NC Pediatric Society Annual Meeting Day 2

You’d think there wouldn’t be anything left to talk about after that first day, but you’d be oh-so-wrong! Pull up a steel chair, sit down at a folding table with stretchy cloth over it, grab a sweating pitcher of ice water, and join us for day #2. Oh, and to make it super-realistic, turn the AC way down and get up every 2 hours to stretch and use the bathroom. (Photo credits again go to Dr. Ed Spence, who seems to be able to stay up just as late and me and yet awaken early enough to take amazing sunrise panoramas.)

John Rusher, MD, JD
Legislative Update

• Medicaid Reform: Senate/Governor and House disagree on plan, still have not come to any agreement. Decision was punted to a possible special session in November or December, seems unlikely to happen. 
• Committees are continuing to meet, long session will resume in January of 2015. Our staff an lobbyists are monitoring committee meetings.
• Please take time to educate your own senators and representatives on Medicaid and how it’s working. NC Pediatric Society believes strongly that the Senate/Governor model, which preserves CCNC and physician control, is far preferable to farming out Medicaid to private, for-profit companies under a model that would include no physician input.
• Look for a list of talking points later this year to bring to your incoming or incumbent legislators.
• Tanning bed bill passed the House easily, but it was never brought to the floor of the Senate.
• Autism insurance coverage bill also passed house but was never brought up in the Senate.
• Epipens in schools bill made it through in the budget bill, but no dollars were allocated to help schools buy those pens.
• In January, 2015 we are facing a 4% reduction in Medicaid reimbursement if nothing changes. This cut will be in addition to the possible loss of ACA parity payments to make Medicaid equal to Medicare.
• This year saw a $10 million cut to Childrens Developmental Services Agencies. We still have 12 CDSA centers now, but with 20% fewer personnel.
• Child Protective Services and Foster Care did receive increased funding.
• What we are seeing overall is a shift in policy from preventing bad things from happening to children to responding when they do. Ideally we would explain to our legislators what we have learned about toxic stress in early childhood and can help them understand what an enormous return on investment (10X) there is on money spent in early childhood care.
• We supported raising the age of juvenile jurisdiction for misdemeanors and felonies to 16-17 years. Only New York and North Carolina treat these children as adults, denying them the sort of rehabilitation offered in juvenile facilities. Again, it passed the house and was not taken up in the Senate.
• Scope of Practice issues will come up again. Certified Midwives want to practice without supervision. Lay midwives want to perform home deliveries without any liability. Chiropractors want to do sports physicals.
• At the federal level, saving CHIP and the ACA parity payments are enormous priorities. Federal funding for state newborn screening is also in danger this year.
• VOTE! Of all the MD’s who came to Raleigh to participate in White Coat Wednesdays with the North Carolina Medical Society, <50% had actually voted in the most recent election.
• Legislators can look at the list and see who voted! Make sure they see your name.
• Encourage your friends to vote, too.
• Please consider donating to NC Pediatric Society to help fund our advocacy efforts. ncpeds.org
• Top point: the cut in Medicaid is relatively small for the state budget, but it will have massive effects on patients’ access to care in the state, drive them into ED’s, possibly cost even more in the long run.

Christoph Diasio, MD
Practice Council

• Awful timing: had to install a new computer system just as the most transformative law in the history of Medicaid was being implemented.
• Practice Managers’ ListServe was an incredible resource for practices.
• What is the ACA Primary Care Reimbursement Increase? The idea was to use money to help expand access to care for Medicaid recipients. North Carolina chose to turn back $52 billion of our taxpayers’ money to send it to other states for their Medicaid expansion. Still, enrolled Medicaid doctors got 2 years of Medicare parity.
• NC Peds was able to correct an NC Tracks computer error that would have decreased payments to pediatricians by 3%.
• Graham Barden and NC Peds discovered that Well Child Care codes were programmed to be reimbursed at an incorrectly reduced rate, 35% of everything we were promised under the ACA. The difference was from $80.33 to $99.81 for each well child care visit. Thank you, Graham Barden!
• They were going to disallow all vaccine administration codes due to a modifier. NC Pediatric Society helped NC correct this error, correctly increasing payments to  pediatricians by millions of dollars for our hard work vaccinating and protecting children for terrible diseases.
• NC Pediatric society helped NC correct an error that would not have applied the ACA rates to quadrivalent influenza vaccines and denied not just the vaccine but the entire visit!
• NC Peds (really Graham) helped push the attestation date for ACA payments forward by a year. The only place to know that you had to attest was the website where you go to attest. Went from 5000 doctors to 16,000 successfully attested.
• ACA stated that vaccine administration code should pay $20.45. NC was coding to pay $13.71 instead. Dr. Barden helped correct this issue.
• Other issues involved cardiology codes, nebulizer reimbursement, and one practice that was in danger of going out of business without emergency loans facilitated by NC Peds.

