Taking a walk with A is like trying to control Brownian motion. His path is so random. He'll walk down the walkway from our home, turn the corner and walk along the sidewalk, circle a fire hydrant and some street posts, then walk up and down driveways and walkways of our neighbors' homes. Okay, so I guess it's not totally random, but it certainly is nonlinear. It might take 30 minutes just to get to the corner and back (which should normally take about 5 minutes).

Tags: A

This is a rare, multisystem disorder that generally occurs in males younger than 20 years of age. There is a classic triad of mouth ulcers, genital ulcers, and uveitis. Focal neurological deficits may also be present.

Lab results usually show elevated ESR, and nonspecific changes on biopsy.

Treatment choices include corticosteroids, dapsone, colchicine, azathioprine, cyclosporine, and chlorambucil.

I just placed an order for a few custom calendars from Shutterfly.com (that were free with certain purchases from Amazon.com in December - they are expiring at the end of January). I noticed that they currently have a tiered sale going on until February 5, giving you an instant discount up to 25% off your order, depending on your order total:

$15-$19.99: 15% off
$20-$24.99: 20% off
>$25: 25% off

Don't forget to also use the free shipping code AF31-SHIP on orders over $30 (I posted it on my Shopping Resource page). That expires February 5 as well. And, if you use an American Express card, you can save an additional 20% with the code AC20-AMPX.

I just spent $50 on three 12-month calendars and five 26-page snapbooks (stuff for the grandparents too), shipped. Not bad, considering Shutterfly has pricey shipping. I got two calendars for free, and saved $60 off the rest of the items.

I like to send a bunch of photos to the grandparents before I start a string of busier months (coming up soon, mom), so in case they don't hear from me in a while, they've got lots of photos to look at. I usually buy regular prints at Costco.com but because I had the promotional calendars, I decided to do it all in one place this time. Plus, the snapbooks look neat (spiral bound prints), so I though we'd try them out. And, of course, I wanted to have one for myself, to peek at on the wards.

Tags: photography

There was a time early on when M was little that we thought that having an only child would be just fine. Soon after he turned one, I knew that I wanted my children to have siblings. J and I would play with M, but it's nothing like it is when the boys play together now. And now that they are playing together more every day, it's become obvious that the best gift I could give them both (at least right now) is each other. Now if I only had time to raise a puppy too. Gosh, that would be cuteness overload. Wouldn't that be a disaster riot?

Tags: M, A

We recently took the boys to a park with a petting zoo, where they enjoyed being up close to the animals. A was fearless, despite being around some aggressive goats (it was early morning so they were hungry). M was more cautious, preferring to toss the food near them rather than have them eat from his hand. It's interesting to see the differences in their personalities at such a young age.

It was a bit drizzly, so the park wasn't crowded, which was really nice. The boys loved wearing their rainboots too. It was a really cold day. While I always dress the boys in layers, I often forget to dress myself appropriately. After living in California for so long, my standard outfit is pretty much a t-shirt and casual pants. And a jacket thrown on top if it is chilly. The temperature has been dipping into the 30s and 40s lately, so it's been cold, even for me.

Tags: A, J, me, M

For a previous photo of M on the train, click here.

Tags: A, me

We're playing this game again.

Tags: M

A simple, inexpensive method to assess the degree of vascular insufficiency in peripheral vascular disease. It is calculated by measuring the resting (and post-exercise if necessary) systolic blood pressures in the ankle and arm.

The highest of four measurements in the ankles and feet (posterior tibial and dorsalis pedis arteries) is divided by the higher of two brachial artery measurements.

Normal ABI ratio is 1 - 1.3 (pressure is higher in the ankle than the arm). Values > 1.3 suggest a noncompressible, calcified vessel.

ABI < 0.9 is associated with at least 50% stenosis in one or more major vessels.

