Saturday, June 29, 2013

Anemia and fatigue in CKD

Tomorrow at the NeKF Annual Kidney patient and Family Education Day I will be presenting the following about Anemia and Fatigue in Chronic Kidney Disease in case you can't make it tomorrow I wanted to share my presentation.

“You may start to feel tired“…is what I was told 15 years ago when I began this journey with chronic kidney disease. Anemia and fatigue have been the biggest challenge I have faced. It went far beyond “feeling tired” though there where days when I could barely lift my head from the pillow. Anemia happens when your red blood cells are in short supply. Red blood cells carry oxygen from your lungs to all parts of your body, giving you the energy you need for your daily activities.

Symptoms of Anemia include:
1. Looking pale
2. Shortness of breath
3. Trouble sleeping
 AND
4. Feeling dizzy and having headaches

I can remember the very first time I felt these symptoms. I was vacationing on Cape Cod and had spent the day at the beach. After hours in the sun I had to climb up the steep dunes to get back to our car. About half way up I felt so exhausted that I just dropped everything I was carrying and fell to my knees. I hadn’t ever recalled feeling that way. It wasn’t until I returned home and went back to my kidney doctor that I found out what was going on.

I later learned that one of the functions of your kidneys is to make a hormone called EPO. Hormones are secretions that your body makes to help your body work properly and keep you healthy. EPO tells your body to make new red blood cells. When you have kidney disease, your kidneys cannot make enough and this causes your red blood cell count to drop and that’s when you develop anemia.

Most people with kidney disease will develop anemia. Anemia can happen early in the course of kidney disease and grows worse as the kidneys lose their ability to work well and make EPO. Anemia is especially common if you:

1. Have diabetes
2. In stages 3,4, or 5 of kidney disease
AND
3. Are female

But because not everyone with anemia gets symptoms you should have regular blood tests to measure your hemoglobin levels.

Hemoglobin is the part of the red blood cell that carriers oxygen throughout the body. Your doctor can tell if you have anemia by measuring your hemoglobin levels. If your hemoglobin levels are below normal which is 12.0 for women and 13.5 for men. Your doctor will start a treatment plan to raise your hemoglobin. This usually includes drugs that work as an EPO stimulate. These agents  are called ESA’s and helps your body to make new red blood cells that your kidneys cannot. It is usually given as an injection under the skin and most CKD patients learn to do this at home as self injections.

The other treatment part of anemia is controlling your iron stores. Your body needs iron to make red blood cells especially when you are receiving an ESA treatment. Without enough iron, your treatments will not work as well. Iron can be given either in pill form or through IV.  Your iron stores should be at least 20%  and should be checked along with your hemoglobin levels.

Your doctor will check your hemoglobin levels on a monthly basis to bi~monthly basis. This tells your doctor how well your doing and your dose of the ESA will may need to be changed, depending on how well you respond.

If untreated, anemia can make your health conditions worse and cause your heart to work harder.

So what did I do about this?  When it appeared that I would be dealing with anemia and fatigue for a long time.

1. Started a log of my symptoms so when I returned to my kidney doctor I could give her specifics details on how I was feeling.

2. I embraced the way I was feeling and realized it was a symptom of my disease.

3. When I was started on Procrit  which was my ESA, I was certain to follow my doctors instructions to the letter.

4. I allowed myself something called "PJ days" and got the rest I needed when I needed it.

5. I began working with my dietitian to include iron rich, kidney friendly foods.

And last but not least

6. I stayed as active as I could adding in exercise when possible.

Although anemia and fatigue are unavoidable in Chronic kidney disease there are steps you can take to limit the impact on your every day life. Just knowing what to look for and being prepared is half the battle. Keeping up on your ESA, having your hemoglobin and iron levels checked and recognizing the symptoms will go a long way in controlling these. Whether your newly diagnosed or have been dealing with CKD for a long time anemia and fatigue will be part of your life so prepare yourself now even if your doctor has not.

I want to thank you for joining me on this journey, I look forward to your comments, questions and concerns. 

Keep on fighting all you Kidney Warriors.

