text:
CoCo Key's Ben Westbrook slides into third base as The Grill on 21st Street's Darian Reeves catches the throw during Sunday's action at the Shrine Tournament. / Jerid Davies, The Advocate
Sunday's results
CoCo Key (NN) def. The Grill on 21st Street (NN)
SJ Professional Painting (SWL) def. Newark Optometry (NN)
Park National Bank (NN) def. Mystic Snow Photography (St. L)
Texas Roadhouse (LCSA) def. Piper Heating (St. L)
Ours Wrecking (Lw) def. Kiwanis (LCSA)
Don Duvall Auctioneer (H) def. Dan's Family Pizza (NN)
Vaughn's Barbershop (LCSA) def. Owens Corning Fiberglas (MC)
Licking Memorial Hospital (NN) def. Contract Lumber (SWL)
Coming up
Read The Advocate all week for more coverage leading up to next weekend's Licking County Shrine Tournament quarterfinals and semifinals.
NEWARK -- Heath's Don Duvall Auctioneer is the exception at the Licking County Shrine Tournament.
Most of its opponents have played countless games throughout the years together, coming up through the ranks around various area leagues, but Don Duvall's is a hodgepodge of players. It has not made a difference.
Don Duvall beat North Newark's Dan's Family Pizza, 2-1, Sunday in Varsity Division action at the Mound City Little League complex.
"I can't believe we came together this quick," shortstop Logan Potts said. "We are in the great eight; that is all I care about. This is the biggest tournament in Licking County basically."
Don Duvall's narrow escape behind the pitching of Jaivon Gresham moved it with seven other teams into next weekend's quarterfinals. Also winning Sunday was Lakewood's Ours Wrecking, which will be Don Duvall's opponent at 3:30 p.m. Saturday. Licking County Sports Association's Vaughn's Barbershop will play North Newark's Licking Memorial Hospital also at 3:30 p.m.
Four other teams advanced Saturday. Southwest Licking's Park National Bank will play North Newark's Med Ben at 1 p.m. Saturday, and North Newark's J & D Storage also will play Southwest Licking's Classic Trophy at 1 p.m. Saturday.
"My son Jaivon -- his brother (Charles) made it to the elite eight -- and we were there watching that game," said Charles Gresham, Don Duvall's assistant coach. "When you play farm and varsity and come down and watch the other kids playing in the Shrine Tournament, you visualize yourself being down here. I think all of the kids have that feeling in their mind."
Vaughn's Barbershop hung a 7-0 shutout on Mound City's Owens Corning Fiberglas. Vaughn's scored three apiece in the second and fourth innings to gain control. OCF has much of the same team that finished second in last year's Farm Division.
"They are all good teams down here now," Vaughn's coach Mark Spivey said. "To hold a team like OCF to no runs is a confidence boost. (We) hit the ball well, too."
A runaway victory for Texas Roadhouse in the Farm Division made it a banner day for LCSA. Texas Roadhouse beat St. Louisville's Piper Heating to give the league an entry in the quarterfinals in both divisions.
North Newark's Park National Bank, one of six teams from the league in the Farm Division quarterfinals, will play Texas Roadhouse at 3:30 p.m. Saturday. The other game in that time slot will be North Newark's CoCo Key against SWL's SJ Professional Painting, the defending champion.
At 1 p.m. Saturday, Licking Memorial Hospital will play Med Ben, and Dan's Family Pizza will play J & D Storage. All four of those teams are from North Newark.
"The Kiwanis park has always been the smallest league in Newark, and we are just trying to have fun, play ball and compete with the other leagues," Texas Roadhouse coach Kenya Black said. "We are trying to bring a smile to the league's face. It is a little bragging rights."
After Saturday's quarterfinal games, the two semifinal games in each division will be played at 1 p.m. Sunday. The Farm Division championship night will be July 9, and the Varsity Division championship night will be July 10.
Kurt Snyder can be reached at (740) 328-8556 or firstname.lastname@example.com.


text:
This Is Not A Photo Of A Rock
Who needs a hotel? Roadtrippers highlights this singular Swiss Alps cabin, which is tucked into a sculpture garden and looks for all the world like a giant boulder. »
Who needs a hotel? Roadtrippers highlights this singular Swiss Alps cabin, which is tucked into a sculpture garden and looks for all the world like a giant boulder. »
I finally had a chance to read John McPhee's book La Place de la Concorde Suisse, his somewhat off-puttingly titled 1984 look at the Swiss military and its elaborately engineered landscape defenses. »
In the -25C° pitch-black cold of the French Alps, filmmaker Jacob Sutton captured William Hughes shredding through the night like some radioactive snowboarder. This otherworldly glow was achieved using a full-body LED suit designed by John Spatcher. Explains Sutton of this project: »
On December 2 in Orléans, France, a crew of four quadrocopters assembled a six-meter-tall tower using 1,500 foam blocks as part of the FRAC Centre's "Flight Assembled Architecture" exhibit. The project was a collaboration was helmed by the Swiss Federal Institute of Technology in Zurich, whose researchers had… »
Along a lonely stretch of road in Quarten, Switzerland, two strange figures and/or camera smudges survey the terrain, planning nefarious and/or blurry machinations. The figures follow the camera as it travels down the road. Some commenters on Reddit are claiming this is a gateway to Valhalla, but I'm of the mind that… »
If you've been convinced for years that John Madden has been replaced by an iPod filled with generic football commentary, you might be excited to learn that Switzerland's Ecole Polytechnique Federale de Lausanne has been working on an even more advanced version. This one is equipped with artificial intelligence so it… »
We love those wacky quadrotors, what with their ability to flit around and build structures. Now check out quadrotors engaging in some aerial circus. »
Virtobot may be helping humanity now, but it'll know all our weaknesses when Skynet achieves sentience. That's because it's the world's first autopsy robot - and it can examine a dead body inside and out without ever lifting a scalpel. »
In Lausanne, Switzerland, people don't congregate under real trees. They sit under the branches and on the steel roots at the base of this giant metallic tree designed by Samuel Wilkinson and Swiss design firm Oloom. »

subset: commoncrawl


text:
The Good DinosaurShowtimes for: November 27 - December 3Nightly: 7:00 PM (3D), 9:15 PM
Weekend Matinees: 2:00 PM & 4:00 PM (3D)
Runtime: 102 min
Advisories: Violence
Starring: Raymond Ochoa, Jeffrey Wright, Frances McDormand, Jack Bright, A. J. Buckley, Steve Zahn, Anna Paquin, Sam Elliott
Synopsis: 'The Good Dinosaur' asks the question: What if the asteroid that forever changed life on Earth missed the planet completely and giant dinosaurs never became extinct? Pixar Animation Studios takes you on an epic journey into the world of dinosaurs where an Apatosaurus named Arlo makes an unlikely human friend. While traveling through a harsh and mysterious landscape, Arlo learns the power of confronting his fears and discovers what he is truly capable of.
CreedShowtimes for: November 27 - December 3Nightly: 7:00 PM, 9:15 PM
Weekend Matinees: 2:00 PM & 3:00 PM
Runtime: 132 min
Advisories: Coarse Language, Violence
Starring: Sylvester Stallone, Michael B. Jordan, Graham McTavish, Tessa Thompson, Phylicia Rashād, Hans Marrero, Hans Marrero, Will Blagrove
Synopsis: A spinoff of the hit Rocky franchise is in the works titled Creed, the new film will follow the grandson of Apollo Creed. Stallone is planning to reprise his Rocky Balboa role, acting as the younger Creed's reluctant trainer. - The elder Creed, played by Carl Weathers, appeared in the first four Rocky films until a fight with Ivan Drago in Rocky IV led to his death in the ring.
The Night BeforeShowtimes for: November 27 - December 3Nightly: 7:00 PM, 9:15 PM
Runtime: 100 min
Advisories: Coarse Language, Drug Use, Nudity
Starring: Joseph Gordon-Levitt, Seth Rogen, Anthony Mackie, Lizzy Caplan, Jillian Bell, Mindy Kaling, Kanye West, Lorraine Toussaint
Synopsis: In New York City for their annual tradition of Christmas Eve debauchery, three lifelong best friends set out to find the Holy Grail of Christmas parties since their yearly reunion might be coming to an end.
The Hunger Games: Mockingjay – Part 2Showtimes for: November 27 - December 3Nightly: 7:00 PM, 9:30 PM
Weekend Matinees: 3:00 PM
Runtime: 136 min
Advisories: Violence
Starring: Jennifer Lawrence, Josh Hutcherson, Liam Hemsworth, Woody Harrelson, Elizabeth Banks, Julianne Moore, Philip Seymour Hoffman, Donald Sutherland
Synopsis: With the nation of Panem in a full scale war, Katniss confronts President Snow in the final showdown. Teamed with a group of her closest friends – including Gale, Finnick, and Peeta – Katniss goes off on a mission with the unit from District 13 as they risk their lives to stage an assassination attempt on President Snow who has become increasingly obsessed with destroying her. The mortal traps, enemies, and moral choices that await Katniss will challenge her more than any arena she faced in The Hunger Games.


text:
- PeruAgricultureFunding via Asociación de Productores de Tara del Norte (APTN)
JesusaPeruFoodFunding via Asociación Arariwa
Maria EmiliaPeruRetailFunding via Edpyme Alternativa
La Paz Group
The members are engaged in different businesses, such as the sale of groceries, clothes, cheeses, foods, fruits, firewood, drinks and small animals.
The members need different amounts of loans; some of the amounts are 300 soles or 600 soles, adding up a total of 12,000 soles of loans in the Community Bank.
The loans will be used for the purchase of rice, noodles, oil, sugar, beer, soft drinks, eucalyptus trees, animals, cheeses, polos, sweaters, fruits and firewood.
The dreams of the members are that their businesses prosper, they have a good house and their children have a good education.
Translated from Spanish by Helen C. Smith, Kiva Volunteer.
El Banco Comunal "La Paz" es un banco que recién inicia con 24 socios. Los socios son provenientes D. la comunidad D. Yanama, distrito D. Carmen Alto, que esta a 30 minutos D. la ciudad D. Ayacucho. Esta comunidad esta integrado en gran mayoría por personas que migraron D. diferentes provincias del departamento y que invadieron estas tierras.
Los socios realizan diferentes negocios como la venta D. abarrotes, ropa, quesos, comidas, frutas, leña, bebidas, animales menores.
Los socios necesitan diferentes montos D. préstamos, algunos montos son D. 300 soles, 600 soles, haciendo un total D. 12,000 soles D. préstamos en el Banco Comunal.
Los préstamos lo invertirán en la compra D. arroz, fideo, aceite, azúcar, cerveza, gaseosas, árboles D. eucalipto, animales, quesos, polos, chompas, frutas y leña.
Los sueños D. los socios es que sus negocios prosperen, tener una buena casa y que sus hijos tengan una buena educación.
Additional Information
About FINCA PeruThis loan is administered by FINCA Peru, one of Kiva's Field Partners in Peru. FINCA Peru is dedicated to empowering socially and economically disadvantaged women in Peru, contributing to the development of their families, and building sustainable communities.
In 1990, FINCA Peru began by lending to a small group of women widowed by the Shining Path terrorist movement in Ayacucho. Beyond loans and financial services, FINCA offers business development training, personal and family development training, gender empowerment sessions, life insurance products, and financial and social literacy sessions for the children of borrowers. Visit FINCA Peru's Kiva Field Partner page to learn more.
This is a Group Loan
In a group loan, each member of the group receives an individual loan but is part of a larger group of individuals. The group is there to provide support to the members and to provide a system of peer pressure, but groups may or may not be formally bound by a group guarantee. In cases where there is a group guarantee, members of the group are responsible for paying back the loans of their fellow group members in the case of delinquency or default.
Kiva's Field Partners typically feature one borrower from a group. The loan description, sector, and other attributes for a group loan profile are determined by the featured borrower's loan. The other members of the group are not required to use their loans for the same purpose.
About Peru
120View loans »
Success!! The loan was 100% repaid
- Repayment Term
- 9 months (Additional Information)
- Repayment Schedule
- Monthly
- Disbursed:
- May 11, 2008
- Listed
- Apr 17, 2008
- Currency Exchange Loss:
- Covered
- Ended:
- Dec 15, 2008


