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Best of
the Twin Cities
Abstaining from booze shouldn't mean settling for ice water or fountain pop. At Eat Street Social, bartenders mix craft sodas with the same care that's taken with the alcoholic side of the menu. With ingredients like cherry bark vanilla bitters and molasses, each drink has a balance of flavors that makes it taste more like a cocktail than a Coke. There's even a house version of a Shirley Temple concocted with a sophisticated blend of pomegranate, peppercorn, and thyme.


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« Virtual Preschool: Yes, That's Now a Real Option | Main | Teachers, Developers, Researchers Quickly Evaluate Ed Tech in N.Y.C. »
Obama Budget Calls for Reviving Federal Ed-Tech Program
By guest blogger Sean Cavanagh
Roughly four years after he joined Congress in eliminating the Enhancing Education Through Technology program, President Obama is proposing its rebirth—in modified form.
The EETT program was jettisoned in 2010, but the administration's new budget proposal, unveiled Monday, calls for recreating with $200 million as a vehicle for using competitive grants awarded by states to create "model districts" at the local level.
The plan would also help states build the capacity of school districts to use technology to improve instruction, and support the hiring of state officials who would demand "evidence-based" practices in technology, according to a description posted on the U.S. Department of Education's website.
Local school districts that receive grants would need to have basic technology, including an unspecified minimum computer-to-student ratio and level of Internet speed, in addition to committing to following evidence-based standards.
In its description of the proposal, the Obama administration said that "based on the department's experience" running the previous EETT program, the administration will press for several changes to how it distributes funding, including the awarding of competitive grants by states, the promotion of practices grounded in research, and limits on local spending on hardware.
The Consortium for School Networking, a Washington organization representing K-12 technology officials, described Obama's proposal as "an important first step" that would complement the recent efforts by the Federal Communications Commission to devote billions in new E-rate funding to school broadband technology, among other steps. (President Obama backed the FCC's overhaul.)
The new money would "give educators and district technology leaders the ability to share ideas and discover and implement proven practices to use digital tools to improve educational experiences," the consortium said in a statement.
"We hope Congress and the administration will lock arms and secure this critical investment for the nation's students and teachers."
The Education Department's online blueprint for the proposal points to recent surveys of classroom educators who said they see great potential for technology to help students—yet it notes that many teachers are frustrated at not receiving the training they need to make it happen.
A third of teachers surveyed said the biggest barrier they face to using technology in the classroom is the need for greater professional development, and only 8 percent of classroom teachers described themselves as "self-sufficient" in using professional development to improve their skills, according to the department.
The administration argues that its proposal would meet those needs by giving teachers new access to tech training and tools, helping them use timely data to "personalize" learning, encouraging them to forge connections with families and other teachers through technology, and giving them access to coaching from peer educators.
At one point, spending on the EETT program was as high as $700 million annually. Here's a breakdown, below, of its funding levels in the years before it was eliminated:
Doug Levin, the executive director of the State Educational Technology Directors Association, a Glen Burnie, Md.-based organization, said the proposal is likely to be greeted with enthusiasm by supporters of ed-tech in schools, even if its political prospects are uncertain, at best.
Congressional Republicans have shown little appetite for increasing funding for domestic programs, he noted. And some of the EETT's champions, such as former U.S. Rep. George Miller, a Democratic lawmaker who was heavily involved in education issues, have left Capitol Hill.
"In this environment, it's starting with two strikes against it," Levin said.
Levin said that in its previous life, the EETT program had been a vehicle for addressing inequities in ed-tech, and he hoped it could still serve that function. The new proposal seemed designed to "scale best practices and get around some thorny issues," in teacher training and other areas, he pointed out.
Even so, "it's hard not to be encouraged that the department is once again interested in partnering with states on creating structural supports for the best uses of technology," Levin said.
Today, districts face complex and potentially costly questions about how to implement technology, he added, and "individual schools and teachers should not have to figure this out on their own."
See also:
- E-Rate Undergoing Major Policy, Budget Upgrades
- Teacher Colleges Seek to Shift to Digital Age
- Superintendents, Principals, Move to Conquer Tech Weaknesses
- Ed-Tech Advocates Look to Life After Federal Budget Cut
Follow @EdWeekSCavanagh and @EdWeekIandI for the latest news on industry and innovation in education.

subset: commoncrawl


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If you suffer from TMJ disorder, the pain and discomfort can be overwhelming. If your bite is misaligned, you may also be doing irreversible damage to your teeth and jaw.
You need a solution. But many TMJ treatments available today merely mask symptoms without addressing the underlying causes of your pain.
If you've tried everything but the pain persists, neuromuscular dentistry is your best option for a long-term solution with proven results.
What is neuromuscular dentistry? We get this question all the time, so we've put together this post on what it is, what makes it different, and how to tell if it's the right option for you.
What is neuromuscular dentistry?
Neuromuscular dentistry is a non-invasive technique that focuses on correcting the origin of your TMJ problems, instead of merely treating the symptoms to relieve pain.
Neuromuscular dentists understand that a bad bite and poor posture can cause persistent pain and dysfunction. So they work to find the optimal bite for your teeth, bones, muscles, and tendons. The end result? A corrected bite that reduces or eliminates TMJ pain and tooth damage.
How does neuromuscular dentistry work?
First, your dentist will gather data about your bite pattern. They will observe your TMJ signs and symptoms, and take radiographs of your teeth and jaw.
Your dentist will use this information to develop a specialized treatment plan to realign your bite and shift your teeth to their optimal location. By evaluating how your jaw, teeth, muscles, and tendons fit together, a neuromuscular dentist can find the jaw position that is best for your whole mouth.
Why do neuromuscular dentists work together with other specialists?
Your body is made up of interconnected parts and body systems. Neuromuscular dentists recognize this and may work with a number of other specialists to find the jaw position that is best for your whole body.
These specialists may include:
- Ear, Nose, and Throat (ENT) Specialist – Ear pain is a common symptom of TMJ because the temporomandibular joint is located so close to the so close to the middle ear and ear canal. If you suffer from sinus trouble that does not seem related to the TMJ, your dentist may also refer you to an ENT specialist.
- Physical Therapist – If you suffer from TMJ Disorder, you may also have built-up tension in your face, neck, and shoulders that exacerbates your symptoms. Physical therapy can improve your jaw function and posture, decreasing tension in these areas.
- Chiropractor – If your TMJ pain is related to spinal issues, a chiropractor may help you alleviate related pain and discomfort.
- Cognitive Behavioral Therapist – If you suffer from anxiety, this may be helpful for you because anxiety is known to contribute to TMJ and bruxism (teeth grinding). TMJ can also contribute to anxiety and depression if left untreated.
I'm looking for a TMJ specialist. What qualifications should I look for?
Here are 3 signs of a good TMJ specialist.
- Commitment to Continuing Education: Dentists are learning new things about TMJ every day. So, it's important to find a TMJ specialist with a commitment to continuing education. Look for a dentist who has received specialized TMJ training at an organization like the prestigious Las Vegas Institute (LVI).
- Neuromuscular Approach: "When traditional approaches to treating TMJ Disorders are not able to resolve your symptoms, you may need the help of a neuromuscular dentist," says Dr. Chad Boger, DDS. "Neuromuscular dentistry uses reliable methods to find a balanced physiologic bite. This supports the harmony of your muscles, joints, and teeth, reduces tooth damage, and enables you to open and close comfortably."
- Use of Modern Technology: You need a dentist that makes use of recent advances in technology to get an even more precise, accurate picture of your jaw function. Ask your dentist if they use technology like CT scans and K7 systems to evaluate your jaw and find its optimal position.
Is neuromuscular dentistry right for me?
Neuromuscular dentistry offers a long-term solution to eliminate headaches, jaw pain, and other issues associated with TMJ. If you suffer from TMJ, neuromuscular dentistry may be the solution you need to fix your bite and start living again.


