Master Clinician Series - Diverticulitis

This morning I presented a case-study on "diverticulitis." At 0700, a Master Clinician Series was held where I led a discussion on one of my surgical cases: a patient who required colonic resection due to recurrent disease. In the standard 3 minutes, I presented the patient's chief complaint, history of present illness, past medical/surgical/family history, current medications, allergies, a systems review, and physical exam and laboratory findings. From there, the faculty led a discussion of the medical and surgical issues involved in this person's care. I obviously pulled out the pink tie and blue shirt for the affair (brings out my eyes), and I wrote a short little summary of diverticular disease for the class.

So. In an effort to chart my progress throughout my medical training, and to see how medicine changes in the years to come, here is my short little ditty on diverticulitis...

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When describing diverticular disease, it is important to first clarify a few terms. A “diverticulum” is an outward protrusion of the colonic wall. “Diverticulosis” simply comprises the existence of diverticula in the colon, and “diverticulitis” is active inflammation of these diverticula. The disease itself encompasses all three pathologies. Diverticula are usually formed in areas of weakness, caused by increased intraluminal pressure. These colonic projections are common: 30% of all individuals age 60 have diverticular disease, and the incidence jumps to 65% by age 85. The disease is found equally in men and women, although a preponderance of males are diagnosed with acute diverticulitis under the age of 40. Diverticular disease is almost exclusively left-sided in “westernized nations,” with perhaps only 1.5 percent of patients presenting with right-sided disease. This summary will briefly describe the pathophysiology, clinical manifestations and complications, and treatment of diverticular disease.

Pathophysiology. Diverticula develop near the vasa recta in the colonic wall. As the wall of the colon grows thicker with age (due to multiple dietary and hereditary factors), these weaknesses in the wall undergo greater and greater stress. Anything that increases intraluminal pressure will exacerbate the diverticula. As the colon thickens over time, pressure in the sigmoid colon becomes the greatest of any segment, since it’s lumen is the smallest in diameter. Diverticular disease is associated with a high fat diet, red meat consumption, and low dietary fiber intake (RR: 2.35 and 3.32 in different cohorts). High dietary fiber intake, resulting regular, large, and bulky stools, may normalize intraluminal pressure, and decrease the risk of hard stools that precipitate constipation and straining during defecation. However, it is important to note that “there is no clear correlation between constipation and diverticular disease,” due to the difficulty of designing an appropriate study for this association.

It is also important to note that use of alcohol, tobacco products, and caffeine does not increase one’s risk for diverticular disease. The presence of diverticula is inversely related to strenuous physical exercise: patients who exercise more are less likely to develop this disease. As a corollary, obese patients typically have a propensity for developing symptoms.

Diverticulitis, which results from inflammation of the diverticula, is due to micro- or macro-perforations along the bowel. Although fecaliths were initially thought to be the primarily etiology, the mechanism of injury actually involves erosion of the diverticular wall due to high intraluminal pressure or “inspissated food particles” (such as indigestible small nuts and seeds). After inflammation begins, necrosis of the bowel wall ensues, resulting in perforation. Depending on size and the surrounding anatomy of the perforation, a patient may present with different pathologies. Mesentery and nearby fat may “wall off” a small perforation; or, if the tear is near another organ, a fistula or obstruction may result. However, if the leaking contents are not well-contained, peritonitis can be a major complication. In these cases, generalized tenderness of the entire abdomen is seen.

Clinical Manifestations and Complications. While approximately 70% of patients with diverticulosis are asymptomatic, one out of every four may develop diverticulitis, and one out of ten will experience bleeding. These are considered the two major complications of diverticulosis. While symptoms such as “cramping, bloating, flatulence, and irregular defecation” may be present, “it is unclear if these symptoms are attributable to the underlying diverticulosis or to coexistent irritable bowel syndrome.” Left lower quadrant (LLQ) pain is the most common presenting symptom of diverticulitis in Western countries. Past history of similar episodes, nausea, vomiting, constipation or diarrhea, and urinary symptoms may help to narrow the differential diagnosis toward diverticular disease. LLQ tenderness, low grade fever, and mild leukocytosis may also be present. Hematochezia may be discovered in the patient history or physical exam. This is due to progressive injury to the surrounding vasa recta, leading to diverticular bleeding. Painless, self-limited rectal bleeding is a common manifestation.