~Kidney Blogger







Friday, June 28, 2013

Sunday fun! and appreciation


I would like to remind everyone of the Northeast Kidney's Annual Kidney Patient and Family Education Day this Sunday June 30, 2013,  Its going to be held at the Holiday Inn Express 400 Old Loudon Rd. in Latham from 12pm to 4:30pm. Registration will be starting at 11:30 am and they will be kicking things off with a delicious kidney friendly lunch. Some of the topics will include "Current Treatments, Innovations and Advances, What No one tells you about Kidney Disease and What to do about it,  and Patient Activation~ Informed Choice and Decision Making." This will be a great resource whether your a newly diagnosed patient or have lived with Chronic Kidney Disease for many years. They will also discuss how to eat well to maintain healthy lab values. I hope too see many of you there and would love to meet any of the followers of the blog. It's not too late to register you can do so by contacting Northeast Kidney at (518)458-9697 or 1-800-999-9697, you can also locate them on Facebook on their "Kidney Club" site to print a registration form.  https://www.facebook.com/groups/kidneyclub/


I want to take a moment to welcome all the kidney warriors to the blog, thank you for choosing to follow me. Please feel free to leave comments, questions or concerns on any of the entries. Whether your a patient, caregiver or a kidney professional I hope you find this information to be useful. If there is a subject or issue you would like me to address please leave a comment and I would be more than happy to address it. I'm writing this blog in the hopes of helping others battling this life changing illness. After nearly 15 years of living with CKD I feel that I have learned so much and I want to share it with others.

I would also like to thank The Northeast Kidney Foundation for allowing me the opportunity of writing this blog in conjunction with them. This has been a dream come true to lend my voice and years of experience in helping others battling CKD.  Please visit  Northeast Kidney @  http://www.healthykidneys.org/   for more valuable information about kidney disease and to participate in any of the many programs they offer.

Keep on fighting all you Kidney Warriors.

~ Kidney Blogger

Tuesday, June 25, 2013

Stepping up for Chronic Kidney Disease



I want to thank Kathe Lebeau, of the NeKF for being a guest blogger on Friday.  Today I was planning on continuing posting about the renal diet and the challenges that come with it but I wanted to speak more about advocacy and why it is so important for kidney patients to take action. With over 96,000 people waiting for lifesaving kidney transplants the time is now for all kidney patients to step up and take action. We need to put a face to this disease and get involved. Only a person with CKD can explain what its like living with the disease. Whether its on a local, state of federal level we need to get involved. We have all faced dealing with the cost of medications or issues with transportation. These are just a few of things the NeKF will help address through the Advocates' Alliance. If you have the passion and any amount of time I urge you to contact them and get involved. Be an advocate for yourself and others!

Last Tuesday we began talking about sodium, phosphorus and potassium. Since I have been on dialysis for the last five and half years, I will start with their effect on the dialysis diet and the importance of keeping each of these in balance and under control. We will start with an explanation of what each is, what foods are high in each, and the effects when the levels are too high and the risks of each.

Sodium: is a major mineral found in the fluid surrounding the cells in the body, It helps to regulate blood pressure and fluid volume. It also helps maintain ph balance in the body. Both muscles and the nervous system rely on sodium to function correctly.

Phosphorus: is a mineral that makes up 1% of a person's total body weight, and is present in every cell of the human body. Most phosphorus is found in the teeth and bones. It plays an important role in how the body uses carbohydrates and fats. It is also needed for the production of  protein which is necessary for growth, maintenance, and repair of cells and tissue. It also helps in kidney function, muscle contractions, normal heartbeat and nerve signaling.

Potassium; is a dietary mineral necessary for balancing ph and fluids in the body. It's important to maintain normal blood pressure and works in opposition to sodium. It also is needed for normal muscle growth and function of the nervous system and brain functions.

Some foods high in sodium include: Fast foods and processed foods, canned goods, baked goods, cheese, salted snacks and luncheon meats. High sodium increases the risk of stroke, high blood pressure, heart attack and kidney disease. In dialysis patients it also causes increased edema or swelling in the feet or ankles.Which can lead to breathing issues and pulmonary edema. That's why its so important to limit sodium intake.

Some foods high in phosphorus include: dairy products, chocolate, processed meats, beer, cola's and dark soft drinks, nuts/seeds and dried beans and peas. High phosphorus levels causes your body to pull extra calcium from the bones and can weaken them. When you have both high phosphorus and calcium, which usually go hand and hand, it can lead to dangerous amounts of  calcium deposits in the lungs, eyes, heart and blood vessels. You want to maintain a phosphorus level of 3.5 to 5.5 mg/dl.

