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I have a new friend. Her name is Karen and she works at the local UPS office. I see a lot of Karen as I help my wife with her clothes shopping. She buys the clothes and I return them. The other day, I did the calculations (I am good at those) and realized that my wife spends more on returning clothes than I spend on buying clothes. And that includes the clothes I buy for our son. My daughter doesn't let me anywhere near her clothes purchases. Perhaps she is wise. Karen told me that I should be thankful that my wife returns purchases she won't wear. For a long time, she was too embarrassed to return her unwearable purchases - and she never even told her husband about them. Until of course, he found out. Now she is not allowed to shop any more. Me, I just keep retuning any box that I find lying around that has an address label on it. Of course, I have no idea what is in any of the boxes, but Karen is a good guesser - especially when it comes to guestimating the insurance value.

Some of you may be doubting the accuracy of the above, but I assure that it is true. How can I possibly spend so little money on clothes. Here are the principles by which you can save time and money on clothes shopping.

1. Day of the week clothes. Yup, that's right. Seven shirts for seven days. In the Winter wear an undershirt and a sweatshirt. In the Spring remove the sweatshirt. In the Summer, remove the undershirt. In the Fall, put the undershirt back on. Wash shirts once per week.
2. Buy new clothes when the old ones have holes. Buy the exact same item - pick a new color if you want. I buy Lands End mesh cotton polo shirts. Each lasts for about two years. Sure the color changes over time, but that just adds variety. Let others pick the colors for you - it's fun for them.
3. For growing kids - just pick the next size up when necessary.
4. Occasionally we have to buy things that we don't purchase online - e.g. shoes/sneakers. Set the 5 minute goal. Pick the item and get on the checkout line in 5 minutes. We have never missed the deadline.

Some of you might think that this takes all the fun out of dressing every morning. My response - lots of other opportunities for fun. This approach will help your kids know what day of the week it is.
Others will argue that people will notice. Trust me, they actually don't notice. Sometimes I wear the wrong shirt - and no one ever notices - and I have broadcast that I wear the same shirt. And if they did notice, consider it an opportunity to gain a new recruit to the Simple and Easy lifestyle.

Now perhaps your life is already simple, easy, full of leisure time and long spans of nothing to do. Let's assume you are already working out daily and that your closets are cleaned out. Then, by all means, spend lots of time shopping for things and if you don't like them, just get your spouse to handle the return. :)

Posted by Richard Berger at 07:03 PM | Permalink | Comments (0) | TrackBacks (0)

She's Come Undone
Author: Wally Lamb
Amazon info

The story of Dolores Price, her mother, her missing father, and her grandmother. All of whom will die during the story (except for Dolores). But mostly this is the story of Dolores' weight and its impact on her life. The story has some interesting twists and turns and Dolores is an interesting and memorable character, but yet I was not very impressed with the novel.

What I did like was the interaction between the three generations and how the personality traits of one generation impact the next generation. I also enjoyed the healing process through which Dolores is "rebirthed". However, I felt that the author did not truly address the realities that Dolores would face in the world.

At her peak, Dolores weighs over 250 pounds on her 5'5" frame. She manages to lose 150 without any discussion of exercise and only minor (that I recall) references to the drastic changes in eating habits that would be required. I believe that to lose that much weight one's caloric intake would become a central feature of their life for a very significant time. Furthermore, she just seems to keep this weight off - again without exercise. Finally, I don't see how quickly she would get back into the dating world given her history with men, weight, and all her other issues. So that part of the book, which I think is a pretty large part, just didn't work for me.

Recommended: Big fans of "coming of age" stories, people who are perhaps less literal than I am.

Posted by Richard Berger at 04:56 PM | Permalink | Comments (0) | TrackBacks (0)

I spoke to my neurologist today and summarized the situation and asked follow up questions.

First, in terms of the summary - my situation can more accurately be described as "in the MRI prominent blood vessels were seen". This could be normal, or it could be our friend, the AV fistula. The AV fistula would certainly account for the symptoms that I am seeing. However, the cause could still be unknown.

OK, on to my questions, please bear in mind that my doctor is a neurologist, she is not a vascular surgeon, but as my case manager, she will get answers to my questions for me.
1. I know that a spinal angiogram necessary before treatment or is it done during surgery?
She did not have a clear answer to this. My research indicates that the angiogram is usually done first to confirm the fistula, although if an MRA showed a very clear location, a more limited angiogram could be done during the embolization surgery.

2. If the spinal angiogram showed the fistula, I assume we would schedule treatment quickly.
Yes, it would not be urgent, but it would likely be done within a month.

3. So the big question is how likely is the angiogram to show the fistula? Could it be too small to see even through the angiogram?
Yes, that is possible.

4. Did the MRI show a high T2 signal - this is very strongly correlated to spinal dural AVFs that show up in a spinal angiogram. If no T2 signal, we probably won't see anything on the angiogram, so why do it?
This was the key question - and the answer is that the T2 signal was NOT high. This would lead me to conclude that the angiogram would not show anything at this point in time. That conclusion is heavily influenced by Spinal Dural Arteriovenous Fistulas: MR and Myelographic Findings. Also see my earlier decision algorithm.