There is also some evidence that diverticulosis may be associated with an increased risk of colon cancer; however, the line between these two diseases is blurred, as the risk factors that precipitate both diverticula and colon cancer are very similar.

Diagnosis and Treatment. History and physical exam are the primary tools when diagnosing acute symptomatic diverticular disease. Abdominal radiographs can be used to evaluate for free air in the peritoneum, but a CT scan with IV and oral contrast is the gold standard for diagnosis. “The sensitivity, specificity, positive, and negative predictive values of helical CT…were 97, 100, 100, and 98 percent, respectively, in a study that included 150 patients presenting to the emergency department with clinically suspected diverticulitis.” Since diverticulitis is a disease of the soft tissue, a CT scan allows for better visualization of bowel wall thickening, inflammation, and masses. In the non-acute setting, colonoscopy is the preferred approach, allowing for both direct visualization and biopsy.

Treatment recommendations depend on whether the disease is “uncomplicated” or “complicated.” Complicated diverticulitis includes inflammation with subsequent perforation, obstruction, abscess, or fistula. Conservative therapy of antibiotics and bowel rest (clear liquid diet, etc.) is currently recommended for patients with uncomplicated disease, and ciprofloxacin plus metronidazole are the medications of choice to target enteric bacteria. “Following successful conservative therapy for a first attack of diverticulitis, 30 to 40 percent of patients will remain asymptomatic, 30 to 40 percent will have episodic abdominal cramps without frank diverticulitis, and one-third will proceed to a second attack of diverticulitis.” Treatment of complicated diverticulitis or recurrent uncomplicated disease commonly requires surgical intervention. These cases should be managed on a patient to patient basis, with regard to differences in pathology and treatment goals.

1. Young-Fadok T, Pemberton JH. Epidemiology and pathophysiology of colonic diverticular disease. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2011.
2. Acosta JA, Grebenc ML, Doberneck RC, et al. Colonic diverticular disease in patients 40 years old or younger. Am Surg 1992;58:605.
3. Fischer MG, Farkas AM. Diverticulitis of the cecum and ascending colon. Dis Colon Rectum 1984;27:454.
4. Young-Fadok T, Pemberton JH. Clinical manifestations and diagnosis of colonic diverticular disease. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2011.
5. Rao PM, Rhea JT, Novelline RA, et al. Helical CT with only colonic contrast material for diagnosing diverticulitis: prospective evaluation of 150 patients. AJR Am J Roentgenol 1998;170:1445.
6. Young-Fadok T, Pemberton JH. Treatment of acute diverticulitis. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2011.

Eat when you can, Sleep when you can... And then eat some more!

Food has always been incredibly important to me. When I was in high school, I was 6'5'' and 165 lbs., despite eating my parents out of house and home. My mother had to put raw eggs into milkshakes at night, or have me eat my entire evening meal and then force me to chug an Ensure just to add a few more hundred calories. I saw a nutritionist. I ate 4-6 meals a day. I ate almonds during 7th period. I bought the most expensive unlimited meal plan in college. I've gained weight on every single trip abroad, because I eat each meal like it's my last. Food is important, and that hasn't changed as a third year medical student.

I realize that my obsession with food is constant, and I can be preoccupied during downtime about what my next meal is going to be. Thus, I have derived a system that ensures instant access to calories at every stopping point in my day: morning til night. I make sure to eat a balance breakfast each AM, and I have weekend-made meals at night. However, it's the hours in between that are anxiety provoking. "What, when, where, and how?" are the questions I ask each day at high noon (and most days, hours before). So I want to share my system, and I ask for any quality improvement tips one might have.

I'm going to start with my favorite hiding place, INSIDE-LEFT-COAT-POCKET, and then I'll take you location by location in increasing importance and excitement to my food Mecca: PHYSICIAN'S LOUNGE.