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Migratory birds are unlikely to infect humans or poultry in U.S. with deadly avian flu, say Cornell bird experts
By Krishna Ramanujan |
For the virulent H5N1 strain of avian flu to establish itself on U.S. soil via wild birds, a string of events must come together, none of which can be predicted, according to experts at Cornell's Lab of Ornithology.
They are part of a new avian influenza task force at the lab, intent on understanding, tracking and relaying accurate information to the public about avian influenzas.
While infection by the H5N1 strain of flu is rare in humans, it quickly kills half of those infected. In poultry, the highly pathogenic virus can be extremely deadly, killing more than 90 percent of infected birds within 48 hours. But many wild birds, especially certain waterfowl, can carry the deadly virus in their intestines with few symptoms.
Experts believe wild birds from Asia -- where the disease is widespread among free-flying birds and where the majority of the more than 100 human deaths globally have occurred -- will bring the highly pathogenic H5N1 to the United States, possibly this year. Still, nobody knows which species of birds are capable of flying thousands of miles across the ocean after contracting the disease. Right now, a government task force has its eye on Alaska, where about 30 species of migratory birds, including Arctic warblers and yellow wagtails, will breed this spring after wintering in Asia. The government's task force plans to sample thousands of birds for H5N1 as part of an early detection program.
It is highly unlikely, lab experts say, that a bird would fly from Asia to Alaska and then to the lower 48 states. The fear, however, is that later this summer an infected bird from Asia could mingle with birds from the lower 48 states and Central and South America that also breed in Alaska, like snow geese, common eiders and tundra swans. If that were to occur, a bird could return to the lower 48 states with the deadly virus and hypothetically infect other birds.
But even if the virus did arrive, the chance of wild birds infecting people (who rarely contract the disease in its present form) or poultry (protected by very stringent industry standards and lack of contact with wild birds) is slim.
"If avian flu were to show up in U.S. poultry, migratory birds are probably the least likely source of infection," said Ken Rosenberg, director of conservation science at the Cornell Lab of Ornithology.
"It's a whole lot easier to see someone smuggling an infected gamecock or parrot into the U.S. through Mexico or Canada," added Kevin McGowan, a research associate at the lab, noting that all birds that are sold are regularly exposed to other birds from all over the world in both illegal and legal bird markets.
The Cornell ornithologists, however, point out that bird migration routes are "leaky" -- they are broad pathways rather than narrow streets, and birds regularly get lost. Birds from Asia that breed in Alaska could be found elsewhere, such as along the U.S. Pacific coast. But even if an infected bird landed in the lower 48 states, the poultry industry is probably safe.
"At present there are still no thoroughly documented records of wild birds infecting domestic poultry or humans anywhere," said McGowan.
Highly pathogenic H5N1 appears to have mostly spread in Asia through unregulated movement, trade and handling of infected poultry.
While the researchers are less concerned about avian flu impacting humans or domestic poultry, they point out that the virulence of the highly pathogenic H5N1 creates a real danger to threatened or endangered bird species. Whooping cranes and such species related to poultry as prairie chickens, grouse and quail are all in trouble and could be some of the most susceptible species to the highly pathogenic avian flu.


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RehabWire - Volume 8, Number 1, February 2006.
Assistive Technology Outcomes
NIDRR Grantees on the Cutting Edge.
Advancing Assistive Technology Outcomes
Duke University (H133A010401) led by Frank DeRuyter, PhD. Carol Cohen, Project Officer.
Abstract: This program advances the field of AT outcomes measurement. Research activities include: (1) performing a critical analysis of existing approaches to measurement and further developing instruments that are promising; (2) identifying unmet needs and assessing barriers to AT outcomes measurement; and (3) undertaking a prospective longitudinal study of factors associated with assistive device adoption, use, and discontinuance. Development activities include: (1) developing and evaluating independent electronic data collection or computer-assisted systems for the capture, analysis, and interpretation of AT outcomes information; (2) developing and evaluating improved methods and systems for communication of outcomes information among significant stakeholders; (3) automatic log file performance data-capturing for AT outcomes assessment; and (4) development of new or improved AT outcomes tools.
Find out more at: www.AToutcomes.com.
ATOMS Project: Assistive Technology Outcomes Measurement System
University of Wisconsin/Milwaukee (H133A010403) led by Roger O. Smith, PhD. Carol Cohen, Project Officer.
Abstract: The ATOMS Project (Assistive Technology Outcomes Measurement System) targets the definition and pre-development phases of a next-generation AT outcomes measurement system. A comprehensive needs assessment, prototype instrument development, and consensus building activities frame an integrated set of research and development activities to address urgent needs to identify components of a future AT outcomes measurement system. In addition, these activities generate information about the relationships of AT outcomes factors that produce a better understanding of AT use and abandonment.
Find out more at: www.atoms.uwm.edu
Assistive Technology and Cognitive Disabilities
University of Akron (H133A030810) led by Roberta DePompei, PhD. Bonnie Gracer, Project Officer.
Abstract: This project assesses the use of several types of information technologies by children and adults with cognitive disabilities, specifically individuals with TBI and mental retardation. Outcomes include: (1) a catalog of existing portable devices for memory and organization (2) a list of features that enhance or inhibit use of these general purpose and special-use technologies, (3) results of needs surveys regarding use of these technologies, (4) white papers describing project findings, (5) tip cards to assist families in purchasing devices, (6) stronger partnerships between the consumer and research and development communities, and (7) recommendations for memory and organization device modifications and features for individuals with brain injury and mental retardation. The Brain Injury Association, Inc. leads and administers this collaborative partnership, which includes the Traumatic Brain Injury Model Systems Projects at Moss Rehabilitation Research Institute and Spaulding Rehabilitation Hospital, the Institute on Disabilities/Center for Excellence on Developmental Disabilities at Temple University, and the University of Akron.
Find out more at: www.uakron.edu/colleges/faa/depts/sslpa/faculty/Depompei.php
Development of an Assistive Technology Outcomes Measurement System Utilizing the International Classification of Functioning (ICIDH-2/ICF)
University of Colorado Health Sciences Center (H133G030187) led by Cathy Bodine. David W. Keer, Project Officer.
Abstract: This project furthers the development of a secure, Health Insurance Privacy and Accountability Act of 1996 (HIPAA) compliant, multi-site, web-based assistive technology (AT) outcomes system designed to capture data that enables the measurement of the impact of AT devices and services for children and adults with disabilities. The project results in the design and development of a working prototype complete with instructional support for users. The project is designed for easy addition of data fields to support the ever-evolving schema for outcomes assessment in AT. The use of the International Classification of Functioning, Disability and Health (ICIDH-2/ICF) as the framework for development builds on initial pilot work already completed by faculty of Assistive Technology Partners, University of Colorado Health Sciences Center, and collaboration with two NIDRR funded national projects focused on AT outcomes development (ATOMS/CATOR). Information gained leads to maximizing the full inclusion and integration into society, employment, independent living, family support, and economic and social self-sufficiency of individuals with disabilities, especially individuals with the most severe disabilities; and will lead to improved information and research on the effectiveness of AT devices and evidence-based practices.
Find out more at: www.uchsc.edu/atp
Please note: These abstracts have been modified. Full, unedited abstracts, as well as any available REHABDATA citations, are available at naric.com.
|For January, RehabWire focuses on assistive technology (AT) outcomes. How are centers evaluating AT assessment, usage, and abandonment?
For your calendar
CSUN 21st Annual Conference on Technology and Disability
March 20-25
Los Angeles, CA
NARIC will be exhibiting at CSUN along with fellow KT project ABLEDATA.
New Research: Selections from REHABDATA
Schwanke, T., Smith, R. (2005) Assistive technology outcomes in work settings. Work: A Journal of Prevention, Assessment, and Rehabilitation, 24(2), 195-204. NARIC Accession Number: J48749. Project Number: H133A010403.
Abstract: Article describes efforts to identify existing data that might be used to develop a system for measuring AT outcomes in the workplace. Researchers evaluated sample records from five AT service programs. Analysis revealed that generally, AT service programs fail to collect consistent or sufficient data for outcome analysis, but the AT programs that serviced state vocational rehabilitation agencies interacted with a larger data collection and management system. Combining the data from these two diverse systems could provide information on a range of AT outcomes. Legal and ethical issues related to the linkage of the two existing databases are discussed.
Lenker, J., Scherer, M. (2005) Psychometric and administrative properties of measures used in assistive technology device outcomes research. Assistive Technology, 17(1), 7-22. NARIC Accession Number: J49454. Project Number: H133A010401.
Abstract: Article summarizes the evaluation of 82 outcome studies published between 1980 and 2001 involving AT devices (ATDs). Three principle characteristics were examined: the composition of sample populations, the outcome domains that were measured, and the reported psychometric and administrative properties of the measurement instruments that were used. Findings indicated that the "typical" ATD outcomes study: (1) used a sample population that was diverse in terms of age, disability population, and type of ATD being used; (2) measured user-reported dependent variables with instruments designed specifically for the study; and (3) did not report the psychometric or administrative properties of the measurement tools used. Recommendations are offered to researchers, policymakers, journal editors, and reviewers in order to improve the reporting of ATD outcomes research.
Rust, K., Smith, R. (2005) Assistive technology in the measurement of rehabilitation and health outcomes: A review and analysis of instruments. American Journal of Physical Medicine and Rehabilitation, 84(10), 780-793. NARIC Accession Number: J49728. Project Number: H133A010403.
Abstract: Study examined how AT is treated in the scoring process of selected health and rehabilitation outcomes assessment instruments. Review of 100 instruments revealed that: (1) 30 percent of the instruments did not mention AT in their scoring procedures; (2) when instrument included AT, 44 percent of the instruments lowered the functional outcome score; (3) 22 percent of the instruments allowed AT to raise the outcome score, but did not differentiate among types of device used; and (4) 4 percent of the instruments provided a mix. The findings indicate that rehabilitation and health outcome instruments inconsistently consider AT as an intervention for people with disabilities, which leads to potentially invalid assessments of rehabilitation outcomes.
Schwanke, T., Smith, R. (2004) Introduction to assistive technology data in the RSA-911 case service report for application to assistive technology outcomes measurement. In D. Anson (Ed.), Proceedings of the RESNA 27th International Conference: Technology and Disability: Research, Design, Practice and Policy. Arlington, VA: RESNA Press. NARIC Accession Number: O15739. Project Number: H133A010403.
Abstract: Paper provides an overview of the ATOMS (Assistive Technology Outcomes Measurement System) Project, the Case Service Report (RSA-911), and the AT outcomes-related data it contains. The Rehabilitation Services Administration (RSA) collects the data for RSA-911, which is a compilation of data submitted annually by state vocational rehabilitation agencies that reports all case closures during a given fiscal year. The data set's content, including specific AT fields, national coverage, and uniformity make it a valuable resource for AT outcomes studies.
Also from the RESNA 27th International conference:
Bodine, C., Van Straaten, M. (2004) Development of an assistive technology outcomes measurement system utilizing the international classification of functioning (ICIDH-2/ICF). NARIC Accession Number: O15779. Project Number: H133E030187.
Abstract: Article provides an update on the progress and the future directions for the development of a multi-site, online AT outcomes system to measure the impact of AT devices and services for people with disabilities. The International Classification of Functioning, Disability and Health is used as the framework for development of the system.
Mendelsohn, S. Smith, R. (2004) Technical report - Town hall meeting on legal issues involved in measuring assistive technology outcomes (version 1.0). NARIC Accession Number: O16137. Project Number: H133A010403.
Abstract: Report summarizes a meeting convened to discuss legal and ethical issues relevant to assistive technology outcome measurement and research. Twenty-seven questions were posed, and the backgrounds to them discussed, in the following seven subject areas: (1) the context of research, (2) cost benefit and cost effectiveness, (3) leveling the playing field, (4) definitions of disability, (5) privacy, (6) mitigating measures, and (7) the marketplace.
Taugher, M. (2004) Focus groups on assistive technology use and outcomes: A consumer perspective. NARIC Accession Number: O16139. Project Number: H133A010403.
Abstract: Report presents results from focus groups that examined the perceived outcomes of using AT by the consumers of the technology. Participants included groups of university students, vocational rehabilitation clients, and adults receiving outpatient rehabilitation. The data from all three groups indicated that the consumers' understanding of "outcomes" is very different from that held by service providers or researchers. Group members focused on the AT devices themselves, not outcomes or effectiveness of the devices.
Smith, R. Rust, K. (2005) Technical report - History of assistive technology outcomes (version 1.0). NARIC Accession Number: O16140. Project Number: H133A010403.
Abstract: Report describes a study conducted to place assistive technology (AT) outcome measurement in the context of time. The field scan reviewed the literature from the last 30 years and summarized major events related to AT and AT outcomes. The resulting chronology includes years, description, significance, and references.
Where Can I Find More? A quick keyword search is all you need to connect to a wealth of disability and rehabilitation research. NARIC's databases hold more than 75,000 resources. Visit www.naric.com/research to search for literature, current and past research projects, and organizations and agencies in the US and abroad.
Additional Resources
- AT Outcomes and Benefits Journal is available online at www.atia.org/atob/ATOBWeb/index.htm
- A new AT Listserve is now available from RESNA. Email email@example.com with SUBSCRIBE AT-FORUM firstname lastname (i.e., John Smith) in the body.
- Proceedings from RESNA's annual conference are available in the Publications section at resna.org


