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Rationale & Objective: Chronic kidney disease (CKD) can progress rapidly, and patients are often unprepared to make kidney failure treatment decisions. We aimed to better understand patients’ preferences for and experiences of shared and informed decision making (SDM) regarding kidney replacement therapy before kidney failure. Study Design: Cross-sectional study. Setting & Participants: Adults receiving nephrology care at CKD clinics in rural Pennsylvania. Predictors: Estimated glomerular filtration rate, 2-year risk for kidney failure, duration and frequency of nephrology care, and preference for SDM. Outcomes: Occurrence and extent of kidney replacement therapy discussions and participants’ satisfaction with those discussions. Analytic Approach: Multivariable logistic regression to quantify associations between participants’ characteristics and whether they had discussions. Results: The 447 study participants had a median age of 72 (IQR, 64-80) years and mean estimated glomerular filtration rate of 33 (SD, 12) mL/min/1.73 m2. Most (96%) were White, high school educated (67%), and retired (65%). Most (72%) participants preferred a shared approach to kidney treatment decision making, and only 35% discussed dialysis or transplantation with their kidney teams. Participants who had discussions (n = 158) were often completely satisfied (63%) but infrequently discussed potential treatment-related impacts on their lives. In multivariable analyses, those with a high risk for kidney failure within 2 years (OR, 3.24 [95% CI, 1.72-6.11]; P < 0.01), longer-term nephrology care (OR, 1.12 [95% CI, 1.05-1.20] per 1 additional year; P < 0.01), and more nephrology visits in the prior 2 years (OR, 1.34 [95% CI, 1.20-1.51] per 1 additional visit; P < 0.01) had higher odds of having discussed dialysis or transplantation. Limitations: Single health system study. Conclusions: Most patients preferred sharing CKD treatment decisions with their providers, but treatment discussions were infrequent and often did not address key treatment impacts. Longitudinal nephrology care and frequent visits may help ensure that patients have optimal SDM experiences.

Rationale & Objective: Digital health system tools to support shared decision making and preparation for kidney replacement treatments for patients with chronic kidney disease (CKD) are needed. Study Design: Descriptive study of the implementation of digital infrastructure to support a patient-centered health system intervention. Setting & Participants: 4 CKD clinics within a large integrated health system. Exposure: We developed an integrated suite of digital engagement tools to support patients’ shared decision making and preparation for kidney failure treatments. Tools included an automated CKD patient registry and risk prediction algorithm within the electronic health record (EHR) to identify and prioritize patients in need of nurse case management to facilitate shared decision making and preparation for kidney replacement treatments, an electronic patient-facing values clarification tool, a tracking application to document patients’ preparation for treatments, and an EHR work flow to broadcast patients’ treatment preferences to all health care providers. Outcomes: Uptake and acceptability. Analytic Approach: Mixed methods. Results: From July 1, 2017, through June 30, 2018, the CKD registry identified 1,032 patients in 4 nephrology clinics, of whom 243 (24%) were identified as high risk for progressing to kidney failure within 2 years. Kidney Transitions Specialists enrolled 117 (48%) high-risk patients by the end of year 1. The values tool was completed by 30/33 (91%) patients who attended kidney modality education. Nurse case managers used the tracking application for 100% of patients to document 287 planning steps for kidney replacement therapy. Most (87%) high-risk patients had their preferred kidney replacement modality documented and displayed in the EHR. Nurse case managers reported that the tools facilitated their identification of patients needing support and their navigation activities. Limitations: Single institution, short duration. Conclusions: Digital health system tools facilitated rapid identification of patients needing shared and informed decision making and their preparation for kidney replacement treatments. Funding: This work was supported through a Patient-Centered Outcomes Research Institute (PCORI) Project Program Award (IHS-1409-20967). Trial registration: ClinicalTrials.gov NCT02722382.

