Today I am thankful for my dog, Mimi. She's a beautiful dog, sweet, loving and usually very mild-mannered, but she'll bark her head off whenever she hears someone in the driveway.
Tonight, she barked at potential trick-or-treaters and we have lots of candy left over. :)
Thanks, Mimi!
We report on an 8-month-old female infant who developed Cushing’s syndrome and adrenal insufficiency after diaper dermatitis treatment through the misuse of Clobetasol without doctor’s prescription. Physiologic dose of hydrocortisone was prescribed to prevent an adrenal crisis for 3 months and discontinued when HPA axis recovery was confirmed by normal morning cortisol and ACTH levels.
Content Type Journal ArticleDOI 10.1007/s12020-010-9393-6
Authors
Therdpong Tempark, Division of Dermatology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330 ThailandVoraluk Phatarakijnirund, Division of Endocrinology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Sor Kor Building 11th Floor, Bangkok, 10330 ThailandSusheera …
Today I am thankful that the skunk already passed by when I took Mimi out for a walk!
It's so not fair! I can't smell lots of flowers or perfumes but I can smell a skunk blocks away.
I hope I'm not jinxing myself but today I am thankful that I haven't had any migraines for a long time.
It's not "just" not having migraines, but the fact that, should I get one, there's nothing I can do about them anymore.
I used to get migraines quite often, a hormone thing probably. I spent lots of hours in a completely dark room, blocking out sound, trying to keep my head from pounding.
There was a long period of time that I had a migraine 6 days out of the week for several weeks. By accident, a friend asked me on a Monday if I had one that day and that started me thinking - why do I have them every day except Mondays? I figured out that it wasn't a migraine at all but an allergy headache - I was allergic to the bath oil I was using Monday-Saturday. I gave that to my Mom and those headaches went away.
I still often get allergy headaches. Since my Cushing's transsphenoidal pituitary surgery, I can't smell things very well and I often don't know if there's a scent that is going to trigger an allergic reaction. In church and elsewhere, my Mom will be my "Royal Sniffer" and if someone is wearing perfume or something scented, she'll let me know and we'll move to a new location.
There's a double whammy here - since my kidney cancer surgery my doctor won't let me take NSAIDs, asperin, Tylenol, any of the meds that might help a headache go away. My only hope would be that coffee from Day Fourteen. And that's definitely not usually enough to get rid of one of these monsters.
So, I am very thankful that, for the moment, I am headache/migraine free!
Paola Fierabracci, Aldo Pinchera, Silvia Martinelli, Giovanna Scartabelli, Guido Salvetti, Monica Giannetti, Andrea Pucci, Giulia Galli, Ilaria Ricco and Giorgia Querci, et al.
Bariatric surgery allows stable body weight reduction in morbidly obese patients. In presurgical evaluation, obesity-related co-morbidities must be considered, and a multidisciplinary approach is recommended. Precise guidelines concerning the endocrinological evaluation to be performed before surgery are not available. The aim of this study was to evaluate the prevalence of common endocrine diseases in a series of obese patients scheduled for bariatric surgery.
We examined 783 consecutive obese subjects (174 males and 609 females) aged 18–65 years, who turned to the obesity centre of our department from January 2004 to December 2007 for evaluation before bariatric surgery. Thyroid, parathyroid, adrenal and pituitary function was evaluated by measurement of serum hormones. Specific imaging or supplementary diagnostic tests were performed when indicated.
The overall prevalence of endocrine diseases, not including type 2 diabetes mellitus, was 47.4%. The prevalence of primary hypothyroidism was 18.1%; pituitary disease was observed in 1.9%, Cushing syndrome in 0.8%, while other diseases were found in less than 1% of subjects. Remarkably, the prevalence of newly diagnosed endocrine disorders was 16.3%.
A careful endocrinological evaluation of obese subjects scheduled for bariatric surgery may reveal undiagnosed dysfunctions that require specific therapy and/or contraindicate the surgical treatment in a substantial proportion of patients. These results may help to define the extent of the endocrinological screening to be performed in obese patients undergoing bariatric surgery.
Keywords Bariatric surgery - Obese patients - Endocrinological evaluation
Today, and every day, I am thankful for coffee. Without it, I would have a daily headache and I'd have even less energy than I have now.