text:
Eliot Glazer
Revolving Door (0)
Who's coming and who's going. Tell us about your job move! Receive the Revolving Door Newsletter with expert analysis by email twice a week.No Revolving Door results were found.
Sightings (1)
Spotted around the media universe
Happy Mother's Day: How Daughters Perceive Their Moms On Facebook - Posted May 13, 2012
In celebration of Mother's Day today, Olay presents ... [AllFacebook]


text:
Painting in Dana Point, CA
Call for Fast FREE Quote
Dial Area Code first please.
"I have called upon Chris Chamberlain several times in the past two years to repair damages to drywall in my home. He has been competitively priced, timely in his appointed arrival and thorough in his work. I would recommend him to anyone needing drywall repair services."
Herb Allison
"I was very happy with the work Chris did. He showed up on time(actually 5 min early) and finished when he said he would and did what he said he would do. I would hire him again."
Phil B., Drywall Repair in Trabuco Canyon, CA
"Living Room ceiling hole (small water leak) is wonderfully repaired... You cannot tell there was damage... Additional drywall repairs in garage also very well done."
Drywall Repair in San Clemente, CA
"Chris did an incredible job at fixing water damage in our bathroom. He matched and textured the walls perfectly. Beautiful work, great guy and very responsive to any questions and/or concerns you may have. Hire Chris if you want quality work."
Kellie Y, Drywall Repair in Aliso Viejo, CA
Call for FREE Painting Quote
Dial Area Code first please.
Zip Codes Served: 92624, 92629
Other Services in Dana Point, CADrywall Repair in Dana Point, CA
Interior Painting in Dana Point, CA
Exterior Painting in Dana Point, CA
House Painting in Dana Point, CA
Commercial Painting in Dana Point, CA
Mold Removal in Dana Point, CA
Wallpaper Removal in Dana Point, CA
Water Damage in Dana Point, CA
Painting in nearby townsPainting in Capistrano Beach, CA
Painting in Capo Beach, CA
Painting in Ladera Ranch, CA
Painting in Laguna Beach, CA
Painting in Laguna Niguel, CA
Painting in Mission Viejo, CA
Painting in Monarch Bay, CA
Painting in Monarch Beach, CA
Painting in San Clemente, CA
Painting in San Juan Capistrano, CA
Painting in Dana Point California
Dial Area Code first please.
|Painter 92624
|Painter 92629


text:
Being the best man is kind of an honor, but being the ninth best man isn't quite as honorable. (1:13)
Tags: andy woodhull, live at gotham, men/women, marriage, sleep, friends, star wars
© 2015 Comedy Partners. All Rights Reserved. Comedy Central and all related titles, logos and characters are trademarks of comedy partners.


text:
Exclusive finds with a new theme each month.
Shop: Pop-In
Our VP of creative projects shares what she's into.
Read More
Stay updated with a steady stream of new info.
Write a review for a chance to win a $1,000 gift card. See details.
Chat with a Customer Service Representative or call 1.888.282.6060.
Wrapped, overlapping ruched panels sculpt the fitted hourglass silhouette of a short mesh dress finished with an exuberant organza ruffle atop the single shoulder strap.


text:
More About WICKIEWOO
Recipes I've Shared:
From Hugh Fearnley What his face book
ooops - far more calories in this than I expected - but delicious
No surprise here - just using up the leeks i grew last year ready to plant this years crop :)
Something this decadent shouldn;t really be on a diet site but i made it so i had to create the recipe!
Serve on it's own or with rice.
Can be served hot or cold.
Serving size assumes that this is eaten as a complete meal but more servings can be assumed if eaten as a side dish.
This would make two very large servings but could be stretched to more smaller servings.
Grow as much of this as possible in your garden - it taste's better.
Nice with Feta or Goats cheese if you can spare the calories
Perfect packed lunch inside wholemeal pitta bread.
Sweet Peppers stuffed with sweet potato & goats cheese
Recipes I've Rated:
Recipe Collections I've Shared:
|Wickiewoo Cookbook


text:
Related Searches: Rado Watches | Omega Watches | Michael Kors Watches | Top Pages | Top Related Searches
Calendar & Date13
Digital Display1
Power Reserve1
Three Time Zones1
Water Resistant54
World Time1
as low as $895.00
as low as $895.00
as low as $1,195.00
as low as $869.99
as low as $420.00
as low as $995.00
* Shipping costs are based on an estimate of UPS ground or equivalent carrier within the contiguous US, excluding Alaska and Hawaii. Please see Seller's website for actual shipping costs.
PriceGrabberAbout Us Jobs Advertise Sitemap Mobile Site
SupportMerchant Login Market Reporter Mobile Apps Help
Choose your Region:
Copyright ©2015 PriceGrabber.com, Inc. All Rights Reserved


text:
YourNews: The Authors Guild of Tennessee is open for business
The Authors Guild of Tennessee is a newly-formed association of independently-published writers who live in our area. While some of the books are set in East Tennessee, the books cover a broad spectrum of subjects and interests including: mystery, crime-noir, childrens literature, poetry, true-life novels, science fiction, humor and biography.
The writers started the group to better serve the public by offering their books in collaboration and personally through book-signings and meet-the-author events, several of which have been scheduled for this summer and fall, with others to be determined for the future.
Sam Bledsoe, a group founder, explains some of the aspirations of the Guild and its purpose: "Although our guild is still in its formative stages, we are rapidly adding new authors to our roster, and we have big plans. We expect to host our own literature-based events, celebrating Tennessee authors both well-known and newly-minted. Our state has already contributed substantially to the annals of American culture, and we hope to nurture the continuation of this long tradition."
The Lenoir City Arts and Crafts Festival, June 1-2, is the next scheduled event where the public can meet the authors and review the many books on display for sale.
The Grainger County Tomato Festival, July 26-27, is also a set date. Other meet-the-author events will be sponsored by local businesses, as well, including: Annabelle's Emporium and Café in Loudon on June 22 and Hensley's Happenings Café in Norris on July 6.
For more infor about the guild, the authors, and their books, as well as how to join the group, visit www.authorsguildoftn.org or call Lyn Neilans, 865-458-1355.
This story is contributed by a member of the community and is neither endorsed nor affiliated with Knoxville News Sentinel.
Subscribe to the News Sentinel
Need Help?
Call us at 1-877-304-7769.
Monday – Friday: 7 a.m. – 3 p.m. / Saturday & Sunday: 7 a.m. – 11 a.m.


text:
Christopher's BadgesJetSetter - Level 3
Hopping around the world one airport at a time... safe travels!
That's 10 different airports! Here's to hoping there's free wi-fi. Visit 5 more new ones and get a first class ticket to Level 4.
Christopher unlocked the JetSetter badgeJune 18, 2012
Download Foursquare for your smart phone and start exploring the world around you!