In intraocular tumors, diagnosis is usually based on clinical examination and imaging without the need for invasive surgery or tissue sampling. The diagnosis can be confirmed by biopsy, however, in the case of intraocular malignancy, the biopsy is considered controversial. Due to the development of uveal melanoma cytogenetic prognostics and the progression in generalised uveal melanoma treatment, intraocular melanoma biopsy is becoming increasingly important. Diagnostic biopsy of intraocular tumors is indicated in cases of diagnostic uncertainty for findings with conflicting non-invasive test results and for small melanocyte lesions. Tumor prognostic biopsy is performed to obtain a tissue sample for tumor cytogenetic testing, which can help to determine the prognosis and specific metastatic risk of the patient. For anterior segment tumors, anterior chamber fluid sampling, thin-needle iris biopsy, punch biopsy, surgical biopsy or biopsy using vitrectomy may be used. For posterior segment tumors, procedures include transscleral or transretinal thin-needle biopsy, vitrectomy-assisted biopsy, punch biopsy, endoresection or transscleral exoresection. Complications of intraocular melanoma biopsy include too small or non-valuable sample collection, intra-tumoral heterogeneity, intra-ocular trauma and induction of intraocular or extraocular tumor dissemination.

Rationale & Objective Chronic kidney disease (CKD) can progress rapidly, and patients are often unprepared to make kidney failure treatment decisions. We aimed to better understand patients’ preferences for and experiences of shared and informed decision making (SDM) regarding kidney replacement therapy before kidney failure. Study Design Cross-sectional study. Setting & Participants Adults receiving nephrology care at CKD clinics in rural Pennsylvania. Predictors Estimated glomerular filtration rate, 2-year risk for kidney failure, duration and frequency of nephrology care, and preference for SDM. Outcomes Occurrence and extent of kidney replacement therapy discussions and participants’ satisfaction with those discussions. Analytic Approach Multivariable logistic regression to quantify associations between participants’ characteristics and whether they had discussions. Results The 447 study participants had a median age of 72 (IQR, 64-80) years and mean estimated glomerular filtration rate of 33 (SD, 12) mL/min/1.73 m2. Most (96%) were White, high school educated (67%), and retired (65%). Most (72%) participants preferred a shared approach to kidney treatment decision making, and only 35% discussed dialysis or transplantation with their kidney teams. Participants who had discussions (n = 158) were often completely satisfied (63%) but infrequently discussed potential treatment-related impacts on their lives. In multivariable analyses, those with a high risk for kidney failure within 2 years (OR, 3.24 [95% CI, 1.72-6.11]; P < 0.01), longer-term nephrology care (OR, 1.12 [95% CI, 1.05-1.20] per 1 additional year; P < 0.01), and more nephrology visits in the prior 2 years (OR, 1.34 [95% CI, 1.20-1.51] per 1 additional visit; P < 0.01) had higher odds of having discussed dialysis or transplantation. Limitations Single health system study. Conclusions Most patients preferred sharing CKD treatment decisions with their providers, but treatment discussions were infrequent and often did not address key treatment impacts. Longitudinal nephrology care and frequent visits may help ensure that patients have optimal SDM experiences., Graphical abstract

Prescribed fire has increasingly been used to manage and restore eastern oak (Quercus spp.) forests. Fire has the potential to influence habitat use by forest-dwelling small mammals, including species of conservation concern such as the Allegheny woodrat (Neotoma magister). Thus, an understanding of how Allegheny woodrats respond to habitat changes caused by fire is of increasing importance. We investigated the effects of prescribed fire on a population of Allegheny woodrats in a mixed-oak forest in south-central Pennsylvania. We surveyed 18 rock outcrops for Allegheny woodrats using remote game cameras in September–October 2019. We fit single-season occupancy models in Program PRESENCE to examine the effects of site covariates related to burn history (burned or unburned) and burn frequency (number of burns), topography, and vegetation structure and composition on occupancy (Ψ) of Allegheny woodrats while accounting for imperfect detection (p). In 252 camera trap-nights, we recorded 356 detections of Allegheny woodrats at 50% of sites surveyed. Top-ranked occupancy models (ΔAICc ≤ 2) indicated that Allegheny woodrat occupancy was positively related to burn frequency, overstory tree species richness, and elevation; however, the effects of these covariates were not significant. Our results suggest that low-intensity prescribed fire implemented at moderate (3–5 y) return intervals in oak forests is unlikely to impact Allegheny woodrat populations, but the effects of more frequent and intense fires remain unknown. Additional studies are needed to determine how Allegheny woodrats respond to post-fire vegetation regrowth and recovery over time.

