography contest hosted by Roger over at Idaho Photo. But here is my entry just in time for the last week of the challenge.

This past weekend, Boo Wife and I went to Kristen and Jason’s wedding. Mother-in-law was kind enough to take Anthony for the night so Boo Wife and I could hang out with friends and have a good time. It was a fun Wedding and it was great to hang out with all of our friends and meet some new ones from Boo Wife’s college days.

Most of our friends continued the party at one or two of the downtown clubs after the reception ended. Boo Wife also wanted to go, but despite her initial enthusiasm 20 weeks of interrupted sleep finally caught up to her. But knowing we could have more than 3-4 hours of uninterrupted sleep was pure bliss.

The picture was the centerpiece at our table. I took one of the Rose’s out and placed it in front of the bowl and rested the camera on the table. Click on the photo to enlarge.
Exposure: 4 secs
Aperture: f/4.8
Focal Length: 46mm
ISO speed: 200

Ruby Tuesday

2008-10-21T10:15:00.003-04:00

It's a Ruby Tuesday, Halloween edition. Here is the costume I wore 2 years ago for Halloween. See if you can find the Ruby red color (just a little sarcasm). Thanks to Mary the Teach over at Work of the Poet go there and see all the Ruby Tuesday submissions.

Ruby Tuesday

2008-10-14T10:48:00.003-04:00

Well after missing last weeks Ruby Tuesday I'm back for this weeks. I like all the reflections in this pic hence the title of the pic 'auto reflections', you can even catch a glimpse of me shooting the photo. Thanks again to Mary the Teach over at Work of the Poet. Stop by and check out all the other participants, which have been running over 100 for the past several weeks now.

The Problem with Lung Cancer

2008-10-13T09:56:00.007-04:00

A gentleman in his late 50's with an 80 pack year history of smoking presented to a local hospital after feeling dizzy and passing out. His Chest X-ray was read as pneumonia and he was treated with antibiotics and discharged after two days. His history also included significant weight loss which he was unable to quantitate but reported he had to 'tighten his belt' over the last several months. A few days after his discharge he starts coughing up blood and presents to our ED. Chest X-Ray read as possible infiltrate vs mass due to external compression of trachea and hilar fullness. CT scan reveals an 5 cm x 84 cm mass with apparent extension into his right mainstem. Of note he had an old Chest X-ray in our system from November of 2007 which only showed hyperinflation, no mass, no infiltrate. Therein lies one of the many problems we face when trying to diagnose lung cancer and one of the reasons why screening for lung cancer is so controversial.

The picture above is oriented a little funny but the dark hole at the 7-8 pm position is actually the takeoff of the Left main stem bronchus and is normal. The right mainstem bronchus is at the 2-3 pm position and is completely occluded by what turned out to be a Poorly Differentiated Non-small cell carcinoma (favor squamos cell carcinoma).

We ended up burning away some of that tissue in the Bronchoscopy suite and then taking him to the OR a couple of days later to place a stent in the airway to keep it open and prevent him from getting a post-obstructive pneumonia. After clearing things up a bit we could see that the tumor was growing out of his right upper lobe and extending into the right mainstem. Obviously this is only a palliative measure and the size of the malignancy precluded any surgical intervention.

This taken from the CDC website.
There is fair evidence that low dose CT scans chest x-rays, and sputum cytology can find cancers earlier than they would be found without screening.
There is little evidence that these screening tests actually prevent people from dying from lung cancer. Screening also has its downside. Screening tests may find spots in the lungs that are not cancers.

There are ongoing studies to help clarify the role of lung cancer screening. More information can be found here.
-National Cancer Institute.
-NCI: what is screening?
-CDC on cancer screening.
-U.S. Preventive Services Task Force. Lung Cancer Screening: Recommendation Statement

Ruby Tuesday

2008-09-30T12:09:00.003-04:00

Happy Ruby Tuesday. Please visit Mary the Teach over at work of the poet to view all of today's Ruby Tuesdays entries. it has grown quite a bit even since i joined in the fun, the last week there were over 100 entries. Mary the teach is also listed in my side bar under 'other fun/cool blogs or links'

Creative Photography Contest #13 week 4

2008-09-29T09:46:00.005-04:00

I like this photo because it has texture, contrast, and motion. With the water flowing over the rock it appears slippery despite the texture. The water fall provides both motion and contrast. I shot this with my Nikon D80, shutter speed 1/4 sec, f25 in aperture priority mode, focal length 150 mm and iso 200.

Click the title to see the other entries in this weeks Creative Photography contest.

mark's tails

2008-09-26T10:10:00.004-04:00

Becoming a physician was a career choice I made very early on in my life. To be quite honest it was the only career choice I made from Kindergarten onward. I couldn't imagine doing anything else and so I worked hard to make that dream a reality. Of course getting into medical school was, and still is, a difficult process and during college many of my 'pre-med' friends would talk about strategies and tips about how to interview and how to 'boost' your CV so that you would be a more attractive candidate to the admissions committee.

During my Sophomore year a friend of mine convinced me that being involved with student politics would be great for my CV, so we started attending the student senate meetings, but only occasionally. During My Junior year he convinced me that running for student council would also be a great thing for my CV. Of course he would be running for President and I would be running as his VP. So we we named our party and we went around to our friends and came up with the necessary signatures so that we could be placed on the ballot. As part of this we also were expected to participate in the debates and be 'interviewed' by the student newspaper.

We called ourselves the BG party, most of the people we were running against thought it stood for Better Government, but the real meaning was a little more cynical. Another one of our friends used to greet everyone by saying "Hey, Big Guy" and there you have it BG.

I remember not knowing much about the 'politics' of our school and during our debates both my friend and I often floundered when we were asked specific questions, and I began to regret agreeing to participate in this given that 99% of the students who participated in the student government all new each other and were all Political Science Majors.

Of course we lost the election, by a landslide, and the only solace for me was that I obtained more votes for V.P. than did my friend who was running for President. I chalked this up to 'a lesson learned' and put it all behind me, and to be quite honest, forgot all about it until recently. I didn't even mention this on my CV when I applied to Medical school.

What brought all these memories flooding back into my conscious? Well, I saw the interview Katy Couric had with Sarah Palin, and couldn't help but think of my own floundering as I heard her responses to the questions posed. Our School newspaper wrote up an editorial piece on each of the candidates with their endorsements. I remember succinctly what they wrote about me and can't help but think that it fits so well here.

They wrote, "Mark's tails is in no way qualified to be V.P" and although I was embarrassed by this I couldn't help but agree and for several months would quote that back as a joke to my friends whenever they asked me a question.

Just in case I'm being too subtle here, "Sarah Palin is in no way qualified to be Vice President of the United States of America."

Having said that I encourage everyone who can vote, to vote in the upcoming election for the candidate whom you feel is best able to serve our Country, that is what Democracy is all about.

Ruby Tuesday

2008-09-23T08:21:00.005-04:00

Happy Ruby Tuesday! Well Mary the Teach over at work of the poet asked for pics with just a little red this week so here is my entry. This is Anthony taking a little nap. Of course he doesn't always nap when we would like him to.

He has been in daycare now for a couple of weeks, he is just as fussy there as he is at home. My mother tells me it is payback because as a baby I used to cry an awful lot as well. Most of the time when I drop him off in the morning he is asleep, but sometimes, like today, he is awake and as soon as he gets set down into his crib the crying starts. Its hard to leave him when this happens and it is also tough to see all the other babies just sitting there with Anthony being the only one crying. Sister Ann, at day care, always looks at me reassuringly and tells me "Don't worry, He'll be OK." I think that is code for OK time for you to leave so I can get to taking care of these kids.

Creative Photography Contest #13 week 2

2008-09-19T08:35:00.005-04:00

After being inspired by the submission from Ivory over at tales from the clinical lab (love the title of your blog by the way). I've decided to add my own sciencey photo. While I still prefer the beautiful histology of the lung I am in the process of writing up some manuscripts and am unable to 'publish' anything online until I know which images are going to be submitted for publication.

The picture is of a murine heart, the outer, almost cobblestone appearance is the myocardium or muscular layer of the heart, the two oblong tubes at the very top are the blood vessels that supply the myocardium and the black spaces are the heart chambers. There is typically not a connection between the left and right sides of the heart, that is an artifact due to the way the heart was cut and cross sectioned.

Profile Tails

2008-09-17T08:27:00.004-04:00

I’ve finally added a picture to my blogger profile. I took this shot of a Ring-tailed Lemur while at the Buffalo Zoo a few weeks ago. I actually majored in Anthropology in college and the lemur was always one of my favorite primates. (Actually I have a double major; Biology and Anthropology, I took Anthropology so that I could meet a particular girl, but that is another story for another time.)

The ring-tailed lemur has almost a cat like appearance and of course they have the long-ringed tails, which is perfect for my blog, as I like telling tails (tales). Lemurs are actually known as Prosimians, meaning before monkeys or sometimes-termed pre-primates. At one point I actually new the phylogeny of the Prosimians, New World Monkeys (Platyrrhines –flat nosed), Old World monkeys and Hominidae (Catarrhines –down nosed), although much of that has been forgotten. From an evolutionary standpoint humans are Catarrhines and in the superfamily Hominoidea (Hominidae) which also includes Chimpanzees, Bonobos, and Gorillas.

Interestingly Lemurs are a rare mammalian example of a female dominant social structure. Imply what you wish, I just think Lemurs are cool. The term “lemur” is derived from the Latin lemures meaning “spirits of the night” or “ghosts” as some species are nocturnal, have large reflective eyes and some can have loud wailing cries. The Ring-tailed Lemur is diurnal however.

Today, most Lemurs are native only to Madagascar and some of the smaller surrounding islands. Some theories suggest that on mainland Africa Lemurs were out competed and thus became extinct but on Madagascar there was no competition from other primates and they were able to survive.

Resources and References:
-Duke Lemur Center.
-Lemurs: ghosts of the forest.
-Wild Madagascar.
-Primate Behavior.

Ruby Tuesday

2008-09-16T08:40:00.004-04:00

Here is my Ruby Tuesday photo with a lot of red. Of course next week I will tone it down since Mary the Teach is requesting photos with just a little red. Happy Ruby Tuesday!

Black Monday

2008-09-15T12:00:00.004-04:00

Photo credit

I probably should have posted this Friday and called it “Black Friday” but I have been busy trying to catch up with things at work and haven’t had the time until today. Additionally, I don’t have a picture yet because the weather in my neck of the woods hasn’t been that co-operative as of late.

I’ve always thought buying a car was a more of a PIA than it needed to be. I mean I’m all for the car dealers making their profit because after all they have a business to run, but the question is just how much profit do they need to make on each car they sell and why does it have to be different for each person coming in to buy a car? My bottom line is that if they sold it to me then they probably made a reasonable profit otherwise they wouldn’t have sold it to me, right? But I always wonder if I could have gotten more for my trade in or had them drop the price a bit more on the car I was buying.

Because I am a scientist, I always do my research, usually I use Edmunds.com but I also scan sites looking at used car prices to get an idea of how much I can expect for my trade-in. Anyway, I knew I wanted to buy a used car because there are great deals this time of year, plus not having to loose all that money on the huge first year depreciation etc.

