Friday, March 27, 2009
I did not faint on the tilt-table test, which was not exactly what I expected but was fine. They left me upright for 30 minutes, and although I was dizzy and got hot and sweaty (apparently the only one in the room who thought the room got really hot), my blood pressure stayed pretty steady and my pulse didn't jump as much as it sometimes does when I go from prone to upright.
Then I did the stress test on the treadmill. Man, when I used to go to the gym and walk on a treadmill, I don't think I ever did an incline higher than 5 percent, and usually stuck closer to 3 percent. I'm from the Midwest and grew up in the flatlands. I don't do hills! And I didn't realize that they would have treadmills that didn't show any info or controls. It was all done by their computer. So they started me off at a reasonable pace but at 12 percent incline. I literally held on to the bar at the front of it because I felt like I'd go sliding off the back if I didn't!
My heart rate was at 100 bpm when I was lying down. Upright, it was about 120 or so as long as I didn't talk, which made it go higher. Once I started on the treadmill, I jumped immediately to about 140 and it climbed from there. When it hit 183, I said I'd had enough. Somewhere in the last couple minutes I was on it, they raised the incline to 14 percent. I didn't even know that was possible! And apparently it can go steeper than that too.
So, Dr. McAnulty concluded that my heart is healthy in that I'm unlikely to have a heart attack although it clearly gets going pretty quickly. I eavesdropped as he dictated to his medical student what to type in the computer for the summary/notes, and he said I appeared to have mild dysautonomia and "inappropriate sinus tachycardia." (I was like, "Inappropriate?!" Funny way to describe it.)
I'm supposed to go back to see him in six months, sooner if my internist needs his input on my evolving symptoms.
Meanwhile, I got the radiologist's report on my brain MRI from earlier this week. I'm just going to type it in verbatim because I haven't had enough time/energy to analyze and completely figure it out.
Findings: The ventricles appear to be within normal lijmits in size and configuration. No abnormal extra-axial fluid collection is observed. No significant mass effect or significant midline shift is noted.
In image 12 of the FSEIR axial sequence, two punctate foci of increased signal are observed adjacent to one another in the white matter of the right frontal lobe. These may be the result of volume averaging. They may also be associated with chronic small vessel ischemic disease or, perhaps, vasculitis. The larger of the two may be present, in retrospect, in the comparison examination from 10-4-2007. It has not clearly changed significantly in size. Plaques of multiple sclerosis cannot definitely be excluded but would appear to be less likiely. These foci do not enhance following the administration of intravenous contrast.
No findings are observed that would suggest the presence of an acute or subacute infarction. Very mild to mild mucosal thickening is identified in the left maxillary sinus. Very mild mucosal thickening is noted in the right maxillary sinus, and in the frontal sinuses, ethmoid air cells, and sphenoid sinuses, bilaterally. This mucosal thickening is new or has progressed since the earlier study. Increased signal is also identified in the mastoids, bilaterally, in the T2-weighted sequences. There may be small air-fluid levels within multiple mastoid air cells on the right. These findings are new since the earlier examination.
1. Two, punctate foci of increased signal are observed in the white matter of the right frontal lobe in the FSEIR axial sequence. Please see discussion above.
2. Mucosal thickening is observed in the paranasal sinuses, bilaterally, as described above. Ther are also findings suggesting the presence of bilateral mastoiditis.
Ok, I have to say, that now that I've looked up mastoiditis, I'm wishing I'd called the ENT this week. Apparently, there's some really bad stuff that can happen if it's left untreated, and it used to be the leading cause of death in children before the advent of antibiotics. It's apparently very rare in the U.S., so I guess I'm just lucky once again. :)
I'll be calling the ENT on Monday to make an appointment. I wonder if the mastoiditis is the cause of the severe vertigo that I was having last week. And actually, come to think of it, I did have a fever and ear pain as well last week. I did not have a middle ear infection, though, when I was checked twice last week.
[Update: Here's a better article on mastoiditis. Potentially scary stuff. How funny that I could possibly get something that has a 0.004 percent rate in the U.S. and developed countries. I'm thinking of calling my immunologist, who griped about my getting put on antibiotics for a double ear infection not long ago. He thought it was unnecessary. Hmmph!]
And I still need to get that neti-pot to see if that will help my sinuses. I'm definitely uninterested in sinus surgery at this point, although I am prone to getting frequent sinus infections.