I first started drinking coffee when I had my first job as a waitress at a Hayes-Bickford in Boston, MA. This was a summer job. A bunch of my college friends had gotten an apartment near Fenway Park in Boston and most of us were waitresses in various places. Hayes-Bickford was marginally better than a dive.
I was fortunate that I was the youngest waitress at that Hayes-Bickford, so I got the best tips. This was a l-o-n-g time ago - I'd get out of work sometime after midnight, take the Boston subway alone to our apartment, with an apron full of my tips, mostly in jangly change. That could never happen any more! Even without the money, I still wouldn't wander around the Boston Common area of Boston alone after midnight.
The food at HB wasn't so great. Sometimes, a patron would order some type of meat and the chef would say we were out of it, to put gravy on whatever-we-had and tell the diner that it was what he had ordered. We were usually out of a lot of things.
But the coffee was good and I learned to drink it, lots of it, and black, something I still do today. If I could do the IV thing, I would!
The author: Professor Yasser Metwally
INTRODUCTION
October 8, 2010 — The most concerning cause of acquired hypopituitarism is a tumor in the hypothalamic-pituitary region. The most common tumor that arises in this region in childhood is a craniopharyngioma. While craniopharyngiomas are derived from epithelial remnants of Rathke’s pouch, the same tissue that forms the anterior pituitary gland, they are not usually found exclusively within the pituitary gland, but more likely they are confined to the suprasellar region or are found in both suprasellar and intrasellar locations.[1] The presenting symptoms are dependent both on the main location of the tumor and on the direction(s) that the tumor grows. For example, if the tumor grows downward, it may cause alterations in the anterior and posterior clinoid bones or in the floor of the sella turcica and/or compress the pituitary gland. If the tumor grows upward, it may compromise vision by effects on the optic nerves.
While medical textbooks typically describe the most common visual change in patients with craniopharyngioma as "bitemporal hemianopsia" (loss of the outer visual fields of both eyes) due to compression of the optic chiasm, this rarely occurs so precisely. More likely is the development of "quadrianopsias," which are smaller, more irregular field cuts. If the tumor grows even farther upward beyond the visual tracts, it may block the third ventricle and cause obstructive hydrocephalus, leading to headaches, vomiting, and/or blurry vision (in association with papilledema). Craniopharyngiomas are benign tumors histologically, but they are often described as "geographically malignant" based on their location and ability to wrap around vital structures (eg, optic nerves) precluding complete surgical removal. As stated previously, tumors originating in the pituitary gland are uncommon causes of acquired hypopituitarism in children. However, any surgery to remove a tumor in the hypothalamic-pituitary region may lead to hypopituitarism if it is not already present.
Figure 1. A, Craniopharyngioma, compressing the optic chiasma, hypothalamus and extending upward into the lateral ventricle. The tumour is partially cystic with calcified material. B, A sagittal section of the brain shows a large craniopharyngioma below the cerebral ventricle. Note the stippled pattern of the tumor.
Another cause of acquired hypopituitarism is radiation treatment of a cancerous tumor in the head or neck region. More specifically, the radiation that is required to cure the child’s tumor may, of necessity, damage normal tissue in its path or beyond. When hypopituitarism ensues in this situation, it is usually the result of radiation-induced damage to the hypothalamus, as the pituitary gland is relatively resistant to radiation. Different hypothalamic-pituitary axes have different sensitivities to radiation. Doses as low as 18 Gy using conventional fractionation can interfere with GH dynamics; doses higher than 40 Gy can cause deficiencies of gonadotropins, TSH, and ACTH, while >50 Gy may cause hyperprolactinemia, especially among young women.