text:
Patients with head and neck cancer are at high risk of malnutrition and dysphagia. Enteral tube feeding via a gastrostomy or nasogastric tube is often required in response to dysphagia, odynophagia or side effects of treatment that lead to dehydration and/or weight-loss. A recent systematic review concluded that the optimal method of tube feeding remains unclear; however prophylactic gastrostomy, placed in anticipation of its use during and after treatment, is common practice, following a number of demonstrated benefits. However the majority of these studies have been undertaken in patients receiving radiotherapy alone. More recent studies in patient populations receiving concurrent chemoradiotherapy are showing that despite prophylactic gastrostomy placement significant weight loss still occurs, placing the patient at risk of the consequences of malnutrition. Therefore we set out to investigate innovative prophylactic nutrition support via the gastrostomy to optimise the nutritional outcomes of patients with head and neck cancer.
Patients with head and neck cancer will be eligible for this single centre randomised controlled trial if they are identified for referral for a prophylactic gastrostomy using local guidelines. Patients will be excluded if they are: under the age of eighteen; pregnant; unable to give informed consent; or severely malnourished or moderately malnourished with significant dysphagia requiring a liquid or puree diet. All eligible patients who consent for the study will be allocated randomly to either the intervention or control group (usual care). The intervention group will commence prophylactic supplementary nutrition support via the gastrostomy immediately following placement compared to usual care where nutrition support is commenced via the gastrostomy when clinically indicated during treatment. Key outcome measures will be percentage weight loss, body composition, nutritional status and quality of life, measured at baseline and three months post treatment.
To our knowledge this is the first study to evaluate the effectiveness of early prophylactic tube feeding compared to commencement of feeding during treatment, as per current standard practice, in patients undergoing prophylactic gastrostomy prior to treatment for head and neck cancer.
Trial registration
This trial has been registered in the Australian New Zealand Clinical Trials registry as ACTRN12612000579897.
Keywords:Prophylactic; Gastrostomy; Head and neck cancer; Nutrition support; Enteral nutrition; Quality of life
Patients with head and neck cancer are at high risk of malnutrition and dysphagia. Evidence based guidelines are available to provide optimal nutrition care to this patient group throughout the treatment trajectory [1]. There is good evidence to support the role of dietetic counselling to improve nutrition outcomes in patients with head and neck cancer receiving radiotherapy [2]. Enteral tube feeding via a gastrostomy or nasogastric tube is often required in response to dysphagia, odynophagia or other side effects of treatment that lead to dehydration and/or weight-loss during or after cancer treatment. A recent systematic review concluded that the optimal method of tube feeding remains unclear [3], although this was based on only one eligible randomised controlled trial (RCT) comparing the use of nasogastric tubes and gastrostomy tubes placed when required during treatment [4]. Since then a new RCT has been published [5] which supports the use of gastrostomy over nasogastric tubes, however the actual timing of the tube placement in relation to the treatment is unclear. Two further RCTs have compared proactive to reactive enteral feeding approaches, and while less weight loss is seen with the proactive approach, the differences are not statistically significant [6,7] There are benefits and disadvantages to both types of enteral feeding and their timing [8].
Prophylactic placement of a gastrostomy, in anticipation of its use during and after treatment, is common practice. Consideration must be given to the risks associated with the procedure of gastrostomy placement [9] and there is increasing concern that gastrostomy placement leads to prolonged tube dependency and long term dysphagia [4,10,11]. Although one additional study comparing two different centre's approaches with reactive gastrostomy placement versus proactive gastrostomy placement found a higher rate of gastrostomy dependency in the proactive placement group at three months there was no difference at six or 12 months [12]. The risks of gastrostomy placement are often outweighed by the number of benefits that have been demonstrated with a prophylactic gastrostomy tube with, earlier commencement of nutrition support [13], reduced weight loss [14,15], improved quality of life [6,16,17], and reduced admissions and healthcare costs [18-20]. Of note the majority of these studies have been undertaken in patients receiving radiotherapy alone. As concurrent chemoradiotherapy is the generally accepted non-surgical standard of care for many of these patients, the additional toxicities associated with this dual modality treatment place the patient at greater nutritional risk. More recent studies are showing that despite prophylactic gastrostomy placement significant weight loss still occurs [7,21,22], placing the patient at risk of the consequences of malnutrition. One large study of patients receiving chemoradiotherapy which compared reactive (n = 279) and proactive (n = 166) gastrostomy placement reported no difference in weight loss outcomes between the two groups but the proportion of patients with weight loss >10% at the end of treatment was 37-42%, and by 12 months post treatment is was 42-53% [12]. A separate study utilising a reactive feeding approach with nasogastric tubes also reported a mean weight loss of 10.4% during treatment, with a weight loss of >10% affecting over half of their patients (54%) [23]. Similar to the literature, our current clinical practice guidelines with prophylactic gastrostomy tubes [24], whilst effective in reducing unplanned hospital admissions and length of stay [20], did not appear to be effective in achieving positive nutrition outcomes [25]. We have hypothesised from clinical observation that this may be due to: poor tolerance to nutrition support during treatment due to the side effects; difficulties adhering to nutrition recommendations secondary to other barriers such as time, finance or fatigue; increased nutritional requirements during treatment; and/or reluctance of patients to engage with utilising the tube for nutrition support. Therefore it was hypothesised as to whether earlier nutrition intervention can improve these patient's nutritional outcomes.
The majority of studies published in the literature utilising prophylactic gastrostomy tubes generally commence nutrition support when clinically indicated in response to deterioration in swallowing or nutritional status [13,26,27]. Some studies have reported on commencement of enteral feeds prior to treatment [28-31] however these study designs are quite different to our proposal, with their patients often having a poor nutritional status or dysphagia at baseline therefore requiring immediate or therapeutic nutrition support, in comparison to our target population being primarily well nourished with minimal dysphagia. Whilst this innovative pre-treatment nutrition intervention strategy of prophylactic feeding may not address all our concerns or barriers experienced with current practice with gastrostomy feeding, the intervention is intended to particularly aid the psychological aspects.
Anecdotally in practice, we have seen that patients who have a gastrostomy placed for surgery and then require nutrition support again during radiotherapy, appear to be better adapted to the tube, than patients who have had the tube placed for definitive chemoradiotherapy. This observation was supported by recent studies in the literature where Salas et al. reported a negative physical effect of the gastrostomy just after the beginning of treatment, but also a positive mental effect over time as patients became used to the tube [6]. Merrick et al. also recently explored patient experiences with a gastrostomy tube through a qualitative study design, and three themes were found [32]. The majority of patients demonstrated "constructive cognitive appraisal" whereby they positively adapted to the tube and accepted tube feeding. However some patients were described as displaying "cognitive affective dissonance", whereby although they experienced no physical concerns with the tube, there was a negative mental reaction to the tube. Smaller numbers of patients were found to have "emotion focused appraisal" so while accepting the necessity of the tube, there was a lot of anxiety and fear. Therefore part of the rationale for this current study design is to also assist patients with adapting to their tube by commencement of earlier tube feeding, so that when tube feeding becomes absolutely necessary during treatment, there is less anxiety and it becomes easier to adapt to and manage.
This study aims to compare the outcomes of early prophylactic tube feeding compared to commencement of feeding during treatment, as per current standard practice, in patients undergoing prophylactic gastrostomy prior to treatment for head and neck cancer. The research will directly inform future clinical practice and will provide more evidence on the role of pre treatment nutrition support in this patient population.
Study design and setting
This study is a single centre randomised controlled trial. Recruitment will be from patients attending the Combined Head and Neck Clinic at the Royal Brisbane and Women's Hospital, a tertiary hospital for cancer care services in Queensland, Australia. The study has been approved by the Royal Brisbane and Women's Hospital Human Research Ethics Committee on 19th July 2012 (HREC/12/QRBW/162) and The University of Queensland Medical Research Ethics Committee on 8th August 2012 (2012000890).
Participants and recruitment
Patients will be eligible for the study if they are identified as high risk patients and referred for a prophylactic gastrostomy as per the Royal Brisbane and Women's Hospital Swallowing and Nutrition Management Guidelines for Patients with Head and Neck Cancer [24]. A patient would be deemed high risk at the multidisciplinary combined head and neck clinic if they meet the following criteria: oral cavity or oropharyngeal cancer receiving bilateral chemoradiotherapy; nasopharyngeal or hypopharyngeal cancer receiving chemoradiotherapy; or an unknown primary tumour receiving chemoradiotherapy; or if they have severe malnutrition. The final decision of tube placement is made by the treating team. Patients will be excluded if they: are under the age of eighteen; are pregnant; have cognitive impairment, an intellectual disability or a mental illness; or are receiving non-curative intent treatment. Patients meeting these criteria will be identified by a member of the treating team (radiation oncologist, medical oncologist or surgeon) who will discuss the study and provide a copy of the Patient Information and Consent Form if they are interested. The research dietitian (author TB) will be notified of these patients and a follow up telephone call will be made to provide full details of the study and to answer any patient questions. If the patient wishes to enroll the research dietitian will assess the patient when they attend for their gastrostomy procedure to complete eligibility criteria. A full nutritional assessment will be undertaken using the Patient Generated Subjective Global Assessment (PG-SGA) tool [33]. This is a validated tool recommended to assess nutritional status in patients with cancer [34], and encompasses assessment of weight history, dietary intake, nutrition impact symptoms, function/activity, and physical assessment of muscle/fat stores. The tool provides a subjective global assessment (SGA) rating of well nourished (SGA A), moderate malnutrition (SGA B) or severe malnutrition (SGA C). A numerical score is also generated indicating the level of nutritional risk. A score >9 indicates a referral to the dietitian for management. Patients will be excluded if they are found to have either: severe malnutrition or moderate malnutrition with significant dysphagia requiring a liquid or puree texture modified diet. Remaining eligible patients will provide written consent and baseline data will be collected.
All eligible patients who consent for the study will be allocated randomly to either the intervention or control group (usual care). All patients will receive education from the dietitian and nursing staff on the care of their gastrostomy tube pre treatment and will receive joint dietetic and speech pathology review on a weekly basis during treatment.
In the hospital's usual care, patients will commence enteral nutrition via their prophylactic gastrostomy when required during treatment following assessment by the clinical dietitian. Indicators for commencing enteral nutrition are: oral intake less than 60% of estimated energy requirements (based on 125-145 kJ/kg) for a period of or anticipated to be, greater than 10 days; or the patient is unable to maintain weight; or the patient requires significant texture modification of diet; or the patient has increased or uncontrolled nutrition impact symptoms. The regimen will be determined by the clinical dietitian to suit the patients' individual requirements and adapted as required during treatment. All patients are encouraged to maintain oral intake as much as possible during treatment and as long as it remains safe to do so as advised by the speech pathologist.
The intervention group will commence prophylactic nutritional support via their gastrostomy at the time of tube placement (pre treatment) in addition to their current oral intake. The supplementary enteral nutrition will consist of a 200 ml bolus feed (1.5 kcal/ml polymeric formula) to be administered twice a day between meal times, and will continue until completion of treatment. The enteral nutrition products for this intervention will be provided to the patient by the Department of Nutrition and Dietetics. Adherence will be monitored by the patient completing a self-reporting diary and verified by the clinical dietitian. If during treatment the patient displays any of the clinical indicators described above in usual care, the enteral feeding regimen will be increased by the clinical dietitian to suit the patients' individual requirements.
All patients will be referred to their local dietitian service on completion of treatment for ongoing care as required. The research dietitian will provide monthly telephone review with all patients to determine ongoing use of the gastrostomy tube for a maximum of six months post treatment.
The aim of this study in patients undergoing prophylactic gastrostomy prior to treatment for head and neck cancer is to compare the nutritional, clinical and patient outcomes following an early prophylactic tube feeding approach versus our standard care of commencing tube feeding via the prophylactic gastrostomy as required. It is anticipated that the intervention group will have improved nutritional outcomes, which in turn is expected to improve patient outcomes, such as quality of life, and clinical outcomes, due to the earlier commencement of nutritional support. The null hypothesis is that there is no difference in the outcomes between the two groups.
The primary endpoint is percentage weight change from baseline (pre treatment) to 3 months post treatment. Secondary endpoints will also be measured at baseline and 3 months post completion of treatment and include: nutritional status using the Patient-Generated Subjective Global Assessment tool (PG-SGA), body composition using Bioelectrical Impedance Analysis (BIA), and quality of life using the European Organisation for Research and Treatment of Cancer (EORTC) tools. The questionnaires to be used include the quality of life of cancer patients (EORTC QLQ-C30) and the module for head and neck (EORTC QLQ-H&N35). Additional qualitative data will be collected through the patient diary to assess adherence to the intervention. If patients are unable to meet the recommended goal intake, the reason why will be recorded by the patient e.g. nausea, lack of time, too tired etc. Tertiary endpoints will include: tolerance to chemotherapy and radiotherapy (dose received, changes to treatment, interruptions); unplanned hospital admissions; gastrostomy complications; and treatment response. Follow up to assess gastrostomy use (duration and degree of tube use post treatment) will occur monthly for six months post treatment or until tube is removed. If the tube is still in situ at six months, then follow up would also occur at 12 months post treatment to assess long term gastrostomy dependency. Survival will also be measured at 1 years and 5 years. The primary and secondary outcomes have been set at three months to ensure maximum follow up and prevent attrition from the study. As the centre is a major tertiary hospital in Queensland which covers an area of 715 309 square miles, many patients do not receive ongoing follow up at the tertiary centre, but at regional cancer centres or local health services. In addition the aim of this study is to see whether an early nutrition intervention can minimise weight loss in the acute period of treatment. Other studies have shown the nadir of weight loss occurs around this time point [25,35], and looking at weight outcomes beyond this time point can be impacted upon by so many other variables such as the effect of recurrent disease or a change in the nutrition management goals from weight maintenance during treatment to achieving a healthy weight through lifestyle and dietary changes as recommended for cancer survivorship. Therefore the aim of this study was to investigate the effect of an early nutrition intervention on minimising this nadir of weight loss.
To enhance the quality of the measurements and to reduce any inter-rater variability in assessment the data will be collected by the designated research dietitian. The research dietitian is responsible for recruitment and data collection only, and is not providing any dietetic patient care.
Adverse events
A data monitoring committee will meet quarterly to review and collate serious adverse events. Any serious adverse events resulting from the study intervention will be reported to the RBWH Human Research and Ethical Committee as per standard procedures, and would be appropriately managed by the medical team to minimise or eliminate the effect of the adverse event on the patient.
Intervention team roles
The study intervention team consists of: one research dietitian (author TB) who is responsible for the recruitment and outcome assessments at baseline and follow-up, and a second research dietitian (author MB) who is responsible for the randomisation process. The dietetic care is provided by two different treating clinicians (not blinded): one is allocated to the care of the standard arm; the second is allocated to the care of the intervention arm. This is to prevent any cross contamination between the cares given in each arm of the study. The multidisciplinary treatment team is also notified of the randomisation outcome so that there is reinforcement of the nutrition protocol from all professions involved in the patient care. The research dietitians are not involved in the clinical care of the patient. The research dietitian responsible for recruitment and outcome assessment is blinded to the randomisation sequence but not to the randomisation outcome, as they also provide support and encouragement to the intervention group to maximise adherence to the protocol.
Sample size
The primary outcome in this study is a continuous response variable (% weight loss) from independent control and intervention patients, which have been randomised in a ratio 1:1. In a previous study we have found high risk patients recommended for a prophylactic gastrostomy (i.e. the target population for this RCT) to experience a mean 9% weight loss at three months post treatment with standard deviation 9.4 [25]. The aim of this intervention is to reduce this weight loss; however there are no other studies which have investigated the impact of prophylactic enteral tube feeding on which we can draw an anticipated response for this study for the sample size calculation. Ideally the goal for the intervention group is a mean weight loss of <5% as this is not deemed to be clinically significant, and thus a positive nutrition outcome. Therefore to detect a 5% true difference in% weight loss between the intervention and control groups, 56 patients in each group will be required to be able to reject the null hypothesis that the population means of the intervention and control groups are equal with probability (power) 0.8. The Type I error probability associated with this test of this null hypothesis is 0.05. Given that mortality during treatment is low and good follow up at three months is expected, as patients are returning to the hospital for their treatment scans and appointment with the oncologist, an attrition rate of 10% is used. Therefore the total sample required is 123 patients (62 patients in each group).
There is a study to consider of patients receiving chemoradiotherapy in which an early pre-treatment nutrition intervention of dietary counselling with or without oral supplements or tube feeding was compared to patients without a pre treatment nutrition assessment and intervention. They found a mean weight loss at three months post treatment of 9.75% +/− 5.75 in their standard care group compared to a mean weight loss of 2.77% +/− 7.93 [35]. Therefore the sample size was also calculated based on this demonstrated difference of 7% and examples of multiple sample sizes based on varying assumptions are illustrated in Table 1. Therefore sample size could be reduced to 39 patients per arm, with an attrition rate of 10%, which then results in total sample size of 86 (43 patients in each group), at a power of 90%.
Table 1. Examples of sample sizes required with varying assumptions and a Type I Error of 0.05
Both of these sample sizes are deemed feasible from historical data at our institute. Each year approximately 500–550 patients attend the Combined Head and Neck Clinic at our institution. In a sample year (2010–11) 270 patients went on to have curative treatment with a standard referral to the dietitian. Of these; 106 patients were planned for adjuvant or definitive concurrent chemoradiotherapy with 88 categorised as high risk. The majority of these proceeded with a prophylactic gastrostomy as per the guideline recommendation (n = 86), and nil were considered high risk due to severe malnutrition. Based on 86 eligible patients per year, factors such as patients not giving consent (20%) and other factors such as scheduling difficulties (5%) were considered, resulting in an estimated 64–65 patients per year (or approximately 5 patients per month). Therefore recruitment is anticipated to be achievable in 2 years from a single centre.
The research dietitian (author TB) will inform the clinical treating dietitian of newly recruited patients following consent and baseline data collection. The clinical dietitian will provide patient details to an independent member of the research team (author MB) for randomisation. The random allocation sequence is generated by computer and stratified according to baseline nutritional status (well nourished versus moderate or suspected malnutrition). Additional stratification based on tumour site or treatment was not undertaken, as the high risk category of the guidelines used to determine prophylactic gastrostomy placement has been based on these factors. As the guidelines have been found to be highly specific at predicting the requirement for a gastrostomy [24] it was not deemed necessary that additional stratification was required. It is not possible for this study to be double-blinded; however the allocation sequence is concealed to the participants, their health care providers, and the research dietitian responsible for recruitment, as it is undertaken by an independent member of the research team not involved in patient care or data collection.
Statistical methods
To determine whether there are any differences between the two groups at baseline - participant characteristics will be summarised using mean and standard deviation for continuous variables and analysed using student t-tests, and categorical variables will be summarised using frequencies and percentages and analysed using chi-squared tests of association. If the data is not normally distributed and found to be skewed, then the data can be transformed using log transformation before applying the appropriate parametric test. If this is not successful, then alternative non parametric tests can be applied, such as the Wilcoxon-Mann–Whitney test for continuous variables.
Analysis will be undertaken on an intention to treat basis. To determine the effect of the nutrition intervention group versus the control group (the independent categorical variable) on the primary outcome of % weight loss (the dependent continuous variable), analysis of variance (ANOVA) will be used. For the secondary outcomes,% fat free mass, PG-SGA score and quality of life score, the change over time from baseline to 3 months will be analysed between groups using the repeated measures ANOVA. Univariate analysis will be used to determine the association of any other independent variables on the outcome measures. Any statistically significant associations found will then be used to add each variable into a normal regression model along with any other clinically important variables such as the tumour site, staging, treatment type, and baseline BMI and weight loss. Age and gender will also be added to adjust for any confounding effects. The regression model will also enable adjusting for any important clinical differences found between the intervention and control group at baseline.
All tests will assume normal distribution; otherwise alternative non parametric tests will be applied for non-normal distributed data. Statistical significance will be set at p < 0.05. All outcomes will be reported in the future report.
This study will evaluate the effectiveness of prophylactic nutrition support via a gastrostomy compared to current standard practices of commencing nutrition support in a reactive way during treatment. To our knowledge this is the first study to trial this approach of prophylactic nutrition support in a formal research setting. Of those studies that report specific details on the actual timing of the commencement of nutrition support, all commence a number of days after the commencement of treatment: 1–33 days [26], 21 days [27] and 10 days [13]. See Table 2. The studies which have reported on the early commencement of tube feeding have quite a different study design and intent to our protocol. See Table 3. Nguyen et al. stated criteria in their study for the initiation of enteral feeds prior to treatment being; poor oral intake prior to treatment, or aspiration on pre treatment Modified Barium Swallow assessment [28]. However the authors did not describe the number of patients in their study that met these criteria. Wiggenraad et al. reported 26% of their patients commenced enteral feeds prior to treatment [29], however this was likely in response to poor swallowing or nutritional status, with 48% of patients already requiring a puree or liquid diet and 78% of patients with weight loss prior to treatment. It was also found that when there was dysphagia at baseline, tube feeding was commenced earlier (day 2) compared to when there was no dysphagia at baseline (day 17). There have been two other studies which have looked at initiating tube feeding immediately following prophylactic placement [30,31]. Both of these studies also had a significant proportion of patients who were nutritionally compromised at baseline and therefore the characteristics of the patients commencing early nutrition support are likely to be quite different to the patient characteristics we are anticipating studying. Both also appear to provide the majority of nutrition via the gastrostomy tube, with minimal oral intake. This is a very different approach to our proposed intervention where we are providing supplementary nutrition via the tube and advocate patients maintain/continue with oral intake for as long as possible to minimise the risk of long term dysphagia and prolonged rehabilitation post treatment [36]. Salas et al. reports on a randomised controlled trial on the quality of life in patients with a systematic gastrostomy (n = 21) versus no systematic gastrostomy (n = 18) [6]. In the control group 13 patients later receive an insertion of a gastrostomy and the other 5 patients remained on oral intake alone. There are no details in the methodology on the nutrition interventions provided to either group and the results do not include information on the actual timing of gastrostomy placement or the timing for the commencement of feeding. Therefore it is difficult to ascertain whether prophylactic nutrition support was utilized or whether it was prophylactic (systematic) tube placement.
Table 2. Comparison of key studies which report on timing of commencement of enteral feeding during treatment
Table 3. Comparison of key studies which commence enteral feeding via a prophylactic gastrostomy immediately
Some of the anticipated problems with this current study protocol will be patient adherence to recommendations. Capuano et al. have shown that patients who adhere to dietary recommendations have improved outcomes compared to those that do not adhere [37]. Therefore patients have been asked to keep a record of the number of feeds they have each day so that adherence can be considered as a confounding variable. Patients have also been asked to record any reasons why they have not had the recommended amount. This may be due to feeling full or bloating, or from side effects of treatment such as nausea, or from practical issues such as not having enough time in the day due to treatment schedules/appointments, being fatigued or financial difficulties to purchase the recommended feeds. This additional information from the study will provide evidence for the feasibility of implementing the early intervention into clinical practice, and will also assist in identifying factors that patients experience during treatment so that alternative strategies can be found.
With the advent of evolving techniques using intensity modulated radiotherapy and helical tomotherapy, the dose to surrounding tissues (pharyngeal constrictor muscles) and salivary glands can be spared due to steeper dose gradient outside target volumes, and as a consequence there are less reports of long term dysphagia and xerostomia [38-40]. Therefore it is hypothesized that patients may be less likely to require feeding tubes. The guidelines for prophylactic gastrostomy at our institution were previously validated in a patient cohort receiving standard 3D conformal radiotherapy [24] and so additional research is also planned to retrospectively re-validate these guidelines in patients now receiving helical tomotherapy to see whether the requirement for a feeding tube has changed. However it should be noted there are a range of other reasons why patients may have an inadequate oral intake other than dysphagia and xerostomia. Therefore these patients are still susceptible to weight loss and malnutrition, and the adverse consequences. So despite the reduction of some side effects in this population with evolving treatments, nutrition support can still be indicated for other reasons. Patients in this study protocol are being asked to record the main reason they are using the gastrostomy for nutrition support e.g. pain on swallowing (odynophagia), difficulty swallowing (dysphagia), painful ulcers (mucositis), difficulty chewing/dry mouth (xerostomia), taste changes (dysgeusia), nausea/vomiting or general poor appetite. These nutrition impact symptoms can all lead to a decline in nutritional status and weight loss, both of which have been associated with poor quality of life [41,42].
In conclusion the results from this study will aim to address the questions regarding the optimal nutrition interventions required to manage patients with head and neck cancer and will also assist in our understanding of the impact of the new treatment regimens. Together this will inform future clinical practice for the nutritional management of this patient population to achieve positive outcomes.
RCT: Randomised controlled trial; PG-SGA: Patient generated - subjective global assessment; BIA: Bioelectrical impedance analysis; EORTC: European Organisation for Research and Treatment of Cancer; BMI: Body mass index.
Competing interests
None of the authors have any competing interests relevant to this trial to disclose.
Authors' contributions
TB is a PhD student and conceived the study, contributed to the design of the study, and is responsible for patient recruitment, data collection, data analysis and drafting of the manuscript. MB, BH, LK, CL and JB contributed to the study design, data analysis interpretation and critical revision of the manuscript for important intellectual content. All authors read and approved the final manuscript.
The authors would like to thank the staff of the Combined Head and Neck Clinic at the Royal Brisbane and Women's Hospital for support in recruiting eligible patients, the Department of Nutrition and Dietetics who assisted with providing support for the study intervention, and of course the patients who participated in this study.
TB received a Royal Brisbane and Women's Hospital Research Scholarship to assist with part time studies in 2012, 2013 and 2014.
Brown T, Findlay M, Von Dincklage J, Davidson W, Hill J, Isenring E, Talwar B, Bell K, Kiss N, Kurmis R, Loeliger J, Sandison A, Taylor K, Bauer J: Using a wiki platform to promote guidelines internationally and maintain their currency: evidence-based guidelines for the nutritional management of adult patients with head and neck cancer.
Garg S, Yoo J, Winquist E: Nutritional support for head and neck cancer patients receiving radiotherapy: a systematic review.
Nugent B, Lewis S, O'Sullivan JM: Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy.
Cochrane Database Syst Rev 2010., 3
Corry J, Poon W, McPhee N, Milner AD, Cruickshank D, Porceddu SV, Rischin D, Peters LJ: Randomized study of percutaneous endoscopic gastrostomy versus nasogastric tubes for enteral feeding in head and neck cancer patients treated with (chemo)radiation.
Sadasivan A, Faizal B, Kumar M: Nasogastric and percutaneous endoscopic gastrostomy tube use in advanced head and neck cancer patients: a comparative study.
Salas S, Baumstarck-Barrau K, Alfonsi M, Digue L, Bagarry D, Feham N, Bensadoun RJ, Pignon T, Loundon A, Deville JL, Zanaret M, Favre R, Duffaud F, Auquier P: Impact of the prophylactic gastrostomy for unresectable squamous cell head and neck carcinomas treated with radio-chemotherapy on quality of life: Prospective randomized trial.
Silander E, Nyman J, Bove M, Johansson L, Larsson S, Hammerlid E: Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer: a randomized study.
Koyfman SA, Adelstein DJ: Enteral feeding tubes in patients undergoing definitive chemoradiation therapy for head-and-neck cancer: a critical review.
Grant DG, Bradley PT, Pothier DD, Bailey D, Caldera S, Baldwin DL, Birchall MA: Complications following gastrostomy tube insertion in patients with head and neck cancer: a prospective multi-institution study, systematic review and meta-analysis.
Langmore S, Krisciunas GP, Miloro KV, Evans SR, Cheng DM: Does PEG use cause dysphagia in head and neck cancer patients?
Mekhail TM, Adelstein DJ, Rybicki LA, Larto MA, Saxton JP, Lavertu P: Enteral nutrition during the treatment of head and neck carcinoma: is a percutaneous endoscopic gastrostomy tube preferable to a nasogastric tube?
Olson R, Karam I, Wilson G, Bowman A, Lee C, Wong F: Population-based comparison of two feeding tube approaches for head and neck cancer patients receiving concurrent systemic-radiation therapy: is a prophylactic feeding tube approach harmful or helpful?
Scolapio JS, Spangler PR, Romano MM, McLaughlin MP, Salassa JR: Prophylactic placement of gastrostomy feeding tubes before radiotherapy in patients with head and neck cancer: is it worthwhile?
Tyldesley S, Sheehan F, Munk P, Tsang V, Skarsgard D, Bowman CA, Hobenshield SE: The use of radiologically placed gastrostomy tubes in head and neck cancer patients receiving radiotherapy.
Beaver ME, Matheny KE, Roberts DB, Myers JN: Predictors of weight loss during radiation therapy.
Fietkau R, Iro H, Sailer D, Sauer R: Percutaneous endoscopically guided gastrostomy in patients with head and neck cancer.
Senft M, Fietkau R, Iro H, Sailer D, Sauer R: The influence of supportive nutritional therapy via percutaneous endoscopically guided gastrostomy on the quality of life of cancer patients.
Lee JH, Machtay M, Unger LD, Weinstein GS, Weber RS, Chalian AA, Rosenthal DI: Prophylactic gastrostomy tubes in patients undergoing intensive irradiation for cancer of the head and neck.
Piquet MA, Ozsahin M, Larpin I, Zouhair A, Coti P, Monney M, Monnier P, Mirimanoff RO, Roulet M: Early nutritional intervention in oropharyngeal cancer patients undergoing radiotherapy.
Hughes BG, Jain VK, Brown T, Spurgin AL, Hartnett G, Keller J, Tripcony L, Appleyard M, Hodge R: Decreased hospital stay and significant cost savings after routine use of prophylactic gastrostomy for high-risk patients with head and neck cancer receiving chemoradiotherapy at a tertiary cancer institution.
Li B, Li D, Lau DH, Farwell DG, Luu Q, Rocke DM, Newman K, Courquin J, Purdy JA, Chen AM: Clinical-dosimetric analysis of measures of dysphagia including gastrostomy-tube dependence among head and neck cancer patients treated definitively by intensity-modulated radiotherapy with concurrent chemotherapy.
Rutter CE, Yovino S, Taylor R, Wolf J, Cullen KJ, Ord R, Athas M, Zimrin A, Strome S, Suntharalingam M: Impact of early percutaneous endoscopic gastrostomy tube placement on nutritional status and hospitalization in patients with head and neck cancer receiving definitive chemoradiation therapy.
Clavel S, Fortin B, Despres P, Donath D, Soulieres D, Khaouam N, Charpentier D, Belair M, Guertin L, Nguyen-Tan PF: Enteral feeding during chemoradiotherapy for advanced head-and-neck cancer: a single-institution experience using a reactive approach.
Brown TE, Spurgin AL, Ross L, Tripcony L, Keller J, Hughes BG, Hodge R, Walker Q, Banks M, Kenny LM, Crombie J: Validated swallowing and nutrition guidelines for patients with head and neck cancer: Identification of high-risk patients for proactive gastrostomy.
Brown T, Ross L, Jones L, Hughes B, Banks M: Nutrition outcomes following implementation of validated swallowing and nutrition guidelines for patients with head and neck cancer.
Support Care Cancer 2014.
Nugent B, Parker MJ, McIntyre IA: Nasogastric tube feeding and percutaneous endoscopic gastrostomy tube feeding in patients with head and neck cancer.
Raykher A, Correa L, Russo L, Brown P, Lee N, Pfister D, Gerdes H, Shah J, Kraus D, Schattner M, Shike M: The role of pretreatment percutaneous endoscopic gastrostomy in facilitating therapy of head and neck cancer and optimizing the body mass index of the obese patient.
Nguyen NP, North D, Smith HJ, Dutta S, Alfieri A, Karlsson U, Lee H, Martinez T, Lemanski C, Nguyen LM, Ludin A, Sallah S: Safety and effectiveness of prophylactic gastrostomy tubes for head and neck cancer patients undergoing chemoradiation.
Wiggenraad RG, Flierman L, Goossens A, Brand R, Verschuur HP, Croll GA, Moser LE, Vriesendorp R: Prophylactic gastrostomy placement and early tube feeding may limit loss of weight during chemoradiotherapy for advanced head and neck cancer, a preliminary study.
Marcy PY, Magne N, Bensadoun RJ, Bleuse A, Falewee MN, Viot M, Bruneton JN: Systematic percutaneous fluoroscopic gastrostomy for concomitant radiochemotherapy of advanced head and neck cancer: optimization of therapy.
Beer KT, Krause KB, Zuercher T, Stanga Z: Early percutaneous endoscopic gastrostomy insertion maintains nutritional state in patients with aerodigestive tract cancer.
Merrick S, Farrell D: Head and neck cancer patients' experiences of percutaneous endoscopic gastrostomy feeding: a Q-methodology study.
Bauer J, Capra S, Ferguson M: Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer.
Isenring E, Zabel R, Bannister M, Brown T, Findlay M, Kiss N, Loeliger J, Johnstone C, Camilleri B, Davidson W, Hill J, Bauer J: Updated evidence-based practice guidelines for the nutritional management of patients receiving radiation therapy and/or chemotherapy.
Paccagnella A, Morello M, Da Mosto MC, Baruffi C, Marcon ML, Gava A, Baggio V, Lamon S, Babare R, Rosti G, Giometto M, Boscolo-Rizzo P, Kiwanuka E, Tessarin M, Caregaro L, Marchiori C: Early nutritional intervention improves treatment tolerance and outcomes in head and neck cancer patients undergoing concurrent chemoradiotherapy.
Rosenthal DI, Lewin JS, Eisbruch A: Prevention and treatment of dysphagia and aspiration after chemoradiation for head and neck cancer.
Capuano G, Grosso A, Gentile PC, Battista M, Bianciardi F, Di Palma A, Pavese I, Satta F, Tosti M, Palladino A, Coiro G, Di Palma M: Influence of weight loss on outcomes in patients with head and neck cancer undergoing concomitant chemoradiotherapy.
Kam MK, Leung SF, Zee B, Chau RM, Suen JJ, Mo F, Lai M, Ho R, Cheung KY, Yu BK, Chiu SK, Choi PH, Teo PM, Kwan WH, Chan AT: Prospective randomized study of intensity-modulated radiotherapy on salivary gland function in early-stage nasopharyngeal carcinoma patients.
Pow EH, Kwong DL, McMillan AS, Wong MC, Sham JS, Leung LH, Leung WK: Xerostomia and quality of life after intensity-modulated radiotherapy vs. conventional radiotherapy for early-stage nasopharyngeal carcinoma: initial report on a randomized controlled clinical trial.
Nutting CM, Morden JP, Harrington KJ, Urbano TG, Bhide SA, Clark C, Miles EA, Miah AB, Newbold K, Tanay M, Adab F, Jefferies SJ, Scrase C, Yap BK, A'Hern RP, Sydenham MA, Emson M, Hall E: Parotid-sparing intensity modulated versus conventional radiotherapy in head and neck cancer (PARSPORT): a phase 3 multicentre randomised controlled trial.
Langius JA, Van Dijk AM, Doornaert P, Kruizenga HM, Langendijk JA, Leemans CR, Weijs PJ, Verdonck-de Leeuw IM: More than 10% weight loss in head and neck cancer patients during radiotherapy is independently associated with deterioration in quality of life.
Ravasco P, Monteiro-Grillo I, Camilo ME: Does nutrition influence quality of life in cancer patients undergoing radiotherapy?
Pre-publication history
The pre-publication history for this paper can be accessed here:


text:
Lawmate PV-RC200HD 720P Keychain w/ WDRIn Stock
- 720P HD Video & Audio Recording
- Battery Life of 4 Hours
- Up to 16 GB Micro SD Card (4GB Card Included)
- Includes Wide Dynamic Range Technology
- Includes One Year Warranty
- Built by Lawmate
808 #26 - 1080P Full HD Video Camera KeychainIn Stock
- 1080P HD Video & Audio Recording
- 1080P 30FPS or 720 60FPS Video
- Battery life of 1 Hour
- Records in Loop Recording or Still Images
- Takes up to 32 GB SD Card
- Built by Hetai
Lawmate PV-RC200 HD Video KeychainIn Stock
- HD Video & Audio Recording
- Battery Life of 4 Hours
- Up to 16 GB Micro SD Card (4GB Card Included)
- Includes One Year Warranty
- Built by Lawmate
Video Camera KeychainIn Stock
- High Resolution Video and Audio Recording
- Up to 16 GB Storage Space (Not Included)
- Battery Life of 45 Minutes
- Small Portable Design
- Built by Generic
Lawmate AR100 Audio Recording KeychainIn Stock
- Excellent Quality Audio Recording
- Law Enforcement Grade
- Looks like a Car Lock Remote
- 15 Hour Battery Life
- PC and Mac Compatible
- Easy On/Off Recording
- Microphone Sensitivity: 15 ft, 30 ft Diameter
- Built by Lawmate
It's easy to covertly record video and audio when you have a hidden camera Car Remote Keychain. These devices look like standard car door lock remotes but have hidden cameras housed inside the casing. We have affordable consumer video keychains and Lawmate brand professional grade video car remotes, the same ones used by law enforcements. We also have professional grade audio only car keychains capable of recording over 15 hours straight of audio.