Thursday, March 26, 2009
But apparently I'm angsting about my cardiac testing tomorrow ... er, later this morning. And I'm not sleeping, although I should be.
I'm not worried there's anything wrong with my heart, although when my chest pain is bad enough, I do always wonder if I'd be able to tell if I really did have a heart attack.
So, when I saw the cardiologist, he told me he was going to order an echocardiogram just to make sure there was no inflammation in my heart that had developed since my last echo in July 2007. With both my SED rate and my CRP elevated, it's clear I have inflammation somewhere, and he felt it had been long enough since my last echo to be worthwhile looking at it to be sure it hasn't been affected.
But by the time he sent a letter to my internist, he apparently changed his mind and decided he was going to order a stress test and a tilt-table test. The latter will rule out POTS, which I thought he had already ruled out during my office visit.
The stress test, done the traditional way on a treadmill, will let him see what's happening when my heart rate goes up during exertion. They think it's probably not a serious problem, but this will tell him more than the little finger monitors I've worn while walking in hallways.
And apparently no echo. But I'll be asking him about that when I see him.
Anyway, I'm not worried so much about the results of the test so much as whether the end result will be major exhaustion, which always causes me to flare. And since I really don't feel like I'm recovered from my flare that started in mid February, I'm dreading the effect it will have on me.
On the upside, I've got nothing scheduled next week other than an acupuncture appointment, so if I spend it all in bed, I won't have a lot of stuff that needs rescheduling.
Think positive, right? Maybe I'll find out that the forced exercise on the treadmill makes me feel better rather than worse. That would be nice ...
Meanwhile, I spoke to my internist on Tuesday about my brain MRI. She's mailing me a copy of the radiologist's report, and then I'll have more detail including proper medical terminology.
Essentially, she said the radiologist didn't see anything that screamed MS lesion. So that's good, right? However, there were two bright spots in my right frontal lobe that it's not clear what, if any, effect they're having on me. She said it could be a sign of vasculitis, but she didn't think so because when they compared it to my October 2007 scan, it appeared one of the spots may have been present then. She said that if it were vasculitis, it would have grown much more in the past two years than it had. But she said that really, I need to talk to the neurologist, who I see on April 20 to discuss what she sees in the scans and what she thinks it all means.
The radiologist also commented on my sinuses, which apparently have a major thickening of the mucosal lining ... or something like that. Apparently, I had a little bit of it back in 2007 in one set of sinuses, but now it's much, much worse and in three sets of sinuses. My internist called my ENT to discuss it (they're in the same practice), and he asked her why he hadn't done sinus surgery on me yet. (Gee, maybe because I don't really want it, and it hasn't been a priority over the past two years of my being sick?) She says I need to go see him, and I'm sure I will eventually consider dealing with it. But right now? Anyway, I'm going to try a neti pot first. After all, Dr. Oz talked about them on Oprah a year or so ago! Can't hurt, and it's a lot cheaper than surgery. So many of my friends swear by them.
And that's the news ...
Monday, March 23, 2009
Well, ok, I don't know that it's all that big or that beautiful, but I've been enjoying looking at the MRI photos from today's scan.
They actually had me a DVD with both today's MRI and the brain MRI I had in October 2007. The 2007 one did not have contrast, but today's did.
Unfortunately, although I have the photos, I don't have an interpretation of them. I assume my internist will get a copy of the radiologist's report in a week or so. And I have an appointment with a neurologist on April 20, where I'll get her opinion of them as well. (I know from experience that sometimes the doctors interpret the photos differently than the radiologists. My neurosurgeon says I definitely have a tethered spinal cord, but the radiologists on the two spine MRIs I've had split on whether I do or not.)
The photo at the top of the blog is unenhanced (i.e. no contrast). The following photos have contrast and are different views.
I of course don't really know what I'm looking at. I've found some photos of MS plaques/lesions on the internet, and I don't have anything that looks clearly like what those are. But I don't know for sure that I don't have any either.
I'll let you know what I hear, when I hear it.
Thursday, March 19, 2009
It's a apparently a growing trend that instead of being cared for in the hospital by a doctor who knows you and your case, you instead see a "house" physician, who works full-time for the hospital and whose primary job, apparently, is to get you discharged as quickly as possible.