Specifically,
0.4 - 0.9: arterial obstruction, claudication
< 0.4: advanced ischemia

Tags: A, J

A little while ago, we all went to our friend Isabella's second birthday party, which was held at Chuck E. Cheese. I haven't been there in about 20 years, so it was interesting to see what it was like from an adult's perspective. Noisy and chaotic! And I don't know if they are all like the one near us, but it seemed a lot smaller than I the one I went to as a kid (but I guess I'm quite a bit bigger now).

In any case, after the party, J and I realized something in common about all the guests (parents) at the party - they were all residents or attendings (I was the only student). I have never been around that many doctors at the same time (other than being on the wards, I mean). It was a weird experience, particularly since nearly every field in medicine was represented. Isabella's parents are both graduates of my school - her dad is a plastic surgery resident, and her mom is an internal medicine attending (and expecting a second girl soon - congrats you guys!). The other guests consisted of residents and attendings from: pathology, anesthesia, neurosurgery, radiology, pediatrics, urology, endocrinology, psychiatry, and cardiology. And there were more, but I can't remember them all. Little did the other Chuck E. Cheese patrons know that if anyone had a medical emergency there, they would have been covered.



Here's the birthday girl blowing out her candles:


I think the boys had a good time, even though they were a bit skeptical about the giant animatronic mouse:


Chuck E. Cheese school? I wonder if it's a party school.

Tags: A, J, M, me

This is an X-linked immunodeficiency disorder which presents with eczema, thrombocytopenia (bleeding), and recurrent otitis media. There is an increased risk of lymphoproliferative disease.

Patients have increased levels of IgE and IgA, and decreased levels of IgM. They get recurrent infections from S. pneumonia, S. aureus, H. influenza Type B, CMV, PCP, and HSV.

Treatment is supportive (IVIG and antibiotics), and patients frequently die of hemorrhage from the thrombocytopenia (rarely survive into adulthood).

Tags: M

Used to evaluate immediate health status of a neonate (not a predictor of health). Five parameters are measured and scored at one and five minutes after birth for a maximum score of 10 points. It is repeated at regular intervals if the scores are low (<3). Scores above 7 are generally considered reassuring.

Each parameter is given a score of 0-2 points (see below). There are several mnemonics to help you remember the parameters, but this is the one that I favor:

Score: 0, 1, 2
Appearance (color): blue, extremities blue, pink
Pulse (heart rate): absent, <100, >100
Grimace (reflex irritability): no response, grimace when stimulated, pull away when stimulated
Activity (tone): none, some flexion, active movement
Respiration: absent, weak or irregular, strong

It's what happens when you pile a bunch of pillows and blankets in the middle of the living room floor. Just for fun.

Tags: A, M, me

McCune-Albright syndrome (MAS), is a genetic disease also known as familial gonadotropin-independent precocity. It affects the bones (fibrous dysplasia) and skin (cafe au lait spots), and causes precocious puberty, particularly early menarche in females.

MAS is believed to be caused by mutations in the GNAS1 gene. While there is no specific cure, it should be treated with drugs that inhibit gonadal steroidogenesis or gonadal steroid action to preserve fertility.

In girls, tamoxifen and bisphosphonate pamidronate have been shown to be helpful. Boys have been treated with ketoconazole (inhibits androgen synthesis), or a combination of spironolactone, (inhibits androgen action) and testolactone (blocks the conversion of androgen to estrogen), with good results.

Complications included broken bones, cosmetic bone deformities, blindness/deafness (pinched nerves as a result of bone deformities).

I know, I'm a lucky gal.

Tags: J, M, A

See? We do did stuff.

Tags: J, me

As promised, here are the photos that show A's expression when they boys ride into each other. Such a dramatic little boy, isn't he? I think it's funny how M appears as though he is totally minding his own business, when he probably steered his car towards A to begin with.

Tags: A, M

Classic triad for cardiac tamponade.

1. decreased arterial pressure (hypotension)
2. distended jugular veins
3. distant heart sounds

This one always cracks me up.