So Boo Wife and I dropped Anthony off at daycare and headed to the dealership to look at used cars. My hands were already sweating and my heart was racing as we made the drive. There were the typical catch phrases like, “You guys look like nice people so I’ll see what I can do for you.” And, “Oh this car was actually listing for $1,000.00 more than what I told you but because I said x price we’ll have to stay with that.” Which I knew was a lie because I saw the price you had listed this car for on your own freakin’ web page! But I have to say, overall it wasn’t as bad as previous encounters I have had with car salesman. Yes the initial offer on my trade in was about half of what the car was worth but I only had to come back with one offer and it was practically a done deal. Of course this makes me think I wasn’t hard enough on them but on the other hand it is what I thought was a fair price based on the research I had done and at some level that is what mattered to me.

There were two sort of unexpected bonuses. The first, as the salesman was adding up all the taxes, title, license crap the total came out to $XX, 753.56 and he said, “Why don’t I just deduct the $753.56 and add it on to your trade in so that the price is an even $XX,000.00. “Umm, OK.” The second bonus came a day later; I financed a small portion of the price and found the lowest interest rate online, which the dealership matched. The next day I received a call from their financial person who wasn’t in the day I took delivery of the car but informed me that I could get an even lower rate than they had given me and wondered if I could come back in and sign the new papers. “Umm, OK.”

So the best part of this for me is that I actually paid LESS for this car than I did for my “Randy Beemer” 3 series convertible back in 1999. And although Kimmie commented on that post about how I was making a sacrifice getting a black 4-door sedan, she really shouldn’t feel sorry for me. I now have a 2007, black, 4 door, BMW 530xi sedan with a trunk big enough to put Anthony’s stroller in, and his car seat actually fits nicely in the back seat with room for an additional passenger or two.

Abby Reboot

2008-09-10T11:33:00.005-04:00

Because Randy and Ramona were interested in seeing the creative photo submission below in either black and white or B&W with a little sepia I decided to oblige. As always click on the pic to enlarge. While I like them both, I still like the original submission because the color of her coat and the stare in her eyes are more discernable in the original.

Creative Photography Contest #13 week1

2008-09-10T08:27:00.006-04:00

So I realize some of the judges are not fond of pet pictures, but every time I scan by this one I can't help but take a second look. To me it has almost a portrait quality about it and reveals the hidden intelligence of Retrievers. I was on my stomach shooting this and usually Abby will come running up to me and want to play and indeed she did do just after I took this shot.

I adjusted the sharpness a bit to bring out the hair especially around her face and I used the blur tool in photoshop to soften the background a bit. Click on the title above to take you to the contest or click on creative photography to take you to the blog home page.

Ruby Tuesday

2008-09-09T09:12:00.002-04:00

Happy Ruby Tuesday. Visit Mary the Teach over at Work of the Poet to find out how to participate.

Blue Monday

2008-09-08T08:57:00.006-04:00

I tend to keep cars that are reliable a relatively long time. The biggest reason is that I HATE the the time needed and the dealing that goes into buying a car. I had 2 cars during my college years both were used, both were unreliable. I bought my first new car the year I started medical school, a white Ford Escort GT. It was a manual with no A/C and I had them take out the radio and give me the $250 credit so that I could put in a new Alpine system. I had that car for over 7 years, it never gave me any trouble, it got me through many a snow storm and I drove it throughout the Northeast in January as I made my way to most of my residency interviews. Buffalo to Baltimore, Philadelphia, New York City, Hartford, Hanover and then back to Buffalo. On the leg from Philly to NYC there was a big snowstorm and the New Jersey turnpike was being closed just behind me as I slowly made my way to my destination. This was in the days before GPS and all I had were my AAA triptiks and the confidence that comes with being a young medical student. Nowadays I hate driving in any inclement weather.

I traded in the Escort for a black Mazda Miata when I started my fellowship training in Nashville, sadly that car was totaled in an accident after I had it for 3 years. The sequence of events and the car I had after this accident is somewhat convoluted and long due to my marriage and impending divorce so I'll skip those details. But, after my divorce I had what I called my "early mid-life crisis". Like many a recently divorced middle aged man I wanted to get a sporty convertible but wanted something with a little more trunk space and and something that at least resembled a back seat. So in march of 1999 I bought the Avus Metallic Blue BMW 323ic, with leather interior, sport package, and the Harmon-Kardon sound system. I loved this car, not enough to give it a name like some people do, after all it is only a material possession, but it was a blast to drive and it never gave me any trouble. I never had an accident with it, never got a speeding ticket or even a traffic infraction with it. When I moved back up North I purchased a Subaru to drive in the winter but gave that to Boo Wife when we got married so I bought some snow tires for my BMW and drove it all year round.

As I passed 70,000 miles the 'routine maintenance' started to include new brakes, or shocks and most recently I had to replace a cracked spring, due to the tremendously large potholes that pop up during the freeze thaw cycles as winter fades into spring. I probably would have kept this car longer had it not become somewhat impractical. A small backseat made it nearly impossible to put a baby seat back there and it had an even smaller trunk which made any sort of travel difficult unless you had small luggage. Safety was another issue, while it had front and side airbags it was a convertible and it didn't have any rollover protection. (it wasn't standard on BMW convertibles until 2000 or 2001)

So it was with much sadness that I traded in my Avus Metallic Blue BMW 323ic, with leather interior, sport package, and the Harmon-Kardon sound system, with just under 80,000 miles on it this past week. What I missed the most though was not being able to call my Dad after purchasing my 'certified pre-owned' car and telling him about the wheeling and dealing that went on in order for me to get the car I wanted at what I thought was a fair price. He would listen to me tell my tale and then say to me that it sounded as though I got a good deal, which always seemed to make me feel better about spending money on something that depreciates as soon as you drive it off the lot.

Daddy daycare tails

2008-09-05T11:00:00.005-04:00

Well, it has been an exhausting summer, I would like to say "where did all the time go." but it seems like I can relive the past 3 months with ease, both with joy and pain, happiness and sadness, excitement and frustration.

As usual it has been a hectic week. I returned from Buffalo on Tuesday and Wednesday was Anthony's first day at daycare. Boo Wife is still off this week so we ended up staying a little while with him the first day. Right now he seems NOT to like it too much, we're told he does a lot of crying and is only comforted when being held. Not to make too many excuses, but with all the travel we've done in the past few months it was rare that Anthony was ever out of someones arms, except at night to sleep. I'm sure this will get better with time and he is already showing some improvement at home. Last night when we put him in his crib he only cried 45 minutes before falling asleep for a whole 3 hours! Don't worry too much, he still gets ALOT of attention.

Our plan is for Boo Wife to go to work early while I feed Anthony and take him to daycare in the morning, that way Boo Wife can pick him up early in the afternoon, around 2-3 pm. Today was my first dry run and it didn't go well at all. I got up early and took the dog out, was able to shower and get partially dressed before Anthony woke up. He wouldn't take the bottle right away so I decided to change his diaper, unfortunately I was not prepared when he started to pee on me (only the second time). Luckily Boo Wife came to my rescue and helped out. (I learned I need to be better organized in the AM if this is going to work) Boo Wife took care of the feeding and dressing and I finished changing myself and getting organized for my first day back. I'm finally ready and place Anthony in his car seat, lock him in place, and off we go. Just as I think everything is finally falling into place my cell phone rings. Arrggh! I forgot his bottles. Head back home and head out once again.

I did learn that Although Anthony has been tolerant of most of the music I play in the car he seemed to hate White Stripes 'Dead leaves and the dirty ground'.

Hopefully things will go smoother come Monday.

Ruby Tuesday

2008-09-02T08:20:00.004-04:00

Well after a break to be with my family, I'm back again for Ruby Tuesday courtesy of Mary The Teach at Work of the poet.

I promise to respond to the comments on my last three posts that I haven't had the time to get to yet. But for now here is my pic.

My father kept a beautiful garden, although every year he would complain about the time it took and the constant weeding he had to do he was always tending to it from the spring and summer then well into the fall. One of his favorite plants was the moss rose or Portulaca. He loved how the many colors would just brighten up the garden.

So above is one of his red portulaca's that was in bloom during my stay in Buffalo.

Dad

2008-08-26T16:54:00.003-04:00

Today is my parents 47th wedding Anniversary. One week ago today (August 19th) early in the evening my father passed away. His condition deteriorated despite palliative therapy at which point he decided to stop treatment altogether. He and our family were provided aid and care by Hospice of Buffalo. He died at home, with his family, as he wanted it.

We noticed his shoes sitting out on the deck, from the last time he went out to trim the miniature tree way in the back. My brother and I cleaned up the trimmings that day, I'm not sure any of us want to move them just yet.

"Beloved husband of 47 years to Carreen; father of Matthew M. (Carole), Mark (Kathryn) and Lori Ann (Michael); Grandfather of Jessica, Jacob, Marlee, Melissa and Anthony; brother of Donna Lou."

My sister wrote the following poem for his 60th birthday party, it was read by my wife at his eulogy.

In 1940 on the fifth day of June,
Matthew was born in a small Columbus hospital room.
On the west side of Buffalo at a young age you see
is where Matt began to be the best son there could be.

In 1942 a little sister came,
a new page in his life, nothing would ever be the same.
Matty knew,
it was easy to see,
he needed to become the best brother there could be.

In 1961 he married his wife,
a new challenge, and adventure,
for they were partners for life.
With this new beginning it was easy to see,
he needed to become the best husband there could be.

Soon after that baby number one came to be,
but that wasn't all,
then came two and three.
With an entire family it was easy to see,
he needed to become the best father there could be.

The best son,
the best brother,
that was a breeze.
The best father,
the best husband,
he accomplished with ease.
What more could he become,
that was easy to see,
the only thing left,
the best papa there could be.

Creative Photography Contest #10

2008-08-19T16:30:00.008-04:00

I took this pic with my very first digital camera. It was a Nikon Coolpix but I forget the number (2600 or something like that). It was only a 1.1 mp camera. This picture has not been edited other than cropping, and was taken at the Monterey Bay Aquarium. Later that night I proposed to my then girlfriend who is pictured here observing the Jellyfish.

There are some incredible entries this week. Please click on the title above to take a look at all the other participants in this weeks contest.

Ruby Tuesday

2008-08-19T09:55:00.003-04:00

Happy Ruby Tuesday from myself and the originator, Mary the teach over at Work of the Poet.

Some days you just feel like your running into one. Other days you need it to bang your head on.

More growing tails

2008-08-15T14:40:00.003-04:00

The sling, working its magic.

Well, Anthony James will be 10 weeks old this Sunday and he had his 2-month check-up last week. Weight gain was a problem very early on, he lost more than 10% of his weight after being taken home from the hospital, which was a reason for us to go see the Pediatrician relatively early after discharge. It wasn’t that surprising to us, the first night we came home he cried and cried. I told Boo Wife that if he continues we should try and give him some of the formula they sent home with us. Later we gave him a bottle and he slept for about 2 hours. You may recall that he was born weighing 7 lbs. 10 ozs. (which put him in the 45th%), 3 days later and our first visit to the Pediatrician he weighed 6 lbs. 6 ozs. (a drop down to the 14th%). Pediatrician wasn’t too worried; sometimes it just takes a little longer for breast milk to come in for new moms. So we began to supplement his breast feedings with formula/bottle feeds for the next several weeks and on our return visit one month later he jumped to 11 lbs. 12 ozs. (all the way up to the 87th%). Yea he was really chubby by then, his length has been fairly steady around the 64th%, so we cut back and pretty much eliminated all the formula feeds and at his 2-month check-up he weighed in at 12 lbs. 12 ozs. (76th%).