1. White coat pocket: inside left. Food always has to be within arms' reach. I wake up in the morning and have a bowl of Cheerios or a bagel with cream cheese, plus or minus a banana. Basically that means I'm hungry again around 10am, if I'm lucky to make it that long. If I'm moving around a lot that day, I can arrive at lunch unscathed, but I prefer to have access to INSIDE-LEFT-COAT-POCKET goodies at a moment's notice. I always have one Cliff bar ready and available. If this gets eaten, then a Cliff bar is immediately taken from my BACKPACK FRONT ZIPPER, and then INSIDE-LEFT-COAT-POCKET is fully stocked again. I try to amass other snacks as well throughout the shift. Typically a granola bar from SURGEON'S LOUNGE is a popular Cliff companion. One must be appropriately stocked; we can't have any hypoglycemic events in the operating room (OR). If I'm dying for something to chew on, white Tic-Tacs can also be retrieved after a deep left pocket cavity search. Those are only if I'm in dire straights, and for when I have OR mask breath.
2. UNC Swimming Backpack: front zipper. The white coat should always be within an arm's reach, but the back-up is BACKPACK FRONT ZIPPER. As stated earlier, I keep a stash of Cliff bars handy. Second line Tic-Tacs are available, and everything is subject to restocking at night when I return home. BACKPACK FRONT ZIPPER is not a primary food source, but it is usually closer than GRAY TARGET LUNCHBOX.
3. Gray Target Lunchbox. Self-explanatory: this is my lunch. When thinking logistically, however, it is not always easily accessible. I may leave it in the SURGEON'S LOUNGE refrigerator, or in the cooler at the office. So, on trips to the OR, I may have to run back between cases to retrieve GRAY TARGET LUNCHBOX. I keep it dull: peanut butter and jelly sandwiches, cheez-its, applesauce, carrots, sometimes an apple, and of course, a Cliff bar. Most days, fortunately, I don't have to eat my lunch, because there are better options available. If food has been provided at OFFICE KITCHEN, I might snag some Moe's or chicken fingers from Fatz before opening up GRAY TARGET LUNCHBOX, and eating the perishables. These first three options are really just my security blankets, decreasing the anxiety about the possibility of going hungry.
4. Cafeteria. Bleh. I guess it's okay, but there are better options (see below). We have a card for access, but we only use it when on call or at the hospital for hours on end. I'd prefer to just grab a Cliff from INSIDE-LEFT-COAT-POCKET.
5. Office Kitchen. Now we're talking. These lunches are always a surprise, but I've been lucky enough to grab a few good ones over the past couple weeks. In a unlucky twist of fate, the office EMR was down temporarily, so the health records company bought lunch on the days they came in to fix it (there's a silver lining in every cloud). Half-sandwiches, Mexican, Moe's, Fatz, Subway, and a variety of other foodstuffs have made it into OFFICE KITCHEN. Again, I try to snack on these and the perishables from GRAY TARGET LUNCHBOX, but if it's Moe's, then the fruits and veggies have no chance. Those carrots and apple can wait until dinner. If a drug company buys food, I have mitigated the ethical dilemma by grabbing the grub on the run. Who am I to let quesadillas go to waste?
6. Surgeon's Lounge. This place is very special, mostly because it's where I get my cheese and crackers, and hydration. The great thing about SURGEON'S LOUNGE is the bucket-full of rectangular cheese that I don't think anyone eats (I'm serious. I literally think I'm the only one in the hospital that eats these. The amount in the box is almost always the same as it was when I was last there). I grab two saltines from the drawer, slap a piece of cheddar in between, and I have a carefully crafted between-case snack. Hungry betwixt a gallbladder and appendectomy? Cheese and crackers. Surgeons talking about things over your head? Cheese and crackers. They also have cold juice and milk for rehydration. Sandwiches, salads, and other snacks are available in an emergency, and that can be a good option... but all I need is cheese and crackers.
7. Physician's Lounge. The Mecca. It is a special place, with access granted only by invitation. It's basically an upscale doctor's cafeteria, where all the plates are square and pearly white. Linen napkins fall from the sky, and waiters in tuxes unveil wedding finger foods. Breakfast and lunch are served Mondays through Fridays, exactly when our key cards deny access to this delicious cornucopia. I've only eaten at PHYSICIAN'S LOUNGE twice. Once when marinated chicken, succulent green beans, and rice pilaf were served, and today when I had chicken wraps and bananas. If I were an attending physician, this would be the only thing you would need to court me to your hospital. Forget money or the parking space. I want a chef. I want meals cooked up on a whim. Midnight chicken cordon bleu. Give me filet or give me death! I don't take these opportunities for granted. If I'm invited in, I make the most of my surroundings... Oh! And the cookies! So soft and moist; and, I don't even like sweets! Perfect almonds in peanut butter dough. Delectable.