Tags: M, toys

Sleepytimestore, which is my main source for Barefoot Dreams and Little Giraffe blankets (which make great baby gifts, by the way) is having a 20% off sale on Barefoot Dreams stuff (a decent discount, since these don't go on sale that often - and hardly at 20% off). Just use coupon code 20Dreams during checkout. Sale ends Sunday, January 20th, at midnight EST.

Tags: clothing, gear

Click here if you missed Part I.

Okay, let's review. Where is your nose?


How about your eyes? And your goldfish cracker too - does it have an eye?


And M, can you show me your head and your nose?

Tags: A, M

I previously mentioned that A has a few words. His vocabulary is growing every day, and he tries to mimic almost everything he hears. This photo is from several days ago (we've taken down the tree).

Here's a short list of words (that are used in appropriate context): ball, bubble, more, milk, yeah, dog, bird, uh oh (now it sounds more like ah oooooo), row (as in boat).

In addition, he can make lots of animal sounds, including: moo, quack, roar, brrooooo (elephant), neigh, and goldfish sounds. And we can't forget the airplane and train sounds.

I know he can understand more than he can speak, since I can pretty much talk to him in full sentences and he can follow basic instructions (take off your socks and come to the tub or come lie down here so I can change your diaper).

Tags: A

Earlier this month (on New Year's Day, I believe), I bought a whole bunch of clothes for the boys from Old Navy. Mostly long sleeve tees, thermal shirts, zip-up hoodies, knit pants, some pajamas and a lot of socks (you can never have enough socks). I think I bought something like 40 items for about $130 shipped, which comes out to just over $3 a piece. I even picked up a pair of pants for me and two polos for J (they have tall sizing, which is a plus). Some of these were for the spring, but most of the items will probably be washed and stored away for next fall (I picked up mostly 3T and 4T sizes). With two boys in daycare, we need a lot of practical, inexpensive clothing. They're so messy at the end of the day, and often have to go through a couple of sets of clothes if they get wet during the day (particularly if they splash in rain puddles). Most of the items are 100% cotton jersey, which is great for them since they have to spend the whole day in them, including naptime (I hate falling asleep in denim, and I imagine they would too).

I lucked out, actually, since Old Navy started their huge winter clearance sale this past Friday, marking down everything even more. And their policy is to do a one-time price adjustment within 14 days of your purchase, so all I had to do was email customer service, and the very next day (a Saturday!), I got an email stating that over $30 would be credited back to my card. Wow, what an unexpected surprise.

I have to admit that in the back of my mind, I have worries about how inexpensive the clothes are (where are they coming from and who is making them?). I know I am putting a lot of faith into the Gap corporation to make responsible business decisions. It's tough to only purchase approved eco-friendly, socially-conscious clothing, especially given our financial situation. Hopefully, in the future, we'll be able to do a better job directing where our money goes.

Tags: clothing

This is a great series of soft books by Roger Priddy for the youngest of readers. We've actually got several of them but "Squishy Turtle and friends" is a household favorite. Book Review

Tags: books, Amazon

We went to a local shopping center for brunch last weekend and brought along some ride-on toys for the boys to play with afterwards (it's a large outdoor area). I think we need to find something a bit bigger for M, since the Big Bobby car is looking a bit small (it was technically A's first birthday present). The other ride-on was a present to M from my brother a few years ago and is still going strong.

You can only see M's face in this photo, but if you were able to see A's expression (I'll post some photos soon), you'd see him squawking out of frustration that he can't back up his car. You see, rather than going around each other, when the two of them bump into each other, A gets frustrated that he can't move. And M just thinks that is plain funny. Those guys are too cute.

I love how they play together now, even though they occasionally scuffle over toys. Being in daycare has helped them learn how to take turns, and now even A understands when I tell him that he has to be patient because M was playing with something first. Since M is used to waiting his turn, he's usually pretty good about waiting his turn, although sometimes he complains that A has been playing with a toy for a long, long time (which can be as short as two minutes).