The aim of intraocular melanoma therapy is to achieve local tumor control, reduce the risk of metastasis development, preserve the eyeball and possibly the visual function of the eye. The choice of therapeutic approach requires a comprehensive view and individual approach to each patient with uveal melanoma. Factors considered include local finding (location, tumor size and shape, tumor activity, central visual acuity, intraocular complications), age and the patient‘s overall physical and psychological condition, as well as the patient‘s wishes. The most widely used method of uveal melanoma treatment is radiotherapy. The effect of radiation is caused by the absorption of ionizing radiation energy, the effect of radiation on the cell is manifested by cell death (depletion), or by a cytogenetic information change (mutation). Brachytherapy uses scleral applicators with radionuclide - ruthenium (Ru-106) applicators dominate in Europe and iodine (I-125) applicators in the USA. In external radiotherapy, the source of ionizing radiation is outside the patient‘s body. Both stereotactic radiosurgery and fractionated stereotactic radiotherapy are used. In the Czech Republic, treatment is carried out using Leksell gamma knife or CyberKnife, while proton therapy dominates in the world. The development of serious radiation complications (radiation retinopathy, neuropathy, neovascular glaucoma, toxic tumor syndrome, etc.) should be considered. Surgical therapy involves a variety of invasive procedures. Iridectomy is performed for iris melanoma. Anteriorly located choroidal melanomas and / or ciliary body melanomas can be resolved by transscleral resection (exoresection). For posterior choroidal melanomas, a combination of external tumor irradiation with pars plana vitrectomy is used. Enucleation is a method of choice in advanced tumors that cannot be effectively irradiated. Orbital exenteration is indicated in advanced tumors with extrabulbar spread or in relapsed tumor after previous enucleation.

Hibernation, the use of prolonged torpor to depress metabolism, is employed by mammals to conserve resources during extended periods of extreme temperatures and/or resource limitation. Mammalian hibernators arouse to euthermy periodically during torpor for reasons that are not well understood, and these arousals may facilitate immune processes. To determine whether arousals enable host responses to pathogens, we used dual RNA-Seq and a paired sampling approach to examine gene expression in a hibernating bat, the little brown myotis (Myotis lucifugus). During torpor, transcript levels differed in only a few genes between uninfected wing tissue and adjacent tissue infected with Pseudogymnoascus destructans, the fungal pathogen that causes white-nose syndrome. Within 70-80 min after emergence from torpor, large changes in gene expression were observed due to local infection, particularly in genes involved in pro-inflammatory host responses to fungal pathogens, but also in many genes involved in immune responses and metabolism. These results support the hypothesis that torpor is a period of relative immune dormancy and arousals allow for local immune responses in infected tissues during hibernation. Host-pathogen interactions were also found to regulate gene expression in the pathogen differently depending on the torpor state of the host. Hibernating species must balance the benefits of energy and water conservation achieved during torpor with the costs of decreased immune competence. Interbout arousals allow hibernators to optimize these, and other, trade-offs during prolonged hibernation by enabling host responses to pathogens within brief, periodic episodes of euthermy.