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A great way to surprise someone who loves to write.
Now everyone can have a gift for writing, with a voucher from the Australian Writers' Centre!
Available in a range of values (see below), these vouchers make the perfect gift for anyone in your life who loves to write.
How do I purchase a gift voucher?
We thought you'd never ask! You can purchase a gift voucher for one of the dollar amounts listed below. Or, if you're looking for a different amount or want to discuss a specific course voucher, call our team on 02 9929 0088.
Choose a voucher value below to begin:
Once you've placed your order, you'll immediately receive your digital gift voucher in your inbox. Vouchers are valid for three years from the date of purchase and are not exchangeable for cash.


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Staff Directory
Seattle Historical Sites
New Search
Summary for 1930 BOYER AVE / Parcel ID 8722101005 / Inv # 0
Historic Name:
Walker Residence
Common Name:
48 Friedman Residence
Built By:
Year Built:
This residence is a good and generally intact example of the Colonial Bungalow style. It is associated with early 20th century development in the Montlake area and is a contributing resource to the Montlake NRHP Historic District. The earliest known owners, in 1928, were Frederick E. & Beryl Walker in 1928. He was a salesman for J.A. Campbell Co. in 1938, bookkeeper Lucille McIntyre owned the house. In the 1940s, Mary E. Knapp, a clerk for the Veterans Administration Finance Division, owned the house. By 1958, Hugh A. & Mae Littlejohn in owned the home. He worked as a warehouseman for Savage Lumber & Manufacturing.
Montlake is generally described as extending from the Washington Park Arboretum west to Portage Bay/15th Avenue E., and from the Montlake Cut on the north to Interlaken Park. The area is a significant and cohesive collection of residential architecture typical of early 20th century Seattle and is eligible as a NRHP historic district under Criterion C. Construction occurred primarily between 1910 and 1940, with a variety of Craftsman and revival styles ranging from modest cottages and builder's houses to high-style architect-designed residences, impressive institutional buildings, and notable parks and natural features. There are few intrusions of newer buildings. In the early 1960s, construction of SR 520 and the unfinished R.H. Thomson Expressway bisected Montlake, but the neighborhood retains its basic integrity as a pre-World War II Seattle neighborhood.
Montlake was incorporated into the City of Seattle in 1891. Although the first plats (Union City 1st and 2nd additions) were filed by Harvey Pike in 1869-1871, development did not really begin until plats were filed by John Boyer (Interlaken, 1905) and H. S. Turner (1907). Montlake Park (north of SR 520) was platted in 1909 by the developers James Corner and Calvin and William Hagan. With the 1909 Alaska-Yukon-Pacific Exposition came a streetcar line on 24th Avenue E. and an impetus for development. In 1916, the Lake Washington Ship Canal was completed and the Montlake Bridge linked the neighborhood to the university area in 1925. A small commercial district grew along the car line.
The 1903 Olmsted Parks and Boulevards Plan of 1903 surrounded Montlake with parks. Montlake Boulevard (then call University Boulevard) connected Lake Washington Boulevard to the A-Y-P grounds. Washington Park, the eastern boundary, was acquired by the City in 1900 and developed as an arboretum in 1936-41. At the southern edge is steep, forested Interlaken Park and boulevard.
By 1915, the neighborhood had developed enough to require a temporary school building; the permanent structure opened in 1924.Soon afterwards came a playfield and shelter house (1933-36) and a library (1944, replaced 2006). Other noteworthy structures include the Seattle Yacht Club (1920), the NOAA Northwest Fisheries Center (1931), the Museum of History and Industry (1952) and St. Demetrios Greek Orthodox Church (1962).
Major Bibliographic References:
King County Tax Assessor Records, 1937-2014.
Becker, Paula. Seattle Neighborhoods: Montlake--Thumbnail History. HistoryLink File # 10170, accessed 12/2/2013.
Gould, James W. Montlake History. http://www.scn.org/neighbors/montlake/mcc_history.Jim_Gould.html
Smith, Eugene. Montlake: An Urban Eden, A History of the Montlake Community in Seattle. La Grande OR: Oak Street Press, 2004.
This 1-1/2 story house is rectangular in plan, is clapboard clad, and has a side gabled roof with returned eaves and two peaked eyebrow dormers with fanlights. The front (south) façade includes a centrally placed entry vestibule, which is sheltered by an arched pediment roof with returned eaves, supported by rounded piers. Windows on the first story include bands of four single-light casement sash, which are not original to the house. Secondary facades have similar materials with many original double-hung wood sash. There are two brick chimneys, one interior and one exterior.
Detail for 1930 BOYER AVE / Parcel ID 8722101005 / Inv # 0
District Status:
Wood - Clapboard
Concrete - Poured
Roof Type(s):
Roof Material(s):
Building Type:
Domestic - Single Family
Structural System:
Balloon Frame/Platform Frame
No. of Stories:
one & ½
Unit Theme(s):
Architecture/Landscape Architecture
Changes to Plan
Changes to Original Cladding
Changes to Windows
Major Bibliographic References
King County Assessor Property Characteristics Report, database at http://www5.metrokc.gov/ --parcel locator
Photo collection for 1930 BOYER AVE / Parcel ID 8722101005 / Inv # 0
Photo taken Jan 31, 2015
© Copyright 1995-2015
City of Seattle
Privacy and Security Policy
App v