Other causes of acquired hypopituitarism in childhood include previous brain infection (encephalitis and/or meningitis), hydrocephalus (even without an underlying tumor), vascular abnormalities (such as a varix in the hypothalamic-pituitary area)[2], and major head trauma usually associated with a significant loss of consciousness.[3]
Potential Anterior Pituitary Hormone Deficiencies
In childhood hypopituitarism, GH is the most commonly underproduced pituitary hormone, often as the result of loss of hypothalamic GH-releasing hormone (GHRH) (Table 2). The deficiency of GH primarily leads to short stature and slow height velocity. Untreated GH deficiency in children also causes disturbed body composition, with a reduction in lean body mass (ie, muscle) and an excess of fat, the latter accumulating predominantly in the cheeks of the face and in the abdomen, creating a cherubic or angel-like appearance.[4]
Table 2. Hierarchy of Hypothalamic-Pituitary-Target Organ Hormones
Hypothalamus
Pituitary
Target Organ
Hormone/Function
Growth hormone-releasing hormone (GHRH)
Anterior:
Growth hormone (GH)
Cartilage/liver
Insulin-like growth factor-1 (IGF-1)
Thyrotropin-releasing hormone (TRH)
Anterior:
Thyroid-stimulating hormone (TSH)
Thyroid gland
T4/T3
Gonadotropin-releasing hormone (GnRH)
Anterior:
Luteinizing hormone (LH)
Ovary
Estradiol
Follicle-stimulating hormone (FSH)
Testicle
Testosterone
Corticotropin-releasing hormone (CRH)
Anterior:
Corticotropin (ACTH)
Adrenal glands
Cortisol
Prolactin-inhibitory factor
Anterior:
Prolactin
Breast
Milk
Hypothalamic factors
Posterior:
Antidiuretic hormone (ADH)
Kidney
Urine concentration
Deficiency of hypothalamic thyrotropin-releasing hormone (TRH) or pituitary TSH causes central hypothyroidism. Unlike children whose hypothyroidism is due to thyroid gland damage, those with hypopituitarism typically have somewhat higher thyroid hormone levels and thus may have few or no symptoms. In other cases, as occurs in patients with primary thyroid disease, short stature and slow height velocity, relative weight excess, constipation, dry skin, cold intolerance, and fatigue may be present.
Younger children with deficiencies of either hypothalamic gonadotropin-releasing hormone (GnRH) or the pituitary gonadotropins typically show no abnormalities since luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels are normally low prior to puberty. In contrast, adolescent-aged children with deficiencies of the gonadotropins present with failure to start or progress through puberty (breast development and menstrual periods in girls and enlargement of the testicles and penis in boys). Infrequently and paradoxically, central sexual precocity can be seen in the setting of hypopituitarism.
Loss of hypothalamic corticotropin-releasing hormone (CRH) or pituitary ACTH results in an ability of the adrenal zonas fasciculata and reticularis to manufacture normal amounts of cortisol (central adrenal insufficiency). If deficient, this hormone is most likely to place a child in a life-threatening situation. While there would likely be no symptoms under normal circumstances, except maybe mild fatigue, lack of cortisol in the setting of infection, fever, surgery, trauma, etc, may cause vomiting, dehydration, shock, and even death. Biochemical correlates of cortisol deficiency include hypoglycemia and hyponatremia (with normokalemia). In this setting, mineralocorticoid function is completely normal, as aldosterone production by the zona glomerulosa of the adrenal cortex is regulated by the renin-angiotensin and not the CRH-ACTH system.
Potential Anterior Pituitary Hormone Excess
Serum levels of prolactin are usually normal or only mildly increased (if there is disruption of the hypothalamic-pituitary stalk) secondary to the loss of a normally predominant inhibitory signal from the hypothalamus. Although there are typically no symptoms in this situation, in rare cases a small amount of galactorrhea might occur.
Potential Posterior Pituitary Hormone Excess
As stated previously, a deficiency of ADH causes central or neurogenic DI. Infants and toddlers manifest DI with excessively wet diapers. If unrecognized and hence untreated, dehydration with elevated serum sodium concentrations will ensue in this age group as young children cannot report and easily satisfy heightened thirst. Older children with DI typically present with excessive day-and night-time urination, new onset of bed-wetting, and increased thirst. DI most often occurs unintentionally as a result of surgical treatment of a hypothalamic-pituitary tumor, such as a craniopharyngioma. In some cases, DI is temporary due to local postsurgical edema, but it will be permanent if surgical sacrifice close to the hypothalamus or of the stalk itself is required for complete cure of a brain tumor in the suprasellar region.[5] DI may also occur in association with a diencephalic germinoma.