Dr. Graham Barden accepts the "Bulldog/Sage of the ACA" award from Dr. Diasio. We owe this man a lot more than a plastic dog, but it's a creative start.

Airway Obstructions
Sujay Kansagra, MD

(Confession: I stayed a few minutes too long in the Exhibit Room and came in late. Sorry.)

• Often airway obstructions from Pierre Robin sequence can be simply prone positioning.
• Nasopharyngeal airway effectively stabilizes another large number of Pierre Robin patients.
• Parents can learn to manage these airways on their own at home.
• Mandibular distraction alone can be successful in managing airways, but often tracheostomy is also required.
• Tracheostomy rates are falling in these children as other management modalities improve.
• New Down Syndrome guidelines mandate a sleep study by age 4. What to do with the results can be challenging.

Circ/Phimosis/Adhesions
John Wiener, MD 

• Circumcision rates in the US are still 80.5%, but only 44% among Hispanics, as high as 90.8% among caucasians. In England the rates are 4%.
• Worldwide rates are 12.5 to 33%
• NC Medicaid does not pay for circumcision.
• Will pay for posterior urethral valves, neurogenic bladder, recurrent UTI’s if they need circs.
• Non-newborn, true phimosis causing urinary obstruction or pain on urination.
• AAP Guidelines 2012 suggests that health benefits outweigh the risks enough to justify the procedure for families who choose it.
• Decrease UTI’s in infant males; 95% of male infants hospitalized with UTI’s were uncircumcised.
• Circ leads to a 10X decrease in infant UTI’s in males.
• Up to 10% of men will require medical circumcision later in life.
• In Africa, circumcision reduces HIV 50% to 60% in heterosexual transmission
• In South African studies, circumcised men were having more sex. Does not seem to protect female partners.
• Risks: may include death rarely. Hemorrhage in 0.1% to 0.6%. Also infection, poor cosmesis, partial amputation, meatitis/stenosis, pain.
• Decreased sexual sensation?
• Steps: informed consent, examine  penis for size, anomalies, hypospadias, chordee, consider amount of skin to be removed, apply local anesthetic.
• Lidocaine block.
• Mogen is fastest, least painful, but also cosmetically challenging and introduces risk for partial amputation, bleeding.
• Risk with kids who have loose skin, hydroceles, may lead to poor length, hidden glans, adhesions.
• Most docs won’t do a circ after 28 days (this is driven by obstetric insurance coverage). Also, when baby is too large to strap down, glans is too large. Biggest problem is increased vascularity with increased age: increased bleeding. For Dr. Weiner, 2 months or 12 lbs.
• Circ in clinic often runs around $350. Circ in OR as $2400. Covered by all carriers except Medicaid.
• Following Gomco, apply Vaseline with diaper changes until healed.
• Preventing adhesions: push skin off glans/corona with a Q-tip (Gomco) once or twice a day.
• Skin bridges occur when the circumcision line has been pulled up. Must be cut. Most have to go the OR to avoid bleeding.
• What about care of the intact penis?
• Phimosis can be treated with observation, medical therapy, circumcision, or dorsal slit.
• Phimosis usually resolves on its own.
• Betamethasone valerate ointment 0.1% BID with pulling down with gentle pressure. Try to reach the phimotic band where the inflammation is.
• Medical therapy success rate 86% to 92%, 6 month failure rate may be as high as 30%
• Adhesions tend to go away by adolescence.
• Don’t break adhesions! It hurts, and they recur.
• Steroid creams don’t accelerate the resolution of post-circumcision adhesions.
• Smegma is not pus, it will fix the adhesions.
• Suggest retraction and cleaning at age 2 with routine bathing, only retract as much as is comfortable, then put it back.