This is how I survive as a third year medical student. Primarily on Cliff bars and cheese and crackers.

Cholesectomies, Cholecystectomies, and Poop

Surgery is a language. This first week and a half has been a challenge trying to figure out this particular dialect of medicine, but I've loved almost every minute of it. I mean that. I've worked a variety of cases: from emergent laparoscopic appendectomies to breast tumor resections, as well as colectomies for chronic distal diverticulitis. I've gotten the opportunity to round on patients in the Surgical Intensive Care Unit (SICU), writing notes and presenting my peeps to an attending; I've gotten time in the operating room (OR) closing incisions and maneuvering the laparoscopic camera. Some days are long, but it's amazing how quickly 14 hours go when you're on your feet all day running from rounds in the hospital, then to the clinic, then to the OR. I've also met some really inspiring patients; some have dealt with very tough procedures, bounce back a couple days later, ready to be discharged and recover at home.

Of course there have been many mishaps: not filling out a "history and physical" on a preoperative patient because I didn't know I was allowed to write on official documents (I am, but an attending has to co-sign after reading it... don't worry!), answering at least 75% of "pimp" questions incorrectly (maybe closer to all), or the time I wrote on the preoperative note that we were going to do a "cholesectomy" instead of a "cholecystectomy" (my surgeon promptly corrected my spelling, and queried me about which procedure I was planning to do on the patient). So when I say that surgery is a whole new language, it is... and perhaps my first goal should be to figure out how to spell its more common words and phrases.

Everything is a learning curve, and I have already taken home some very important lessons. Here's what I think I know:

1. Poop is very important. I need to know if you've pooped, when you've pooped, and where you've pooped. What is the consistency of your poop? How many times have you pooped? Did it hurt when you pooped? What does your poop look like? What color is it? Have you passed gas? How many times have you passed gas? Are you passing more gas than you were yesterday? All joking aside, it is imperative to assess bowel function in the hospital post-op. Many things related to surgery can cause "ileus" or disruption of your normal bowel motility, and this can be a serious complication. So we have to get those bowels flowing!
2. Be ready for any type of question. When you're in surgery or on this clerkship, you have to be ready for questions, questions, questions! And, you can't get tripped up by the ones that come out of left field. I've had two favorites so far. First, while operating the camera for a laparoscopic choleCYStecomy (removal of the gallbladder), I was asked to point out the "cystic vein." Given that there is a cystic artery that the surgeon must clamp off during the procedure, the vein must be nearby. Fortunately I had gotten a little help earlier in the day (thanks, Steve!) and reviewed some of the anatomy... there is no cystic vein. Apparently that one gets students all the time. However, my favorite favorite was when I was asked during nursing rounds what the Latin word for hiccups was (the answer is singultio according to Google Translate). I didn't know it. Thanks for nothing St. Anselm's Abbey School. It's not all fun and games though. After doing a thorough H and P (history and physical) on a patient for an appendectomy, my attending asked me how many previous children the patient had. I knew she had one. When asked what her daughter's name was, I couldn't answer. It was Abigail. Lesson: patients are people, so get to know them. It is a privilege to be a part of their medical care team, so show that you do indeed care. Lesson learned.
3. If you don't think you should touch it, DON'T. I have yet to break scrub during this clerkship (meaning I haven't contaminated the surgical field by touching anything in the room that either isn't blue and between my waist and shoulders, or isn't an instrument dedicated to that specific surgery), but I'm knocking on wood as we speak. I did it once in college and it is a feeling I will never forget. Move slowly and purposefully; keep your hands locked in a praying position; and, don't touch anything! I must thank Dr. Fullum over and over again for hammering this into me.
4. You might be confused with being an actual real live surgeon. As I walked in to see a patient in the ER and pulled back the drape, the man started stuttering into the phone, "Mom? Mom? Mom. My surgeon just walked in so I'm gonna have to call you back. Okay okay. Bye." Admittedly I was wearing scrubs, a white coat, a surgical cap, and surgical "shoe-socks," and had my stethoscope draped around my neck, but come on. I still don't look a day over 18, even in a surgeon's uniform. I politely told the gentleman that I was a medical student who was part of his team. It'll be a while before he needs to get off the phone to speak with me...
5. I don't know anything. Pretty much nothing. Every day is an adventure, just trying to hold on to as many pieces of knowledge as possible. It's a very slow process for my thick skull, but I do think I'm learning at least a little something each day.