He has his fussy times particular right around dinner time and about the time he is supposed to go to bed. We tried swaddling him, he hates it, likes to have his hands out in the open. We tried sleeping him in his car seat, seemed to help a little but not always consistent. Feeding him right before bedtime, NOPE. Bathing him right before bedtime, NOPE. The one thing that has been a tremendous help for us is the HotSling. I think Boo Wife picked it up at Target for $30, she says it was the best $30 she has ever spent and I agree. Although it is not the right size for me, on occasion, last night being one of them, I slip him in it and just hang the sling around my neck, within 5 minutes he stopped crying and settled down, by 15 minutes he was sound asleep. Once that happens we, gently, very, very, gently move him to his bassinet where he sleeps for 2 hours before waking up and wanting to eat again. I’m sure different things work for different infants but this has worked great for us.

Other than that, over the past few weeks he has started to smile more regularly (and not just when he has gas), he coos a lot more and has become interested in objects and faces. We’ve even been out to dinner a few times with him, generally choosing somewhat noisier/busier places, and most of the time he has done well. If he has cried he usually settles down with a bottle or the sling. Although this week was an exception, Boo Wife was out with her friend and had to leave the Restaurant because nothing was working. Yes, I despise crying babies at Restaurants too, and we’re always ready to leave if we need to.

That’s about it, he’s growing fast, he takes a lot of our time, he keeps Boo Wife up, he is our joy, and he has only peed on me once.

Creative Photography Contest #9

2008-08-13T14:12:00.005-04:00

I was traveling I90 this past Monday night on my way home and heading towards Erie, PA. It was dusk and the sky was beginning to look ominous. On the radio came a severe thunderstorm warning, which I ended up driving through a short time later. I pulled off at a rest stop just across the PA line and attached a Red filter to my lens because I knew I wanted to catch these images in black and white.

It also looks interesting to keep the red and fade it a bit or to add the sepia filter once it is black and white, but I thought those looked less real. I tweaked the exposure by about 1 in iPhoto and also increased the saturation as well as increasing the tint towards green to enhance the already nice effect of the red filter in accentuating the contrast of the storm clouds beginning to move into the area.

Luckily, it was a localized storm and was able to pass through the worst of it in under 15 minutes. I hate driving on a highway in blinding rain, especially when you slow down and all the trucks want to pass.

Anniversary tails part 3

2008-08-13T10:58:00.004-04:00

Today is my third wedding anniversary. It seems as though our wedding was so long ago, don’t get me wrong, I don’t mean that in a bad way. It just seems that Boo Wife and I know each other so well it’s like we’ve been together longer than we actually have. I am grateful and lucky to have found her, and I realize that more and more each day. Her love and generosity is unending and her patience with Anthony and ME is astounding.

This year has been very hectic for many reasons (see previous posts) and although my Mother-in-Law offered to watch Anthony while we had a night on the town, we (I) just didn’t get around to organizing anything as of yet. Hopefully, Mother-in-Law will keep the offer open so we’ll be able to go out for a nice evening in the near future.

Despite that, I did my usual search of the Internet to find an appropriate gift for our third year anniversary. Some may recall that the first year I gave her a traditional gift (paper), an origami box that had a heart necklace inside. My gift for our second anniversary was sadly, a bit lame. So this year I wanted to try and makeup for it. The traditional gift for third year anniversaries is leather and the modern gift would be crystal or glass. Well, Boo wife really isn’t into crystal or glass so I decided to tackle the leather approach.

Boo wife likes jewelry but she really doesn’t wear a lot. One Christmas I bought her what I thought was a beautiful necklace, a piece by Scott Keating. When she hadn’t worn it for several months I asked her why and she said, “It’s too nice, I’m afraid I’ll lose it if I wear it.” Luckily she got over this fear and began wearing it shortly thereafter, perhaps to appease me.

So I try to balance getting her something that is nice but not too nice that she is afraid to wear it. Does that make sense? I found this leather-braided bracelet with sterling silver accents at the National Geographic website. The description from the website follows;

Jewelers on the island of Java work in open-air studios creating the sterling silver beads that have been a local art form since the 16th century. This bracelet begins with a technique called repoussé where designs are hammered into a sheet of metal. The textured metal is then curled into a long cylindrical bead, and a mold is made. Sterling silver beads cast from this original mold are then slid onto a braided leather cord to make a handsome bracelet that flatters both men and women.

Happy Anniversary Boo.

Ruby Tuesday

2008-08-12T09:50:00.004-04:00

It's Ruby Tuesday at Mary's over at work of the poet, so post your pic and head on over to her blog to sign Mr Linky.

This pic is was taken at my sister-in-laws, it was her sons first birthday. He was in the process of eating his 'smash cake'. I like the fact that he has a bright red shirt, also given his new found mobility he has developed a few scraps and scratches, not that it bothers him at all. So he also has a little red scratch on his hand. Oh, and of course, his rosy cheeks.

up and down and up and down

2008-08-08T15:42:00.006-04:00

Well it has been a busy few weeks as well as being kind of an emotional roller coaster since my post on July 18th regarding my father. Boo Wife and I headed to my hometown on Saturday morning July 19th and my Father greeted us with tears in his eyes even though at the time we did not know the diagnosis. He felt a bit tired and as I mentioned in the earlier post was still suffering from short-term memory lapses. Related more to the organization of information than actually forgetting things out right. He knew he had all these Doctor’s appointments and tests coming up he just didn’t know the details of those appointments. He knew he had a bunch of new meds he was prescribed but didn’t recall what they were for or when to take them.

Monday July 21st we went for the PET/CT scan which took several hours, we were given a copy of the images but I waited until later in the evening before looking at them myself. It was kind of a surreal experience for me to look at these images and very difficult for me to be objective. This was made apparent to me when I viewed the CT scan, saw a large ‘lesion’ on the kidney and assumed this was the primary lesion when in actuality it turned out to be only a cyst.

Tuesday we headed back to the Neurosurgeon and we were given a copy of the final Radiologist reading of the studies. Two of the lesions in his brain, the largest one in the thalamus and the smaller one in the temporal lobe ‘lit up’ on the PET scan suggesting that these were malignant. The third lesion that was seen on initial MRI near the pineal gland turned out to be a cyst. This meant that we were dealing with a primary brain tumor (Glioblastoma) or a CNS lymphoma the radiologist favored the former. So my father was scheduled for a brain biopsy on Thursday July 24th and he had to go for yet another imaging study, a second MRI, to provide the ‘map’ for the stereotactic guided biopsy, in addition he needed medical clearance prior to surgery. (Biopsy only, as the lesion in his thalamus was/is unresectable, which I had already known to be the case.) So we left the Neurosurgeon, went home and had a quick bite to eat before heading to see his primary care physician, as we were leaving his office a message was given to us to head right to the hospital to have the MRI. Needless to say this made for a very long day for everyone.

Unfortunately, I had to leave that night but Boo Wife volunteered to stay and help my parents out until I came back. It was hard and frustrating to say goodbye, still unsure of the diagnosis, so much anger at the unexpectedness of this illness in an otherwise healthy person, leaving my parents, my wife and my son, but I was also comforted by the fact that Boo wife was there to help, and my Dad could spend some more time with his new grandson.

I was working in my own clinic when my Father went into surgery on Thursday July 24th; unfortunately the news was not encouraging. Preliminary pathology supported a diagnosis of Glioblastoma multiforme or a primary brain tumor. My father was released home that evening and I was surprised at the upbeat tone of his voice when I spoke to him that night. He wanted me home for the weekend so I could take off his bandages on Sunday morning, which, of course, I did. Monday we had the first appointment with the Radiation Oncologist.

I left Monday night but Boo Wife stayed back again. Every time I called, my parents expressed their gratitude for her being there. She wasn’t the only one helping out, my brother and sister live nearby and have been able to help around the house, but they both work and have families of their own to take care of Their children, my nieces and nephews, have also been stopping by to help and visit when they can and my Aunt, my father’s sister, has been a tremendous help and support as well. In addition were expecting visits from my out of town cousins and Aunt in the near future.

I drove home again Thursday night July 31st, although I had to stop and pick up some food from PF Chang’s before my ride home. My father wanted some of Chang’s spicy chicken, so I made the 200-mile journey back to Buffalo with take out for the family. Friday August 1st was our visit with the Oncologist, the last of the Doctor’s my father needed to see, and the only reason was to get the prescription for the chemotherapy agent used to treat Glioblastoma (temozolomide), he was supposed to start his XRT on Monday August 4th. This was the longest of all the visits, 3 hours of waiting and only 15 minutes with the Doctor, only to be told that they needed to get ‘prior authorization’ before we could even get the drug. The nurse told my mother to call after one week if they haven’t heard from them regarding the prior authorization. I told my Mother to be sure and call on Monday since it usually takes 24 hours or less to get prior authorization for a drug which is standard of care. The good news is that it was delivered to my parent’s home Monday evening.

Boo Wife, Anthony and I left Sunday evening, my parents were sad to see us go and especially sad to see Boo Wife and Anthony leave. Not every wife would volunteer to spend two weeks with her in-laws, not every wife is like mine.

There has been and continues to be a barrage of emotions, random thoughts, and odd observations that cross my mind on a daily basis but I don’t think I want to write them all down at this time. Not that anyone wants to get a diagnosis of cancer but Glioblastoma is one of those that is not easily treated and rarely cured, although patients can have good responses to therapy and some extended time with a good quality of life.

My father started his therapy this past week and everyone is taking it one day at a time, which is all any of us can do.

Growing tails (so far so good)

2008-08-06T10:58:00.006-04:00

Here is an update on my 'seeds of life' post from last month. The Croton (Thanks Randy) seems to be doing well and is growing quite nicely. I'm debating whether or not to start one or two more and to replant them in a larger pot. My goal would be to keep them relatively short and trim rather than letting them grow out of control as I did with the original plant. Although I am not sure how exactly to 'pinch them back' so as to maintain the leafiness and not so much stemminess (yea I know that is not a word).The mighty Oak is also growing. I turn it every few days in order to keep it growing straight, or as close to straight as I can. I'm thinking this is going to need a larger pot in the very near future and hope I can maintain it indoors through our gray Midwest winter.

Of course Anthony is growing as well, he has his 2 month check up this Friday and will post something shortly thereafter.

Ruby Tuesday

2008-08-05T09:39:00.003-04:00

I know I haven't posted anything since last Ruby Tuesday but I will have some new posts up shortly, mostly updates on recent life events, so to speak. But for now, here is my pic for Ruby Tuesday, a meme by Mary at work of the poet, the details and instructions are provided in my post below and on Mary's blog.