text:
Thinking of learning Portuguese in Faro? If you want to know more about the local beach resorts, FaroUncovered.com have some useful information, to give you a feel of the local area and the wonderful Faro beaches on offer. "The beaches around the Algarve's city of Faro are "ilhas" (sandspits) that form the outer edge of [...]
Summer Courses for Teens 2015:
Start dates, prices & full details
Work on your French, Spansh or German with other teenagers this summer, there are some fantastic courses on offer - talk to us - we have some fabulous options to help hone those skills and give your linguistic self confidence a real boost (and have a good time too!).
Dan studied French & Surfing with CESA in Biarritz (2) and had a great time with Anne Robinson on the Weakest Link. Thanks Dan for sharing this with us!
Japanese Courses in Fukuoka:
Course options 2015
Study Japanese over the summer in Fukuoka, across all language levels. Places will become fully booked - so early reservations are recommended. Combine your language lessons with Pop Culture or Traditional Culture workshops.
CESA Tag CloudA-level Antibes/Teenagers Austria Barcelona Berlin Buenos Aires Cannes Chinese Chinese Language Course FAQs Florence France French French Language Courses Gap Year German German Language Course Germany Granada Italian Italian Language Courses Italy Japanese Japanese language course Kitzbuhel Lisbon Madrid Malaga Montpellier Nice Over 50s Course Paris Portugal Portuguese Portuguese Language Course private tuition Russia Russian Russian Language Courses Salamanca San Sebastian Spain Spanish Spanish language courses Summer School