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The new range of KBF99 products brings a revolution to Horse Health Care. KBF99 products will assist in the prevention of infection and reinfection of these troublesome and painful diseases. KBF99 has been tested by Coventry University using the standard test for Anti Microbial Activity. Laboratory tests resulted in KBF99 material killing 99% of the bacteria test culture. Any reduction of harmful bacteria and fungus in the stable environment assists in reducing the chances of the diseases being transmitted from horse to horse. The KBF99 product range has been developed to help protect and safeguard horses and in some cases humans from contracting these and other conditions.
Take the 4 week challenge, Brush your horse every day for 4 weeks and if after 4 weeks there is no visible change in your Horse's coat you will receive a 100% money back Guarantee. Remember to take a photo before and after.


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Law-making officials and experts hoped the Internet would play an increasingly important role in boosting the democratic element of the country's legislation.
As China boasts more than 100 million web surfers, the Internet has provided unprecedented scope for expressing different points of view on laws that concern personal rights.
The law covering property rights is being mapped out to regulate practices that affect the interests of almost everyone.
The draft law, with five chapters and 268 articles, had been under discussion three times by National People's Congress Standing Committee members by the end of June.
The top legislature decided to release a complete version of the draft law to encourage suggestions for revisions last month.
Citizens are urged to offer their opinions on the draft law before August 20.
By July 26, the Commission of Legislative Affairs had received 6,515 responses, according to Yang Minglun, an official at the commission.
He said the majority of submissions were made over the Internet, with just 384 in physical written form.


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The holidays are behind us now and everyone is making their New Years resolutions. Truth be told, I generally never make a bold statement of resolution. I pretty much feel that you should be resolving every day of your life to do better, live well and be happy. I have a little quote on my Facebook page that I saw many years ago that says "Life is not measure in the number of breaths we take, but by the number of moments that take our breath away." Living each day to the fullest and as healthy as possible is pretty key to my happiness.
Last week there was an article in the paper by Linda Lombrosco titled Jump-start January with juicing. I have been thinking about buying a juicer for a few months and reading the article gave me the final nudge I needed. After a little research on machines and consulting with my juicing-goddess friend Sandi Benz in California, I had a plan. Armed with my 20% off coupon I headed to Bed Bath and Beyond to pick up the Breville.
First let me say that the footprint of this model is on the larger size. So unless you have space on your counter be prepared to pull it in and out of the cabinet or closet. After a little countertop reorganizing I said adios to my molcajete and sent it packing to the pantry.
There are basically six removable pieces to the machine, seven if you count the little brush. By the looks of it you would think it to take a long time to clean, but it comes apart in a snap and cleans up in less than 5 minutes.
The first thing you notice when you juice is all the pulp left behind in the grey container. The chef in me was thinking "what a shame to throw that out." Apparently not the case. That can be used to flavor stocks and sauces – but more research on my part will be needed for that! What you do get is a clean crisp and delicious juice, filled with tons of vitamins and nutrients.
More after the jump ….
But the whole pulp-left-behind idea was weighing on me, so I decided to seek out some advice from a couple of friends. First I called a fellow chef who I met on the Farmers Market circuit last year, Marti Wolfson, a New York City based natural food educator. We talked at length about the upside to juicing and how it's a great way to get a whole variety of fruit and vegetable nutrient and vitamins compacted in one glass. "Juicing is a great way to give your body a break and calm down your digestive system," Marti explained, "but it should not be an all or nothing proposition."
So what is the downside? Sadly, there some in life! Aside from the fiber that is left behind, you could experience a spike in your glucose level. What is coming out of the juicer is natural, but sugar non-the-less. Common sense would tell me that my body needs a compliment of both vitamins, nutrients and fiber. Let's face it, fiber is what "moves" the toxins out of our body.
On another call with my friend Kathy McArdle, Administrator of the Sarah Neuman Center and Registered Dietician, we talked at length about the virtues of eating a well rounded diet which includes fat, protein, vitamins, nutrients and fiber. The key Kathy explained is "portion control."
So where does that leave me and my new juicer? The creativity of it all knows no bounds in my mind. In just the few days of having it I've made 4 different concoctions that both Larry and I really enjoyed. Topping the list was a juice made with 1 starfruit, 2 granny smith apples and a couple of slivers of lemon. It was bright, tangy and sweet.
My second favorite, was a little surprising: a pear and parsnip combo. That was actually in the booklet that came with the machine. I love pear juice and the parsnip added a very interesting dimension to the flavor.
One last important bit of information I read on numerous health sites including the Mayo Clinic, was to take care to drink your creations pretty quickly, or at the very least within 24 hours. Light and air will immediately begin to affect the quality of the juice and potentially harmful bacteria will follow. No sense in getting sick when you are trying to be healthy, right? That said, I have the perfect container for my juice, and to remind me of our girl living so far away! Yes, it will be in the 'fridge, but probably never more than 8 hours. My goal is to juice at night so we have something fresh to drink in the morning.
I'd love to hear your thoughts on juicing and if you have any special recipes for me to try. Below is one that was sent to me by former Small Bites blogger JL Fields. It's bright, zippy and herbaceous.
Buon Appetito!
- 1 Granny Smith apple
- 5 leaves of romaine lettuce
- 3 stalks of celery
- 1/2 of a fennel bulb
- 1/2 of an English cucumber, peeled
- 4 kale stems, hard stem part removed
- 1" piece of ginger, peeled
- 1/2 small lime, peeled
- Process all in a juicer. Serve immediately.
Seasonal Chef blogger Maria Reina comes to the world of food as a third career, spending a great portion of her adult life in the field of Human Resources. With her private company Bella Cucina Maria she is a personal chef, caterer and recreational cooking class teacher in Westchester. She's an avid food television watcher and cookbook collector, always looking for a new take on a traditional dish. In her free time she loves hanging out at local farmers, chatting it up with the farmers and doing cooking demos with their seasonal ingredients. In addition to her blog, which is loaded with easy recipes, you can follow her on Facebook, Twitter and Pinterest.