Here is another 'red saturated' pic, I've been on the look out for more subtle red but just don't like anything I've taken recently. I would have liked a bluer sky and a polarizer filter for this shot and perhaps adjusting the exposure would have improved the over exposed sky, but I do like the contrast in the building itself and the crosswalk leading to it.

Ruby Tuesday

2008-07-29T15:56:00.006-04:00

Here is a picture of my Dad tying his shoe on a fire hydrant. For some reason I have been fascinated by this picture since I took it early this Spring. Boo Wife was not so enthralled and couldn't understand my composition.

Saw this on Mimi writes. Ruby Tuesday is a meme started by Mary at work of the poet. Here are the rules.

On Tuesdays you can post any photo you like (it must be your own) that contains the color RED. The photo can contain lots of red or a little red.

When your done go back to Work of the Poet and enter your name in Mr Linky.

Bleeding Heart (balance part 2)

2008-07-25T10:36:00.005-04:00

Photo Credit, Me

Yes, I realize you have heard, read, and/or seen this a million times before, but the Internet is truly a wealth of information. Never before have so many people been able to access so much information. Not just news but hobbies, interests, and almost any fetish one can think of are easily accessible by this “series of tubes” that is the internet.

But sometimes I sit and wonder whether the Internet is, in part, the reason why our nation has become so divided, so left and right, lacking balance if you will. The Internet provides a unique opportunity for us to read and interact with people that share our same viewpoints, but is that good or bad? I have tried to balance my blogroll with a variety of viewpoints, largely Medical in nature, but even the best Medical blogs can’t help but talk politics once in a while. Certainly, some readers become critical when this is the case, vowing never to read them again, while others leave comments expressing their own viewpoints and why they may agree or disagree with the writer. It is the former commenter that is most concerning to me.

If we use the internet to find people or sites that share the exact same opinions we have, doesn’t that just promote and solidify your own viewpoint, making you ‘less able’ to see the other side, less likely to even want to understand someone else’s viewpoint or concerns. Less likely to seek out alternatives or compromise, making the chasm between what you believe as right and what others believe as left that much wider.

I have been and probably still will be called a ‘Bleeding Heart Liberal’ by many, and I freely admit that I do tend to lean a bit to the Liberal side but I am actually fairly balanced when it comes to politics and life. During the primaries there were several web sites that would ask a series of questions and best match you with a candidate. Although Democrat candidates were in my top 2 a Republican candidate was not far behind as number three (and it wasn’t Ron Paul). In addition the score separating Democrat from Republican wasn’t that great.

In a way extremism is necessary to help us know where the middle ground is, on the other hand if all we seek is confirmation of our own viewpoint we leave little opportunity for discussion, for learning, for compromise, or for balance.

BTW I love Dicentra Spectabilis, they bloom very early and to me signify that Spring has come.

Honey! can you treat my infection?

2008-07-23T11:53:00.003-04:00

Here is an interesting article on the use of medical grade honey for the eradication of skin colonizing bacteria. As the reviewer notes, DO NOT TRY THIS AT HOME as commercial honey can be contaminated with small amounts of bacteria.

Last Resort for Drug-Resistant Infections: Honey?

"Medical-grade" honey has attractive microbicidal properties.

Surging rates of antibiotic resistance have kindled interest in all possible treatment alternatives, even those from centuries past. Honey has a folk reputation as a microbicide, and a small repository of literature backs its effectiveness (and that of granulated sugar) for treating infected wounds.

Researchers in the Netherlands, with government and industry support, investigated the antimicrobial properties of a "medical-grade" honey, which is produced by bees in closed greenhouses. In in vitro studies of bactericidal activity, a 40% solution of honey reproducibly killed all bacterial isolates tested, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant Escherichia faecium, and multidrug-resistant gram-negative rods. Forty-two healthy volunteers then had small forearm patches of skin swabbed with honey and covered with polyurethane dressings for 2 days. Compared with control skin patches (covered with polyurethane, but without honey) on the same volunteers, the honey-covered patches were culture-negative for bacteria significantly more often.

Comment: These results probably belong to the "don’t try this at home" school of medical investigation, because grocery-grade honey is not standardized and can be bacterially contaminated. Still, honey might one day take its place alongside mupirocin as a topical microbicide or even as a treatment for wounds that are infected with multidrug-resistant organisms.

— Abigail Zuger, MD

Published in Journal Watch General Medicine July 3, 2008

Citation:
Kwakman PHS et al. Medical-grade honey kills antibiotic-resistant bacteria in vitro and eradicates skin colonization. Clin Infect Dis 2008 Jun 1; 46:1677. [Medline® abstract]

Copyright © 2008, Massachusetts Medical Society. All rights reserved.

emotional balance?

2008-07-18T16:08:00.002-04:00

I’m not quite sure that this post will make sense as it seems to be a bunch of loose associations right now but it is the best I could do under the circumstances.

I’ve written several posts about ‘balance’ in the past. Balance in life, balance in medicine, balance in politics, balance in science. I’ve always tried to maintain a balance in my life; perhaps this is because I am a middle child and seek a middle ground. In a way my personality reflects this balance as well. I’ve been accused of not showing enough emotion at times or expressing feelings as much as I should. Whether or not this is good or bad can probably be debated. Boo Wife has always expressed her emotions both happy and sad very openly and that is just one of the many reasons why I adore her.

Is there such a thing as emotional balance? I’ve rationalized possible reasons as to why this might be the case. One of which has been that life is fill of uncertainties and if you are too happy you are only setting yourself up for a let down. Now I know this sounds very pessimistic and many people would say that you need to find as much happiness and joy in the good times that life does give you and I whole heartedly agree. But there are times when it is hard not to believe my somewhat pessimistic view.

Others in the medical profession and here on the blogosphere have expressed their opinions about caring for or treating family members. I would link to some but to be honest I am tired and feeling rather lazy at this particular time. I can tell you that I have always tended to downplay symptoms if a family member contacts me worried about some malady or ailment and occasionally have made comments such as “Your Doctor put you on THAT medication!” “Why were you given an antibiotic!” and “It’s a waste of time and money to get that test.”

Similar feelings occurred this past week when my father called to tell me that he ‘felt funny’, like his legs felt like rubber or something. I downplayed his symptoms and although he was going to see his doctor I thought he would be fine if he rested a few days since he was out gardening all day prior. He called me that night to tell me that a bunch of lab tests were ordered and I kind of scoffed but waited the weekend until he got the results. The lab work was all normal but he really didn’t feel any better and now I was getting calls from my mother and brother telling me that he was also having memory problems as well as balance issues and he was seeing his doctor again that day.

My father has always been somewhat of a worrier (My wife will attest that I have that affliction/trait as well), and when he called and said he was worried about a brain tumor I once again scoffed and told him that he automatically thinks the worst and lets just wait until he sees his doc. I denied the possibility vehemently to him and my mother even though deep in the recesses of my own mind, as I tried to piece together his constellation of symptoms and the acuity of onset I couldn’t help but wonder the same thing.

He was scheduled for an MRI on Wednesday and my immediate reaction was once again dismissal. But came to the sad realization that if I were in clinic seeing someone other than my family member a head CT or MRI would be the first thing on my list of orders.

He has three separate lesions, the largest in the right thalamus and smaller ones in the Temporal lobe and pineal gland, suggesting metastatic disease from some, as of yet unknown, primary malignancy. Less likely would be satellite lesions from a multifocal glioma.

Boo wife and I are heading home this weekend to visit, he really wants to see Anthony again. In addition, he is scheduled for a PET scan on Monday and to re visit the neurosurgeon on Tuesday, I told him I would go with him for his appointments so that no information is ‘lost in translation’. My father is a regular reader of my blog, although I’m not sure how much blog reading he has wanted to do recently. I am not sure what he’ll think of this post but will delete it if he wants me too.

I was, and still am excited, ecstatic, and overwhelmed with the birth of my son. I know my father was just as, if not more, excited as I was. However, I am now saddened, depressed and still overwhelmed as he and we face this current challenge. Unfortunately this just reasserts my pessimistic viewpoint. Perhaps by not letting myself become too emotional I can protect myself from the roller coaster ride of emotions that occurs during life…NOT.

Power tails

2008-07-09T19:10:00.007-04:00

photo credit

Today as I walked into to work I noticed it is a little darker than usual, a little quieter than usual and a little warmer than is typical for this time of year. As I head up towards my office and lab I notice that the power is out in our building. I heard a few different stories as to why but people heard that it would be at least 12 hours before power was restored.

Power, what would life be without power? It’s such an inconvenience when the electricity goes out; we depend on it for so much. At home we would miss the TV, the air conditioning, computers, Internet access etc.

The problem in research is we are very dependent on power. Power is necessary to run all the machines, to keep the incubators incubating, the centrifuges spinning, the PCR machine cycling but most importantly the freezers need to keep freezing. Almost every researcher will tell you that their freezer is the most important piece of equipment in the lab. It is where we store all of the precious samples from our experiments, often times many years of samples and experiments are stored in the -80 freezer, so you can imagine the trouble and frustration if this piece of equipment goes with out power. Most of our –80 freezers are plugged into emergency outlets, such that if the power does go down our institutions generator kicks in and the freezer will still have power, providing the generator is functional of course. Many of our other freezers are not, so when I heard that the power outage occurred at 5:30 AM I became nervous. As I walked into my lab I noticed that my other freezers were already plugged in. Turns out one of the Post-Docs from another lab went around and began plugging in all the floors freezers into the emergency outlets. How thankful and relieved was I? More than I can express in writing.

I’ve lost over a years worth of work before. When I took the job here the –80 freezer I had would seem to shut down spontaneously. Twice I was called in at night when the alarm went off, driving in from home so that I could move all of my samples to another freezer. Twice the repairmen swore the problem was corrected. Finally, it went down when no one was around to here the alarm and I lost everything. The manufacturer finally admitted that there was a problem with the compressor in the freezer and ended up replacing it. Sadly when I moved to my new department and got a new freezer it to would drop temperature every once in a while and again there was no problem to be found. I finally argued with the manufacturer long enough that they replaced the freezer for me and have had no such problem since (knock on wood). Our freezers are now on a alarm system which is linked to the security office, such that if they do drop temperature the alarm is triggered in the security office and we can be called 24/7.

The good news, I was able to come home early and spend time with my family, and although the power was still not restored as of 5:30 pm, the generator was still functioning and the freezers were still freezing.

Happy Independence Day

2008-07-04T10:27:00.005-04:00

I'm not big into themed ties but I admit I have more than a couple. All but one were given to me as gifts and although I occasionally wear one of my Christmas ties most of the other themed ties just hang in my closet except for this one. Back around 1999 I spent 2 weeks in Boston at a lab that we were collaborating with. The lab was in Charlestown right next to the USS Constitution. During some off time I took a tour of Old Ironside and stopped in the gift shop where I saw this tie. I wore it yesterday for my clinic and sometimes put it on around Memorial Day as well. Its still one of my favorites.

Have a Happy and Safe Holiday.