text:
After losing the Romanian Olympic Committee presidency elections last Thursday to Rugby Federation president Alin Petrache by more than 100 votes, legendary Romanian coach has announced his resignation from the Olympic committee.
"I wish the new president success in his mandate …
… I don't think that anyone will be hurt if I quit the gymnastics team. Now I have realized that I lost 30 years in the gym and I went to 7 Olympics, but it doesn't matter. It seems that what I've done for 30 years doesn't matter. … "
4 thoughts on "Octavian Bellu threatens to quit"
National Olympic Committee's are political organizations in every country… Romania is certainly no different. At that level, it is not about sport or kids or competition. It is about politics.
I don't feel sorry for him. Quit. It will probably be better for the gymnasts mental and physical health in the long run
What a pity. Seems to be what the modern world is all about these days. Theses great champions of coaching the art of gymnastics are being pushed out all over the world to the lesser of commercial gymnastics.
Krakow, PL


text:
Send V Paul a message explaining your needs and you will receive a response by email. Have you already emailed V Paul or another tutor? If so, you have an account! Sign in now
If you select this option, WyzAnt will ask interested tutors to contact you by email if they are able to help. A maximum of five different tutors will email you and none of your personal information, including your email address, will be released.
Bradley University Peoria, Il
You want to improve your basic Accounting knowledge or skill level in QuickBooks for business applications...
I am certified by the State of Illinois to teach both Basic and Business Accounting. I have taught these courses at the above school as well as the B.I.R. Training Institute in Chicago. I am QuickBooks Certified to teach the practical use of their Software programs and am thoroughly familiar with all version releases through 2016.
You've applied for a general accounting or Bank Operations Position and you want to stand-out from the other new Employees...
I am a Retired Bank Controller who started as a teller and went on to head up the International Banking and Business Institute in Los Angeles as their Faculty Administrator. I have also started 2 new Savings and Loan Associations and a Credit Union in California. I am a Graduate (In Bank Operations) of The Banking Institute completing courses in both Chicago and San Francisco.
I currently run a very successful independent accounting practice for small to medium size businesses which include a law firm, a commercial real estate management company, art galleries, food service businesses, construction services, and a animal transport company to name a few.
I take an approach which is very inter-active with all of my students (whether one-on-one or in a classroom setting). My first course of action is to determine my student(s) proficiency level and build upon that. I believe that learning is most accomplished when the setting is relaxed yet professional. Humor achieves more in retention than criticism. As my experience working with the Japanese has taught me - learning needs to be 'PARTICIPATORY'. All views count and 'No Question' is dumb. Testing is always important and the repetition of important elements of a subject proves to achieve long lasting knowledge. You want to improve your basic Accounting knowledge or skill level in QuickBooks for business applications...
I am certified by the State of
$45/hr Accounting 'student' rate. $55/hr Business rate for QuickBooks installations & training. $60/hr Business QB training sessions with multiple participants. *Rates are negotiable.
I am very lucky to have worked with Paul as my quickbooks tutor. I had previous knowledge of a quickbooks type software accounting program but not the version Paul tutored me on. He was an excellent teacher and very patient. He understood the places I kept getting stuck and really explained how to trouble shoot and problem solve. I think we are done now as he has really helped me create some templates I can refer back to and again, the process to problem solve was very clearly explained. I would recommend him highly.
Paul is such a wonderful tutor who can teach everything about Quick Books. I have also learned how to set up a business and got ideas about website design from Paul.
Paul helped me setup Quickbooks pro for my small business. He has an excellent grasp of the software and of accounting principles, allowing us to set up the entries correctly so that I could report properly to my investors. He is also a very friendly instructor and is committed to his students.
His prices are reasonable.
Approved subjects are in bold.
In most cases, tutors gain approval in a subject by passing a proficiency exam. For some subject areas, like music and art, tutors submit written requests to demonstrate their proficiency to potential students. If a tutor is interested but not yet approved in a subject, the subject will appear in non-bold font. Tutors need to be approved in a subject prior to beginning lessons.
Accounting, oh those debits and credits, what do they do, how do they develop a company's Balance Sheet or Income Statement? Why is a dual system of accounting important (whether it's a manual system or packaged through a software program such as QuickBooks)?
If you're a bit overwhelmed with the subject matter in 'Accounting Basics' or if you want to improve your knowledge of accounting for marketing a better skill set in employment or, lastly, if you simply want to improve your business accounting routines and procedures, then I can help.
As an operations banker with over 35+ years in the industry, as well as, running a successful small business accounting practice, the skill set that I offer is tight and concise.
I am certified by the State of Illinois to teach accounting and am proficient in both manual and automated systems with a definite preference for QuickBooks accounting.
My skills and abilities to generate good business documents include generating budgetary proposals within various business environments, preparing grant applications for the Literacy Volunteers of Western Cook County, and working for foreign corporations such as Sumitomo Bank in California.
My writing abilities and skills are superb. I can guide and teach these same skills to all who desire this talent. My approach to this teaching method is example, practice, and repeat. Just like the T.V. commercial 'wash and repeat' cycle. If you have smiled just once - you learned!
Let's go back in time for a moment as I sat at my desk in Operations at a number of prominent banks. With my trusted calculator at my disposal, I was required to balance out the entire bank as well as complete the financial reporting to the Federal Reserve for the organization. Then came the astounding tool called Microsoft Excel which allowed me to quickly determine cash positions, summarize balance sheet and Income statement reporting and do hundreds of other tasks with this new found tool.
That was 20+ years ago and I now have a successful accounting practice, Teach and tutor, and do a number of other activities which keep my skill level sharp in using Excel as a focused accounting tool.
What I am not is an Excel whiz which means 'embedding complex formulas' over multiple worksheets or doing other 'hand-stand activities'. But if you're looking for the introduction or 'basics' to 'mid-level' skill set then I can definitely help.
I am extremely professional and personable. Believe in 'sample' practicing and stress repetition as a means of learning.
I am certified by the State of Illinois to teach Accounting and strongly believe that this adjunct ability to teach the Microsoft Excel mechanics flow from this certification.
Microsoft Word is the typewriter of now. I know... it's sort of an antiquated term but actually true. Here you will learn how to compose a letter, format it, adjust margins, and paragraph presentation. The program also spell checks you and recommends appropriate text changes.
From this 'CREATED' document you can mail merge, copy and paste, as well as, insert to the document.
It is a relatively easy program to learn, practice at, and developed the appropriate professional documents required by you and your profession.
Simply stated, I am QuickBooks Certified, Have Taught QuickBooks at B.I.R. Training Institute, and have 12 years of practical QuickBooks experience at client sites which include Legal Offices, Property Management Operations, and Retail Operations.
V Paul D. passed a background check on 9/16/13. The check was ordered by V Paul through First Advantage. For more information, please review the background check information page.
After sending a message to V Paul, you will be able to order a new background check for $7.99. As part of your tutor selection process, we encourage you to run updated background checks. Please also review the safety tips for hiring tutors.