Some foods high in potassium include: raisins, prunes, dates, strawberries, bananas, watermelon, soy and soy foods, turkey and beef. High potassium levels causes irregular heartbeat, nausea and a slow, weak or absent pulse. Low potassium level causes fatigue, muscle pain, cramps, constipation and dizziness. You want to maintain a potassium level of 3.5 to 6.0 mg/dl,

Okay before we go much further lets discuss the functions of  the kidneys and how important they are to our over all well being. Our kidneys are 24/7 cleaning machines. These twin shaped organs located below the rib cage work 365 days a year removing waste from the body.  Each and every day these organs pump about 200 quarts of  blood through about 140 miles of tubes. On top of removing waste products,  the kidneys remove extra fluid, produce hormones like Erythropoietin, and they also help maintain the balance of minerals and chemicals (like sodium, phosphorus, and potassium) to keep us healthy. And we can’t forget to mention one of the most important functions of the kidneys which is to control blood pressure.

One of biggest challenges of the dialysis renal diet is balancing these three levels. It has been the biggest struggle for me. Educating myself about what they where and the ideal levels helped me get them under control and I hope this helps each of you as well.

I want to thank you for joining me on this journey and looks forward to your questions, comments and concerns.

Keep on fighting all you kidney warriors!
~Kidney Blogger





Friday, June 21, 2013

Be an Advocate: National Patient Congress and NEK Advocates' Alliance


Happy to share the following posting from our guest blogger today, Kathe LeBeau of Northeast Kidney, on the National Patient Congress and becoming a patient advocate.  Please consider joining the NEK's Advocate Alliance, and be in touch with Kathe at kathe@healthykidneys.org or call 518-458-9697 ext. 2:



“Where you live and how much money you have should not determine whether you live or die…”

These words, spoken by a cancer survivor at the beginning of two days of advocacy meetings and Capitol Hill visits, were among the inspiring messages shared by attendees at the National Patient Congress this week in Washington DC.  Sponsored by the National Patient Advocate Foundation and Patient Advocate Foundation, people dealing with a variety of chronic and acute illnesses and conditions and many family members, shared their amazing stories with Congressional representatives and their staffs to help illuminate the changes needed in health care policy at the federal level.

The experiences of living with illness and the vagaries of care received make for very poignant testimony as legislators try to help make cost effective health care decisions that will serve to drive improvements in that care.  You all know what I’m talking about – you know what it’s like to sit in that dialysis chair, to have your drug regimen changed and changed again, as you struggle to pay sometimes high co-insurances for those medications, you feel alternately well and unwell, and you work hard to make that heard and understood by your medical providers.  This takes that conversation to a different plane; these people at the highest level of government who represent you need to hear your stories so they understand what it’s like to live with a chronic illness like kidney disease for someone like you or me  – or for that matter, for anyone living with Hiv/AIDS, multiple sclerosis, diabetes, arthritis and so on.  They are the ones who make the regulations about how care is provided and paid for – and so ultimately, how well you are able to access and receive that care, and how good the quality of that care is. 

So in DC, with virtually every spectrum of those receiving ongoing medical care – and every single state in the country represented – we met, talked about the issues we all share and then descended on Capitol Hill with the message: we know what it’s like to live with a medical challenge – and this is what you can do to make a positive difference in our lives.

Each of us - almost 100 strong in total from across the country - had somewhere between 10 and 30 legislative office visits each, depending on our state delegation.  And at the end of the day, we returned to our hotel tired and with achy feet, but inspired by the feedback we received.  We were able to develop relationships with our representatives, got some of them to cosign onto bill proposals, and encouraged others to become patient champions. 

We also had incredibly moving presentations as a group: from Rep. John Dingell of Michigan, who has been in the House since the 1950’s – and introduced health care reform legislation every single year he served until it was signed into law in 2010.  We heard from Sen. Max Baucus, who helped work through difficult bipartisan compromises to shepherd that law to passage.  And from Dr. Cary Presant, who wrote “Surviving American Medicine,” and who talked about how to become involved and proactive patients. Most importantly, we heard from others who share this journey; it was an amazing few days.