Graphical Abstract, Rationale & Objective Chronic kidney disease (CKD) care is often fragmented across multiple health care providers. It is unclear whether patients rely mostly on their nephrologists or non-nephrologist providers for medical care, including CKD treatment and advice. Study Design Cross-sectional study. Setting & Participants Adults receiving nephrology care at CKD clinics in Pennsylvania. Predictors Frequency, duration, and patient-centeredness (range, 1 [least] to 4 [most]) of participants’ nephrology care. Outcome Participants’ reliance on nephrologists, primary care providers, or other specialists for medical care, including CKD treatment and advice. Analytical Approach Multivariable logistic regression to quantify associations between participants’ reliance on their nephrologists (vs other providers) and their demographics, comorbid conditions, kidney function, and nephrology care. Results Among 1,412 patients in clinics targeted for the study, 676 (48%) participated. Among these, 453 (67%) were eligible for this analysis. Mean age was 71 (SD, 12) years, 59% were women, 97% were white, and 65% were retired. Participants were in nephrology care for a median of 3.8 (IQR, 2.0-6.6) years and completed a median of 4 (IQR, 3-5) nephrology appointments in the past 2 years. Half (56%) the participants relied primarily on their nephrologists, while 23% relied on primary care providers, 18% relied on all providers equally, and 3% relied on other specialists. Participants’ adjusted odds of relying on their nephrologists were higher for those in nephrology care for longer (OR, 1.08 [95% CI, 1.02-1.15]; P = 0.02), those who completed more nephrology visits in the previous 2 years (OR, 1.16 [95% CI, 1.05-1.29]; P = 0.005), and those who perceived their last interaction with their nephrologists as more patient-centered (OR, 2.63 [95% CI, 1.70-4.09]; P

Care for patients transitioning from chronic kidney disease to kidney failure often falls short of meeting patients' needs. The PREPARE NOW study is a cluster randomized controlled trial studying the effectiveness of a pragmatic health system intervention, ‘Patient Centered Kidney Transition Care,’ a multi-component health system intervention designed to improve patients' preparation for kidney failure treatment. Patient-Centered Kidney Transition Care provides a suite of new electronic health information tools (including a disease registry and risk prediction tools) to help providers recognize patients in need of Kidney Transitions Care and focus their attention on patients' values and treatment preferences. Patient-Centered Kidney Transition Care also adds a ‘Kidney Transitions Specialist’ to the nephrology health care team to facilitate patients' self-management empowerment, shared-decision making, psychosocial support, care navigation, and health care team communication. The PREPARE NOW study is conducted among eight [8] outpatient nephrology clinics at Geisinger, a large integrated health system in rural Pennsylvania. Four randomly selected nephrology clinics employ the Patient Centered Kidney Transitions Care intervention while four clinics employ usual nephrology care. To assess intervention effectiveness, patient reported, biomedical, and health system outcomes are collected annually over a period of 36 months via telephone questionnaires and electronic health records. The PREPARE NOW Study may provide needed evidence on the effectiveness of patient-centered health system interventions to improve nephrology patients' experiences, capabilities, and clinical outcomes, and it will guide the implementation of similar interventions elsewhere. Trial registration: NCT02722382

The Cooperative Research Network (CRN) of the National Rural Electric Cooperative Association (NRECA) has identified GridLAB-D as a tool that would provide significant benefit to its member utilities. However, they have also noted that the complexity of the tool would be a significant barrier for adoption. As can often happen in complex simulation environments, as the available capabilities and flexibility increases, the usability of the software decreases except for a few “power” users; this is not unique to GridLAB-D. While GridLAB-D has expanded to a considerable user base, with a few notable exceptions (e.g., American Electric Power) most users are focused on research and development. As a result, NRECA/CRN has proposed an Open Modeling Framework (OMF) designed to make the capabilities of GridLAB-D, and other advanced grid tools, available via a web interface. This will allow utility users to access many of the capabilities of GridLAB-D, with little to no knowledge of the tool itself. Other components will be layered over the simulation engines to provide the user with business support functions, allowing full business case scenarios to be created from the technical data generated within the simulations. Because of the open availability and potential national benefit of the OMF,more » PNNL has been tasked with supporting NRECA/CRN’s development of the tool, with a focus on incorporating GridLAB-D within the OMF structure and expanding GridLAB-D capabilities to support OMF functions. The GridLAB-D enhancements will be provided first to the OMF developers, but will also be delivered to the wider GridLAB-D community after validation via the community repository. This report is intended to provide a roadmap for the intended enhancements to be delivered by PNNL. Seven tasks were identified in cooperation with NRECA/CRN – each is briefly discussed, including potential outcomes and deadlines.« less