From the article:
(Dr. Tim) Thunder, 37, says he's a good match for the hospitalist job because he's a multitasker who likes immediate results.
"I like to come up with a treatment plan and help a patient get out of the hospital," he says, "rather than the long-term chronic-care management, which is really important but isn't what a hospitalist does."
Thunder also says: "And because our entire practice is in the hospital, we look very carefully at how patients move through. Are we moving people through in a quick and safe manner? As opposed to the primary doctor, who is focused more on the individual patient.I can understand that using hospitalists saves money. As Thunder says, hospitalists focus on moving patients through the system faster. And the faster someone gets out of the hospital, the less money it costs everyone. (Is it more profitable for hospitals to have their beds turn over? Or does it not matter as long as beds are occupied?)
From the patient standpoint, though, I want a doctor who's focused on me as an individual. As my health gets more and more complicated, I dread having to give my history to yet another new doc. My chart is so thick, it's not like any new doc can just skim it and understand everything I've been through and all the tests that have been done.
I know my primary care doc cares about me as a person, not just as a statistic. When I was in the hospital early in my illness, she visited daily to check on my progress and discuss the results of the latest batch of tests.
When patients are in the hospital, we're at our most vulnerable. We're probably feeling at our worst, and therefore are not as able to advocate for ourselves as we can normally. It can only help to have a doctor who's familiar with our history and our case guiding our treatment in the hospital. Yes, I do believe that sometimes a fresh pair of eyes can see something that the treating physician may have missed or ignored. But I don't think the primary care doc should be taken out of the equation entirely during the hospital stay and then have to mop up once the patient is discharged.
Am I wrong? Is this really a better quality of health care? Or is it just another cost-cutting measure to get around Medicare and insurance company reimbursements? (Do hospitalists get paid more than primary care docs?)
Ok, I just need to get one more vent off my chest while on the topic of this Oregonian article.
Dr. Thunder breezes into an 83-year-old woman's hospital room and says, "Hi Beatrice. I'm Dr. Thunder."
What's up with that? Why do some doctors not realize how disrespectful it is to call an elderly woman (or anyone, really!) by their first name upon first meeting and yet introduce themselves as Doctor So-and-so?
Yes, I know I'm a bit old-fashioned.
I like it when a new doc addresses me as Ms. Brandt until I tell him to call me Aviva. Or, even better, asks me how I'd like to be addressed. I also like it when doctors introduce themselves with a first name, i.e. Dr. Joe Smith. (And I hate it when nurses/medical assistants/dental hygienists refer to their boss as "doctor" like that's the person's name and not their title. "Doctor says you should ..." )
Just call me a curmudgeon.
[Note: The link to the Oregonian article will likely only be good for a week or two. Then their articles move into a pay-for-access archive. Sorry if you're seeing this past when you can view the article.]
No surprise, I suppose, that the combination of a sick kid (strep throat) and immune-system suppressants like IV solumedrol meant that I got sick.
That, combined with the fact that the infusion nurses were concerned about my rising blood pressure and pulse and the headaches the infusions gave me meant my doctor took me off the steroids. I had three of the "call your doctor immediately" symptoms on the list of possible side effects: headaches, shortness of breath and racing heart with palpitations.
Sadly, on Monday, which would have been my third infusion, my right eye seemed to be slightly better. I don't know if it was wishful thinking or true improvement. But by Tuesday, the vision and pain was as bad as before.
(Side note: I don't know if I just hadn't noticed it previously or if it's a newer development, but I noticed Tuesday that when I look at the green light on the cable box in my bedroom, it's no longer a circle. It looks like a snowflake, with pointy spikes in every direction. When I look with just my left eye, there's just two spikes from an otherwise round light. When I look with just my right eye, it spikes all directions. Kind of pretty, but a little weird too, especially since I know it used to not be like that.)
So. Now I still have my eye problems, and I'm sick with what I suspect is turning into bronchitis (I have an amazing wheeze going ...) and my energy is even more non-existent than before. Lovely.
I saw the new hematologist on Tuesday, too. Really nice guy, great personality. He pretty much reiterated what I already knew -- that my monoclonal gammopathy of undetermined significance (MGUS) likely just needs to be monitored regularly and only develops into cancer in a small percentage of cases, many years down the line.
But he also expressed a little concern with my iron levels and said that since over-the-counter supplements have been unable to raise the levels enough, he will consider giving me IV infusions of iron.