Figure 2. Craniopharyngioma. (A) Sagittal T1-weighted image shows a cystic mass in the suprasellar region. (B) Coronal T1-weighted image shows a large cystic mass in the suprasellar region with compression of the optic chiasm. (C) Coronal postcontrast T1-weighted image shows enhancement of the irregular cyst wall. (D) Sagittal postcontrast T1-weighted image demonstrates enhancement of the cyst wall with a nodular area on the right side.
Figure 3. Craniopharyngioma. (A) Axial postcontrast CT scan shows a cystic mass with rim enhancement in the suprasellar region. (B) Sagittal T1-weighted image shows a large cystic mass involving the sellar and suprasellar regions. The mass shows high signal intensity on T1-weighted imaging, consistent with high protein content. A fluid-fluid level is seen within the cystic lesion. (C) Coronal T2-weighted image demonstrates a high signal intensity mass with suprasellar extension and slight parasellar extension into the cavernous sinuses.
Figure 4. Sarcoidosis. (A) Coronal T1-weighted image demonstrates a suprasellar isointense mass. (B) Coronal postcontrast T1-weighted image shows intense enhancement of the mass just inferior to the optic chiasm.
Figure 5. Histiocytosis. (A) Sagittal postcontrast T1-weighted image demonstrates an enhancing mass in the suprasellar region involving the infundibulum. (B) Coronal postcontrast T1-weighted image shows an enhancing mass in the suprasellar region along the infundibulum. Compression of the optic chiasm is seen. (C) Coronal postcontrast T1-weighted image obtained 3 months later after treatment shows a significant decrease in the size of the mass lesion along the infundibulum.
Figure 6. A, Postmortem case of hypothalamic tuberculoma. B, Tuberculous infection of the hypothalamus (arrow)
References
Lafferty AR, Chrousos GP. Pituitary tumors in children and adolescents. J Clin Endocrinol Metab. 1999;84:4317-4323.
Martin NA, Macagba-Crain CL, Geffner ME, et al. Isolated growth hormone deficiency associated with a giant arteriovenous varix. Neurosurgery. 1990;27:295-298.
Benvenga S, Campenni A, Ruggeri RM, et al. Clinical review 113: hypopituitarism secondary to head trauma. J Clin Endocrinol Metab. 2000;85:1353-1361.
Carrel AL,Allen DB. Effects of growth hormone on body composition and bone metabolism. Endocrine. 2000;12:163-172.
Blevins LS Jr, Wand GS. Diabetes insipidus. Crit Care Med. 1992;20:69-79.
From http://yassermetwally.wordpress.com/2010/10/08/acquired-hypopituitarism-2/
Today I am thankful for my church choir.
I've had a long history with singing from the time I was a kid singing in the choir at my Dad's church. In High School we had a great choir and it was the time before "political correctness" would have banned us from singing such wonderful classical music like Brahms' German Requiem. In college, as a music major, there were choirs and when we finally got to our current home, I joined Sweet Adelines.
I was a member of Sweet Adelines for 10 years, before Cushing's robbed me of that particular pleasure. SA takes lot of energy between rehearsals, performances, competitions, travelling. I just loved it but I couldn't keep up.
For a few years, I belonged to a local woman's group but even that got to be too much after a while. There wasn't the travelling or the competitions but rehearsals and performances cut into that energy.
Last year, our choir director opened up the opportunity to sing for just the Christmas Cantata. No long term committment and only half the rehearsal time for about 10 weeks.
I hadn't sung anywere outside my car for about 10 years but, with trepidation, I signed up. Because of my bell-ringing and work with children's choirs, I knew most of the other choir members and that made it a LOT easier on shy-me.
Christmas came and singing with the choir and orchestra was just fantastic. There was the invitation to stay, to become a part of the choir for good but I had my Cushing's Interviews on Thursday nights and I couldn't see how I could work all this in.
Last spring the choir sang How Lovely Is Thy Dwelling Place from Brahms' German Requiem and I was hooked. How could I not join?
So, I moved the interviews to Wednesday nights and Thursdays are free for choir rehearsals.
, Yong-Kwang TueReceived 12 November 2009; received in revised form 8 April 2010; accepted 1 May 2010.