Seeds of Life

2008-07-02T09:36:00.011-04:00

I'm really not much of a 'green thumb' and try to limit my gardening to things that are difficult to kill, like plastic for example. As a kid I sent away for a Venus fly trap, of course that meant I had to catch and de-wing the occasional fly so as to feed it. It lasted through the spring and summer but alas, could not tolerate the cold and flyless Buffalo winters, even indoors.

Recently I am testing my 'gardening skills' (yes I'm using a lot of 'finger quotes' here) with two little projects. We have one plant in our house, I don't even know what it is, but was given to us by my mother-in-law. It has seriously overgrown its current pot and looks a bit unruly, so I decided to try and trim things down to start anew.About a month or so ago I trimmed off a piece and placed it in some water by our kitchen window. Boo wife was a little pessimistic at first, she didn't think it was going to survive. But low and behold after about 4 weeks some roots began to form and I decided it was time to move my little baby plant into some real soil. Yes, that is a Snoopy glass.The second project was a gift from Boo Wifes lab Boss and lab mates for Baby Anthony. Seeds of Life is a Do-it-yourself, plant a tree kit. An Oak tree actually, complete with pot, acorn, and soil, and some mossy stuff to put on top.

So that is what it all looked like at first. It has been about 2 weeks now and there is a little 'sprout' that can be seen growing up from the cracked acorn. The only problem is, I am not sure where I am going to plant this once it gets big enough to move outdoors, I guess I'll deal with that when the time comes. Until then there are so many things to tend to and watch grow, and they all grow fast.

Questions

2008-06-25T09:49:00.003-04:00

If 80% of your home is hardwood or tile why is it that your pets will always find the one area rug or carpet to throw-up on? And why do they do it at 3 AM?

-Is it because of the better traction on carpet?
-Is it easier to lick up from a carpet rather than having it slide across hardwood or tile?
-Are they really, really, bored at 3 AM?
-Is it better the second time around?

Does anybody have an answer? Just wondering.

Special delivery tails Part 2

2008-06-22T22:25:00.003-04:00

Approximately 7:45 pm were in the L&D suite; a liter of lactated ringers already is in and the anesthesiologist comes by to place the epidural. I have two pics of Boo wife, one before the epidural and one after the epidural, I even made Boo wife laugh when I toggled between them a few days ago, but she told me not to post them so you’ll just have to imagine.

I realize that it is going to be a long night and I was ready to call ‘shotgun’ as I walked into the room and saw the couch but didn’t think the In-laws would see the humor at that time. To be quite honest I don’t recall much of what transpired between the hours of 8 PM and midnight. The Doctor came in every 2 hours or so to check on Boo wife and we used that as a cue to change seating arrangements. Essentially, rotating who got to sit on the couch and who got to sit by the bedside staring at the fetal monitor, watching as wave upon wave of contractions occurred with Boo wife resting comfortably. It was kind of humorous at first, although it is my understanding that the monitor really doesn’t give an accurate assessment of the severity of the contractions the In-laws and I would get excited each time a ‘new record’ was obtained on the monitor. “Ohh, that was a good one you broke 100,” “Holy cow that one was strong it hit 110.” “OMG a new record 121!” Of course, pre epidural it wasn’t as fun for Boo wife to listen to our excitement while she endured the pain.

By midnight I was starting to get a bit tired, after all I had been up since 4 AM and it was my turn for the couch. I think I was able to get a good hour or so between midnight and the 2 AM. The Doctor came by around 2:05 AM, the signal for me to move from the couch. Boo wife was also able to sleep for a few hours as well. From 2-3 AM I was awake and ready to go as I took up my post by the bedside and intently watched the monitor. It was around this time that we noticed the first episodic decelerations, with the heart rate dipping into the 80’s, after a few more episodes the nurse came in and had Boo wife move to one side, 30 minutes later when she had a few more decelerations it was a change to the other side and oxygen was added. Boo wife didn’t particularly care for the mask but I made sure she kept it on.

From 3-5 AM I was really running out of steam, this was always the hardest time for me when I was a resident as well. We stopped getting admissions after 4 AM and after all my patients were ‘tucked in’ I could usually head to the call room for an hour or two of sleep before morning rounds. So 4 AM rolls around and I’m expecting to see the Doctor come in again to check my wife and signal a change of seating shift but nobody shows up. 4:30 AM and still nobody, I get up to walk a bit and notice the bag running low on the epidural, still about a half hour to go though. Finally at 5 AM the bag is almost empty so I decide to head out to the nursing station to let them know. As I walk out the door and head to the nurse’s station I run into our Obstetrician Dr. A. (No not Doctor Anonymous, but our OB’s last name starts with an A).

As another little aside Dr. A told us a while back that he would be going on vacation the week of June 8th, no problem we thought Boo wife’s original due date was June 19th. As I mentioned in Part 1, we had a visit with him on Friday June 6th. Dr. A told us that he thought Boo wife would deliver while he was away but told us that if she went into labor on Saturday to make sure he was called. He shook my hand and told me that he last received an update around 2 AM and when he woke up at 4:30 AM and hadn’t heard anything he decided to come in and check things out. I asked him what time his flight was today (it being early Sunday morning) and he told me that he wasn’t leaving until noon so he had plenty of time. Now many people have been posting lately on the Resident restriction hours here, here and here, and I have left my own comments on them as well. But this is what I mean, here is a physician, not on call and leaving on vacation that day and he is still willing to come in and deliver a baby. You may think oh it is because I am a physician that he did this. But he promised my wife during their first visit that he would be the one to deliver if at all possible. In addition, when I told the nurses to call him, they first said that they were unable to reach him at his home phone. I told them that he mentioned to my wife and I that he would be reachable by cell and the nursing station has his number. The nurse told me, “Oh yea we do, I’ll make sure we call him, Dr. A doesn’t mind when we phone him even when he isn’t on call.” I’m not saying a physician shouldn’t have a personal life, but I would rather be cared for by a tired doctor who has the ability and character to balance his/her life for the 3-5 years it takes to go through a residency working 80 or more hours a week than the well-rested, can't stay for rounds because my times up, sissy pants that may be coming down the pike. But I digress.

So, things started moving pretty fast from here on out. Dr. A came in and checked things out, 9cm and 90% effaced, “I think we’ll be ready in about 30 minutes.” Dr. A said. 30 minutes seemed to fly by, actually it was about 38 minutes but who was counting? Another check, “Oh, he’s really low, are you ready to have a baby?”

So the nurse comes back in and asks if we’ve taken Lamaze classes. “Umm, no.” Boo wife states.

“OK, so we might have to practice pushing a little bit.” The nurse tells her.

The nurse goes on to tell us, “This could take ten minutes or several hours.”

After explaining the how’s and why’s, the Father-in-law leaves the room and Mother-in-law and I take our places on either side of Boo wife to take hold of her legs.

OK, the first ‘practice’ push, I notice the heart rate drop to the 60’s and I get a little nervous. The nurse looks down and says alright, there’s the head and has he got a lot of hair, at the same time she starts to jostle things around down there to get the heart rate back up. I think its time to call the Doctor back. Dr. A and the extra nurse are there shortly.

“Who’s going to cut the cord?” Dr. A asks.

“Boo wife’s Mom.” I tell Dr. A. I figured I’ve gotten to cut cords during my training and this is Mother-in-laws first. (Boo wife was adopted and is Mother-in-laws only child)

The heart rate is back up to the low 100’s but starts to dip as another contraction occurs and Boo wife is told to push again. Dr. A decides to use the vacuum, which I’m actually glad to see. A little suction and the third series of pushes and the babies head is out, cord around his neck.

“Well, that explains the low heart rate.” Dr. A states as he quickly reaches between the cord and the neck, to clamp off the umbilical cord. “Grandma won’t be able to cut the cord right now.” As he reaches in and snips the cord, one more push and out comes the left shoulder, then the right and thwoomp, babies out and passed on to the nurses. I wait for what seems like an eternity waiting to hear the first scream, waiting, waiting…”AAAHHHHH!” What a sweet sound.

Special delivery tails Part 1

2008-06-17T15:22:00.006-04:00

Details, details, details. So here is how it all went down, it’s a long post and a two parter but it was an even longer night.

Saturday June 7, 2008 Boo wife got out of bed at 4 am and shortly thereafter called my name from the bathroom reporting that she is having contractions. She came back to bed where we sat for another 90 minutes trying to estimate the length and duration of each contraction. They were approximately 10 minutes apart, not to bad. So realizing that I was not as prepared as I should be I decided to get up, get showered and get ready. I had to pack a little bag for myself, camera, snacks, a deck of cards, a book, and my H2 blocker. Boo Wife had packed her suitcase a few days ago so she was ready.

Boo wife moved to the couch and started keeping track of the contraction interval and length. I proceeded with my morning routine of taking the dog out, making some coffee and reading the morning paper. She wasn’t having that much pain at this particular time. Anyway, after I finished reading the paper I took over logging the times of the contractions and also deciding on the best time to try and contact some people to watch Abby if we needed to go to the hospital. Around 10 am I decide it is safe to try and call a few people so I dial up Abby’s breeder, Nora. We haven’t taken Abby to Nora’s in a long time because whenever we gone somewhere we have always taken Abby with us.

Just for a little background, Nora owns about 10 acres of land, has a bunch of Labradors, as well as a variety of other dogs that occasionally hang out at her place and about a dozen or so Alpaca’s which she also breeds. So I call Nora and she informs me that she is currently at a seminar, she can take Abby but not until Sunday afternoon. Around this time, the contractions are starting to get a little closer, 6-8 minutes apart, and we were thinking that we are probably going to go to the hospital before nightfall. So I call one of our Allergy fellows who lives just a few blocks from us. She and her husband are the owners of Jake, a Labrador, Golden retriever mix that I wrote about here. She was out shopping for Fathers day but can be at my place in about 2 hours. Not a problem, I think we still have some time.

So now it is around noon and Boo Wife is having contractions almost every 5 minutes, her parents just arrived, and Abby is off to visit with Jake. Boo wife looks at me, I look at Boo wife and it’s clear that she wants to go to the hospital. So we load up the car and the parents are following close behind as we head in to the hospital. We get checked in to the evaluation area and they hook her up to the fetal monitor and we can see the contractions now occurring every 4-6 minutes and the fetal heart rate is normal with good accelerations (I’m trying to remember all of this from my Medical school years but so much has been forgotten). Anyway, the resident on call comes in and gets a brief history and exam. We had just seen her Obstetrician the day before and Boo Wife was only 2 cm dilated and 30% effaced. Well, she is 3 cm dilated and maybe 40% effaced. So the Doctor says we can leave or walk around for an hour or 2 and be rechecked. Boo Wife is a bit uncomfortable with the idea of going home and decides to stay and walk the halls.

