text:
Q: tensorflowjs_converter InvalidArgumentError whilst trying to convert TF Saved Model Whilst trying to convert a TF Saved Model to TFJS Graph Model the conversion fails and throws a InvalidArgumentError.
InvalidArgumentError: Input 0 of node StatefulPartitionedCall/LSTM_92444743/rnn/while/body/_29/AssignVariableOp was passed float from Func/StatefulPartitionedCall/LSTM_92444743/rnn/while/body/_29/input/_318:0 incompatible with expected resource.
Command:
tensorflowjs_converter --input_format=tf_saved_model --saved_model_tags=serve --signature_name=serving_default ./3.4model.pb ./output
Versions:
tensorflow 2.6.2
tensorflowjs 3.13.0
For reference the TF Saved Model was originally converted from ONNX (opset-10 ) using the following command:
onnx-tf convert -i ./dna_r9.4.1_e8_fast\@3.4.onnx -o 3.4model.pb
Full trace log:
To enable them in other operations, rebuild TensorFlow with the appropriate compiler flags.
2022-02-25 11:36:18.237098: I tensorflow/core/grappler/devices.cc:75] Number of eligible GPUs (core count >= 8, compute capability >= 0.0): 0 (Note: TensorFlow was not compiled with CUDA or ROCm support)
2022-02-25 11:36:18.237169: I tensorflow/core/grappler/clusters/single_machine.cc:357] Starting new session
2022-02-25 11:36:18.319180: I tensorflow/core/grappler/optimizers/meta_optimizer.cc:1137] Optimization results for grappler item: graph_to_optimize
function_optimizer: Graph size after: 1418 nodes (1389), 2125 edges (2096), time = 52.338ms.
function_optimizer: function_optimizer did nothing. time = 2.186ms.

WARNING:tensorflow:From /user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflowjs/converters/tf_saved_model_conversion_v2.py:397: load (from tensorflow.python.saved_model.loader_impl) is deprecated and will be removed in a future version.
Instructions for updating:
This function will only be available through the v1 compatibility library as tf.compat.v1.saved_model.loader.load or tf.compat.v1.saved_model.load. There will be a new function for importing SavedModels in Tensorflow 2.0.
WARNING:tensorflow:From /user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflowjs/converters/tf_saved_model_conversion_v2.py:402: convert_variables_to_constants (from tensorflow.python.framework.graph_util_impl) is deprecated and will be removed in a future version.
Instructions for updating:
Use 'tf.compat.v1.graph_util.convert_variables_to_constants'
WARNING:tensorflow:From /user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/framework/convert_to_constants.py:927: extract_sub_graph (from tensorflow.python.framework.graph_util_impl) is deprecated and will be removed in a future version.
Instructions for updating:
Use 'tf.compat.v1.graph_util.extract_sub_graph'
Traceback (most recent call last):
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/framework/importer.py", line 497, in _import_graph_def_internal
graph._c_graph, serialized, options) # pylint: disable=protected-access
tensorflow.python.framework.errors_impl.InvalidArgumentError: Input 0 of node StatefulPartitionedCall/LSTM_92444743/rnn/while/body/_29/AssignVariableOp was passed float from Func/StatefulPartitionedCall/LSTM_92444743/rnn/while/body/_29/input/_318:0 incompatible with expected resource.

During handling of the above exception, another exception occurred:

Traceback (most recent call last):
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflowjs/converters/tf_saved_model_conversion_v2.py", line 635, in _convert_tf_saved_model
frozen_graph = _freeze_saved_model_v2(concrete_func, control_flow_v2)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflowjs/converters/tf_saved_model_conversion_v2.py", line 434, in _freeze_saved_model_v2
aggressive_inlining=True).graph
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/framework/convert_to_constants.py", line 1154, in convert_variables_to_constants_v2
converted_input_indices)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/framework/convert_to_constants.py", line 1080, in _construct_concrete_function
new_output_names)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/eager/wrap_function.py", line 650, in function_from_graph_def
wrapped_import = wrap_function(_imports_graph_def, [])
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/eager/wrap_function.py", line 628, in wrap_function
collections={}),
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/framework/func_graph.py", line 1007, in func_graph_from_py_func
func_outputs = python_func(*func_args, **func_kwargs)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/eager/wrap_function.py", line 87, in call
return self.call_with_variable_creator_scope(self._fn)(*args, **kwargs)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/eager/wrap_function.py", line 93, in wrapped
return fn(*args, **kwargs)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/eager/wrap_function.py", line 648, in _imports_graph_def
importer.import_graph_def(graph_def, name="")
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/util/deprecation.py", line 549, in new_func
return func(*args, **kwargs)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/framework/importer.py", line 405, in import_graph_def
producer_op_list=producer_op_list)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/framework/importer.py", line 501, in _import_graph_def_internal
raise ValueError(str(e))
ValueError: Input 0 of node StatefulPartitionedCall/LSTM_92444743/rnn/while/body/_29/AssignVariableOp was passed float from Func/StatefulPartitionedCall/LSTM_92444743/rnn/while/body/_29/input/_318:0 incompatible with expected resource.