Then he ordered a whole bunch of tests, including another one for celiac disease even though I told him I'd been tested and had the endoscopy biopsies come back normal. But he wanted to do his own tests and I didn't feel well enough to argue that it was an unnecessary cost.
So the lab took a bunch of test-tubes of blood. I don't know if it's because of the recent pokes I'd gotten for the infusions but the nurse had a hard time finding a good vein that didn't collapse on her. And I'm still kind of embarrassed but I passed out at the end of the blood draw. That's never happened to me before! I do know that my blood pressure was very low when I was checked in to see the doctor -- 89/56 -- and my pulse was high at 125 (sitting). I don't know if that had something to do with it or not, but I'm glad I see the cardiologist next week for my cardiac testing.
I also was scheduled to have my brain MRI on Wednesday, but that was a mess too. I had trouble lining up a ride, so I went without taking the Valium to help me through my claustrophobia and it did not work well. It's rescheduled for Monday, which is spring break and Scott will be off work and can drive me.
Sunday, March 15, 2009
I'm still beyond exhausted, but it's very hard to fall asleep. And I'm overly chatter-y, which is a nervous/jittery thing for me. I guess I'm always pretty opinionated, but I'm even more so right now.
But the stuff I find most distressing is the way my heart is racing even worse than usual. I'm incapable of taking my own pulse for some reason, but luckily my husband isn't, so he clocked me at 120 bpm while lying down, which is high even with my tachycardia.
At the infusion center, they noted that my blood pressure was creeping up and that they'll need to keep a close eye on it.
And my dilemma this afternoon is trying to figure out if I'm just having a panic attack triggered by the steroids (which is pretty common) or if my chest pain, shortness of breath and racing heart means I really need a trip to the ER. I hate running to the ER when it turns out to be no big deal healthwise but is still a big bill to pay afterwards.
I've been off anti-anxiety medication for a long time (pretty much since I got off steroids the last time about six months ago or so), but I popped a Klonopin about an hour ago to see if that would ease my symptoms. And it has, a little, but I don't know if it's enough.
I know if I call the on-call doc, they'll tell me to go the ER just to be on the safe side because the steroids can trigger heart attacks and other stuff. But in some ways, that feels like a CYA kind of automatic response rather than a thoughtful look at my history which so far hasn't had anything turn up on EKGs or echocardiograms (although my last one of those was back in July 2007, but I've had several EKGs since then).
Gotta go lie down now. That eases the chest pain a bit.
Oddly, I think my hands look more swollen than less, and it seems like the steroids should be reducing inflammation there as well as on my optic nerve. But they haven't turned into little sausages yet so I'm not going to worry about edema or anything. No swelling in my ankles that I can notice.
I guess my big fear about going to the ER today is that when I went to the ER with similar symptoms back in July 2007, I got admitted and came out in worse shape after 8 days than when I went in. I really don't want to do that again ... although it's unlikely since they could look at my history and see all the tests that have been run in the past two years.
Sorry for the stream-of-consciousness. That's about the only way my brain is functioning today, and truthfully, I guess that's pretty much how I blog most of the time anyway.
Oh, and totally off-topic: I got my first ever book review accepted for publication. It's online now and will appear in the April print edition of Palm Beach (FL) ArtsPaper, a startup run by an old friend from my days in the Charleston, WV, bureau of the Associated Press. I wasn't sure if I knew how to write a journalistic critique since it's not something I'd ever done before. So this was the trial run, but Greg has already authorized me for two more books, which I'm waiting for from Amazon. Back when I was doing real freelance writing, I would have been too snobby to work for the low pay involved, but a) I'm excited to have something professional and recent that I can point to if/when I'm ready to rejoin the workforce and b) it's for a friend who's trying to get a new business up and running and fully intends to raise his payscale for these as soon as he can afford to.
And hey, I still remember my mom telling me no one would pay me to read books because I'm such a prolific reader. So I'm excited to prove her wrong! :) (Ok, that dates back to grammar school in the mid-70s when I was in a read-a-thon for some charity and I was unhappy that my mom only sponsored me for 10 cents a book when another girl was getting $1 per book. Of course, she read a total of 5 books, I think. I, on the other hand, read something like 250.) :)
Anyway, please check out my book review -- I'm sure page views help Greg make a little advertising money -- and if you or someone you know is based in the Palm Beach, FL, area, you should consider checking out his print publication too as well as the rest of the website. He's really on top of everything that's going on in the arts community down there.