Tags: M, A

A has learned several of his body parts, and he loves to point them out on himself (and you, if you're within arm's reach). Here he is demonstrating, with Snowy assisting. When you ask him where his eyes are, he squints, which is pretty hilarious.



And here he is showing us where his head is.

Tags: A, me, grandparents

A classmate forwarded this article to the class list. It's a CNN Money article that basically tells the story of two young physicians (residents) who are trying to get by, given the hundreds of thousands of dollars they are in debt as well as their relatively meager resident salaries.

Without going into too many details, I can just say that we can totally empathize. Jason easily has about a quarter of a million dollars in debt from medical school (with interest accumulating), and mine will also amount to a hefty six-figure sum. Currently, we are living off of one resident's salary (okay, a fellow, but they don't get paid any more than an equivalent-year resident). And unfortunately, we live in an area where the cost-of-living is pretty astronomical.

To give you an idea, our on-campus rent (that reminds me, I still have to explain why we moved to a different place in October) cost more than their mortgage payment. And we have daycare costs that approximately double the cost of that on-campus rent (no joke). We can't afford our current lifestyle (we can't even cover rent and daycare with our income) so I am borrowing tons of money for the rest - food, diapers, toys, clothes, you name it. I know how lucky I am that someone (school and the government) is willing to lend it to me, because there'd be no way I could do this otherwise. We are certainly lucky in many ways, even if we are incurring a lot of debt. We rent an old, very small half of a duplex in a safe neighborhood, and we live fairly comfortably (the boys certainly have a lot more toys and books than I did as I kid). We splurge on some things, and save on others (our clothes cost less than the kids' clothes). I cook three or four times each week, saving leftovers for lunches, and we take out or eat leftovers on the other nights. We haven't taken a real vacation since our honeymoon (and even that was on a tight budget). Scratch that, I guess Disneyland was a mini-vacation (road trip).

In any case, you probably get the idea. I could easily go on and on about the hardships (real ones) we've endured to get where we are, but I'll spare you the boring details (plus, I should probably study). We're certainly a lot better off than many people, even though it does feel like we're drowning in debt sometimes. I know a lot of people who often call themselves broke, but as a rule, I've always been careful when using that term, since in my mind, broke doesn't mean you can't afford a cellphone or a new car - broke means having $2 in your bank account and sleeping on your friends' sofa. And while I've fortunately never been broke, during my younger years, my family has certainly come close. Growing up poor certainly gives me an interesting perspective about finances.

I realize that we won't get much sympathy since we're both going to be physicians and all, but it certainly wasn't without a lot of sacrifice, for a very long time. Neither J nor I come from families who are in any position to help financially, so we are pretty much on our own. In fact, I daresay it's the other way around when it comes to supporting family, but that is another story for another day. Since college, we've watched all our friends buy (and sell) homes and cars, travel the world, own every new gadget, you name it. Friends who are actively saving for retirement (like the couple in the article) and actually have a positive net (financial) worth. It can be frustrating at times, since we've lived in dinky apartments with leaky faucets and coin-operated washers and dryers that don't work. But we do live a comfortable existence, and I am grateful for it.

In the end, all that matters is having two happy, healthy, curious little boys who have parents who love them very, very much (remember that, boys!). The rest is just icing on the cake.

Tags: school

I know how you feel, little guy. Long days are tough. I've had days where I just want to collapse in the front entryway and take a nap too.

Tags: M

A loves to make elephant sounds - bbrrrrrooooooo!


And here's M pretending to be one.

Tags: A, me

A new study in "Pediatrics," the official journal of the American Academy of Pediatrics, showed interesting results regarding our current standard of care regarding allergies:

...no evidence supporting a delayed introduction of solids beyond 4 or 6 months for the prevention of asthma, allergic rhinitis, and food or inhalant sensitization at the age of 6 years...