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Microsoft's Bing
decision engine search engine stomached an 8 per cent drop in all-important first-page advertisers during the third quarter, according to the latest report from search research outfit AdGooRoo.
First-page ads are those that turn up on the first results page after a keyword search.
Due out tomorrow - prior to the release of quarterly earnings results from Google, Yahoo!, and Microsoft - the report also says that's Google share of search advertisers has reached a near all-time high of 81.2 per cent. All this, and we're just 18 weeks away from Bing's much-hyped debut.
According to AdGooRoo - a search marketing consultant that tracks search ads from a network of servers across the globe - Bing delivers better conversion rates than Google (as does Yahoo!). And you could argue that Bing is the better organic search engine. But Google provides the reach - and that's what advertisers prefer.
"Google has become the premium supplier of high-volume search traffic," AdGooRoo's Q3 reports reads. "Despite having lower conversion rates on whole than either Yahoo! or Bing, it drives far higher volume and a very respectable ROI, making it an excellent choice for established brand advertisers."
In other words, it repeats the obvious.
And this is why Microsoft and Yahoo! are so keen on tying the search knot. The two finally signed a long-awaited search deal in July, but it still requires approval from regulators.
"Classical marketing strategy suggests that this is a reasonable equilibrium point for a mature market," the AdGooRoo report continues. "Google is unlikely to lose their lead, while Bing will need to spend exorbitant sums to gain (or even maintain) market share, a precarious situation at best. In this light, a Bing-Yahoo! partnership is a sound decision."
Whereas Google controls 81.2 per cent of search advertisers, Microsoft and Yahoo! are limited to 12.8 per cent and 26.0 per cent, respectively (some, of course, advertise on more than one). And whereas Google continued to pick up big-name brand advertisers during the quarter, Bing's biggest additions were comparison shopping engines from the likes of Nextag, k8yel.com, bestcompare.net, shopwhiz.net, and underpay.biz. "Many of the top advertisers appear to be rebranded variations of the same site, suggesting that Bing is being used as an inexpensive marketing sandbox."
AdGooRoo's report also indicates that the number of ads Google shows per keyword continues to climb - as it has done throughout the economic meltdown of the past year. When Google announces its Q3 numbers on Thursday, you can expect the usual epic sums of ad cash. ®


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Advertising, album, Amanda St John, Announcement, BBC, BBC Radio Ulster, Blues, Brighton, Eastbourne, Grow, iTunes, Jazz, Kate Bush, Live Music, London, Milton Keynes, Music, News, PR, Radio, Rigsy, Running Up That Hill, Soul, The Green Note, The Latest Bar, The Stables, The Underground, Tour, UK Mainland, You Blew It
Amanda St John was invited into the BBC Radio Uluster studio last Friday, 19th May to play a couple of songs and also talk about her upcoming UK Mainland Tour.
First song she played live was "You Blew It" from her album "Grow" and a fantastic cover of Kate Bush's "Running Up That Hill".
(1hr 10mins)
Amanda's tour information can be found on her website and her facebook page.
Website – https://www.amandastjohnmusic.co.uk/
Facebook – https://www.facebook.com/amandastjohnmusic
Twitter – https://twitter.com/amandastjohn_
YouTube – https://www.youtube.com/user/BeatnTrackMusic
Buy the album "Grow" here:
And from her website:
For more information contact Ellis on firstname.lastname@example.com or call 07813 984517


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Passione Duo in Deruta: Maiolica and Farm-cooking Goodness
Now over eighty, Raffaello started painting his maiolica masterpieces as a young boy. Massimo started young on the potter's wheel, too, creating the vases, pitchers, urns Raffaello still decorates.
At a young age, too, Giuseppa learned to make homemade tagliatelle: another sort of art. She still does at her farm just outside of Deruta.
Each carries on their respective arts with the same motivating force: passione.
A visit to Deruta is an immersion in passione, evident as soon as you enter the town: in this Umbrian village, everyone lives – directly or indirectly – from maiolica. Storefronts on both sides of the main street leading up to the medieval center are filled with maiolica wonders and here and there, some shops display terracotta objects for gardens. Larger buildings hold the kilns used in maiolica or terracotta production and they are related to each other: terracotta is a clay object of a single firing, maiolica is a twice-fired (with decorative painting before the second firing) wonder.
The centro storico of Deruta is small and unassuming but with maiolica gems scattered here and there and not just in the shops: the bakery, city hall, and the police office have maiolica signs and a reproduction of the lost maiolica-tiled floor of the 14th-century San Francesco church is reproduced on a wall.
Outside of the town, giant vases signal the entrance to maioica factories where tables, immense vases are made. if you pass them and keep driving into the countryside, you might find the farm worked by Giuseppa and Paolo.
Keep your eyes open: you might see Giuseppa near her outdoor wood-burning oven sliding a cheesebread out or maybe even a roast goose and a couple ducks. She might have baked bread or pizzas in the same oven earlier in the morning. If you're lucky enough to be invited into lunch, she'll slice her prized prosciutto for you before homemade tagliatelle, served in a maiolica bowl masterpiece.
The perfect coupling of two sorts of Deruta passione.
Read about Giuseppa's grande passione
Click here to read more about Giuseppa
On Youtube, see Giuseppa as she bakes cheesebreads in her outdoor wood-overn.
Read about "delectable Deruta" and feasting with Giuseppa
Read about rural cuisine and rural warmth near Deruta
2 Comments
I am interested in cooking classes for my daughter and maillica lessons for me in the end of September or October.
The trip to Deruta and the Spello trip are interesting. Half day would be fine. What is the cost of the tours?
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How to Hire Santa Claus
3 Things to Consider when Hiring Santa Claus
Which Professional Santa Claus is right for me?
1) Make sure the professional Santa Claus has experience appearing at similar events. Some Santa Clauses specialize in home visits, others in commercial work, still others are appear mainly at malls. Tell the Santa you are talking to about your event and what you are looking for.
2) Appearance of the Santa is very important. Are you looking for a traditional looking Santa, a Coca Cola Santa, a real bearded Santa? Look at pictures of Santas you are considering and pick one that you think looks great
3) Price and schedule. How much does the Santa cost? Is he available to appear on the day of your event? The cost of having a great Santa Claus varies greatly. If you want the best Santa in your area, it can cost $200 an hour or more! But generally you should expect to spend $150 or more per hour to get a decent Santa. Scheduling is more important. Most Great Santa Clauses start to book up early in the year, so contact a Santa as soon as you know the date of your event.
If you think about these 3 things, you will have lots of luck in finding and hiring a terrific Santa Claus for your Christmas party. Also, find some of the best Santa Clauses for hire at www.SantaClausforHire.com