Friday, March 13, 2009
Ellie was home sick with a fever and what we thought was just a bad cold, but discovered badly swollen tonsils by early afternoon that turned out to be strep.
Meanwhile, I had a routine mammogram and a sonohysterogram to find out if I still had a problem with polyps, something I'd been dealing with two years ago and postponed and then canceled a surgical procedure to correct when I got sick with my mystery illness. (They found three this time, which means I'll probably need to get that taken care of one of these days with a d&c followed by an ablation.)
I got home from that to find out that my internist (who I'd left a message for earlier in the morning and faxed a study that Lisa Emrich had given me a link to -- thanks Lisa!) wanted me to see an ophthalmologist asap and her assistant had scheduled me an appointment for a this afternoon. Meanwhile, she also scheduled me for IV steroid infusions starting Saturday for five days, which apparently is the standard treatment for optic neuritis.
To complicate matters, the ophthalmologist (who I wasn't wild about) said my eyes were not a clear case of optic neuritis, in that he couldn't see anything looking through my retina. However, he said, that the optic nerve could be inflamed in areas he can't see directly. So he's not ruling it out. Also complicating diagnosis: I'm not completely color blind, although I have some loss of color vision. He wants to run another test of my visual field, which will have to wait until Tuesday. I was already scheduled to have an MRI on Wednesday, and he was happy to hear that.
The ophthalmologist was also skeptical of the use of solumedrol for any but the worst cases of optic neuritis, saying it was unnecessary otherwise because it will clear up on its own.
My internist, who spoke to a neurologist who's married to one of my friends, said she would lean toward erring on the side of caution, which to her means going ahead with the solumedrol.
So starting tomorrow morning, I'll be spending an hour or so in an infusion center every day for the next five days. And then I'll take oral steroids in a tapering dose.
A humorous aside: I mentioned to the ophthalmologist that steroids make me crazy. His eyes widened.
"Really crazy?" he asked in a serious tone.
"What do you mean by really crazy? I probably don't mean medically crazy ..." I said.
"What happens to you?" he asked.
"Well, I get paranoid, have panic attacks, I am extremely irritable ... essentially, I'm just miserable to be around. And there's the time I really wanted to kick my cat, who wouldn't stop yowling." (Note: I did not actually kick the cat. I just wanted to. With an intensity that frightened me enough that I called my internist the next day.)
"Oh," he said, somewhat superciliously, "that's not crazy. There's something called steroid psychosis and people with that sometimes have to be put in straitjackets."
"No," I agreed. "Steroids don't make me crazy."
Ok, it's not hilariously funny. But it was probably the most amusing part of my day. :)
Oh, and you should all consider yourselves warned that I'll be beyond grumpy probably for the next week or two while I wean off the steroids ... Try not to take anything personally that I might say.
Wednesday, March 11, 2009
Nichole said that when she saw Ellie at school a few days earlier, she told Ellie that she needed to talk to her mom before the girls could have a playdate.
Then, she tells me, Ellie responded, "Oh, don't call my mom. My mom is sick. Call my dad instead!"
I worry about how my health issues are affecting her. A 4-year-old shouldn't have to tell people that her mom is too sick to set up a playdate. (And it's not true anyway -- no matter how sick I am, I'm still the family social coordinator! I keep the calendar that keeps us all straight.)
The New York Times ran a story a few weeks ago about children who are caregivers for their chronically ill parents. And I don't mean adult children -- I mean kids who should be out playing with their friends or doing homework rather than administering shots and taking care of their parents in other ways. I'm not sure I can imagine a worse horror story ...
It's become a family joke that I say I'm "pooped" and Ellie asks me why I didn't go to the potty first. (She honestly thought I meant I'd done it in my pants the first time she heard me say it. Now she knows it has another meaning, but she likes to go through the conversation about it each time.)
But she also asks me if I "have energy" before asking me to do things for or with her. And she asks me how I'm feeling some days, cupping my face in her hand like I do when she's sick.
I guess I need to be more stoic, since I don't want my preschooler worrying about mommy. But I also learned the hard way a few weeks ago that I can't just ignore my body's limits either without paying some severe consequences.