It's just one study, but could be quite influential in the way parents introduce new foods to their babies. Currently, the recommendation is to wait until 6 months to start solid food (rice cereal), and then to gradually introduce new foods over the next several months (whole cow's milk at one year), while abstaining from giving foods that are known to be more allergenic until a later age. These foods include peanuts, eggs, shellfish, and berries.

It's a tough decision parents have to make (aren't they all?) regarding their kids. I think that some people tend to believe that we over-scrutinize the details, as some parents feed their babies whatever the family is eating as early as four or five months, and they turn out just fine. But for others, allergies are a real and life-threatening entity (hence all the banning of various foods at schools) and any information that might help delay or ward off future food sensitivities is a good thing.

We don't have any family history of food allergies, so we're kind of more laid back. However, both boys have had some form of atopic dermatitis (eczema), which fortunately, M appears to have grown out of. A's eczema seems bit more related to certain foods, and we recently had him tested (recommended by our pediatrician) because the skin on his hands and face would get really itchy and red (pruritic and erythematous). The results are difficult to interpret, as values are all relative. However, he does appear to have mildly increased sensitivities to peanuts and eggs, so we're holding off on all nuts and egg products for the moment (which is tough since they are a great source of nutrition for kids). It's likely that he will outgrow his sensitivity and will be able to enjoy french toast with peanut butter and syrup once again (that's how J likes his).

Tags: food, health

It's always a shock to me how quickly the holidays come and go. Just last week, homes in the neighborhood had tons of colorful lights (that is not our home, by the way) - today, they are all gone. And everyone is back to the regular grind.

Every time someone says the word tree in our home, A points to the now-empty space in the corner of the living room where our little tree once was, only a week ago. The boys actually helped me take down the tree (which was starting to look pretty worn), and M helped J haul it to the curb, so I think he adjusted pretty well. But I'm sure that these traditions must be weird for young children.

In the back of my head, I'm trying to think about what upcoming "holidays" we might want to celebrate at home. Valentine's Day is an easy excuse for some art projects, but it's not really a holiday we tend to get into. Martin Luther King Jr. Day is coming up (as well as Presidents' Day), so we might talk a little bit about people and politics (as much as we can with a three-year-old). I'm thinking we'll probably reiterate what we always say about being a good person, and how sometimes things are not fair and that it is a good thing to speak up (use your words). This is one of many constant challenges about parenting - it is so dynamic and unpredictable. Just when you think you've overcome something (breastfeeding, diapers), there's plenty more to figure out, and it probably never gets any easier.

Tags: M, A, holiday

There certainly are a lot of engines pulling that train! The drawbridge was a Christmas gift, which was an instant hit. The first thing M said was I'm going to bring it for Share Day!

Tags: M, toys, holiday

MEN1 is a rare, heritable (autosomal dominant) disorder, with a prevalence of approximately 2/100,000 people.

It is classically associated with a classic triad of tumors (parathyroid glands, anterior pituitary gland, and pancreatic islet cells) but has been expanded to include tumors of other organs as well (duodenum, thymus, lung (bronchial carcinoid), stomach, adrenal glands). Around 40% of patients also have Zollinger-Ellison syndrome or asymptomatic elevation in serum gastrin concentrations.

The initial presentation is most commonly primary hyperthyroidism (1-2% of all cases are due to MEN1). Treatment is variable and dependent on pathophysiology (similar to isolated tumor therapy). It also depends on the symptoms and severity (can be surgical or medical).

My folks visited for a few days over the holidays, and it was fun to spend Christmas together. For some reason, M has adopted two different languages when referring to my folks, calling my mom "gramma" and my dad "gonggong." They (obviously) love seeing the kids, and I think M and A had a good time too. It would be nice if they lived nearby (built-in babysitting), but unfortunately that's not really an option at the moment. We see them about twice or three times yearly.