Cushing's disease is rare in children and adolescents. We report the clinical presentations of three children with Cushing's disease. All three exhibited the typical symptoms and signs of weight gain and growth retardation.
Two also demonstrated personality changes, hypertension and hypokalemia, the last of these being rarely reported in patients with Cushing's disease. Lack of diurnal changes in serum cortisol levels was the most common biochemical finding. Serum cortisol levels were suppressed by low-dose dexamethasone in one patient, which is not typical for patients with Cushing's disease. Imaging studies are essential for localizing the tumor.
Transsphenoidal surgery remains the treatment of choice, and pituitary irradiation should be considered for those patients whose tumors cannot be totally removed. Careful follow-up of these patients with awareness of the possibilities of relapse and the complications of hypopituitarism is indicated.
Key Words: Cushing's syndrome , Cushing's disease , hypokalemia
a Department of Pediatrics, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin, Taiwan
b Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
c Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
d Department of Pathology, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
e Department of Surgery National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
Corresponding author. Department of Pediatrics, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan
PII: S1875-9572(10)60059-9
doi:10.1016/S1875-9572(10)60059-9
© 2010 Taiwan Pediatric Association. Published by Elsevier Inc. All rights reserved.
From http://www.pediatr-neonatol.com/article/S1875-9572%2810%2960059-9/abstract
Today, I am thankful for Saturdays. It' the one day of the week I don't have to be anywhere, do anything. I can do webwork, if I want, but I don't have any deadlines.
I never have doctor appointments on Saturdays, no medical testing.
No piano students. I don't even talk to prospective students on Saturdays.
It's a day for maybe brunch, a trip to the farm, maybe a little TV, maybe (most assuredly!) a nap.
Saturdays are family days, even though our family is smaller than it was.
Saturdays are always full of promise.
Off to see what today's promise is...
Today, I am thankful for Lisa. Her photography studio ( http://www.dickensstudio.com/ ) held a Girls Night Out fundraiser which benefitted Cushing's Help.
Last night's raffle raised $600.00 and that will go a long way to keeping the message boards up and running for another year.
You, too, can be thankful for Lisa here. :)
Keywords Pituicytoma - Neurohypophysis - Pituitary tumor - Glioma
I am so thankful for all my doctors but today I am thankful for Dr. Amir Al-Juburi who saved my life by removing my kidney cancer (renal cell carcinoma).
In 2006 I picked up my husband for a biopsy and took him to an outpatient surgical center. While I was there waiting for the biopsy to be completed, I started noticing blood in my urine and major abdominal cramps. I left messages for several of my doctors on what I should do. I finally decided to see my PCP after I got my husband home.
When Tom was done with his testing, his doctor took one look at me and asked if I wanted an ambulance. I said no, that I thought I could make it to the emergency room ok - Tom couldn't drive because of the anaesthetic they had given him. I barely made it to the ER and left the car with Tom to park. Tom's doctor followed us to the ER and became my new doctor.
When I was diagnosed in the ER with kidney cancer, Tom's doctor said that he could do the surgery but that he would recommend someone even more experienced, Dr. Amir Al-Juburi.
Dr. Amir Al-Juburi has been so kind to me, almost like a kindly grandfather might be, and he got rid of all 10 pounds of my kidney and cancer.
I owe him, the original doctor, and my Cushing's doctors (who will be featured later!), my life.
I called our son today, just to see how he was doing. I am thankful that he's doing so well for himself, has a good job, good friends, is a fine musician and that he's not afraid to say he loves his parents. :)
We love you, too!
Weight Watchers.
Yesterday, for the first time that I can ever remember, I bought size 12 pants. Even before Cushing's, I was bigger than this. Maybe it was just the company that makes them, cuts them more generously than others but still.
I've been a *bit* off-program since the summer but this will inspire me to get back with it. I want to buy more 12s...and maybe 10s sometime.