So I saw my internist today. I think my optic neuritis is getting worse, which I guess is pretty common before it improves. We're considering putting me on steroids again, but I'm going to wait a couple more days before making that call. I hate steroids -- they make me crazy, especially at high doses.
She also is ordering an MRI of my brain. I had one done in October 2007 that was "unremarkable," but it was done without contrast and did not include an "MS protocol," whatever that is. The insurance company needs to pre-approve it before I can be scheduled, but I hope to get it done in the next couple weeks.
Meanwhile, she's doing the paperwork to try to get me in to see an MS specialist at OHSU. Apparently there's a lot of hoops to jump through before I get an appointment. :P
Sunday, March 8, 2009
For about a week now, I've been telling Scott that I feel like I'm looking through cardboard toilet paper thingies. It's not that I have tunnel vision, exactly -- there's no black edges to my vision, like I get right before I pass out.
But I used to have really good (better than "normal") peripheral vision, and I don't anymore. If I hold hands on both sides of my head where I used to be able to see them, I can just see a hint of my left hand and my right hand is invisible. It's weird, and Scott says the reason I don't have black holes where my vision is bad is because the brain just sort of stretches what it can see so it fills in the blanks. Weird.
I've also been feeling like I can't keep my eyes as open as normal. It's like my eyelids weigh 5 lbs each or something. That symptom, of course, freaked me out a bit because having trouble with her eyelids is the first identifiable symptom my mom had of her myasthenia gravis.
And my eyes hurt, particularly if I have to move them much, but even if I don't. It feels kind of like a bad case of eye strain in some ways, although it has gotten worse over the course of the week.
So the test the eye doc did that showed abnormalities is the Humphrey Matrix with Frequency Doubling Technology. The glaucoma hemafield test was "outside normal limits." Mean deviation: -3.77. Pattern standard deviation: +4.7 P<0.5%. And don't ask me what any of that means since I haven't a clue. :)
Since I just had an eye exam in November 2007 and my glaucoma tests were normal, the eye doc said that definitely wasn't the problem. So he said the most likely cause of my symptoms was the optic neuritis. The following is the printout of my test results for my right eye. The bottom matrices would be all white boxes if my eyes were normal. There's gradations with just a few spots in a square up to the solid black ones. The eye doc said it isn't as bad as it could be, which I guess is good. I could have been happy with all white squares though, which is sort of what I expected in that I didn't expect any of the tests to show anything wrong with my vision.
And then the photo below is the test results for my left eye, which as you can see is much better than my right, although still considered abnormal results:
Saturday, March 7, 2009
The news is that I was diagnosed yesterday with optic neuritis, which essentially is inflammation of the optic nerves. My vision has been weird lately and I've had eye pain and increased headaches (apparently triggered by my eyes), so I went to the eye doctor. After a long computerized test of my vision, I showed significance loss of vision in the bottom part of my retina of my right eye, and a much smaller loss in my left eye.
A photo of my retina showed no damage to the actual eye, so the doctor said that generally means it's inflammation pressing on the optic nerves.
As you may already know, that's a fairly common symptom in multiple sclerosis and often the symptom that leads to diagnosis. Interestingly, I found out that Portland (and Seattle) are considered to have the highest per capita rates of MS. A little scary, especially since I'm rearing a native Portlander, but it also means that we allegedly have some of the best MS experts in the country if not the world.
So I've got a name of a doctor to call on Monday (this all came about just before 5 p.m. on Friday so there was no chance of calling then) and will hopefully get an appointment soon.
My internist says that while I had a brain MRI done a little over a year ago that showed no plaque (the radiologist said my brain was unremarkable, which I strongly disagreed with :), MS docs prefer contrast to be used and often have preferences for a certain kind of contrast that best shows plaques. So we'll see. Dr. Takano said it was also not uncommon for symptoms to show up before things had progressed enough to show up on the scans, so that's another possibility.
Meanwhile, we're trying not to jump to any conclusions about what this might mean. The eye doctor and my internist say that sometimes optic neuritis just happens spontaneously so we're not making any assumptions. I'm still a medical mystery and this could all be yet another red herring.
I'll keep you updated.
Fyi, our DSL is out until possibly Thursday. (I'm currently "borrowing" a neighbor's ... thanks, Joan! :) So don't be surprised if I'm not as reachable as normal via email.