I’d like you to think about making the same kind of difference by getting involved.  Northeast Kidney has an Advocates’ Alliance, and we work on both the state and federal levels, primarily on issues related to kidney, dialysis, transplant and organ donation.  You know the wait for kidney transplants is too long; we are working on increasing organ donation rates.  You know sometimes it’s hard to get access to the medications we need, due to expense or coverage issues; we work on improving that. Please consider joining us –  you don't need to be a policy expert or be able to quote regulation chapter and verse, believe me.  We just need your passionate voice of experience; it really does resonate with those making the decisions, and you can genuinely make an amazing difference in the lives of all patients.  Please think about it - then be in touch.   

 
 
 
 

Thursday, June 20, 2013

Guest blogger and Advocacy Alliance

Hey Kidney Warriors we are in for a special treat, Kathe Lebeau who is the Director of Patient Services and Public Policy of the Northeast Kidney Foundation is going to be a guest blogger tomorrow. She is very excited to talk to you about the National Patient Advocate Congress and also about the Northeast Kidney's Advocacy Alliance. I'm really looking forward to reading all about this and I hope you will be too. I will back on Tuesday and continue talking about nutrition and the renal diet.

Thanks again for joining me on this journey. I'm looking forward to sharing once again on Tuesday. As always look forward to your input, questions and concerns.



Tuesday, June 18, 2013

Sodium and Phosphorus and Potassium oh my.........

 For me one of the most complex issues in dealing with CKD was embracing a renal diet. From day one, the way I approached food needed to change. Throughout every stage of CKD there are different requirements and it was  important to educate myself  during each stage.  Calorie intake, limitations of salt, phosphorus, potassium and protein were all concepts that I had to learn. Some of these things  I had never even heard of before I was diagnosed and now I realize the importance of controlling them all. I  learned that having proper nutrition can help reduce the workload on the kidneys and allow the best environment for optimal kidney function. This is very important in the first stages of CKD when you still have kidney function.I was never in my life a label reader and once I was diagnosed that all changed. Reading labels can help make healthy food choices for your kidneys.

 Over the next few posts I will delve into sodium, phosphorus, and potassium and explain not only what they are but also why are so important to your health when dealing with CKD. For the last five and a half years I have been a dialysis patient and thought I would start with the importance of these while on dialysis. I will also discuss the importance these in the other stages of CKD. So whether you're newly diagnosed or have been dealing with CKD  for a long time, like myself,  it's important to have a healthy diet. I will also talk about Calcium and Vitamin D. You will see how vital it is to keep healthy and balanced diet so please be certain to come back next week for the next nutrition post.

The Northeast Kidney Foundation truly understands how vital nutrition and diet plays in the lives of those with CKD, and they are holding a contest to find the best kidney friendly recipes. So whether it's your favorite snack or a meal recipe, if its renal friendly and within the kidney diet, they would love to hear from you! Get that meal, snack, side dish or dessert to them by August 15th to be in the contest running. There will be winners in each category, and the winners will be announced over Labor Day weekend. To submit your entry you can email it to : kathe@healthykidneys.org or send them to Northeast Kidney Foundation 501 New Karner Rd. Ste. 6 Albany New York. Attention: Kathe.

Please visit NeKF at http://www.healthykidneys.org/ for more details on this yummy contest.

Thank you for joining me on this journey, I look forward to your input, comments and questions along the way.





Saturday, June 15, 2013

Making Kidney Connections

My connection with the Northeast Kidney Foundation (when it was still part of The National Kidney Foundation) started way back in 1998 when I first was diagnosed. At the time the company I was working for was mostly based in Manhattan and one of my clients was neighbors with The National Kidney Foundation. My client helped me make contact with them and they in turn helped me contact the local office.
They were extremely helpful in providing me with brochures and other information about Chronic Kidney Disease. They became lifelong allies in the fight against Chronic Kidney Disease for me. And now almost 15 years later I feel the need to give back. This is one reason I wanted to work in conjunction with them and help write the blog and why I love to participate in the Kidney Walks and the Catwalk for Kidneys.

One of the monthly events the Northeast Kidney Foundation hosts is the "Kidney Club" and its a great way to make a Kidney Connection for yourself. The monthly clubs, around New York State and Massachusetts, gives patients and family members a way to connect to other patients and family members. Its a place to ask questions and share experience with those who understand. Its a support group  where patients, family members and friends can come together. And the good news is there is probably one close to you. They currently have meetings in the following areas:

New York 

Albany area meetings are currently held the second Sunday of every month at the Macy's Colonie Center Community Room, from 12 noon until 2 pm.  (3rd floor near the kids clothes).