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Lies in the southernmost part of the Philippines is a cluster of 107 islands and islets scattered around Sulu and Celebes sea even closer to Malaysia is the Province of Tawi Tawi. Not a typical destination to many because of posing dangers that makes its tourism a little blurry, but to me, it's my ultimate travel place-a dream destination. To the brave souls, it's a promising sight and a rewarding treat.
The thought of setting foot on the last province and southernmost tip of the Philippines is such an achievement. In addition, I know only a handful of travelers have ventured to this part of the country. That's probably another reason why I wanted to go here . Thanks to seat sales, combo of Zamboanga and Tawi Tawi, I finally got to tick it off my bucket list.
I am not an expert in national defense situations and very seldom I get updates, but as a private citizen, I can positively say it's safe in Tawi Tawi. As safe as any place could be, I would imagine. The perception that Muslim areas in the Philippines are dangerous still prevails, even among Mindanaoans. Allow me, then, to show you what I experienced in Tawi-Tawi.
It was early morning of Friday when we left Zamboanga City via Cebu Pacific, the only airline flying to Tawi Tawi as of this writing. Packed with a brave heart and a curious mind, my travel mates and I took less than an hour flight to our ultimate destination. Filled with excitement, most of us wanted to take the window seats…of course, so we can have an aerial view. On the plane before touchdown, the alluring coastlines and sparkling sapphire and emerald waters were a sight to behold!
It was almost 8 in the morning when we finally heard, "We have just landed at Sanga Sanga Airport" Oh yeah baby, this is Tawi Tawi! The moment we arrived at the airport, I could see how relaxed people were. Police personnel and Tourism staff warmly welcomed us. And during our entire stay, I didn't sense anything untoward or unusual. All I could feel the whole time was a sense of newness, but at the same time a feeling of familiarity – this is still Philippines after all.
Since we do not have a fixed itinerary there were commotions while we're inside the tourism office. We're asking specific instructions on how to get to particular places but given several answers. Good thing we found ''a local friend" who helped us all throughout the trip. We even met one Taiwanese diver, and in turn, was not able to dive because he joined in almost if not all activities we have for this entire trip.
We met a new friend instantly! We were invited to have coffee in their house before we start our sojourn in this amazing place.
We were still undecided where to stay in Tawi Tawi. I reserved two rooms in Rachel's place but according to the tourism officer, the town sleeps very early and it's best for us to stay somewhere near the beach.
Still not sure what's going to be the activity for the day, we headed to the Beachside Inn. It was about a fifteen-minute ride on cemented roads. (Most roads on Bongao and Sanga-Sanga Islands are cemented.) The main mode of personal transport there is the motorcycle, and tricycles are the best way to get around if you don't have one. Although, sedans and SUVs are also present.
Along the way, I can't help but be amazed with the sceneries. Stilt houses almost everywhere, for real, I am in Tawi Tawi.
Sir Rosendo Reyes, Allen's (the Taiwanese guy) contact in Tawi Tawi met us at the inn and suggested that we do our island hopping the next day for us to make the most out of it, and we agreed. Since we really have nothing much to do for the day, we entertained the idea of getting an intro dive course. We were so excited that we will experience the underwater world in Tawi Tawi.
The Beachside Inn is untrue to its name because I thought it's a resort near the beach but in reality the beach is actually in front of the property. It's in a sprawling compound, with about 22 or so rooms. The rooms, while really basic, are air-conditioned and also outfitted with electric fans to keep it cool when they used a generator during the scheduled power outages.
We settled our things and off we go to Mt. View resort. From there we will be given orientation before the actual diving! Wohooo! I enjoyed the sea breeze and the calm environment while my buddies went for swimming. I don't know why I am not in the mood to swim that day..hehehe! I learned a lot about the place while sitting and relaxing. The name of Tawi-Tawi is a projection of the Malay word "jaui" meaning "far." Prehistoric travelers from the Asian mainland would repeat the word as "jaui-jaui" to mean "far away" because of the distance of the islands from the continent of Asia. The word "Tawi-Tawi" was picked up to later become the official name of the province. Presently, funny and maybe half true ,Tawi Tawi is a "Tawiran" (when people gets transported from one place to another by the terrorists).
While waiting for our lunch, I managed to take pictures of the rugged and rustic beachside making Mt Bongao a great background. Well yeah, we will be climbing that mountain anytime soon :)
We had a sumptuous meal prepared by the resort staff though the bill was unexpectedly high (hehehe! charge to experience) Fresh buko juice to quench our thirst, grilled fish, squid and veggies were served during lunch.
Now, we are ready for another adventure Bud Bongao: The highest mountain in the entire province of Tawi Tawi. One of the main reason why we went here is to climb the most revered mountain. I think it's a must to hike this iconic peak for you to say that you have completed your visit to the southernmost province in the Philippines.
Visited Province Rank: # 56
Date: February 20-22, 2015