5. Are there other techniques that would be less risky/invasive than the catheter angiography - in particular the MDCTA or the onld supine/spinal myelogram (I only hold out hope for the first).
Not clear - the MRA is usually considered the test to do - but the MDCTA is also somewhat new. She will be checking on this.

6. How long does the angiogram last? Can a general anesthetic be administered?
The length varies - typically a conscious sedation is done, but not intubation. With a conscious sedation, the patient is usually given a combination of pain medication and sedative through an IV. The patient remains conscious, but sleepy and relaxed. People do not usually remember what occurs. The two common drugs are Fentanyl (the pain medication) and Midazolam (the sedative). I get the sense that a two hour procedure would be fine with conscious sedation, but it is not clear to me if it could go much longer. Which might indicate the necessity to continue the angiogram into the next day.

Next update in two weeks as my doctor is off to various conferences.

Posted by Richard Berger at 04:18 PM | Permalink | Comments (0) | TrackBacks (0)

Today I spoke to my neurologist and got the news that the MRA was negative - which might sound like good news, but actually is a bit more complicated.

Let's start with a review of where we stand. The thoracic MRI indicated something that appeared to be an Arteriovenous Fistula (described in an earlier post). However, it appears to be small and somewhat difficult to diagnose. But if I do have the AV Fistula in the location that it appears to be, then that would indeed explain my symptoms (I went over this with the doctor in detail). Thus, doing something like a spinal tap (i.e. lumbar puncture) would not make any sense. But since nothing showed up on the MRA and it the fistula is too small to be detected by physical exam, we would have to do something more invasive to find it.

That "more invasive" option is a spinal angiogram (or thoracic angiogram). Which involves Arteriovenous threading a catheter up from an artery in the groin up to the aorta (guided by x-ray and contrast imaging). Each of the approximately 12 arteries that lead to the spinal cord must be inspected (e.g. contrast injections). Many images are taken during this procedure, so the patient is required to be very still (local anesthetics are applied to the site of the catheterization). The artery that is used is a fairly large artery and this presents some risk of internal bleeding and other complications.

There is also no guarantee that the Fistula will show up on the angiogram. Should it appear, treatment is usually the embolization I discussed in my prior post.

So the decision (as yet unmade) is whether to go ahead with the spinal angiogram or to wait six months to see if we can spot the AV Fistula using another MRA. This would avoid the risk of the angiogram. Of course, it is better to treat things earlier, but that has to be balanced against the risk of the angiogram that may not yet show anything. Note: I don't yet have solid data on how long a spinal angiogram takes - but one writeup indicates that it can last for as long as 2 days, due to limits as to how much they can do at any one time.

Reading materials:
1. Spinal Angiogram - non technical
2. AV Fistula - somewhat technical, more accurate description of what I have - focus on "Type 1 Spinal AVM: Dural Arteriovenous Fistula" section.
3. A technical review of AV Fistulas and how they are diagnosed
4. MDCTA - Multi Detector row Computed Tomographic Angiography
This is a write up of a new technical for evaluating spinal vasular malformations. It is a small study, three cases of spinal dural AVF (which is what I may have) and one case of perimedullary AVF. It worked in two of the three spinal dural AVF - but not in the third, probably due to the small amount of shunting blood at the fistula. Conclusion is that MDCTA provides useful information for the surgeon in the treatment of the spinal dural AVF... MDCTA should be considered as a choice of investigation in the evaluation of spinal AVFs.
5. Another article on MDCTA as a possible adjunct to catheter angiography. This one concludes that MDCT angiography correlates well with catheter angiography in diagnosing spinal dural AVFs. It might also play a role in shortening the length of a catheter angiography. Disadvantage is the use of ionizing radition. This article also states that catheter angiography is required before embolization.
6. I also found a really good writeup describing how to actually perform a spinal angiogram - but I don't think anyone would actually want to read it.

The next steps for me are to talk to some of my physician friends and see what they recommend.

Questions I will pursue (based on algorithm below)...
1. Did the MRI show a high T2 signal - this is very strongly correlated to spinal dural AVFs that show up in a spinal angiogram. If no T2 signal, we probably won't see anything on the angiogram, so why do it?
2. Are there other techniques that would be less risky/invasive than the catheter angiography - in particular the MDCTA or the onld supine/spinal myelogram (I only hold out hope for the first).
3. Let's say we knew it was a spinal AVF, would we have to do a angiogram before we could treat it? (I believe the answer is yes).
3. What would we do if the angiogram was negative - would it be a wait and see approach? I assume yes.
4. How long does the angiogram last? Can a general anesthetic be administered?