Buffalo area meetings are held the 3rd Thursday of the month at Erie County Medical Center in the third floor conference room at 7 pm.  

Oneonta meetings are at the Foxcare Wellness Center on the third Sunday of each month, starting at 12 noon.

Massachusetts

Pioneer Valley meetings are held the first Sunday of the month starting at 12 noon, resuming in July.

For more information about the Kidney Clubs please email kathe@healthykidneys.org or call
 518-458-9697.  And contact them if you are interested in starting a kidney club near you - they'd be happy to help!

Thank you for joining me on this journey, I look forward to your input, comments and questions along the way. I hope you will consider joining one of the Kidney Clubs and making your own kidney connection with the Northeast Kidney Foundation. 

Friday, June 14, 2013

Tests and Education

My  nephrologists began a series of tests to determine the cause of my kidney disease. The first test involved finding my GFR. Your GFR or Glomerular Filtration Rate is one of the best methods for determining how much kidney function you have. It uses your individual blood creatinice, age, body size and gender. It then calculates a value which determines the stage of  CKD your in. At the time I was well into Stage 3. There are 5 Stages to CKD with stage5 being kidney failure and needing dialysis or transplant. Prevention is the best fight against kidney disease so know your numbers especially your GFR if your at risk.. Knowing these numbers can help decrease the damage to your kidneys

Some of the other tests he did were to determine my BUN which measures the amount of nitrogen in the blood that comes from urea. It's another way to see how much kidney function is left.  He also did a 24hour urine collection to check how much protein was in the urine. Normally there should be little to none, so any increased amount could be some form of reduced kidney function. The final and most telling test he did was called an VCUG or Voiding cystourethgram this test uses x-rays of the  bladder both when its full and then when its emptied to see if there are any abnormalities between the bladder and upper urinary tract. And finally after 2 months of tests he determined that I had Kidney Reflux or Renal Reflux disease. The most common symptom of renal reflux is a urinary tract infection. This occurs because the bacteria that cause the urinary tract infection are able to travel up the urinary tract as a result of the reflux instead of being pushed out during urination. When I was diagnosed I had not had any UTI's and therefore allowed it to go un~diagnosed for so long. By the time the doctor's found it, the damage was already done. The only symptom I had was flank/lower back pain resulting from urine refluxing up to my kidneys. This condition is usually caught in childhood and can be treated and most times cured. 

One of the best things I did for myself in the early stages of learning I had kidney disease was to educate myself on the disease. With the help of the Northeast Kidney Foundation you too can gain the information you need to deal with Chronic Kidney Disease. They are having their Annual Kidney Patient and Family Education Day on June 30, 2013 and I plan on attending. Some of the topics will include "Current Treatments, Innovations and Advances, What No one tells you about Kidney Disease and What to do about it,  and Patient Activation~ Informed Choice and Decision Making." This will be a great resource whether your a newly diagnosed patient or have lived with Chronic Kidney Disease for many years. They will also discuss how to Eat well to maintain healthy lab values. I hope too see many of you there please come find me, I would love to meet any of the followers of the blog. Its going to be held at the Holiday Inn Express  400 Old Loudon Rd. in Latham from 12pm to 4:30pm. You can contact Northeast Kidney at  (518) 458-9697 ● (800) 999-9697 ●     to register for the meeting. And the best thing is they will have a renal  friendly lunch and who doesn't like a free lunch?

Thank you for joining me on this journey, I look forward to your input, comments and questions along the way. I look forward to seeing you on June 30, 2013 at the Patient and Family Education Day. 

Monday, June 10, 2013

10th Annual Albany Kidney Walk

My passion - their mission, I feel truly lucky to write this blog in conjunction with The Northeast Kidney Foundation. Its been their mission “... to improve the lives of those living with kidney disease and related conditions, to increase organ donation, and to empower those we serve to be effective voices for better health care both personally and at the local, state and federal levels.”  After living nearly 15 years with kidney disease I realize how important it is to educate and empower patients about kidney disease, the treatments out there and how vital it is for each and every one to become the captains of their own health care teams.  When patients take charge of their own health and become actively involved they not only improve their lives and health, but also live longer and happier lives. The Northeast Kidney Foundation hosts many community events and the Kidney Walk is just one of them.