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Nutrición Hospitalaria
versión On-line ISSN 1699-5198versión impresa ISSN 0212-1611
Nutr. Hosp. vol.27 no.4 Madrid jul./ago. 2012
Nutritional status and adequacy of enteral nutrition in pediatric cancer patients at a reference center in northeastern Brazil
El estado nutricional y la adecuación de la nutrición enteral en pacientes de oncología pediátrica en un centro de referencia del noreste de Brasil
J. Maciel Barbosa1, F. Pedrosa2 and P. Coelho Cabral3
1Msc in Nutrition. Federal University of Pernambuco (UFPE). Nutricionist in the Departament of Nutrition. Institute of Integrative Medicine Professor Fernando Figueira. IMIP.
2Specialisty in Paediatric Oncology by the Brazilian Medical Association. Medical Director of the Pediatric Oncology Unit. IMIP.
3PhD in Nutrition. UFPE. Professor at the Departament of Nutrition. UFPE. Recife. Brazil.
The Research and Teaching Support Fund (FAPE/ IMIP) offered funding for the publication of this paper.
Introduction: Individualized nutritional support is important to pediatric cancer patients and should be integrated to the overall treatment of these patients.
Objective: Analyze the nutritional status of cancer patients submitted to enteral nutrition (EN) and assess the adequacy of this form of nutrition.
Methods: A case series study was carried out at the Pediatric Oncology Unit of the Institute of Integrative Medicine Professor Fernando Figueira (IMIP, Brazil, Recife-PE) between January and December 2009. Clinical and anthropometric data were obtained from medical charts and nutritional follow-up charts. Z scores for height for age, weight for age and body mass index for age indicators (H/A, W/A and BMI/A, respectively) were calculated using the AnthroPlus® program. Caloric and protein requirements were calculated based on the recommendations of the Brazilian National Council of Oncologic Nutrition.
Results: At the beginning of EN, 32.4% of the sample had short stature and 23.9% were underweight based on the BMI/A indicator. The assessment of EN adequacy demonstrated that 49.3% reached the caloric requirements and 76.1% reached the protein requirements, with maximal intakes of 65.6 Kcal/Kg/day and 1.95 g of protein/kg/day. Malnourished patients had greater mean Z scores for W/A and BMI/A at the end of EN, whereas no significant changes were found among patients with adequate nutritional status and significant reductions in these indicators were found among those with overweight or obesity.
Conclusion: The patients either maintained or achieved a significant improvement in nutritional status, which demonstrates the importance of nutritional support and follow up during hospitalization.
Key words: Nutritional status. Enteral nutrition. Tube feeding. Cancer. Children.
Introducción: El soporte nutricional individualizado se considera una terapia importante en oncología pediátrica y, como tal, debe integrarse en el tratamiento global de estos pacientes.
Objetivo: Evaluar el estado nutricional de los pacientes sometidos a terapia de la nutrición enteral y la adecuación de la nutrición enteral (NE).
Métodos: Una serie de casos realizado en la Oncología Pediátrica del Instituto de Medicina Integrativa Profesor Fernando Figueira (IMIP, Brasil, Recife-PE), entre los meses de enero a diciembre de 2009. Se obtuvieron los datos antropométricos y clínicos de los registros médicos y formularios para recibir asesoramiento nutricional. Los valores de puntuación Z de los indicadores de A/E, P/E y el IMC/E se calcularon utilizando el software AnthroPlus®. Las necesidades calóricas y proteínas se calcularon de acuerdo con el Consenso Nacional de Nutrición Oncológica.
Resultados: Al inicio de la terapia se obtuvo 32,4% de retraso del crecimiento y 23,9% de bajo peso según el IMC/E. La evaluación de la adecuación de NE mostró que el 49,3% llegó a las necesidades calóricas y 76,1% las necesidades de proteínas, cuya contribución máxima fue de 65,6 kcal/kg/día y 1,95 g/kg/día de proteína. Los pacientes desnutridos tienen mayor media de las puntuaciones para Z de P /E y IMC/E al final de la NE. Los pacientes eutróficos tuvieron ningún cambio significativo, mientras aquellos con el sobrepeso o obesos tuvieron una reducción significativa. El grupo de desnutridos tuvieron una mayor ingesta media de calorías y proteínas durante el NE.
Conclusión: Los pacientes tuvieron mantenimiento o una mejoría significativa del estado nutricional, poniendo de relieve la necesidad de asesoramiento nutricional durante la hospitalización.
Palabras clave: Estado nutricional. Nutrición enteral. Alimentación por sonda. Cáncer. Niños.
ASPEN: American Society for Parenteral and Enteral Nutrition.
BMI/A: Body mass index-for-age.
DRI: Dietary Reference Intake.
EN: Enteral nutrition.
H/A: Height-for-age.
IMIP: Institute of Integrative Medicine Professor Fernando Figueira.
IQ: Interquartile.
NCON: National Council of Oncologic Nutrition.
PN: Parenteral nutrition.
W/A: Weight-for-age.
WHO: World Health Organization.
Malnutrition is frequent among children with cancer and may be present at the time of diagnosis or may emerge during treatment. The frequency upon diagnosis ranges from 6 to 50%, depending on the type, location, degree of malignancy and stage of the tumor as well as the criteria used for the nutritional assessment.1 Malnutrition may be caused by a number of mechanisms involving the tumor itself and the host response to both the tumor and treatment. Malnutrition is often associated with a greater risk of infection, a lesser response to treatment, greater toxicity stemming from chemotherapy and lower survival rate.1,2 Individualized nutritional support is important to pediatric cancer patients and should be integrated to the overall treatment of these patients.3
In recent decades, enteral nutrition (EN), also known as tube feeding, has been widely used due to its numerous benefits, such as a lesser risk of infection and other complications related to the catheter in comparison to parenteral nutrition.1,3-5 Moreover, EN is less expensive, more physiological and maintains the integrity of the intestinal mucosa, thereby reducing the risk of bacterial translocation.4,5 Technological advances in the implementation of EN and the development of increasingly specialized dietary formulas have contributed to the growing use of EN therapy.6,7
EN is indicated for all patients who cannot, should not or do not want to eat through the oral pathway and have a functioning gastrointestinal tract, which is essential to the use of this type of nutritional therapy.7 Total parenteral nutrition should be reserved for cases in which the total or partial use of the gastrointestinal tract is impossible or access is hindered due to thrombocytopenia.3-5
There are few well-controlled studies assessing the risks and benefits of EN therapy among pediatric cancer patients. Moreover, EN is suggested in the following situations: when nutrition through the oral pathway is not possible; when food intake falls short of nutritional requirements; and in the presence of nutritional risk or malnutrition.3,8
The aims of the present study were to analyze the nutritional status of children and adolescents with cancer submitted to enteral nutrition, assess the adequacy of this form of nutrition and determine the frequency of complications associated to this therapy.
Study design and site
A case series study was carried out between January and December 2009, involving male and female children and adolescents with a diagnosis of cancer hospitalized at the Pediatric Oncology Unit of the Institute of Integrative Medicine Professor Fernando Figueira (IMIP), in the city of Recife (northeastern Brazil) for cancer treatment or the treatment of complications stemming from this disease.
Study population
All pediatric patients hospitalized with cancer and who received exclusive EN or mixed EN (in combination with an oral diet or parenteral nutrition) for a period of 24 hours or more throughout the study period were included. At IMIP, all patients submitted to EN therapy receive industrialized enteral formulas with infusion in an open system.
Data acquisition
Secondary data was obtained from the EN follow up charts used by the IMIP Department of Nutrition as well as the electronic medical chart of each patient. On the nutrition charts, information is recorded daily on age, type of neoplasm and EN follow up data, such as access pathway, volume, type of diet, calories and protein offered, complications secondary to EN as well as weight and height measurements at the beginning and end of EN therapy. From the patient medical charts, information was collected on the indication for EN and conditions at the end of therapy and discharge from hospital (oral nutrition, enteral nutrition or death).
Anthropometric measures were obtained based on the protocol of the IMIP Pediatric Oncology Unit. For children under two years of age, weight was determined on an electronic scale (Kratos®) with a precision of 0.1 kg and capacity of 15 kg and height was determined in the horizontal position using an infantometer with a maximal length of 1.20 m and a precision of 0.1 cm. For children over two years of age, weight was determined on a digital scale (Filizola®) with a precision of 0.5 kg and a capacity of 150 kg and height was determined using a stadiometer coupled to the scale.
Nutritional diagnosis was determined using height for age (H/A), weight for age (W/A) and body mass index for age (BMI/A) indicators according to gender, using the reference standards recommended by the World Health Organization (WHO) and employing the WHO AnthroPlus® program (WHO, Geneva, Switzerland).9,10 The W/A indicator was calculated only for children under 10 years of age. The results were expressed in Z scores, considering children and adolescents with scores below two standard deviations (SD) as having nutritional deficit, those with greater than one SD for the BMI/A indictor as having overweight/ obesity and those with more than two SD for the W/A indicator as having excessive weight.11
Nutritional requirements
The reference used for the nutritional requirements was the Brazilian National Council of Oncologic Nutrition, done by National Institute of Cancer (INCA, Brazil).7 The caloric requirements were calculated with equations proposed by the Dietary Reference Intake7,12 and protein requirements were calculated based on the recommendations of the American Society of Parenteral and Enteral Nutrition (ASPEN). 7,13 For these calculations, age in years, weight in kilograms and height in meters were considered at the beginning and end of EN therapy. Ideal weight was used for those with malnutrition (Z score for BMI/A < -2SD) and was defined as the weight of the 50th percentile for the BMI/A indicator, provided this value did not exceed 20% of actual weight.7 A physical activity coefficient of 1.0 was also considered for these calculations, as the sample was made up of hospitalized patients. The calculation of the caloric value did not include the glycosylated serum infused with medications.
Data analysis
The adequacy of the offer (calories and protein) was calculated by comparing the values obtained from the percentage relationship between the offer and recommended requirements, and classified as underfeeding (< 90% of required), adequate feeding (90% to 110% of required), or overfeeding (> 110% of required).14,15 Maximal adequacy in the period was also evaluated (day of greatest offer of calories and protein). The duration of therapy was obtained in days beginning with the first day of EN therapy until its complete discontinuance.
Statistical analysis
The data were entered into the Excel program for Windows®. Analyses were performed using the SPSS program (version 13.0). Continuous variables were tested for normality using the Kolmogorov-Smirnov test. ANOVA was used to compare more than two independent groups for data with normal distribution and the Kruskal-Wallis test was used for data with non-normal distribution. The paired Student's t-test was used for the comparison of means for the dependent variables. The chi-square (χ2) test was used for the comparison of proportions. The level of significance was set to 5% (p < 0.05)
Ethical considerations