ENT – T&A.
Jason Roberts, MD 

• What is the role of all this lymphoid tissue? Waldeyer’s Ring: predominately B cell production, but also T cell function such as lymphokine production. Most active between ages 4-10.
• Tonsils and adenoids are key to mucosal immunity. Reports conflict on the immunologic consequences of removing tonsils and adenoids - no major deficiencies, no increase in atopic disease, no decrease in IgM or IgG, and IgA decrease not significant.
• Tonsillitis may be acute or chronic. May have peritonsillar abscess.
• Normal flora are predominately anaerobic.
• Pathogens: most common GABHS, also candida, Corynebacterium diphtheria, Neisseria gonorrhea, syphilis, EBV.
• Mono can be severe, life-threatening.
• Bacterial biofilms can cause chronic tonsillitis with chronic sore throat, halitosis, tonsillitis, tender nodes.
• Antibiotics don’t treat bacterial biofilms - don’t penetrate.
• Acute tonsillitis treatment is based on the organism.
• Chronic: 7 in 1 year, 5/year x 2 years, 3/year for several years, or multiple antibiotic intolerance.
• Abscesses often recur, may be a reason to remove tonsils.
• Also may remove for scarlet fever, acute rheumatic fever, post-strep GN, PFAPA, PANDAS (not clear that tonsillectomy helps PANDAS)
• Childhood obstructive sleep apnea. Unlike adults, kids are not necessarily overweight, have hypertrophic and enlarged tonsils.
• Kids may be irritable, poorly behaved in school, may look like ADHD. Hard to awaken in the AM.
• Ideally children reach stage III and IV sleep early in the evening. May be interrupted by frequent awakenings in sleep apnea.
• Clinical signs: witnessed apnea, enuresis, 88% had OSA, qualified for tonsillectomy.
• May get sleep study when diagnosis is in question, but not when the diagnosis is obvious based on history and exam.
• Childhood consequences of sleep apnea are neurocognitive. Adults additionally have cardiovascular and metabolic complications.
• Medical management includes CPAP, nasal corticosteroids, astelin, 
• Adenotonsillectomy demonstrates subjective and objective improvement in kids’ sleep, executive function.

General Surgery – Evaluation of Acute Abdomen 
Duncan Phillips, MD 

• Most common reason for ED presentation in NC is abdominal pain of unknown etiology.
• Don’t be afraid to admit and observe, consult partners, colleagues, consultants.
• Malrotation and volvulus occur in about 1/500 live births.
• May be subtle and chronic or life-threatening emergency.
• In malrotation, the whole small bowel is hanging from one trunk, which can get pinched off.
• Symptoms usually present early, in the first month of life. 60% in 1 month, 80% in one year. Present with bilious vomiting.
• Bilious vomiting is malrotation until proven otherwise!
• Fussy, irritable, distended. No classic physical exam for these kids.
• Upper GI study is the gold standard for diagnosis. Duodenum must cross midline, ligament of Trietz must be as high as the pylorus.
• Treatment: Ladd procedure. Always take out the appendix. You still have malrotation, but you don’t get volvulus.
• Intussusception affects 1 in 250-500 children. Peyer’s patches swell with infection, ileum telescopes into the colon.
• Waves of abdominal pain and screaming, currant jelly stools, vomiting progresses to bilious.
• In 40% to 70% you can palpate a “sausage” in the abdomen. May be a bad sign if they’re relaxed enough for you to feel it, getting lethargic.
• ED may perform a screening ultrasound, but negative predictive value is poor, so don’t be too reassured.
• Follow with air or barium enema, whichever your radiologist likes to do.
• If unsuccessful try again in 2-4 hours. If that one fails, then operate.
• Often still have fevers and discomfort for a day or two after surgery.
• Appendicitis is the most common emergency abdominal surgery in children. Between 7-8% of Americans get an appendectomy at some point in their lives.
• Pain usually comes first. Pain usually migrates to RLQ. Pain usually is constant. Pain usually progressively worsens. Pain is usually worse with movement. Pain is usually a spontaneously offered complaint, not elicited.
• Periumbilical pain is usually the first complaint. Vomiting is very common. “Screamers” rarely have appendicitis. Sudden motion is uncomfortable. In kids under age 5, perforations are common.
• Ask patient to point to pain with one finger. Examine gently with stethoscope, percussion. Do not check for rebound.
• WBC can range from 6,000 to 32,000, often normal WBC. Poor negative predictive value.
• In a classic case, no imaging is necessary. Ultrasound avoids radiation, but CT scan is more accurate in many places (90% or more).
• Treatment is to resuscitate, evaluate, operate.
• Pediatric cholelithiasis, cholecystitis.
• Get postprandial RUQ pain, may have fever, vomiting. Murphy’s sign. Check LFT’s, CBC, amylase/lipase.
• Go to cholecystectomy in the first 24 hours rather than waiting to give IVF and antibiotics for a few days.
• Pediatric ovarian masses are more common than most suspect. Most are benign and asymptomatic. May get very large, may torse. May occur in newborns.
• Torsion occurs with pain, at any age, may cause nausea and vomiting and lower abdominal tenderness. Needs surgery.
• Ruptured ovarian cyst presents with sudden mild to moderate lower abdominal pain. May persist for days and slowly improve. Usually no GI symptoms. Avoid surgery.
• Ovarian teratoma may present with torsion.