More lessons to come, but this is a start. It's a lot of work, but it's a great way to begin third year.

I eat when I can, sleep when I can, and maybe I do "cholesectomies" in my spare time.

Today I was called "doctor," and that was scary

I'll repeat: Today I was called "doctor," and that was scary. Now I do know I still have a few blog posts in the queue (no worries, they'll be up this weekend), but I needed to write about today before my brain started its evening purge. I took notes after several patient encounters because I knew I had to put pen to paper (or, is it "fingers to keyboard"?). The past few hours have been a bit of a shock to my system: "Hey doc, I've been waiting for you. You mind throwing a few more meds my way?" "Oh, it's so good to see you, Doctor, we've been waiting! I have a couple questions for you if that's okay?"

No no no no no. I'm just a medical student! I have no idea what I'm doing! Don't ask me anything; I'm clueless! And, are you ready for this? Today's my first day! That makes it even worse!

I think it's the white coat or the tie. Maybe it's the stethoscope or my Surgery Recall tucked deep into my coat pocket. Perhaps it's the notebook and the gloves and the scissors. I just know it can't be me. There's no way I look the part. Shadow of a goatee or not, my clothing and tools of the trade might look professional, but my badge says "student" (and my eyes say, "What did I get myself into!?"). Today I was hit by the brutal reality and awesome responsibility of my future profession: when I walk into a patient's room, I'm going to be instantly trusted. Maybe not by every patient, but for the majority of cases, that white coat means a ton. It means that I'm trained, I'm learned, my opinion is founded on years of scientific knowledge. It means that I am the front line of defense against all harm, and sometimes death. And it also means that as a caregiver, I do just that - I give care. My responsibility is both scientific and humanitarian. All because I put on this white coat. Perhaps that job description is oversimplified and broad, but my new responsibility is both simple and profound: when I wear the badge of my profession, there is no escaping symbolism.

I didn't understand this in the first two years (I say that even though it was just yesterday I became a third year!), probably because every time we students were in the hospital, we shuffled into a tiny room by the dozens and were immediately introduced as "medical students." During community weeks, the line was less defined. But it was clear that students were part of the normal practice, and our role was mostly confined to taking a history and doing a brief physical exam (plus I never wore a white coat in clinic - it scared the kids). Today, however, five patients were assigned to me. I spent the afternoon reading their charts and meeting a couple of them, so when I walk into tomorrow morning at 0600, I can pre-round, write their overnight progress notes, present to my attending on rounds at 0800, and continue to monitor them throughout the day. I'm there to help change wound dressings and answer simple questions. I can hold hands and make small talk. I'm part of their care team now. I am part of their lives.

All because I put on a white coat this morning.

Actually meeting the patients was the easy part. The hard part is knowing where to go, where to be, how do I write a note, do I write an official note actually in the patient's chart (the answer is "yes"), where do I get scrubs, how do I scrub in, where do I stand, is my patient presentation format right, am I working this weekend, am I on call, what does this beeper do, what if it beeps, am I allowed to eat food from the physicians' lounge, what is a PSBO ("partial small bowel obstruction"), if I don't know the answer does that make me an idiot, does everybody else get these questions wrong, how long will it take to pre-round on five patients, how much of a physical exam do I do, am I asking too many questions, am I asking too many questions, how should I study for the SHELF exam...

You know, just little stuff like that.

In the grand scheme of things, it was a very short day. I didn't have to wake up early, and I was done after lecture around 1730 (see, I can use military time now!). But, mentally it was taxing. This will take some getting used to, I think. I'm putting so much emotion into everything right now that I was drained by the end of today. Goal: I need to tone down my emotional output, without getting emotionally detached. There's just so much learning to do. It's not just the medicine I need to learn, but how everything works. How to study, how to learn, how to relax, how to exercise, how to eat... how to care. Basically I'm relearning everything, start to finish. Today was Day One of the rest of my life. It's going to be a lot of work; there are going to be a lot of ups and downs. It's going to be tough, and it could be fun. Who knows what tomorrow will bring, but I think I can face it.