This study received approval from the IMIP Bioethics Committee under process n.o1764 and all procedures were carried out in compliance with the ethical standards of the committee responsible for experiments involving human subjects.
A total of 2,927 hospitalizations occurred in the study period, with 71 episodes of EN, corresponding to 2.4% of the total number of hospitalizations. Twelve patients underwent EN in two or more separate hospitalizations, which were considered distinct episodes. Due to cancer treatment, children and adolescents often need hospitalization for the specific treatment of infection, symptoms, hydroelectrolytic disorders, surgery, etc., meaning that the number of hospitalizations does not equal the number of patients at a pediatric oncology unit.
Patient age ranged from one month to 18 years, with a predominance of children under five years of age (56.3%). Males accounted for 62.0% of the sample and the most prevalence neoplasms were solid tumors, accounting for 57.8% of the total, among which 29.6% were tumors of the central nervous system, 11.3% were neuroblastomas and 8.5% were rhabdomyosarcomas.
Table I displays the results of the assessment of nutritional status at the beginning of EN therapy according to gender based on the H/A, W/A and BMI/A indicators. In the overall sample, 32.4% had a short stature for age and 26.3% were underweight based on the W/A indicator, whereas 23.9% were classified as underweight and 28.2% were classified with overweight/obesity based on the BMI/A indicator.
The main indications for EN therapy were intensive care with mechanical ventilation (31.0%), neurological impairment secondary to the base disease (central nervous system neoplasm or encephalopathy) (21.1%); anorexia (15.5%); and malnutrition/weight loss (15.5%).
Table II describes the main variables related to EN. The evaluation of the calorie and protein offer demonstrates that less than half of the sample (49.3%) reached the caloric requirements and 78.9% reached the protein requirements, with maximal intakes of 65.6 kcal/kg/ day and 1.95 g of protein/kg/day. The median duration of therapy was seven days (interquartile [IQ] interval: 3-11). Regarding the type of nutritional therapy, 80.3% of the patients received exclusive EN and 19.7% received mixed EN (combined with oral or parenteral nutrition). EN access in most cases occurred though a nasogastric tube (90.1%). The predominant diet was an industrialized polymeric formula adjusted to age (88.7%), followed by an oligomeric formula (11.3%). At the end of nutritional therapy, 54.9% of the patients were discharged from hospital with oral nutrition and 16.9% were discharged with at-home enteral nutrition, whereas 28.2% died stemming from complications related to the neoplasm.
Throughout EN therapy, changed occurred in the characteristics of the diets prescribed due to the clinical condition of the patient and/or gastrointestinal intolerance to the formula initially offered. Such changes included a change from a polymeric diet to an oligomeric diet (11.3% of the patient), lactose restriction in relation to the initial diet (9.9%), a reduction in the dilution of the initial formula (16.9%), a reduction in the volume during EN (35.2%) and the discontinuation of the diet due to clinical complications or complications secondary to nutritional therapy (26.8%). Figure 1 lists the main complications associated with the use of EN in the sample, highlighting gastric residual volume (57.7%) and vomiting (29.6%).
Table III displays the mean Z scores of the anthropometric indicators at the beginning and end of EN therapy. Malnourished patients had significantly greater mean Z scores for W/A and BMI/A at the end of EN therapy (p> 0.05), whereas no significant changes in the Z scores for these indicators were found among patients with adequate nutritional status and significant reductions in these indicators were found among those with overweight or obesity. Moreover, the malnourished group had the highest mean calorie and protein intake values throughout EN, with statistically significant differences (p < 0.05) (table IV).
In the present study, EN was only employed in 2.4% of the 2,927 hospitalizations in the period analyzed. Studies on the frequency of EN use in pediatric patients, especially cancer patients, are scarce. Oliveira et al.16 report that only 3.2% of patients hospitalized in a pediatric infection infirmary received EN therapy.
The anthropometric indicators revealed important nutritional deficit, as the frequencies for all indicators used in the present study surpassed WHO reference values, in which only 2.3% of the general population is expected to have Z scores below -2SD.17 However, the comparison of the results with other studies is limited due to the use of different indicators, cutoff points and reference curves as well as different study population characteristics, such as the type of neoplasm and phase of treatment.
In a study carried out involving pediatric patients with cancer at the beginning of treatment, Araûjo et al.18 found lower frequencies of nutritional deficit. The H/A and W/A indices revealed that 10% of the sample was short for their age and 3.3% were underweight for their age. The BMI/A index revealed that 13.3% were underweight and 23.6% were overweight. Zalina et al.19 found greater frequencies of nutritional deficit in a study involving children with leukemia between four and 12 years of age, with 37.3% and 31.4% of the 51 patients considered malnourished by the weight for age and weight for height indicators, respectively, and 17.6% had a short stature for age.
Regarding the effect of nutritional deficit on stature, nearly one third of the sample analyzed (32.4%) had Z scores below -2SD at the beginning of nutritional support regarding the H/A indicator. Similarly, Sarni et al.20 report short stature for age in 30% of children under five years of age hospitalized in general pediatric infirmaries in a study involving 10 university or teaching hospitals in the northeastern, southeastern, central western and southern regions of Brazil. Even more alarming figures are reported in a study involving pediatric cancer patients admitted to a reference hospital in the east African country of Malawi, with a stature deficit frequency of 44.5%.21
A number of factors affect linear growth during cancer treatment, including the disease itself, inadequate nutrition, the occurrence of infections, chemotherapy and growth hormone deficiency secondary to cranial radiation.22 The sum of all these factors determines a deceleration of growth during treatment for cancer23 and may be related to the frequency of short stature in the present study.
The majority of indications for EN were related to conditions that render oral feeding impossible, such as the use of mechanical ventilation (31%) and neurologic impairment (21.1%). In patients with cancer, indications for EN are generally more related to situations that limit food intake and/or denote nutritional risk (malnutrition, weight loss, anorexia, mucositis, etc.),24,25 but EN may also be indicated in cases of neurologic impairment and/or a high risk of bronchoaspiration.26 Thus, one cannot discard the possibility that the frequency of EN was below the recommended use, as this aspect was not evaluated in the present study.
There was a low percentage of hyperalimentation, but a greater frequency of patients who did not achieve their estimated nutritional requirements. This finding may be explained by the severe clinical conditions of the patients and occurrence of gastrointestinal complications, which imply restrictions regarding volume and the offer of macronutrients. Moreover, there was a 19.7% frequency of the concomitant use of oral and/or parenteral nutrition, the caloric and protein values of which were not included in the calculation of the total offer.
The most frequent clinical complications associated with EN therapy were gastric residual volume and vomiting. In a study involving children with cancer in EN therapy, Pietsch et al.27 report that vomiting occurred in the majority of the sample (71%), but was likely associated with chemotherapy and generally persisted even after a pause in the infusion of the diet.
Cancer patients often experience complications that affect the gastrointestinal tract, which may be associated with the direct toxicity of treatment and/or an aggravation of the clinical condition. Gastric residual volume is the most frequent complication in critical patients under gastric EN therapy. The cause is multi-factor, but appears to be related to the use of drugs that diminish gastric motility as well as alterations in gastric emptying.28 Vomiting has been associated with gastro-esophageal reflux, which may be related to postural factors, the caliber of the tube and dysfunction of the lower esophageal sphincter.29 In such situations, the use of prokinetic agents and a transpyloric feeding tube is recommended to minimize the risk of bronchoaspiration.28
The median duration of EN was less than one week (median: 7 days, IQ: 3 to 11), which is considered less time than necessary for an effect on nutritional status. In a study involving pediatric patients in EN therapy, Ezge et al.30 found a greater median value for the duration of therapy (median: 21.5 days; IQ: 2 to 547) and higher mean Z score at the end of EN for the W/A, H/A and weight for height indicators. In a review on the impact of nutritional therapy among cancer patients, Bozzetti31 concluded that the improvement in nutritional status in the studies analyzed was likely limited due to the fact that the duration of therapy was less than a few weeks, whereas the development of malnutrition in cancer often occurs over the course of months. The author also suggests that metabolic abnormalities present in cancer may limit the efficacy of nutritional support.
The early indication of EN therapy is currently one of the main goals of nutritional therapy in children and adolescents with cancer.32 A number of studies have demonstrated that EN should be initiated within the first 24 to 48 hours following trauma, surgery or hospitalization, the benefits of which are the attenuation of the metabolic response, maintenance of functional and structural integrity of the intestinal mucosa, with a reduction in its permeability and the translocation of bacteria and endotoxins, a reduction in the impairment of the immune response, etc., with a consequent reduction in hospitalization time and costs.33,34 No data on the time elapsed between hospitalization and the onset of EN were collected in the present study and it is therefore not possible to analyze the adequacy of the timely establishment of this therapy.
The malnourished children had a significant improvement in Z scores for the W/A and BMI/A indicators during the use of EN. These findings may be explained by the greater caloric and protein intake among these patients. However, no statistically significant differences were found regarding the duration of therapy and the time needed to reach nutritional requirements among the groups analyzed. Among the patients with adequate nutrition, no difference occurred in mean Z scores for the W/A and BMI/A, indicating that no nutritional impairment had occurred during hospitalization. The children with overweight or obesity at the onset of EN had a significant reduction in Z scores for these same indicators. While cancer treatment is not the best time for weight loss, this finding may be explained by the replacement of high-calorie foods and sweets with adequate nutritional intake during hospitalization.
EN therapy has limitations in cancer patients due to therapeutic complications secondary to the toxicity of treatment (nausea, vomiting and diarrhea). However, the patients submitted to EN therapy in the present study either maintained or achieved a significant improvement in nutritional status, which demonstrates the importance of nutritional support and follow up during hospitalization. Moreover, a multidisciplinary team is important for the adequate support to children and adolescents with cancer in EN therapy.
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Janine Maciel Barbosa.
Departamento de Nutrição.
Rua dos Coelhos, 300.
Boa Vista, CEP 50070-550. Recife, PE, Brasil.
E-mail: email@example.com
Recibido: 24-III-2012.
Aceptado: 27-III-2012.