 Common Sleep Problems. 
Sujay Kansagra, MD 

• Sleep is a balance between two processes: homeostatic sleep drive, and circadian alerting signal. Driven by adenosine accumulation in the brain. Melatonin drives sleep cycle.
• Circadian rhythm works at the cellular, genetic expression level, and also at the organ system level.
• Average sleep needed 12-18 hours for newborns, 7-9 hours for most adults. Rare to need less than 7.
• Sleep cycles spread out with age, people spend less time in deep sleep, more time with awakenings, most of which we don’t remember.
• Toddlers normally move a whole lot when they’re asleep. These movements decrease by school age.
• Normal variants: sleep talking, hypnic jerks, sleep myoclonus of infancy, snoring, long sleeping, short sleeping (genetic polymorphisms, very rare)
• Three questions of abnormal sleep: 1) Does your child snore or have difficulty breathing at night? Does you child have trouble falling or staying asleep? 3) Does your child have abnormal movements or awakenings during the night that concern you?
• In children, sleep apnea affects non-obese, healthy-looking children (second time we’ve heard that today). 1-3% of kids have sleep apnea.
• Sleep apnea presents with ADHD, behavioral problems, not sleepiness. Also enuresis, hypertension, failure to thrive, irritability.
• There is a 2012 AAP guideline on whom to refer for a sleep study.
• Childhood insomnia affects the whole family. May affect 20-30% of children. Almost always a behavioral problem. Almost never a role for medication.
• Sleep Onset Association Disorder. Whatever you use to associate with the transition from waking to sleeping you become dependent on. If that’s a caregiver, then the caregiver will always have to be there, even for normal nighttime awakenings.
• Kids develop sleep associations very early in life. These kids know what they want, very verbal about it when they don’t get it.
• Kids who go to sleep very quickly have a hard time changing sleep associations - you can’t put them in the crib when they’re drowsy, because they’re either awake or asleep.
• Answer is sleep training to alter sleep associations. Very controversial among parents. Choices range from no crying at all, which works very slowly to cold turkey, which works very quickly. Benefit is for the children, not for the parents. Studies show that bonding/attachment is not affected by which method parents use.
• Extinction: go through the routine, leave, don’t come back. At some point, the child will go to sleep. Works very quickly, but kids will cry for quite a while first. Use a video monitor to make sure the child is safe, or even sit in the room and read your book while the child cries. Proven safe and effective, but most parents just can’t stand it.
• Start using these methods around 6 months of age, not usually before that.
• When can you stop nighttime feeds? Six months is usually safe, but wean off nighttime calories slowly, not all at once.
• “Ferber” method is really a modified extinction method. Wait 5 minutes, then come back. Wait 10 minutes. Wait 15 minutes. At some point the child really will fall asleep, ideally when you’re out of the room. Whatever you do, always add time, don’t decrease time. The timing is arbitrary, but the concept remains the same.
• “Slow and steady” method involves eliminating one association at a time. If it’s feeding, rocking, holding, then take away the rocking first. Then take away the feeding. Then take away the holding (order is arbitrary, but the concept is the same). Takes longer, but will still work.
• “No crying method.” Takes a very long time, but for some parents this is the only one they’ll accept. Actually involves waking your child up before their natural awakening and then letting them go back to sleep on their own. Eventually, they develop their own sleep association.
• Limit Setting Sleep Disorder. In this case, the child gets whatever he wants at night, keeps adding demands/needs.
• Easiest way to address is silent return to bed, ignore demands, put him back in his bed over and over again as needed, same response each time, “It’s time for bed, I love you.” May take 60 returns to bed. Respond like a robot, same response every time. Must be more persistent than your child, which is hard!
• Delayed Sleep Phase Syndrome. Common in teens. Normal sleep quantity and quality, but not at a time that works for school/work/family.
• The shift in teens’ internal clock occurs at the cellular level, not just as easy as putting down the cell phone.
• That said, night time light exposure acts like daytime on the brain. So avoid late-night light exposure from electronics. Melatonin should be given 2-6 hours prior to the normal bed time. A little will do 0.5 to 1 mg, no need for mega-doses. Shift bedtime back 15 minutes a day. Get lots of light in the morning at awakening.
• New book: My Child Won’t Sleep, free on Amazon starting next week, goes through all the various techniques and issues.