Tags: M, A, me, grandparents, holiday

Like last year, we celebrated on January 1, after recording the previous night's ball drop on television. In fact, I was the only one awake at midnight of the actual event (J was sick). In any case, we started counting down around 7:30pm, so that we'd have enough time to wind down and start the bedtime routine. A joined us this year, which was great. And M and I had been practicing counting backwards from ten all week. It's funny how challenging it seems - his brain is hard-wired to count up. Anyhow, the ball dropped and we all yelled "Happy New Year!" and toasted with cups of water. And just like last year, M gave me a kiss, which was very cute.

Tags: holiday, M, me, A

A few weeks ago, we celebrated my birthday with our family favorite - (mini) cupcakes!

He we are toasting with our cupcakes. I love A's expression. Apparently, he didn't get the memo and ate smooshed it into his mouth already! Wait, you mean we weren't supposed to eat them yet?

Tags: me

To all our friends who are parents of young children,

Don't be surprised if you all get a big box of D, C, AA, AAA, and button-cell batteries for Christmas this year. And stocking stuffers of various sized Philips head screwdrivers. And wire cutters for those impossible-to-undo-in-any-reasonable-amount-of-time before-your-toddler-gets-frustrated twist ties (those toys are really anchored down into their boxes!). It sounds strange, but you'll thank me later.

I'm only half joking too, so don't forget to act surprised!

Here's an older photo of J putting together M's first birthday present.

Tags: holiday

Remember how I said that "ball" was A's first word? And how he loves to say it whenever he sees anything ball-like? We saw some ornaments hanging in the bookstore recently, and he started saying it a million times. Bawwwwww, bawwwwww, bawwwwww. Let us demonstrate (silently, for now; I've got it on video but I just don't have the time to format and add the clip - sorry!).

Tags: A, me

Before the new year, I posted about this recall for the eeBoo Tot Tower nesting block set. I just received an email from them today (it took just over a week for them to reply) which directed me back to the eeBoo site, where they have since set up an electronic form for people to fill out regarding the replacement (it'll take them 2-3 days to respond to your submission). Rather than returning it back to the store where I bought it (online at babystyle.com), I have the option of shipping it (prepaid) directly back to eeBoo for a replacement and a small gift for my cooperation.

I just filled out the e-form, and will update again once I hear back. I think they will email me a prepaid UPS form to send it back. It's nice that they provide the shipping label, as it is totally a pain (and can be quite costly) to ship toys back when they are recalled. In many cases, it's not even worth it, and you pretty much have to toss the toy in the trash/recycling bin.

One thing kind of irks me about this replacement process. I bought the eeBoo blocks for $19 (full price I believe - the horror!), and the replacement is a matching game that retails at $12. I think that the replacement item should be comparable to (or even valued at more than) the recalled item. Just a courtesy and fairness thing, you know?

Tags: toys, safety

All my parent friends understand when I say that weekends are often more tiring than weekdays. This was true during the year as well. I always got way more studying done during the week (even just during lunch/pumping breaks at the hospital) than I did on the weekends. And long weekends - well, they're just plain exhausting. And we just had two four-day weekends in a row. Whew. And now it's the weekend again!

Don't get me wrong though. I love having time off from school/work because I get to spend more time with the kids. But I certainly don't get any more rest than usual. In fact, if J is working (he only got 2 extra days off for the holidays) and I am at home with the boys on my own, it actually might be more tiring than usual. A lot more tiring.

But one look at these adorable faces is enough for me to wish the holidays would roll around again really soon.

Tags: holiday, M, A

This refers to spinal cord damage involving the dorsal column, corticospinal tract, and spinothalamic tract unilaterally (hemisection). This causes weakness, Babinski sign, and loss of vibration and proprioception ipsilateral to the lesion, and loss of pain and temperature sensation on the contralateral side (2-3 segments below the lesion).

The most common causes of this syndrome are trauma (knife or bullet wound) and demyelination. Less common are tumors, herniation, and infection.