It takes us 2 minutes to make one make it around the main hallway which means we have to walk around it 30 times to equal one hour. So to pass the time I start with the ‘hallway countdown’. 30….29….28…27…and so on. We make it to about 8 before Boo wife wants to take a break, so we head back to her room. All four of us, did I mention her parents were still with us, yes I’m sure it was an interesting site, a slightly distressed pregnant female being followed by two males and another female around a hallway for 45 minutes. So after a little break and a little more walking she gets hooked back up to the monitor. Her contractions have increased in intensity now and they are 3-5 minutes apart, so were thinking progress right? Well the Doctor comes back in and she is still 3cm dilated and perhaps 40-50% effaced. Again we are faced with the same decision leave now and return when things get worse or hang out and stay for another few hours. Again we decide to stay, walk, rest, walk, rest. Two more hours pass but now the contractions are bad enough that Boo wife is having trouble walking and is in more discomfort. Another check and she is still at 3 cm, the resident is not impressed but Boo wife doesn’t want to leave at this point. It seems like it is going to be a while and it is now around 5:30 pm so the In-laws and I decide to go grab a quick bite to eat while were waiting. There’s a Fatburger just across the street.

When we get back to the hospital Boo wife is still in pain and the on call obstetrician stopped by and told her that she needed to stay because her contractions were too strong and too close together and are now occurring every 2-3 minutes. So we decide to hunker down for the night and wait it out. Around 7:00 pm we finally reach 4 cm, that’s good news for Boo wife and the rest of us because it means we can move to the delivery suite, which is much larger, and after 14+ hours of contractions and a look of exhaustion coming over her, Boo wife can finally get an epidural and perhaps a little rest.

Anthony James

2008-06-12T22:19:00.006-04:00

I'm a little late in posting this and more details to follow, but on June 8, 2008 at 5:52 AM Boo Wife and I welcomed Anthony James into the world. Weighing in at 7 lbs 10 oz. and measuring 20 inches, he has more hair than his father. Now I need to catch up on a little sleep.

Dona Nobis Pacem

2008-06-04T08:36:00.005-04:00

Peace Globe movement, brought to my attention by Doctor Anonymous and Suture for a Living. An idea, started by Mimi Lenox, over at Mimi writes.

The BlogBlast for Peace idea is simple: To have as many people put globes like the one above on blogs around the world. There are various globes on Mimi's blog that you can customize yourself. Mine is a very simple cut and paste job but some are more elaborate.

Three of the many reasons why I want Peace in my peace globe.

edited post: forgot i needed to change the title of my post to dona nobis pacem. done.

Zoe

2008-05-27T14:15:00.002-04:00

I wrote about Zoë not too long a go in a post here. Yesterday we had to put Zoë down; it was a very depressing end to a rather hectic weekend. Zoë developed kidney failure and was pretty advanced when we took her to the Emergency Vet yesterday. I guess what is so frustrating to me is not having noticed the signs prior to things getting so out of hand.

After speaking with the vet yesterday and running through the last month or so in my mind I can recall filling the water bowl more often than usual. It was difficult to tell that she was not eating because we have two cats and we just leave the food bowl out and filled all the time. Over the last few weeks I noticed that her fur was becoming more matted and I just figured I wasn’t brushing her as much as I should, in addition she usually sheds a bit more in the spring anyway. She would still jump on my lap while I sat at my desk upstairs, although the last few days she didn’t. I would see her in her favorite chair sleeping so I didn’t think much of it at the time either. I also didn’t realize how thin she got until I picked her up this past Friday and felt her bones against my hands; she’s got so much fur you couldn’t tell from just looking at her. I told Boo wife that I was going to take her to the Vet first thing Tuesday morning but things just got worse this weekend. Yesterday she didn’t want to move at all and when I went to pick her up she started to cry out. Initially I thought maybe she had diabetes and things would get better with some insulin. The Vet saw the signs right away and blood work confirmed kidney failure. They say that fluid therapy can sometimes buy a cat some extra time, since kidney failure is typically always fatal, but Zoë had already lost so much weight.

I’ve had Zoë for 12 of her 13 years, her birthday was arbitrarily set in May because May is the month I brought her home from the Nashville Humane Society and they did not have a birth date for her. I think we bonded because of our similarities, often times scared of new things, sometimes more comfortable keeping to ourselves rather than being in a crowd, but very loving when we find the right people.

I will miss her.

Panda Bear MD's last post

2008-05-17T12:37:00.004-04:00

Photo Credit

There are days. Panda Bear, MD has decided to stop blogging, many will miss him, I know I will. I wrote of his blog not too long ago “Panda Bear's posts are long and he can be very opinionated and also cynical. Which is probably why I continue to read his blog. I may not always agree with him but he always provides a very strong and educated argument.” Based on his post he will be deleting his blog so these links will not work for long.

What I find unfortunate though is his view of his medical education and training, “Then there are days, fewer now then previously, when I look up from the petty humilities of working in the academic medical environment with the stifling egos, the petulance, and the sheer bad manners that are a hallmark of this kind of thing and swear that, if I had known the level of disrespect with which medical students and residents are treated, I would have laughed and thrown my medical school application in the trash….I doubt I am going to work at an academic medical center ever again, even as an attending. I have just had my fill.”

In a way I pity Panda for having to endure those encounters, on the other hand, someone with such strong opinions as his could certainly use his insight and perhaps become a force for change, though based on his last post it is doubtful that will happen.

I find it difficult to explain why some, so called educators, feel as though the best way to teach someone is by methods equivalent to those of a fraternity hazing rather than actual education. Perhaps one of the reasons that this fraternity culture of petty humilities, bad manners and big egos continues to thrive comes from people who go on to believe that since I was treated like shit as a medical student/resident, I am going to treat medical students/residents like shit in return. Perhaps it is propagated because no one really teaches us how to teach and this is what we were exposed to during our training so it must be the best way. I honestly can’t explain some people’s callousness.

Oh, don’t get me wrong; I have had encounters with this type of sad sack, worthless turd who feels that by diminishing those around him he can enhance his own self-esteem or insecurities, but believe it or not they are not all like that. The reason I chose to enter academic medicine is because of the many role models I encountered during my medical school, residency and fellowship program. Bright, intelligent individuals not easily swayed or down trodden by the frustrations that can occur with patient care, health insurance or lack thereof, or administration. They thrived in their environment and were willing, able and enjoyed their responsibility as educator, as researcher and as physician. I currently work with a group of academic physicians who are just as devoted as my previous mentors and role models. It truly is an environment that I have thrived in. I enjoy teaching and learning from the students, residents, and fellows that I have the privilege of working with.

I can also understand how medical debt can play a huge role in ones decision after training. There are some Medical schools working to change this by providing partial or full scholarships in an attempt to encourage and promote physician scientists. Will it work? Only time will tell, but it’s a start.

I consider myself lucky in that regard, I attended a State university both for my undergraduate degree as well as my medical degree and even though I incurred student loans, which I had to defer throughout my training, my level of debt was somewhat manageable at just under $60,000.

I’ve been linking to rlbates blog a lot lately so what’s one more time. For anyone considering a career in Medicine please see Ramona’s post titled “Words to Live By”.

As for Panda, his decision is made and his mind is set. I wish him well in his future endeavors and hope he finds his happiness. I will miss his wit, his humor and his observations of the human condition.

first patient tails

2008-05-15T17:01:00.001-04:00

I sometimes wonder how many physicians remember the very first patient they saw as an intern. I mean, we literally see hundreds of patients during our training and there are many which we will never forget, but do you remember your very first patient? I can only assume a surgeon might remember the very first patient they operated on even if it was a simple hernia, but in medicine it is typically not as dramatic. A ‘routine’ admission for heart failure or cellulitis isn’t the same as the first time you get to ‘cut’ someone.

I remember the very first patient I was assigned to as an intern. As a slight side, because my last name starts with a letter that appears very early in the alphabet, sometimes I get the short end of the stick when things are decided by alphabetical order. Such was the case with my very first rotation as an intern. Let me start out by saying that during this time in my life I wanted to specialize in the field of Hematology/Oncology. So I was quite happy knowing that my very first rotation as an intern was on the Heme/Onc ward (2 South was the designation in the hospital). Many a Senior resident warned me of the horrors of 2 South, but I dismissed them as people not interested in Heme/Onc as a subspecialty.

As fate, and my last name, would have it my first day on service was also my first night on call. This, on the other hand, actually did make me a little nervous. Especially since the Senior resident on Heme/Onc didn’t have to take call, a moonlighter typically covered the service.

Anyway, first day of service we meet for morning rounds and start out in front of room 201. “Dr. mark this will be your patient.” Said my senior resident. “I’m sorry to say he is a rather angry 58 y/o male with a history of HIV and CNS lymphoma here for intrathecal methotrexate therapy, recently complicated by a CNS infection.”

The resident knocks on the door and we enter the room. “Good morning Mr. Smith, this is Dr. mark, he will be taking care of you for the next 4 weeks.”

Before I could even get a word out of my mouth.

“God dammit, why can’t you people just leave me alone in the morning and let me sleep.” “I wouldn’t even be here if it weren’t for you people.” Said Mr. Smith, who also refused to be examined and ask us to leave.

As we exited his room the senior resident told us that 10 years prior he was hospitalized for a GI bleed. During this time he required several blood transfusions and that is how he contracted HIV. (To clarify, he received a blood transfusion at a time when routine testing for HIV was not being performed.) We continued our rounds and I was assigned probably seven or eight more patients but I honestly can’t remember the details of the other patients at this time, but I will never forget Mr. Smith.

I went back later that day to reintroduce myself to Mr. Smith. He was sitting up in a chair and his wife was also in the room visiting. He apologized to me for the morning and told me the reason he gets so upset is that he has trouble sleeping and the only time he gets really good sleep is early in the morning, but he gets disturbed by the tech coming in to weigh him and the nurse trying to get vitals before we round and then a bunch of docs knocking on his door, and isn’t there something I could do to help him out. We chatted a while longer and he asked where I was from, when I told him I grew up in Buffalo his eyes lit up as he asked me about the Buffalo Bisons. The Bisons, at the time, were the farm league for the Pittsburgh Pirates. Mr. Smith was a big baseball fan, loved to track the farm leagues along with the Pro teams. He told me stories of his youth playing baseball and growing up watching the Pirates. His wife later chimed in and commented that I look and act like their son Davey. I was embarrassed, but thanked her for the compliment; I assumed it was a compliment even though I didn’t know Davey.

Afterwards I went and spoke with his nurse, I asked if they could hold off on the weights and vitals until after breakfast. She looked at me with a slight scowl, knowing this was the first day of my internship, realizing she had been working as a nurse on this floor for 10 years, wondering why she should take an order from me on the very first day of my training. I took the time to explain the situation; I said that I would take full responsibility if the attending physician were upset. She scoffed a bit but seemed satisfied enough that she agreed and passed the word along.

During the next two weeks of his hospital stay we never rounded on Mr. Smith in the morning, but I would update the resident and attending in the early afternoon and once in a while the resident would go with me to see Mr. Smith. Surprised by the perceived ‘sudden’ change in his demeanor and wondering what I had done. Not much really, I just let him sleep in the morning.

The day of discharge his wife gave me a big hug and Mr. Smith gave me a firm handshake. They told me they grew their own vegetables in their garden at home and wondered if they could bring me in some when he came back to the office for his infusions, how could I refuse? Several weeks later I received a page from a nurse telling me that Mr. And Mrs. Smith are here and they have something for me. I made my way to the outpatient clinic area and was greeted with a bag full of zucchini, tomatoes and cucumbers. I was also happy to take a little break from the wards and sit and chat about the baseball season.