During handling of the above exception, another exception occurred:

Traceback (most recent call last):
File "/user/lj/py3.6.8/venv/bin/tensorflowjs_converter", line 8, in
sys.exit(pip_main())
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflowjs/converters/converter.py", line 813, in pip_main
main([' '.join(sys.argv[1:])])
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflowjs/converters/converter.py", line 817, in main
convert(argv[0].split(' '))
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflowjs/converters/converter.py", line 804, in convert
weight_shard_size_bytes, metadata_map)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflowjs/converters/converter.py", line 533, in _dispatch_converter
metadata=metadata_map)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflowjs/converters/tf_saved_model_conversion_v2.py", line 771, in convert_tf_saved_model
metadata=metadata)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflowjs/converters/tf_saved_model_conversion_v2.py", line 641, in _convert_tf_saved_model
output_node_names)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflowjs/converters/tf_saved_model_conversion_v2.py", line 402, in _freeze_saved_model_v1
sess, meta_graph_def, output_node_names)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/util/deprecation.py", line 346, in new_func
return func(*args, **kwargs)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/framework/graph_util_impl.py", line 281, in convert_variables_to_constants
variable_names_denylist=variable_names_blacklist)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/framework/convert_to_constants.py", line 1282, in convert_variables_to_constants_from_session_graph
variable_names_denylist=variable_names_denylist))
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/framework/convert_to_constants.py", line 927, in init
graph_def = graph_util.extract_sub_graph(graph_def, output_node_names)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/util/deprecation.py", line 346, in new_func
return func(*args, **kwargs)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/framework/graph_util_impl.py", line 209, in extract_sub_graph
_assert_nodes_are_present(name_to_node, dest_nodes)
File "/user/lj/py3.6.8/venv/lib/python3.6/site-packages/tensorflow/python/framework/graph_util_impl.py", line 164, in _assert_nodes_are_present
assert d in name_to_node, "%s is not in graph" % d
AssertionError: Identity is not in graph
WARNING:tensorflow:Unresolved object in checkpoint: (root).call
WARNING:tensorflow:Unresolved object in checkpoint: (root).gen_tensor_dict
WARNING:tensorflow:Unresolved object in checkpoint: (root).signatures.serving_default
WARNING:tensorflow:A checkpoint was restored (e.g. tf.train.Checkpoint.restore or tf.keras.Model.load_weights) but not all checkpointed values were used. See above for specific issues. Use expect_partial() on the load status object, e.g. tf.train.Checkpoint.restore(...).expect_partial(), to silence these warnings, or use assert_consumed() to make the check explicit. See https://www.tensorflow.org/guide/checkpoint#loading_mechanics for details```

A: onnx-tf wrote a model which uses TF1 specific features which are no longer available in TF2.
options:

*

*check if onnx-tf can write proper TF2 models instead

*load TF1 model in Python with TF2, but using tf.compat.v1, convert variables to constants and save it

*use older TFJS so tensorflowjs_converter binds to TF1


text:
Eilífr Goðrúnarson (Eil)
10th century; volume 3; ed. Edith Marold;
1. Þórsdrápa (Þdr) - 23
2. Hákonar drápa jarls (Hákdr) - 0
3. Fragment (Frag) - 1
Þórsdrápa — Eil ÞdrIII
Edith Marold with the assistance of Vivian Busch, Jana Krüger, Ann-Dörte Kyas and Katharina Seidel, translated from German by John Foulks 2017, '(Introduction to) Eilífr Goðrúnarson, Þórsdrápa' in Kari Ellen Gade and Edith Marold (eds), Poetry from Treatises on Poetics. Skaldic Poetry of the Scandinavian Middle Ages 3. Turnhout: Brepols, p. 68.
stanzas: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Skj: Eilífr Goðrúnarson: 2. Þórsdrápa (AI, 148-52, BI, 139-44); stanzas (if different): 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21
Full edition, translation and commentary for this verse can be found in the printed volume III, p. 124. See the Brepols website for more information. The text below is from a superseded edition (Skj where relevant). Do not refer to this site when using the text below.
23 — Eil Þdr 23III
The following text is from a superseded edition and is not the work of the editor(s) named on this page. It is included for reference only. Do not refer to this site when using this text but rather consult the original edition (Skj where relevant).
Verðið ér, alls orða
oss grœr of kon mœran
á sefreinu Sónar
sáð, vingjǫfum ráða.
texts: ‹Skm 36›, ‹SnE 38›
editions: Skj Eilífr Goðrúnarson: 1. Et digt om Hakon jarl (AI, 148; BI, 139); Skald I, 76, NN §441; SnE 1848-87, I, 250-1, II, 307, 522, III, 13, SnE 1931, 93, SnE 1998, I, 13.
GKS 2367 4° (R) 21v, 12 - 21v, 13 (SnE)
Traj 1374x (Tx) 22r, 6 - 22r, 7 (SnE)
AM 242 fol (W) 46, 23 - 46, 24 (SnE)
DG 11 (U) 27r, 15 - 27r, 16 (SnE)
AM 757 a 4° (B) 4r, 45 - 4r, 45 (SnE)
AM 761 a 4°x (761ax) 82r, 7 - 82r, 10 (Skáldatal)