Fetal Echocardiography and Pulse Ox Monitoring
Mike Walsh, MD 

• Cardiac anomalies affect 8/1000 live births, most common birth defect.
• Congenital heart disease is the leading cause of mortality from birth defects.
• Fetal echocardiogram moves diagnosis into the second trimester. Pulse ox makes it in the first 24-48 hours of life, prior to discharge.
• While diagnosis of CHD prenatally has increased, about 10% of kids with CHD are still diagnosed after hospital discharge, has not changed over time.
• Fetal echo starts between 18-24 weeks of gestation. Actually gets harder after 32 weeks.
• There are recommendations for who should get a fetal echo.
• Goal of fetal echo is to make an accurate diagnosis prior to birth, especially in babies who will have critical disease shortly after birth.
• Process involves counseling, education, decisioins about delivery site and care team, palliative care, termination. In some cases, in-utero therapies can improve outcomes.
• Most important is to establish a birth plan, perinatal strategy: who needs to be there, what lines need to be placed, what meds need to be available at birth.
• Transposition of the Great Arteries (TGA). Echo can look normal, four chambers. Have to see the outflow tracts do diagnose. Few other clues in terms of other abnormalities.
• Only mixing lesions make TGA survivable. Needs an adequate ASD in addition to a PDA. Balloon atrial septostomy is indicated, needs a cardiac cath lab, needs to be done quickly after birth.
• Prenatal diagnosis makes a tremendous difference in TGA survival and morbidity.
• A good screening ultrasound is critical to catching these kids in time; must evaluate outflow tracts, not just 4-chamber view.
• In North Carolina, only 45% of critical heart lesions are identified on prenatal echocardiogram. That means that over 50% of babies get to the nursery without a diagnosis.
• Universal pulse ox screening of newborns would save about 20 lives a year at a cost of $40,000 per life saved, within the recommended range for screening tests.
• What does pulse ox not catch? Aortic arch obstructions!
• False-positive screens leading to unnecessary echocardiograms predicted to be around 2000 a year.
• As of May, 2013, North Carolina adopted mandatory pulse oximetry screening.
• Child should be as close to 24 hours of age as possible, ideally just after 24 hours. Should scan both hand and foot, look at kids with >3% difference in SpO2.
• Pulse oximetry can miss aortic stenosis, coarctation, and left to right shunts like VSD or AV canal.
• Be alert to home and out-of-hospital births where screening may not have been done!