text:
Not that the Gruul would take the time (or learn the words) to explain this, but they feel civilization is a mockery, an elaborate cage that suppresses desire and makes the weak seem powerful. The Gruul live moment by moment, and they "encourage" others to do the same. Once a strong guild, the Gruul are now merely a loose assemblage of beggars, gangs, and raiding parties. The largest of the gangs has the largest leader: Borborygmos, a huge cyclops known for smashing dissent (among other things). Gruul gangs survive by pillaging and burning neighborhoods, then squatting on the rubble and ashes, living off what they find. When the resources run dry, it's time for another raid.
On the left, you can see an early version of Borborygmos, along with a victim -- er, human for scale. On the right, one of the Gruul goblins: they're hoodlums, plain and simple. These aggressive and capable goblins are nothing to laugh at.
Left: Borborygmos in all his raging glory. He's not a "guild leader" so much as he's "the most dominant of several gang leaders". Right: The Gruul raid an area, smash it up, burn it down, and live in the wreckage until the resources run dry. Then it's time for another raid. Gruul areas are smoldering, half-overgrown ruins, rubble, abandoned neighborhoods, etc.
Gruul humans often wear scavenged clothing and armor. Some (but not all) have ritual tattooing to indicate their allegiance to the guild. Gruul berserkers fight with weapons made from animals' natural weapons.
© 1995-2015 Wizards of the Coast LLC, a subsidiary of Hasbro, Inc. All Rights Reserved.
Terms of Use | Privacy Statement | Code of Conduct


text:
1991 Buick Park Avenue • 6 cylinder FWD Automatic •
How to change ignition switch on 91 park avenue
George Lampkin
February 8, 2011.
February 8, 2011.
Do you mean the ignition lock and tumbler or the electrical ignition switch
Lock and tumbler
George Lampkin
Feb 8, 2011.
Feb 8, 2011.
How to connect are where does the wire from the switch attaches to
You're changing the lock. There are no wires. That's why I asked you what you were changing.
On the cylinder with the key theres a wire that connets to something
That would be the Passkey sensor for the security system. If you bought a lock that doesn't match, then you have the wrong lock. They are made with and without that system.
Wher is it located, where to conect it, dose it go under the dash or to the switch
If the old one didn't have it, then your car isn't equipped with it.
Electrical problem 2000 Chevy Impala 6 cyl Front Wheel Drive Automatic 100000 miles What is the procedure to remove and replace the ignition switch?
1 answer • 2000 Chevrolet Impala
Electrical problem 1999 Oldsmobile Alero 4 cyl Front Wheel Drive Automatic 81,000 miles Im haveing some problem removeing the ignition switch on my Alero, I mamaged to remove the 2...
1 answer • 1999 Oldsmobile Alero
Electrical problem 1995 Jeep Cherokee 6 cyl Four Wheel Drive Automatic 198000 miles How do I replace the ignition switch?
4 answers • 1995 Jeep Cherokee


text: Dress up Manni the rhino!A LOT OF DRESSES12 complete outfits with matching backgrounds.2 hidden complete outfits.Additional clothes for Manni to wear.COMBINE THEMChoose between all the clothing and backgrounds and combine them in any way you want!ADDITIONAL FEATURESRhinoDressUp automatically remembers its last state - Mannis outfit carefully chosen by you will not get lost.You can save your dressed up rhinos as image files to your device, e.g. to use them as wallpapers.Dress Manni with the complete background matching outfits by pressing just one button.Undress Manni with one click.RhinoDressUp is available for free! :)FEATURED BY MIRJA T.All rhinos and clothes were created by the artist Mirja T. you might already know from her app called MirjasGallery that is also available for free!VISIT RHINODEVELPlease visit and like RhinoDevel athttp://www.facebook.com/RhinoDevel


text:
Free Stuff
Contact Us
Site Search
Departments - Choose a category
Knitting Topics
> Spool Knitting
Find us on
Knitting Shopping
Buy Stuff - Knitting Stores
Buy Stuff - Knitting Products
Books - Knitting Books
Magazines - Knitting
Calendars - 2016 Knitting Calendars
Knitting Software, Videos, Shareware
Puzzle - Knitting
Knitting Topics
Knitting Basics
Knitting Stitches
Knitting - Video Tutorials
Knitting Techniques
Abbreviations & Terms - Knitting
Apps for Knitters (iPhone / iPad / i Pod)
Arm Knitting
Calculators - Knitting Calculators
Casting Off/Bind Off
Cast on/Casting on
Catalogs - Free Catalogs for Knitters
Double Knitting
Entrelac Knitting
Fair Isle Knitting or Stranded Knitting
Finger Knitting
Finishing Techniques
Flower Looms & Knit Wit
Fringe - How-To
History of Knitting
Knitting In The Round (Circular Needle)
Knitting Intarsia
Knitting Needles
Labeling Your Project
Left-Handed Knitting
Loom Knitting
Machine Knitting
Measurement Charts
Mistakes - Problem Solving
Plastic Bags - Projects & Info
Short Row Knitting
Sock Knitting Machine
Software, shareware, videos
Spool Knitting
Tools of the Trade
Words of Wisdom
Yarn Color Charts
Yarn Guide
Knitting in Other Languages
Knitting In Danish
Knitting in French
Knitting in Japanese
Knit in Spanish
Knitting in German
Free Stuff
500+ Free Knitting Patterns
30+ Free Afghan and Throw Knitting Patterns
20+ Free Baby Knitting Patterns
20+ Free Tote, Bag and Purse Knitting Patterns
40+ Free Hat, Scarf and Glove Knitting Patterns
30 Free+ Sweater & Cardigan Knitting Patterns
Free Samples & Stuff for Knitting
Free Knitting Graph Paper
Other Features
Knitting Links
Knitting & Crochet Guilds & Organziations
Shows & Festivals
Custom Search
Your small donation will help us keep this site free.
Spool Knitting
Amazon.com Widgets
Corking (Kids Can Easy Crafts)
Need project ideas for those long knitted snakes created by spool knitting. Here's the book for you - lots of creative projects.
by Judy Ann Sadler
- Paperback
- Published 1998
Spool Knit Jewelry: Make Beautiful Bracelets, Anklets and Rings
This book written by Anne Akers Johnson feature step-by-step instructions for creating some simple crochet and spool knit jewelry.
by Anne Akers Johnson
- Published 2004
How to Use a Corker or Do Spool Knitting
Simple text instructions for using a spool knitter or corker.
All Fiber Arts
How to use a knitting spool
Text and pictorial instructions for the knitting spool also known as the knitting nancy, knitting knobby, french knitter, corking.
Knitting Spool Directions
Directions for spool knitting by Parker Brothers.
Free Adobe Reader is required to view this link. Click the icon to open a new browser window and download the Free Adobe Reader.
Spool Knitting
Over the years the spool knitting tool has been called corker, corking spool, knitting spool, knitting knobby, knitting nancy, french knitter and even Bizzy Lizzy. This site has instructions including illustrations on using this tool.
Yarn Lover's Room
Spool Knitting Instructions
Spool Knitting (or Corking) is another method of making a knitted cord, like I-cord. Text and pictorial instructions.
The Lost Art of the Knitting Nancys
Pictures and instructions on how to make and use the knitting nancy (also know as the spool knitter).
Waynes This and That
Needlepointers.com Sponsor Links
Free-Knitting Patterns.com
Find 100s of free knitting patterns by signing up at Free-KnittingPatterns.com. It's fast! It's Easy! It's Free! There's no limit to the number of free knitting patterns you can download.
CraftDaily.com had over 500 craft videos, you'll never run out of ideas. Videos for jewelry making, crochet, knitting, quilting, sewing and more. Make something new TODAY... Subscribe now!
Creatbug - Knit Video Workshops
All-you-can knit video workshops on creativebug.com. Videos offer a chance to learn a project and all the necessary skills, from start to finish from top designers. New workshops added weekly! Choose one of our unlimited subscription plans—either one month, three months or six months or a la carte plan. Learn more....
CreateFor Less
60,000 brand name craft, crocheting, knitting, beadwork, sewing, quilting & scrapbooking supplies at 30-50% below retail. www.CreateForLess.com
Interweave Store - Knitting
Knitting books, eBooks, magazines, DVDs/Videos, patterns and more.
Looking for something you cannot find on our site?
Click here
to e-mail the Needlepointers Information department.
Graphics by
Copyright ©2005 Needlepointers.com. All Rights Reserved.


text:
So it all started in June after the BET awards my husband was searching for different video clips on YouTube. Well this is the day everything changed one of the searches had information about illuminati on it. Now my husband and went so deep into it he looks up and tries to find information about the 'secret society' and so on. He reads about fluoride in the water so now we are buying water filter systems and he even reads all the toothpaste labels and shows all kinds of video clips about how the government is trying to regulate the population. I am a Christian and therefore I do not have interest in researching all of this material. I believe that God has the last say so and nothing happens without him knowing. So I have asked him to please stop talking about it, I don't care to know. We can go on family outtings and there he is bringing it up at a baseball game and other places. I just want my husband back and my home back! We haven't spoke in 3 days because I told him I can't take it anymore, I don't care. Thanks for reading.
My house is no longer a home (vent)
Posted 08/09/2012
Last edited 08/09/2012
Jess&E.J. EST. 2008
Our surprise Boo Baby Girl arrived 11 days late, on Oct.26th!
Posted 08/09/2012
If you are Christian than you know that the bible talks about new world order... Not in those words of course. Why is it so terrible that he wants to be prepared for what is inevitable??? He loves his family and wants to keep you guys safe. I've done a lot of research on this subject. It is what it is... Sorry you can not understand your husband's fears. When it comes time to take the mark of the beast don't you want to know that it is Satan. He can be very sneaky you know.
Posted 08/09/2012
That shit is really scary when you get in to it....I hope he quits soon cuz you can get deep into that shit. I'm sorry I know its scary.
Posted 08/09/2012
As a Christian myself I think it's wise to gain knowledge about various things. Even the bible says "my people perish because of lack of knowledge". I don't think that he is wrong for researching but if it's all he can talk about THAT can be annoying!! I'm pretty sure that once he gets his fill he will move on but until then, maybe you can tell him how you feel and y'all can come up with a compromise/agreement. Hope all works out for you. :-)
Posted 08/09/2012
I don't try to hinder his searching by any means. But seriously we are at the sonic drive-in and here he goes about the united nations. We went to the Jaguars scrimmage taking pictures and he his pulling up video clip after video clip saying watch this real quick. All I am saying is "balance" please. But I brought these things to his attention about the different outtings and how balance is the key and now he won't talk anymore (which he is very good at that, he is already soft spoken and shy). He is in the bed right now as I type looking at videos and will do this until about 1 a.m.
Posted 08/09/2012
Pray with him... Idk if you guys already do that. We have family prayer in our home. It's amazing what God does for us. It's easy to become a little obsessed with what you fear... Just try to be understanding of his fear so you can help him. If you know about it then you can read scriptures to counter it. Assure him that God will provide what you all as a family will need.
Really it is very interesting, you should do a little reaserch. Watch some Disney stuff... You wouldn't see it as innocent anymore. You would have nothing but veggie tales in the house lol.
Really it is very interesting, you should do a little reaserch. Watch some Disney stuff... You wouldn't see it as innocent anymore. You would have nothing but veggie tales in the house lol.
Posted 08/09/2012
Ask him to see a psychologist. For some people, these types of obsessions are harmless, but (not to scare you) they can also signal the onset of paranoid schizophrenia. Especially if your husband is in his late teens or 20's, and if this is a new behavior pattern, I'd get it checked out.
Merrie (43) & David (35) married 10/2005
Fuzzies Kali & Ranger; TTC ~5 years; Angel 02/2010
ADD due ~09/2016 & Rainbow due 10/04/2012!
Posted 08/09/2012
Prayers-sent I will take your advice and become a little more open-minded. So is any of this explained to your children or do you and your husband make decisions in the home without bringing it to the child's attention about the changes that are being made? Just curious
Your growing child
Your 3-year-old: Friendships
Your ever-more-independent child is probably starting to develop some friendships. Read More
Your 3-year-old: Counting
Ask most 3-year-olds how old they are and they'll proudly raise the correct number of fingers. Read More
Your 3-year-old: Playing ball
Some call it the perfect toy. What is it? Read More
Your 3-year-old: Pearly whites
Your child probably has a full set of primary teeth by now. Read More