A few weeks later another page, I promised I would be up but instead became tied up with the scut work that is internship. By the time I finished what I needed to get done it was too late to see them. They left the bag of vegetables sitting at the nursing station with my name on it.

Several more weeks pass by and it is now late fall, past gardening season in the Northeast, and I hadn’t heard from Mr. Smith in a while until one day a fellow intern stopped me in the hall and told me that he was readmitted to the hospital and Mrs. Smith asked about me. I went up to his room; he had suffered several seizures at home and was admitted to help get them under control. We talked about the Pirates again; they finished first in the national league but were defeated by the Atlanta Braves in the first round of the playoffs. Barry Bonds had a decent year with 25 homeruns. He was frustrated by the fact that the anti-seizure medication he was taking was making him feel even more fatigued. Both he and his wife knew things weren’t going well, but he wanted to get out of the hospital and get back to his own home and bed, frustrated again by the many early morning awakenings for blood draws and vitals. I wasn’t around when he was discharged but heard the news from a colleague that he was sent home a few days later.

It was two months later that he was readmitted to the hospital now with mental status changes. I was rotating at the VA hospital when a good friend called me to tell me he was on their service. I knew this person well and was happy in a way because he was a very good intern. He told me the poor prognosis and mentioned that they had begun discussing comfort measures. It was several weeks later that I was told of his death.

I was frustrated and angry with myself for not going to visit him or his wife at the time of his readmission. I called his wife a few months later to express my condolences. She thanked me for all my help, to this day I recall that I did very little to help other than to make some changes in his morning routine and to sit, listen and talk. I am reminded of Dr. Dino’s first law “The Art of Medicine consists of amusing the patient while nature takes its course.” This law holds true, even more so, for patients with a terminal illness.

I have seen thousands of patients since that time, some I will always remember, and some I barely remember. If life were measured in minutes instead of years, during our training we enter most patient’s lives for only fractions of a second, but sometimes that is enough to make a difference both in your own life and the patients.

tails of being overwhelmed

2008-05-13T15:13:00.006-04:00

The last few weeks have been a bit overwhelming for me, overwhelming in a good way that is. A few week s ago was Boo Wife’s Baby shower. Planned and arranged by Boo Wife’s Mom, and several of her friends, including Kelly who was also Maid-of-Honor for our wedding and Jessica who made most of the food. Luckily my father, father-in-law and I were excused, so we headed to a new Irish Pub close by and had a bit of lunch and a pint or two of Guinness. Upon returning I was completely overwhelmed at the generosity of Family and friends. I don’t know of any other words I can use to describe it, nor am I prolific enough to put down into words how both Boo Wife and I felt. Two cars were needed to pack everything up for the trip back home, and we have been sorting through, washing clothes and putting things together since.

I assumed that would be enough but it was not. My friends and colleagues in the Allergy department threw a surprise shower for ME this past week. Planned perfectly, Boo wife was in on it but everyone kept it a secret from me. I assumed I was heading over to the department for one of our Staff Meetings but was honestly shocked when I opened the conference room door and heard a resounding “SURPRISE!” and saw practically our whole department sitting there along with Boo Wife who had a giant grin on her face. As a slight aside, we finished our interview season for our 2009 Allergy/Immunology fellowship class. During the interviews many candidates will ask, “What are the strengths of your program?” We talk about our well-rounded education, our patient population etc. But we also mention our people. We work in a fairly large A/I program compared to others but there are no big ego’s here, everyone gets along, and our ancillary staff is and always has been superb. That, quite simply, is the truth.

Finally, after packing up the car once again and heading home I noticed, sitting on our doorstep, another package. RLBates over at Suture for a Living promised to send us one of her handmade quilts. I was truly honored and overwhelmed by her generosity. It is a beautiful quilt and was sent with a very touching card as well. On one-side footballs, baseballs, and soccer and tennis balls provide the border. Inside are horses and trucks. The other side is a variety of blue fabrics with stripes of airplanes. Thanks Ramona, it is wonderful.

I am truly blessed with a great family and tremendous friends both inside and outside my work environment. Thanks to you all!

Tagged by Midwife

2008-05-05T09:25:00.004-04:00

I was tagged by Midwife with a Knife for the six word memoir meme. This is my first meme and although I am thrilled to participate I am not sure I can come up with 6 people to tag. Anyway, one of the blogs is from a friend of mine who hasn't blogged in a while, Jamye and Jon at "That's Right we're not from Texas", I'll see if gayCMEguy takes the bait at "RANdom thoughts", and although cyberkitten is on vacation maybe "Seeking a little truth" will respond when he gets back.

Instructions: write a 6 word memoir and then tag 6 others.
So if you think my memoir is a cop out then I'll try another but...
"All that wheezes, is not asthma"

OK that is a cop out how about this one:

"Make mice wheeze to help others"

Common Variable Immune Deficiency (CVID)

2008-04-25T11:39:00.003-04:00

Photo Credit

I decided to post on this topic for several reasons. The first, I run a review of immunology topics with our Allergy/Immunology fellows and we are covering the Primary Immunodeficiencies this week. The second, although I only have clinic once a week, every week for the past 5 weeks I have had at least one patient referred for evaluation of immune deficiency. The third and final reason is that Gay CME Guy had a recent post in which he describes his lobbyist experience in Washington, and unbeknownst to me, he has CVID and he was lobbying for better coverage for patients with CVID.

The typical response I have to my patients when they ask about CVID is to first go over the name. It is called Common because it is common with an estimated prevalence of 1 in 25,000 to 1 in 100,000, making it the most common form of severe antibody deficiency. (IgA deficiency is the most common immunoglobulin deficiency with a frequency as high as 1 in 333 but typically these patients do not have trouble with infections like CVID patients do.) It is variable because of the variable presentations and associations, and it is an immune deficiency, well, because it is an immune deficiency.

The quick and dirty characterization of CVID is as follows;
-Patients will have markedly reduced serum levels of IgG and low IgA or IgM.
-Patients will have recurrent bacterial infections.
-Patients have impaired antibody responses despite the presence of B cells.
-Most patients (60%) have normal or near normal T cell immunity.

Interestingly, the molecular defects of many of the primary immune deficiencies seen in children have been well characterized, however the cause of CVID remains elusive. Because it is a heterogeneous disorder it has long been thought that there are probably a variety of gene defects that can lead to the same phenotype. This has proven to be true since over the last 5 years 4 different genetic defects have been identified in patients with CVID but it still only explains the cause in a small percentage of patients.

The age of onset is typically after puberty but before 30 years of age, but the time to diagnosis is often delayed. One of my recent patients is 52 years old and has been suffering from frequent upper respiratory infections since her late teens. She was sent to me after a recent bout of pneumonia complicated by a parapneumonic effusion. Her Pulmonologist ordered Immunoglobulin levels and found that they were almost completely absent.

Patients with CVID are prone to infections of the upper and lower respiratory tract (sinuses and lungs) by encapsulated bacteria such as Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

IN GENERAL, if an adult has 4 or more upper respiratory tract infections per year, has ever had 2 consolidated pneumonias in one year at any age, or an adult with a documented Otitis media you should consider sending immunoglobulin levels to start the work up for CVID. Because children are more prone to URI’s and otitis the recommendation for children is greater than 10 URI’s per year.

Infections can be acute, chronic or recurrent and include things already mentioned such as pneumonia and sinusitis but also may include bronchitis, conjunctivitis and otitis media (NOT otitis externa or swimmers ear). Other less common presentations/infectious complications include bacterial meningitis and sepsis.

Sending immunoglobulin levels is a good screening test but when evaluating a patient for CVID we also want to obtain a functional assessment. Can the patient make his/her own antibodies when challenged? As with any test in medicine the ‘normal’ levels are true for the majority of the population but there are people who can have higher or lower levels and still be perfectly normal, low levels of IgG or an IgG subclass deficiency by itself cannot establish a diagnosis of CVID. To accomplish this we measure antibody titres to things such as tetanus and diphtheria (protein antigens) as well as titres to the pneumococcal bacteria (polysaccharide antigens). We can then vaccinate the patient with a Td vaccine (tetanus/diphtheria) and Pneumovax and repeat the test in 4 weeks to assess the response to the vaccines. If they are able to produce antibodies in response to the vaccines then their immune system is intact, if they do not make antibodies and meet the other above-mentioned criteria, then this is consistent with a diagnosis of CVID.

Treatment involves replacing the deficient immunoglobulins. Intravenous immunoglobulin therapy sometimes abbreviated IGIV although I still call it IVIG is the mainstay of therapy in these patients. It is typically given every 3-4 weeks and dosed so as to maintain trough levels of immunoglobulins in the 400-500 mg/dL range. If a patient receives it as an IV infusion then this typically involves going to a clinic or hospital with infusion services. This can take at least a half and sometimes a whole day. The alternative is to have a visiting nurse come out and start the IV and set up the infusion in the home setting. Another alternative is subcutaneous Ig. Subcutaneous Ig is given on a weekly basis, thus levels are more consistent. Initially patients are taught how to mix and set up there infusion by a visiting nurse. Once the patient understands he/she can then perform it on his/her own time. In addition these patients can typically walk around perform other tasks while the drug is being delivered. Other benefits from the subcutaneous route are that there seems to be less associated side effects with this delivery system. IGIV patients can develop fever, chills, or back pain during the infusion, often these patients are premedicated with acetaminophen and/or diphenhydramine to prevent these side effects, with subcutaneous dosing these side effects are greatly reduced. I had a recent patient who developed an eczematous skin rash after each Ig infusion, it is a rare side effect, and at first I was suspicious but it worsened after each infusion and improved prior to the next infusion only to flare again 24-48 hours after the infusion. We were able to switch him to subcutaneous delivery and his symptoms improved dramatically.

IGIV is not a cure however; patients with CVID still need close follow up since even with therapy they are at higher risk for infections. Patients with CVID are also at higher risk for developing autoimmune disorders such as auto-immune hemolytic anemia, as well as being at higher risk for certain malignancies such as lymphomas. In addition, many tests that we use in medicine to diagnose disease or illness relies on the presence and or measurement of antibodies, this is especially true of many Rheumatologic disorders. These tests become invalid or useless in patients with CVID both prior to therapy and after starting therapy with IGIV.

REFERENCES:

Castigli E, Geha RS. Molecular basis of common variable immunodeficiency.
J Allergy Clin Immunol. 2006 Apr;117(4):740-6; quiz 747. Review.

Di Renzo M, Pasqui AL, Auteri A. Common variable immunodeficiency: a review.
Clin Exp Med. 2004 Apr;3(4):211-7. Review.

CVID at Immunediseases.com

NIH info and references

baby tails part 2

2008-04-22T16:29:00.006-04:00

If you have read the comments from the previous post then you already know. Sure back in the good old days it was a surprise and there are many 'old wives tales' about predicting the sex of the baby. But let's face it, they have a 50/50 shot at being right, right? Those are pretty good odds.