Allergy/Immunology (Food Allergies)
Michelle Hernandez, MD 

• Over-diagnosis of food allergies can lead some kids to have incredibly restricted diets for no medical reason.
• Avoidance diets can have detrimental impacts on growth and nutrition.
• Food allergy: an adverse health effect arising from an immune response that occurs reproducibly on exposure to a given food. That it is reproducible is the critical point: parents will suspect what the food is. If they don’t less likely to be real.
• Should be IgE mediated reaction. Hives, yes, itchy throat, no.
• Milk protein intolerance is not IgE mediated!
• Eczema? Jury is still out, controversial.
• Nasal congestion after drinking milk? No.
• Sensitization: B cell makes IgE to an antigen (takes 2 weeks to happen, requires T-cell mediation).
• After that, IgE sits on mast cells, and the next time you see the allergen, the IgE’s cross-link and activate the mast cell to cause an allergic reaction. 
• Positive predictive value of allergy testing is 50%. You can have all sorts of IgE without having a clinical allergic reaction.
• Anaphylaxis occurs in two phases: itching and wheezing come early as mast cells degranulate. Then the late-phase reaction occurs in 4-6 hours.
• Symptoms may include hives, swelling, nausea, abdominal pain. Don’t have to have hives; GI symptoms alone are enough.
• Food allergy does NOT cause isolated rhinitis symptoms without other systemic symptoms!
• Anaphylaxis: hives, flushing, airway constriction, vomiting, diarrhea, light-headedness, mental status changes, palpitations, sense of impending doom.
• Anaphylaxis tends to be worse in asthmatic patients.
• Lots of parents (30%) believe their children have a food allergy. Real prevalence is 5%.
• 85% of people outgrow milk, egg, wheat, and soy allergy. 85% don’t outgrow tree nut or peanut allergies.
• History: What happened, how soon after eating, and what was everything the child was eating. What has the child eaten since then that was also part of that meal? Because if they didn’t react again, that’s not the allergen.
• How did they treat the symptoms? Did it work?
• Most common cause of hives in children is viral infection.
• Goal: test for as few foods as possible!!!
• Skin or serum testing: negative results are highly accurate. Positive results are 50% accurate.
• Immunocap IgE testing: add serum to solid-phase antigen, then label with fluorescent antibody.
• A level of 0.35 in most labs is undetectable, not clinically significant. BUT remember that history beats testing: sensitivity is not 100%!
• Class of lab result DOES NOT correlate with severity of allergic reaction!
• DO NOT test IgG4. It only tells you that the patient has ever been exposed to that food.
• Diagnosis: the gold standard is a food challenge. Basic idea: give a little, then increase amount. Be aware that very anxious people can get hives with anxiety. If the challenge is negative they probably don’t have an allergy. This test should be done by an allergist.
• Management: for now, avoid the food. Desensitization remains in clinical trial phase. Go to clinicaltrials.gov
• Dietitian can educate patients on label reading.
• Give Benadryl for non-systemic symptoms, but have epinephrine ready for the systemic symptoms.
• Go to the full sized EpiPen at 20 kg (not 30 kg per package insert).
• Teach patient how to use it! Use a trainer pen, show them how to put it in the lateral thigh. Have them count to 10 seconds slowly (or 20 fast). Auvi-Q is 5 seconds.
• Don’t wait to long to give epinephrine!!! Empty heart syndrome is a major cause of death.
• Repeat dose in 5-10 minutes if needed - always give a 2-pack.
• foodallergy.org has a great care plan with visual cues.
• Sensitization occurs through the gut and also through the skin; treat eczema as well as possible!

Headaches in Children, the Child Health Accountable Care Collaborative (CHACC) Initiative
Steve Wegner, MD, Robert Greenwood, MD, Mike Tennyson, MD, David Tayloe, MD

• In North Carolina, because we still have Community Care of North Carolina, we can utilize state-wide guidelines to standardize best practices and save NC Medicaid money (mention this to your state Senator, please).
• Guidelines are still being finalized, not yet on the CCNC website, but draft handed out today.
• CHACC hopes to redesign care for children with chronic illnesses to improve quality of care, reduce costs.
• Headaches are common in children (3%) and even more so in adolescents (8-23%).
• Guidelines developed by participants from all the academic institutions and also from private practice.
• When evaluating headache, screen for depression and other behavioral problems.
• Questionnaire helps identify kids with migraine, red flag headaches.
• Also discussion of a wide variety of possible treatments.
• Remember that some of the best migraine treatments are OTC: B2, Mg, butterbur, biofeedback, yoga.
• Red flags: sudden onset, severe. Occipital or nuchal location. Worst ever. Occurring during sleep, esp with vomiting. Accelerating course. Worse with exertion, esp in teens. Confusion, impaired consciousness. Loss of vision. Focal weakness. New onset seizures. Personality change. Poor school performance. Head trauma. Chronic illness. Use of contraceptives.
• What’s a migraine? International Headache Society criteria. Very specific, but not very sensitive. 

There was even more after this, including a telemedicine talk by Dr. Josh Alexander of UNC and three great topics for Sunday morning, but I had to return to Wilmington, so this is where it ends for the blog this year. We have Winter and Spring Open Forums coming up, so check back here for news, and thank you for reading!