Distributed, generation, demand response, distributed storage, smart appliances, electric vehicles and renewable energy resources are expected to play a key part in the transformation of the American power system. Control, coordination and compensation of these smart grid assets are inherently interlinked. Advanced control strategies to warrant large-scale penetration of distributed smart grid assets do not currently exist. While many of the smart grid technologies proposed involve assets being deployed at the distribution level, most of the significant benefits accrue at the transmission level. The development of advanced smart grid simulation tools, such as GridLAB-D, has led to a dramatic improvement in the models of smart grid assets available for design and evaluation of smart grid technology. However, one of the main challenges to quantifying the benefits of smart grid assets at the transmission level is the lack of tools and framework for integrating transmission and distribution technologies into a single simulation environment. Furthermore, given the size and complexity of the distribution system, it is crucial to be able to represent the behavior of distributed smart grid assets using reduced-order controllable models and to analyze their impacts on the bulk power system in terms of stability and reliability. The objectives of more » the project were to: • Develop a simulation environment for integrating transmission and distribution control, • Construct reduced-order controllable models for smart grid assets at the distribution level, • Design and validate closed-loop control strategies for distributed smart grid assets, and • Demonstrate impact of integrating thousands of smart grid assets under closed-loop control demand response strategies on the transmission system. More specifically, GridLAB-D, a distribution system tool, and PowerWorld, a transmission planning tool, are integrated into a single simulation environment. The integrated environment allows the load flow interactions between the bulk power system and end-use loads to be explicitly modeled. Power system interactions are modeled down to time intervals as short as 1-second. Another practical issue is that the size and complexity of typical distribution systems makes direct integration with transmission models computationally intractable. Hence, the focus of the next main task is to develop reduced-order controllable models for some of the smart grid assets. In particular, HVAC units, which are a type of Thermostatically Controlled Loads (TCLs), are considered. The reduced-order modeling approach can be extended to other smart grid assets, like water heaters, PVs and PHEVs. Closed-loop control strategies are designed for a population of HVAC units under realistic conditions. The proposed load controller is fully responsive and achieves the control objective without sacrificing the end-use performance. Finally, using the T&D simulation platform, the benefits to the bulk power system are demonstrated by controlling smart grid assets under different demand response closed-loop control strategies. « less

This case study surveys by questionnaire the practices, policies and attitudes impacting library video service of the member libraries in the Mid-Hudson Library System. The factors which negatively affect public access to video are discussed and related to resource sharing of non-print materials. Video cassettes are compared to traditional library materials. Format opposed to content is examined. Recommendations for further study chronicle the System Board resolutions for working at the state level to change the New York State Commissioner's Regulations which now permit the exclusion of non-print materials.

Previous studies have shown that changes in the peripheral circulation occur in patients with liver disease. We have investigated the temperature of the hands of 26 patients and 13 controls using a liquid crystal contact thermography system. Significant differences in resting hand temperature and appearance were observed when the patients were categorised according to Child's score. The appearance depended upon the severity of liver disease; Child's A patients have warm hands of normal thermographic appearance; Child's B patients have cold hands with an abnormal thermographic appearance; whilst Child's C patients have warm hands with an abnormal thermographic appearance. After right-hand ice-cold water immersion, right-hand recovery was abnormally slow in Child's B & C groups compared with Child's A patients and controls. In addition, there was left-hand reflex vasoconstriction during the right-hand warm-up period in those with severe liver disease. With regard to autonomic function, no significant difference in right-hand temperature, thermographic appearance or warm-up rate was detected between those with and those without autonomic neuropathy. These results indicate that autonomic nervous system dysfunction is not the predominant cause of these changes.

Small signal stability problems are one of the major threats to grid stability and reliability. Prony analysis has been successfully applied on ringdown data to monitor electromechanical modes of a power system using phasor measurement unit (PMU) data. To facilitate an on-line application of mode estimation, this paper develops a recursive algorithm for implementing Prony analysis and proposed an oscillation detection method to detect ringdown data in real time. By automatically detecting ringdown data, the proposed method helps guarantee that Prony analysis is applied properly and timely on the ringdown data. Thus, the mode estimation results can be performed reliably and timely. The proposed method is tested using Monte Carlo simulations based on a 17-machine model and is shown to be able to properly identify the oscillation data for on-line application of Prony analysis. In addition, the proposed method is applied to field measurement data from WECC to show the performance of the proposed algorithm.