Anyway, we decided to find out the sex and though the odds of the ultrasound being incorrect is less than 1-2%, it as close to a 'sure thing' as we're gonna get. Boo wife was confident we were having a girl. So confident was she that we didn't even have a boys name picked out. Even after one of her Mother' s (and our) friend did the 'needle reading' and predicted it would be a boy.
Just to orient you, the ultrasound pic is as though the baby were sitting on top of a glass table and you are underneath looking up.

baby tails

2008-04-15T14:41:00.006-04:00

Boo wife posted about this long before I felt comfortable. Since our miscarriage last year it seemed as though we should have invested in home pregnancy tests. The bottom pregnancy stick in the picture above was originally thrown out, but something caused Boo wife to go back and take a look. Low and behold a faint line had appeared. At first I blew it off because it had been sitting around for so long but the next day (middle stick) the line got a little darker and a few days later (top stick) darker still.

We are now 30 weeks along and things seem to be going well. Below is the shirt I had made for her as one of her Christmas gifts.PS: My father had giving me a hard time in the past about the phrase "the wife", I never thought much about it till recently. Anyway, Boo is a pet name we have been calling each other since we started dating, I think we started using it as a short cut to Bubala.

More updates a little later.

A Fool's tail

2008-04-01T10:10:00.004-04:00

Photo Credit

Check out the video at the above link as well

This has been floating around the internet for several years now but it is still very funny to me. I believe it is creditied to David Letterman's Top Ten List. But I have seen different versions of the number one reason. So in the spirit of April Fools Day, I will post them both.

Top 10 Polite Ways To Say Your Zipper Is Down, by David Letterman

10. The cucumber has left the salad.
9. Quasimodo needs to go back in the tower and tend to his bells.
8. You need to bring your tray table to the upright and locked position.
7. Paging Mr. Johnson...Paging Mr. Johnson.
6. Elvis has left the building.
5. The Buick is not all the way in the garage.
4. Our next guest is someone who needs no introduction.
3. You've got a security breach at Los Pantalones.
2. Men may be From Mars...but I can see something that rhymes with Venus.

And the #1 way to tell someone his zipper is unzipped.....
1. I always knew you were crazy, but now I can see your nuts.

Alternate
1. You've got your fly set for "Monica" instead of "Hillary".

The Power of Placebo

2008-03-28T11:20:00.006-04:00

Photo Credit

I saw a sweet LOL (little old lady, not laugh out loud) in clinic this past week. She was referred by Cardiology for possible aspirin desensitization. Desensitization to a drug is a procedure in which an allergic individual is exposed to gradually increasing doses of the drug (allergen) in order to inhibit their allergic reactions. Once full dose is achieved, without any untoward effects, the patient is considered desensitized. The problem is that the desensitization is maintained only as long as they stay on the medication, once it is discontinued for a period of time they will need to go through the desensitization process all over again if that medication is ever needed again in the future.

As you might suspect she has significant coronary artery disease (CAD) and was to undergo a cardiac catheterization and possible stent placement due to her history of unstable angina. Aspirin is a good thing for people with CAD, and in the appropriate patient, aspirin desensitization is fairly straightforward. But here is where it also gets confusing, aspirin can cause of myriad of reactions not all of which are allergic and most of them are not amenable to desensitization. From an aspirin standpoint the only people we can really desensitize are those with a condition known as Aspirin Exacerbated Respiratory Disease (AERD), it also used to be called aspirin sensitive asthma, or aspirin induced asthma but those terms have fallen out of favor. Rather than go into the details of AERD I will tell you that my LOL did not have this condition. However, after taking a good history, which is 99% of the issue when trying to figure out true drug allergies from side effects or intolerances, I was convinced that she did not have an aspirin allergy at all. She, on the other hand, was still very skeptical.

She reported being evaluated by an Allergist back in the 1960's for chronic urticaria. She told me that the Allergist told her never to take aspirin as it could kill her. Pretty powerful words if you ask me. She never recalls taking aspirin prior to this nor has she taken any aspirin since. In addition she has a history multiple drug 'allergies', most of which turn out to be intolerances when I asked about them in more detail. The kicker in all of this though is that she admits to taking Ibuprofen, one 200 mg tablet every other day for her arthritis. She can' t take more than this as it upsets her stomach. In many instances of true aspirin allergy there is cross reactivity between aspirin and other NSAIDS such as ibuprofen, the fact that she did not die when she took ibuprofen made it much less likely she would have a true aspirin allergy.

So, there is no skin test or blood test available to prove or disprove aspirin allergy, the only thing we can do is an oral challenge, or what we call a graded dose challenge. Just to clarify this is NOT the same regimen we use for desensitization, this protocol is used in patients with a low likelihood of reaction. We start with one half tablet of a baby aspirin (40.5 mg), and increase the dose each hour as tolerated, next dose is one full baby aspirin (81 mg), then 2 baby aspirin (162 mg), then one adult aspirin (325 mg). Of course our clinic is well suited and experienced in treating allergic or anaphylactic reactions if one were to occur.

When I saw her the day of the test I realized she was still very apprehensive about the whole thing, despite my many reassurances. Heck if someone told me I could die from taking an aspirin I guess I would be to. Because of this I decided it would be best to give her a placebo as her first dose. Since we often do oral food and drug challenges we have a stock of empty capsules which we can fill with any number of items. The nurse placed a little bit of sugar in and closed the capsule. My patient inspected the capsule very closely and asked how much aspirin she was receiving.

The nurse replied, 'Let's not worry about the dose so much as getting through the test.'

Thirty minutes later I received a page, while seeing another patient, that my LOL was complaining of throat tingling and lip swelling. I went and examined her, no visible change in her appearance, she also looked very comfortable and spoke clearly to me. I then proceeded to inform her that there was no aspirin in the first dose and explained why. I told her the importance of trying to distinguish between a true reaction and one that occurs because we are nervous about the test.

She said to me, "Is that what you call a placebo?" I nodded yes and asked if she wanted to continue.

I'm happy to say that she made it through the rest of the oral aspirin challenge with nary a peep and tolerated a full dose without any problems. As I came by to discharge her she looked at me and said. "Now you're going to say 'I told you so'."

No, my new favorite LOL. I simply said "I'm honestly happy that you are able to tolerate aspirin and wish you luck on your upcoming procedure." Of course, in the back of my mind, I was very thankful that I was correct in my initial assessment of her risk.

Tails of words and writing

2008-03-26T14:02:00.009-04:00

Photo Credit

I've come to realize that my blog really has no focus what so ever, although I guess that is the way I want it since I describe it as "some ramblings, the occasional rant, little stories, and sometimes even some useful information that make up everyday life".

Writing has always been difficult for me, I tried to help myself along by taking a writing course in college but didn't do so well there either. Now a days writing is more of an inertial challenge. By that I mean it just takes a great deal of effort on my part to actually sit down and start writing, whether it be a manuscript or a grant or even my blog. Part of the reason I started this blog was the hope that I might improve my writing abilities. I'm not sure that is going to happen though since no one is willing to correct my entries or offer advice on creative writing. However it was this type of feedback that taught me how to write in science.

I recall writing my first Grant application over 12 year ago, it was actually just a small proposal, only supposed to be 5 pages long. Most grant proposals start with a brief introduction or abstract in which you describe the work you are doing, why it is important, and the hypothesis you will be testing. This is typically followed by a slightly longer introduction, describing past work and building up to the still unknown questions in the field that you wish to answer. Then comes your preliminary data supporting your hypothesis and finally the experiments and methods you are going to use to test your hypothesis and answer your questions.

My very first draft of this 5-page proposal was a mere page and a half. When I turned it in to my Principle Investigator (PI) or mentor, he looked at the 'rough draft' and said "You're going to have to write more than this you know." He went over it with me and needless to say there was a lot of red ink, as well as exasperated looks, the occasional heavy sigh, and a few words muttered under his breath that were sometimes loud enough for me to make out. Even without the audible curses his demeanor was readily appreciated. This interaction was repeated on numerous occasions as I would go back and address the issues he brought up, read some more, write some more and then he would correct some more. This same pattern occurred when I wrote my first NIH grant with him as well as the several manuscripts we worked on together. All in all it was a very frustrating process for me as I am sure it was for him. But I learned more from those interactions than I learned in any writing class I took. I learned how to write a scientific manuscript, or a grant. I learned how to frame questions and hypothesis. I learned how to tell a story with the data rather than just reciting the data. Believe it or not even my PI mentioned to me, on one occasion, that he noticed an improvement in my writing style over time.

I am certainly NOT a creative writer and I can't wax eloquent like Sid Schwab at Surgeons blog or describe a snippet of life with the humor that Danielle can over at 6 year med, and I realize sometimes I have trouble with syntax or even misspellings as was pointed out when I mixed up complimentary and complementary recently. On the other hand this is not what I do to make a living, writing grants and manuscripts is. While I doubt this blog has made me a better writer it has helped me get over some of the inertia difficulties I've had in the past about getting started.

One of the useful tools my PI passed along to me was his "Lexicon of GOOD and BAD words and phrases". I still use it today when I write a grant, a manuscript, or even for speaking. I have passed copies along to my colleagues and fellows in training who are in the process of writing grants or manuscripts. When I am asked to review papers or grants for my colleagues I remember the interactions I've had with my PI, and really attempt to offer constructive criticism and comments in a non threatening manner but still using the style and techniques taught to me by my PI and mentor. I like to think I succeed, as many of my colleagues comment on my helpfulness. So below is the brief list, the lexicon of good words and bad words in science.

YES ..............................NO
Investigate------------------Explore (sounds like a fishing expedition)
Infer-------------------------Consider (as in we will consider doing)
Conclude--------------------We think
Will--------------------------We would like to (to indecisive)
Propose----------------------Look for, Look at
Determine-------------------Do
Measure or Quantitate-----See
Observe----------------------Hint
Perform----------------------Prove (few things in biology are fully proven) see post on theory and facts.

Very simple, very straightforward but what a difference it makes when one word is used in place of the other.

Words -- so innocent and powerless as they are, as standing in a dictionary, how potent for good and evil they become in the hands of one who knows how to combine them.
-Nathaniel Hawthorne (1804-1864)

More Dog tails

2008-03-19T09:32:00.003-04:00

Photo Credit (me)

The dog has played such an important role in human history. Thought to be the first animal invited into the household of humans, they became an invaluable tool for early man.

Breeding dogs for specific traits was thought to occur very early on when dogs were used for hunting and protection. This increased tremendously in the 1800's and early 1900's and dogs are probably one of the most divergent species on the planet due to human selective breeding. In fact the discovery of a single gene responsible for dog size was recently published in the Journal Science last year.

In addition to size, specific traits were bred for in many of the working class dogs, all of these traits relate to their innate predatory behavior, scent and sight for tracking and detecting prey, speed and agility for running down prey. A great example of this hunting behavior can be seen in herding breeds such as the Border Collie which perform all aspects of predation except the kill.

Most people have a soft spot in their hearts for our pets and companions, and most of us, even if we don't own or even care to have a pet, are often amazed at the things they can do to help other humans. I'm writing this because of a recent story on ABC news about how a Dog helped an Iraqi Vet suffering from Post traumatic Stress Disorder regain his life. A service provided by Puppies Behind Bars. A service which utilizes prison inmates to train guide dogs which not only benefits the recipient of these Service dogs but also the people raising them.

How cool is that?