This year marked the 10th anniversary of the Northeast Kidney's Albany Kidney Walk. The annual Walk is just one of the community events the Northeast Kidney hosts to allow patients, families, caregivers and kidney professionals to come together to raise both awareness and funds to help find a cure for Chronic kidney disease. In a sea of bright colored shirts,  I was touched to see the mile long line of supporters. Each team was put together to either support a loved one battling this life changing illness or to honor someone that has passed. The event was both family friendly and educational. My little cousins enjoyed the pony rides and the wonderful clown who made them special hats out of balloons. I was even more touched to see some of the area's nephrologists showing their support, even willing to sit in a "dunk" tank where they are soaked with water balloons, all in the name of raising awareness.  I was honored to be part of this event and felt so much love and support by my family members and friends who walked with me and gave donations. 

There are a few more Kidney Walks happening around New York State including: 
Ithaca on October 5, 2013 
Poughkeepsie Walk over the Hudson for Kidneys on October 27 2013
Oneonta/Cooperstown on November 10, 2013

If your interested in participating in any of these Walks you can contact the Northeast Kidney Foundation at  http://www.healthykidneys.org/


Thank you for joining me on this journey, I look forward to your input, comments and questions along the way. 

And so the journey began.....



Nearly 15 years ago I started on a journey with Chronic Kidney Disease and my life would never be the same. Throughout the years I have experienced everything from kidney failure to kidney transplant to now being a home hemodialysis patient.  Throughout this blog I will share my personal journey as well discuss some of the major factors and causes of kidney disease.  I will share expert opinions on issues that directly impact the daily lives of  kidney patients and their families. With the support of the Northeast Kidney Foundation, I proudly offer my life’s journey:


Hello my name is Dena, I’m 43 and have had kidney disease since age 28. After a 6 month battle with migraine headaches I finally broke down and went to see my primary care doctor. To my surprise, 2 weeks after my initial appointment,  I was told that I had bilateral kidney disease. My serum creatinine was already in the high 2’s.  I had to come learn your normal levels are between .6 and 1.2 and mine was already 2.7 and climbing quickly. Serum creatinine is the measure of how well your kidneys are functioning. I was then referred to a Nephrologist, who is a doctor who specializes in the care of kidneys. And so the journey began....


Thank you for joining me on this journey, I look forward to your input, comments and questions along the way.









Friday, June 7, 2013

Welcome and Happy Summer !


As we head into the big weekend with our 10th Annual Albany Kidney Walk and 5K for Kidneys this Sunday, June 9th, we are excited to launch our new kidney blog!  Sponsored by the Northeast Kidney Foundation, we will be offering all the voices and viewpoints involved in the journey of a life affected by kidney disease, most especially those of patients and their loved ones.

Our mission is articulated as working "... to improve the lives of those living with kidney disease and related conditions, to increase organ donation, and to empower those we serve to be effective voices for better health care both personally and at the local, state and federal levels." We hope this will be one way to serve that mission and the renal community by creating an opportunity for interactive discussion about all facets of a kidney life - and everything that means. So though it will be lead and moderated by our patient blogger Dena - who you will learn more about very soon - we will also hear from other patients, family members and care partners, as well as renal professionals involved in every phase of kidney care, before and after the start of treatment, whether it is a dialysis modality or transplant. We'll talk about diet, medications, advocacy and support and all the things that make a difference living with kidney disease.  We hope you will weigh in - add your experience, ask questions and share your own discoveries and concerns. We will also highlight all the activities and events offered by Northeast Kidney that can help you and your families live a best life even with a chronic illness like renal failure.


So ...are you ready to get your summer off to a great start ?  Join us - we have so much to share !  Our blogs will be published every Tuesday and Friday, so stop by and meet Dena - an experienced blogger and patient who has learned a great deal in the 14 years she has been dealing with this that she will begin to share.  And we bet some of what she talks about will sound like things you have gone through and dealt with as well- we can all help each other so much with mutual support.


Perhaps we'll see you at the Crossings Park this Sunday - the run starts at 8:30, the Walk steps off at 11am, and there will be lots of fun activities for kids of all ages, from clowns and pony rides to music and food.  Otherwise we will see you here next Tuesday, when Dena will introduce herself and begin to share her perspectives, including impressions from the Walk.  In the meantime, take care and stay well...