Prospective, single-group, repeated-measures design.To analyze the longissimus thoracis and lumbar multifidi muscle activity with surface electromyography (EMG) during exercises used in back rehabilitation programs.Physical therapists use a variety of exercises when rehabilitating patients with low back pain (LBP). EMG analysis of exercises can provide a measure of muscle activation so a clinician can have a better idea about the effect the exercise may have on the muscle for stabilization, endurance, or strength training.Surface EMG analysis of the muscle activity of the longissimus thoracis and lumbar multifidi was carried out bilaterally on 3 different experimental groups while performing a variety of exercises commonly used in low back rehabilitation programs. Groups 1 and 2 each had 30 subjects and group 2 had 29 subjects, ranging in age from 21 to 35 years. All EMG data during exercises were normalized to percent of the maximum voluntary isometric contraction (MVIC).The lumbar multifidus and longissimus thoracis muscles were most active, with EMG amplitudes of greater than 92% +/- 12% MVIC during prone lumbar extension to end range with resistance applied. Prone lumbar extension to neutral, resisted lumbar extension while sitting, and prone extension with the upper and lower extremities lifted (Superman exercise) produced EMG amplitudes ranging from a mean +/- SD of 77% +/- 13% to 82% +/- 12% MVIC. Exercises that produced EMG amplitudes of less than 50% MVIC were bridging exercises, the side-bridge exercise, and upper and lower extremity raises in either the prone or quadruped positions.The findings from this study may be helpful for physical therapists in selecting exercises when progressing patients with LBP from low-intensity exercises to those that require more muscle activity.

Objective To determine whether changes in hand skin blood flow in diabetic men could be demonstrated with liquid crystal contact thermography and to assess the relative effects of autonomic neuropathy and microangiopathy on these changes. Research Design and Methods Thirty-four diabetic and 12 age-matched nondiabetic men comprised the study. The diabetic men were categorized according to standard cardiovascular autonomic function tests and the presence or absence of background or proliferative retinopathy and/or proteinuria. Bilateral hand thermograms were measured at rest and after immersion of the right hand in ice-cold water. Results Diabetic men with definite or severe autonomic neuropathy (n = 13) had a high frequency of anisothermal baseline thermograms (77 vs. 25% in nondiabetic subjects, P < 0.05). After ice-cold water immersion, right-hand recovery was abnormally slow (514 ± 157 arbitrary U, area under the curve) compared with nondiabetic men (685 ± 135 arbitrary U, P < 0.01). Diabetic men with proliferative retinopathy (n = 8) all had definite or severe autonomic neuropathy and showed the same abnormalities. Diabetic men with nor or early autonomic changes showed normal thermographic patterns. Conclusions These results are consistent with increased palmar arteriovenous shunt blood flow or capillary closure in the hands of diabetic patients with definite or severe autonomic neuropathy. They indicate that thermoregulatory reflex changes in hand skin blood flow are controlled by the autonomic nervous system. It is possible, however, that diabetic microangiopathy, associated with the presence of proliferative retinopathy, also independently affects hand skin blood flow.

Chronic liver disease is frequently associated with a hyperdynamic circulation, with warm hands and capillary pulsations. In our experience, however, a significant number of patients with alcoholic liver disease complain of cold hands. In this study, we have investigated the presence of the subjective feeling of hand temperature in 114 patients with alcoholic liver disease compared with 96 healthy controls, and studied possible correlations of this subjective feeling with the severity of liver disease. Significantly more patients with alcoholic liver disease complained of cold hands than did normals, and these differences were more prominent in the male group. The awareness of cold hands appears to be commoner in an intermediate group of patients, between those with noncirrhotic liver disease without varices and those with cirrhosis with varices. A similar pattern of awareness of hand temperature was found when patients were staged according to the severity of their liver disease. We conclude that a staging can be made; at an early stage of liver disease, patients tend to have warm hands, subsequently develop cold hands, and at a later stage, their hands become warm again.