text:
Choose your preferred language. We speak English (US) and 41 other languages.
Most often used by people in the United States
All languages
Select your hotel from the list. Or search for hotels on the City page of Lollum
|Train Stations
Franeker Station
Dronrijp Station
Harlingen Station
Harlingen Haven Station
(1.3 miles)
Tritzum (1.4 miles)
De Grits (1.8 miles)
Tzum (1.8 miles)
Baarderburen (2.1 miles)
Sjungadijk (2.3 miles)
Doijum (2.3 miles)
Grauwe Kat (2.4 miles)
(2.4 miles)
Fatum (2.4 miles)
Hemert (2.4 miles)
Miedum (2.4 miles)
Sopsum (2.7 miles)
Lutjelollum (2.7 miles)
Bonkwerd (2.8 miles)
Het Vliet (3.1 miles)
(3.5 miles)
Kie (3.5 miles)
Burgwerd (3.5 miles)
Lankum (3.5 miles)
Witmarsum (3.6 miles)
't Heechhout (3.6 miles)
Welsrijp (3.6 miles)
Spannum (3.6 miles)
We've negotiated with thousands of hotels to get the very best deals. We call them Secret Deals and they only last for a limited time.
You can get these deals for free by subscribing to our newsletters. You can even choose your favorite destinations to receive personalized deals.
Get started now by entering your email address. We'll instantly send you a link to our Deal Finder!
Don't worry – your email address is safe with us. We'll never share your private information and you can unsubscribe at any time.


text:
Are you currently a subscriber?
Set up your digital access now.
Blackman rolls Ravenwood 47-14 in Round 2
Notgrass, Davidson combine for 5 TDs
1:49 AM, Nov. 16, 2013
Most Viewed
Email this article
Blackman rolls Ravenwood 47-14 in Round 2
The Blackman football team scored 40 first-half points, racked up more than 400 total yards of offense and forced four turnovers on defense en route to its second straight postseason blowout Friday
A link to this page will be included in your message.
View the last seven days
- Yesterday, Nov. 26
- Wednesday, Nov. 25
- Tuesday, Nov. 24
- Monday, Nov. 23
- Sunday, Nov. 22
- Saturday, Nov. 21
- Friday, Nov. 20
See our paid archives for news older than a week.
Real Deals
Flip, shop and save on specials from your favorite retailers in Iowa City, IA 52245GET DEALS NOW
Top Video Picks MORE VIDEO
View the last seven days
- Yesterday, Nov 26
- Wednesday, Nov 25
- Tuesday, Nov 24
- Monday, Nov 23
- Sunday, Nov 22
- Saturday, Nov 21
- Friday, Nov 20
See our paid archives for news older than a week.
Reset your password
Enter your email and we will send you a link to reset your password.
We hope you have enjoyed your complimentary access.
Become a subscriber today to enjoy these benefits:
- Unlimited access to our Web site
- iPad-optimized edition
- Mobile site & iPhone app
You now have full access.
Thank you for subscribing.
- View articles, videos, galleries and more – 24/7
- Access the tablet-optimized site, mobile site and iPhone app
- Share your access with any friend or family member
- Subscriber exclusive Top 5 daily email newsletter
You will automatically receive the press-citizen.com Top 5 daily email newsletter. If you don't want to receive this newsletter, you can change your newsletter selections in your account preferences.
Create an account or if you have a digital profile log in.
Account issue
We're sorry, this account no longer has full access. You can still look at a limited number of articles per month.
Your trial period has expired
Become a subscriber today to continue enjoying all of the products Iowa City Press Citizen has to offer
Flash is required to continue
To continue using your current Web browser, Adobe Flash must be installed or upgraded:Download Adobe Flash Player
Or you can download any of the following supported modern browsers:


text:
Showing Suppliers 1 - 17 of 17
Boston Computers & Peripherals, Inc.
Address: 6 Merchant Street, Unit 3, Sharon, MA
Business Type: Manufacturer, Distributor
cab Technology, Inc.
Address: 87 Progress Avenue, Unit 1, Tyngsboro, MA
Business Type: Manufacturer
Comark Corporation
Address: 93 West Street, Medfield, MA
Business Type: Manufacturer
Continental Resources Test Equipment
Address: 175 Middlesex Turnpike, Suite 1 PO Box 9137, Bedford, MA
Business Type: Distributor, Service
CSPI, Inc.
Address: 43 Manning Road, Billerica, MA
Business Type: Manufacturer
Fotronic Corporation / Test Equipment Depot
Address: 99 Washington Street, Melrose, MA
Business Type: Distributor, Service
Description: The Test Equipment Depot offers the ultimate value in high quality test equipment. Their factory-trained technicians completely refurbish, align, and calibrate all pre-owned equipment to the original manufacturer's specifications. All new equipment shipped from The Test Equipment Depot undergoes a... (more)
Hardware Specialty Co., Inc.
Address: 430 Northboro Rd. Central, Marlborough, MA
Business Type: Distributor
Description: Hardware Specialty Co., Inc is a leading international distributor of commercial & military fasteners, electronic & electro-mechanical components. Since 1932 Hardware Specialty has specialized in managed inventory programs and value-added services, distributing domestically &... (more)
Heilind Electronics, Inc.
Address: 58 Jonspin Road, Wilmington, MA
Business Type: Distributor
Description: GlobalSpec - Profile Preview Heilind Electronics is the largest interconnect distributor in the world with the world's largest inventory of interconnect products. You will find, in stock, products from TE Connectivity, Molex, FCI, 3M, JAE, Panduit, Hirose, LEMO, JST, Amphenol, Belden, Alpha and... (more)
Mercury Computer Systems, Inc.
Address: 201 Riverneck Road, Chelmsford, MA
Business Type: Manufacturer, Service
New England Digital Computers, Inc.
Address: 4 Forms Way, Middleton, MA
Business Type: Distributor, Service
PCs for Everyone
Address: 290 Vanderbilt Avenue, Norwood, MA
Business Type: Distributor
Pickering Interfaces US Inc.
Address: 12 Alfred Street Suite 300, Woburn, MA
Business Type: Manufacturer
Description: Pickering Interfaces is a United Kingdom based company manufacturing advanced switching and instrumentation equipment for the electronics industry. Pickering's products are used worldwide in applications such as automotive, aerospace and defense. Their test & instrumentation products are used in... (more)
Powell Electronics, Inc.
Address: 4 Mount Royal Suite 210, Marlboro, MA
Business Type: Distributor, Service
Description: Your Connection for Knowledge, Inventory, and Service For more than half a century, Powell Electronics has brought a unique sense of purpose and vision to electronics distribution. Right from the start, when Harold Powell founded the company in 1946, their company has been guided by principles... (more)
SIE Computing Solutions, Inc.
Address: 10 Mupac Drive, Brockton, MA
Business Type: Manufacturer
Description: SIE Computing Solutions, Inc. is an innovative leader in system architecture for computing platforms. The Brockton, Massachusetts based company has been engineering solutions for widespread applications with focuses on the military, industrial and telecom industries since 1971. Their solutions are... (more)
SuperLogics, Inc.
Address: 300 Third Avenue, Waltham, MA
Business Type: Distributor
United Electronic Industries, Inc.
Address: 27 Renmar Avenue, Walpole, MA
Business Type: Manufacturer
WIN Enterprises, Inc.
Address: 300 Willow Street South, North Andover, MA
Business Type: Manufacturer, Service


text:
Would you like to be a member of our research panel? Join here - there's (nearly) always a great incentive offered for your views.
Need a hand to hold(30 Posts)
DreamingOfTheMaldives Mon 04-Feb-13 19:25:20
Pocket1 Tue 05-Feb-13 19:34:33
Christelle2207 Tue 05-Feb-13 18:54:24
elvislives2012 Tue 05-Feb-13 17:54:39
phoenixrose314 Tue 05-Feb-13 17:25:41
DreamingOfTheMaldives Tue 05-Feb-13 17:17:45
rcs19 Tue 05-Feb-13 14:53:33
beckie90 Tue 05-Feb-13 14:50:24
MissyMooandherBeaverofSteel Tue 05-Feb-13 13:37:43
browneyesblue Tue 05-Feb-13 12:49:44
Juanca Tue 05-Feb-13 12:09:20
Haylebop12 Tue 05-Feb-13 11:50:36
DreamingOfTheMaldives Tue 05-Feb-13 11:48:54
browneyesblue Tue 05-Feb-13 10:26:20
Haylebop12 Tue 05-Feb-13 09:47:37
DreamingOfTheMaldives Tue 05-Feb-13 07:36:14
babyradio Tue 05-Feb-13 01:02:24
beckie90 Mon 04-Feb-13 22:57:16
phoenixrose314 Mon 04-Feb-13 22:51:21
DreamingOfTheMaldives Mon 04-Feb-13 20:20:56
browneyesblue Mon 04-Feb-13 19:42:18
lovemybabyboy Mon 04-Feb-13 19:36:13
DreamingOfTheMaldives Mon 04-Feb-13 19:35:49
rcs19 Mon 04-Feb-13 19:32:08
DreamingOfTheMaldives Mon 04-Feb-13 19:31:26
Join the discussion
Registering is free, easy, and means you can join in the discussion, get discounts, win prizes and lots more.Register now
Already registered with Mumsnet? Log in to leave your comment or alternatively, sign in with Facebook or Google.
Talk: Customise | Unanswered messages | Getting started | Acronyms | FAQs
Threads: Active | I'm on | I'm watching | I started | Last 15 minutes | Last hour | Last Day
Please login first.


text:
Add to Favorite List:
Create a new folder:
Next »
Hot tranny sex scene
Recognize a pornstar in this video?
Help make pornstars easier to find on Tube8 by telling us who is in this video.
Thanks! The pornstar names will be added to this video when enough users submit the same names.
You must enter a pornstar name that already exists in our database.
- Category: Hardcore
- Views: 78,632
- Added: 5 years ago
- Description: Adorable tranny giving a deepthroat blowjob while jerking her own cock on bed
- Tags: suzie, tranny, sucking, deepthroat, tran, big-tits
- Pornstars: Add Pornstar
- Favorite by: 13
- Featured: 4 years ago
- Report This Video
Video Comments
All Video Comments (0)
AdBlock blows! Please disable the add-on to ensure you get the most out of Tube8's features and functionality. Read about why you shouldn't use AdBlock. Close