Tatiana Mancini1, Teresa Porcelli2, Andrea Giustina2
1Department of Internal Medicine and Medical Specialties, San Marino Hospital, San Marino, Republic of San Marino, 2Department of Medical and Surgical Sciences, University of Brescia, Brescia, Italy
Abstract:
Endogenous Cushing syndrome is an endocrine disease caused by excessive secretion of adrenocorticotropin hormone in approximately 80% of cases, usually by a pituitary corticotroph adenoma (Cushing disease [CD]). It is a heterogeneous disorder requiring a multidisciplinary and individualized approach to patient management.
The goals of treatment of CD include the reversal of clinical features, the normalization of biochemical changes with minimal morbidity, and long-term control without recurrence. Generally, the treatment of choice is the surgical removal of the pituitary tumor by transsphenoidal approach, performed by an experienced surgeon. Considering the high recurrence rate, other treatments should be considered.
Second-line treatments include more radical surgery, radiation therapy, medical therapy, and bilateral adrenalectomy. Drug treatment has been targeted at the hypothalamic or pituitary level, at the adrenal gland, and also at the glucocorticoid receptor level. Frequently, medical therapy is performed before surgery to reduce the complications of the procedure, reducing the effects of severe hypercortisolism.
Commonly, in patients in whom surgery has failed, medical management is often essential to reduce or normalize the hypercortisolemia, and should be attempted before bilateral adrenalectomy is considered. Medical therapy can be also useful in patients with CD while waiting for pituitary radiotherapy to take effect, which can take up to 10 years or more.
So far, results of medical treatment of CD have not been particularly relevant; however, newer tools promise to change this scenario. The aim of this review is to analyze the results and experiences with old and new medical treatments of CD and to reevaluate medical therapies for complications of CD and hypopituitarism in patients with cured CD.
Keywords: ketoconazole, somatostatin analogs, dopamine agonists, rosiglitazone, Cushing disease, glucocorticoids, hypopituitarism
Today I am thankful that we finished our taxes a day ahead of the extended deadline!
Today, I'm thankful for my "Cushie Car".
Since I started attending Cushing's events, I've always tried to rent a PT Cruiser. There's just been something about them that I liked.
A couple years ago, after my son was out of school, I was getting tired of driving the Mom-Carpool-Van everywhere. I think my mom was getting tired of stepping up into it, too. She doesn't drive anymore, so she relies on whatever vehicle I'm driving to get her to appointments. So, I was delighted when she offered to pay for part of it. She didn't realize it was going to be bright blue, though. I think she was thinking of navy or something more dignified.
Anyway, I had the car picked out, and the exact color I wanted and set off to the car dealership with my specs. They told me that the Cruiser didn't come in this shade of blue. I'm sure that they wanted to sell one of the colors they had on the lot.
I got back to them and told them that I found this car online and I could go get it myself. Suddenly the dealership was able to get it for me, too, so I won out. WooHoo.
I'm just loving this car. :)
From a Cushing's get-together in Columbus, OH, 2007, the yellow version :)
I am thankful today for our CSA farm, Great Country Farms. We've been members there since our son was young, since 1995. We just love being out in the country, picking whatever is available seasonally, having fresh fruits and vegges delivered. The Zurschmeides are the nicest people you could ever want to meet, too.
From their website:
Great Country Farms is a 200 acre working farm situated at the base of the Blue Ridge Mountains outside the village of Bluemont, VA. Great Country Farms offers produce as well as the farm experience to its customers. The Zurschmeide Family has been farming in Loudoun County for over 35 years and Great Country Farms was started by the second generation of Zurschmeides in Loudoun in 1994. The farm started with a Community Supported Agriculture Program (CSA) which has grown over the years and delivers produce to homes as far as Alexandria and Arlington. In 1996 and again in 2007, the Loudoun County Chamber of Commerce voted Great Country Farms, "Agribusiness of the Year" for its unique efforts to farm in a difficult climate through innovation, rather than selling out and growing houses.
We owe it all to Farmer Bob for instilling a love of farming in us. He still visits the farm regularly on weekends to continue that tradition for the new generation of farm visitors. Be sure to look for him on your next visit. As our farm grows, we are thrilled to welcome the next generation of Zurschmeides in the fields, behind the counter, making Kettle Corn and as the Pumpkin Princess of course!We are thrilled to still be a family farm in our growing county and welcome you to visit our farm, pick some produce, create some memories and begin your own farm adventure as part of our farm family.