As the number of women with acquired immunodeficiency syndrome (AIDS) continues to rise in the United States, it becomes important to target preventive interventions as effectively as possible toward those groups at highest risk of acquiring human immunodeficiency virus (HIV) infection. We analyzed the prevalence of serum antibody to HIV in 333 women admitted to the Gynecology Service at San Francisco General Hospital with acute pelvic inflammatory disease in the years 1985-1988. The proportion of women with HIV infection in our sample rose incrementally over this 4-year period, from 0 to 6.7%. A history of intravenous (IV) drug use conferred a 23-fold risk of HIV seropositivity. In contrast, markers of the level of sexual activity did not correlate significantly with the presence of HIV infection, although the power to detect such an association was limited by the small sample size. An intensification of educational efforts directed at IV drug-using women in San Francisco is necessary to prevent further increases in the rate of HIV infection and further spread into the heterosexual population.

Chronic liver disease is frequently associated with a hyperdynamic circulation, with warm hands and capillary pulsations. In our experience, however, a significant number of patients with alcoholic liver disease complain of cold hands. In this study, we have investigated the presence of the subjective feeling of hand temperature in 114 patients with alcoholic liver disease compared with 96 healthy controls, and studied possible correlations of this subjective feeling with the severity of liver disease. Significantly more patients with alcoholic liver disease complained of cold hands than did normals, and these differences were more prominent in the male group. The awareness of cold hands appears to be commoner in an intermediate group of patients, between those with noncirrhotic liver disease without varices and those with cirrhosis with varices. A similar pattern of awareness of hand temperature was found when patients were staged according to the severity of their liver disease. We conclude that a staging can be made; at an early stage of liver disease, patients tend to have warm hands, subsequently develop cold hands, and at a later stage, their hands become warm again.

A farm-scale research and demonstration digester has been constructed, operated and monitored on a private medium-sized swine farm. Materials handling problems have been studied. Bio-gas from the digester is used in a motor generator set to be integrated into the farmstead energy system. The digester has been monitored to determine operational characteristics, amount of energy produced and efficiency of energy production.

Compared MMPI group mean profiles of rapists of adults, rapists of children, and non-rapist sex offenders. All three groups showed similar elevations on scale 4, but they differed in the extent to which scale 8 characteristics combined with those of scale 4. Rapists of adults showed an elevated 8-4 profile, rapists of children showed a 4-8 profile but with scale 8 somewhat lower, and non-rapists showed a high-4 profile with scale 8 elevated still less. Though there was marked heterogeneity in the two-point codes within groups, still the group results supported the notion that while all three types of sex offenders are impulsive and self-centered with poor social intelligence, the rapists of adults are more hostile, resentful, and interpersonally alienated than are rapists of children, and both types of rapists show those hostile and resentful characteristics more than do non-rapist sex offenders.

Compared MMPI group mean profiles of rapists of adults, rapists of children, and non-rapist sex offenders. All three groups showed similar elevations on scale 4, but they differed in the extent to which scale 8 characteristics combined with those of scale 4. Rapists of adults showed an elevated 8-4 profile, rapists of children showed a 4-8 profile but with scale 8 somewhat lower, and non-rapists showed a high-4 profile with scale 8 elevated still less. Though there was marked heterogeneity in the two-point codes within groups, still the group results supported the notion that while all three types of sex offenders are impulsive and self-centered with poor social intelligence, the rapists of adults are more hostile, resentful, and interpersonally alienated than are rapists of children, and both types of rapists show those hostile and resentful characteristics more than do non-rapist sex offenders.

The Bender-Gestalt and WISC or WISC-R performances of two groups of 19 emotionally disturbed children matched in age (9–1 to 16–7) and Full Scale IQ were compared. Each child in one group had a medically documented seizure disorder; a matched child in the other group had no present or past indications of organicity. Neither Bender-Gestalt errors nor Wechsler IQs or Deviation Quotients differed significantly between the two groups. The emotionally disturbed children with seizure disorders could not be differentiated from the other emotionally disturbed children solely on the basis of Bender-Gestalt and Wechsler test scores.