Today I was called "doctor," and that was scary. But I think everything's going to be okay.

Transition Week: A New Blog

This week marked the beginning of the beginning. It is what we've all been waiting for (or at least most of us!). Starting on Tuesday, 160 UNC-Chapel Hill medical students will move from the safe, secure confines of the classroom ("prison" might be more apt), and into the big scary hospitals, with angsty patients, looming attending, and flustered residents and interns. We will inevitably fumble around, get lost every few minutes, and stutter violently whilst presenting patients. And alas, I pity those poor souls in the hospital who we must "take care of" in the beginning of July! We are but useless shadows of our former selves. The goal will be simple: don't mess up, don't mess up, don't mess up. But it is not all gloom and doom; I also welcome the change of scenery. I start with Surgery next week, and I'm sure that whether I know what type of G-protein coupled receptors are found in the kidney won't make a lick of a difference (and that's wonderful). No, I will never be able to escape the multiple choice examinations that we've all grown to hate over the past two years, but at least I can fend them off for just a few minutes as I listen to a patient's heart and lungs. I've blogged about how excited (and nervous) I am for this transition ad nauseam, so I won't belabor my point any longer. I'm ready, you're ready, we're all ready... kinda sorta.

So this week was full of lectures and exercises geared to make our transition a bit easier. What does it take to make a good third year student? One must be on time, always available, cheerful, smiling, ready to take on new challenges, an advocate for patients, a good reader, etc. etc. The most important lesson to be learned, however, was "don't be an asshole." We spent a good bit of time learning about professionalism, i.e., what you should and shouldn't do. We even spent two hours in small group discussing ethical scenarios that one might come across in the next few years. This begets the question (and prompted ample discussion amongst friends), can you teach someone not to be an asshole? Is being a jerk nature or nurture, and can you teach someone who is already a numskull not to be a nincompoop? I've pondered at length concerning leadership, and I think it provides a very similar parallel. I have come to the conclusion that you really can't teach empathy or compassion in a lecture hall. It has to be learned through open discussion and experiences. For me, I need to be yelled at a bit. I would hope that if I'm doing something inappropriate, I would be scolded vociferously. I guarantee you that I won't do it again, that's for sure. An asshole is an asshole; we just need a little more stick than carrot.

This week also marks the transition for this blog. I've been able to pretty much write what I want for the past two years. This is going to change. I have to be very careful about what and who I blog about, because physicians and others in the health care professions have lost their jobs due to HIPAA violations in their musings. Even if laws aren't violated, patients have still identified with their stories detailed on the internet, and this can be a serious problem. Patient encounters and experiences are going to have to be mute of all identifiers. Names, ages, dates, histories, etc. will all have to be changed to protect patient privacy. However, the content, feelings, emotions, ethical quandaries, all may remain the same. I have heard of some residency programs that completely forbid social media, and others that encourage it. One just has to be careful. I originally thought these weekly postings would be a burden on my time and studies, but I've grown to enjoy writing each week. It's a release, spilling my pent up thoughts and emotions onto the keyboard, even if the outlet only serves to maintain my own sanity. I need it, and I'm not going to stop now.

I also look forward to really writing about medicine. This blog is entitled The Language of Medicine, yet it might as well have been called, "The Language of An Angsty Medical Student as He Yearns to be Rid of the Classroom." Now (hopefully) the name will have real meaning. Next week's blog post will actually be a beginning: the first week of real medicine. It will be medicine in the eyes of someone who has yet to behold its wonder and idiosyncrasies, its altruism and its politics. I will have to be careful what I write, but I will remain true and honest about what I experience. These weekly musings will become so much more important to me, as I empty my head each Friday of the ups and downs of days past, but I also hope they will be more intriguing and exciting to the reader.

In other news, my blog was featured by allheartmatters.com, which blogs about current medical narratives. I thought it was pretty cool that my mother isn't the only one who reads my posts each week. Also, although I am so excited to move to Asheville this weekend, I will dearly miss a number of my classmates whom I've come to call my closest friends. You know who you are, and I will pine for you in my sleep each night (or call you 17 times a day). Once life calms down a bit this year (does it?), I will be coming back to Chapel Hill and visiting Charlotte to see my beloveds.

So hang tight, and good luck everyone with the upcoming year!