And now, my algorithm is finally clear - for those that can any type of computer code, it should be clear...
if (T2 = Low) {
//angiogram may not find anything
if (MDCTA available) {
// Try MDCTA
if (MDCTA() == found) {
treatment();
} else {
wait();
} else {
wait(); //?
}
} else // T2 = High
if (catheter angiography required for treatment) {
catheter angiogram(general anesthesia);
if (found) {
treatment();
} else {
wait();
}
} else {
// Try MDCTA
if (MDCTA available) {
if (MDCTA() == found) {
treatment();
} else {
wait();
}
} else {
wait(); //??
}
}
}

Posted by Richard Berger at 07:12 PM | Permalink | Comments (1) | TrackBacks (0)

I thought it would be a good idea if Emily and I could spend some more cuddle time together - and what better way to cuddle than by watching a college course on DVD. So we made a little deal that every Sunday morning, we would watch a course of Emily's choosing. We had a catalog from The Teaching Company - it was the catalog of all their on sale courses - and Emily chose the "Story of Human Language".

We watched our first lecture this past Saturday. Like most lectures, I think we both got a little restless after the first 15 minutes - but the cuddling was great and we did make it through the full lecture. And we probably both learned something in the process. Whether we can make it through all 36 lectures remains to be determined, but it is still a great introduction for Emily as to what college level material is like - and how the catalog descriptions are always more interesting than the courses themselves.

Posted by Richard Berger at 04:59 PM | Permalink | Comments (0) | TrackBacks (0)

For the past several months, Matthew, Yishan, and Austin have been meeting every Tuesday afternoon to work on their entry in the Junior First Lego League competition.

A few words of explanation are in order. The First Lego League is an organization that provides an opportunity for kids to take on a challenging Lego project and to share their ideas with others in a fun, cooperative environment. For kids under 10, there is the "Junior" version - similar concept, but simpler project. The project this year was to choose a room in the home and perform an energy audit - where does each of the objects in the room get its energy. We chose the kitchen and learned that it used a combination of gas, electricity, and battery power. We learned about compact fluorescent lights and we found where gas lines entered the home and we found the underground electrical systems and checked out the electrical panel in the garage. We researched how our electric company generates power - and it is quite a "green" company with something like 75% of the energy coming from renewable sources.

With all that knowledge in hand, it was our job to model the delivery of a particular power source to an item that used it. The kids chose to model wind power delivering energy to the microwave and with that the design/building phase of the project began. We learned lots about how to design projects. In fact, we started with the basic concept of designing something, not just building it ("Plan your work; Work your plan"). We learned (often the hard way) the "Steve Jobs wisdom" about staying true to the design, even if one of the team members doesn't like it. We used design tools (Lego Digital Designer) to prototype and communicate various options. And of course we built with Legos. (Well, the kids built, I didn't). Then we learned how various departments help and hinder - like when our Legal Department (the rule book) determined that one particular design was illegal. We learned about deadlines and tradeoffs and hiring the right people. We learned about doing the "right thing" and the "right now thing". Of course, by "learn" I mean we talked about it and wrote it down on white board. I don't expect anyone really remembered it as they were usually too busy goofing around - assuming that we even got to Legos that day since Lego building only happened after homework was done.

As the day of the Expo grew closer the kids put together their posters of explanation - eschewing any use of color and in general disdaining any type of marketing (they are true engineers these kids). And then it was time for our trip to Buena Vista High School (an amazing high school) for the show.

There were 14 teams and each team was interviewed by 4-5 judges to see how well the kids could explain their construction and the overall project. The kids got plenty of opportunities to see the other projects and answer questions from the other kids. Our project was unique in its use of the motor to power the wind turbine (others used a hand crank) and our modeling of underground wires (as we don't have overhead wires in Alameda).

Matthew, Yishan and Austin were proud to win one of the two awards for "Innovative Construction" but mostly they were happy to spend the day together and have fun. We are going to continue our weekly meetings, moving to Lego Mindstorms NXT - a basic robot building system that will introduce the kids to programming.

PS - Photos are thanks to Yung Chen (Yishan's mom) - more available upon request.

Posted by Richard Berger at 04:10 PM | Permalink | Comments (0) | TrackBacks (0)

Yes, I had the MRA on Friday night. Driving through SF traffic on Friday night was far worse than the MRA experience, which was the usual thing (although with an IV rather than an injection for the contrast dye). Although they can be a bit stressful, I still emerge relaxed.

I should note one looming concern is that the scan was in the thoracic area of my back and that is above where the nerve roots for the foot emerge. So I don't yet see an absolutely direct connection between the AVM (in the thoracic area) and nerve problems in the foot. Of course, anything that impacts the spinal cord would likely cause some nerve problems somewhere (as all the nerves are all bundled together in the cord). Also on the "less than good" news - my plan of multiple treatments going from least invasive to most invasive has one problem. If the first treatment is radiation that will injure the surrounding cells enough that they will never heal quite as quickly in the future, making surgery in that area a bit more difficult. But we will see what the doctors tell me on Wednesday (assuming I remember to call them in the midst of Girl Scout Cookie season :) ).

Posted by Richard Berger at 09:06 AM | Permalink | Comments (0) | TrackBacks (0)