redpajama_set_name: RedPajamaCommonCrawl


text:
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Reply 640
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The Ranger is a camera for 3-D scanner manufacturers and vision integrators that is capable of 3-D vision inspections of up to 35,000 profiles per second. It also can achieve measurements down to less than 10 micrometers. The camera has interchangeable optics and can be combined with light sources in setups optimized for each application, making it suitable for a range of applications-from small-sized electronic component inspection to large-scale log inspections. With multiple interface options, including CameraLink and Gigabit Ethernet, the camera offers more flexibility for integrating these automation tools. In addition, it can perform multiple types of inspections simultaneously-such as high-speed 3-D, high-resolution grayscale and a patented inspection method called scatter.
www.sickusa.com


It's officially September, meaning there are only four months left in 2016. How crazy is that? This entire year has been a whirlwind for us – from Kelly going back and forth between England and the US until May; a summer at the Euros and in Barbados that went by in the blink of an eye; trying to make the most of summer in London; our wedding; and now, four months left in the year.
Many thanks to World Travel Adventurers for sending this picture to us since we don't have one of our own!
This weekend, we are heading to Slovakia! England will be playing Slovakia in football as a World Cup 2018 qualifying match, and we are going to attend with Sean's parents. The match is on Sunday, though, so we have a full day to explore Bratislava on Sunday, and time to explore either Bratislava or Vienna on Monday. We are looking forward to a much needed post-wedding city break. Let us know if you have any recommendations!
Now that our dog has arrived in the UK, we are trying to incorporate him into our travel as much as possible. There are so many dog friendly hotels and villages in the UK, and we have been meaning to explore more of our home country anyway, so it is the perfect fit. We are not sure which trips we will be able to cram into this year, but the places on our radar include: The Cotswolds, Cornwall, Snowdonia, the Lake District, Cambridge, Isle of Skye, and York.
On October 1, we will be starting a challenge to visit as much of the UK as possible through weekend trips and day trips (more details here).We will definitely be cramming in a day trip to Kew Gardens (can you believe we haven't been yet?!) and a weekend trip or two up north to see our beautiful goddaughter, but we are looking forward to seeing which other locations we can squeeze in before the end of the year.
Towards the end of October, we will be heading out on a short, 5 day roadtrip in Southwest Ireland. The plan is to fly into Cork, do a bit of exploring around there, then head to Killarney and base ourselves there to explore the Ring of Kerry. Kelly has been planning this trip for awhile, and it will consist of plenty of romantic B&Bs, castle photos, and Guinness for Sean. This trip is going to be the closest thing we do to a honeymoon this year – we're calling it a minimoon!
Yes, we already went to Berlin this year, but it was only for a weekend! Plus, now Kelly's brother and his wife, Sarah, live there, so we have to go again! We had the chance to explore some of the major sites when we visited last, but did not have enough time to really get a feel for the city. Hopefully we have the chance to visit when there is some sort of festival on – we hear Berliners are pretty good at drinking!
After our trip to Alsace for Kelly and Sarah's birthdays last year, Kelly is all about visiting a Christmas market for her birthday every year. The mulled wine, handmade trinkets, and carnival-like food was so enjoyable, and you can't help but fall in love with the Christmas spirit! A weekend in Cologne is at the top of our list for this year, but we are open to suggestions. What's your favourite European Christmas market?
Zermatt is a frequent trip for us (at least 1-2 times per year) because we have a place to stay out there. However, we have yet to spend Christmas together in Switzerland (Sean has previously with his family). This year, his family is trying to get all of the kids out there at once – if not for Christmas, then for New Years. We are crossing our fingers that we can make it work, and already salivating over the thought of fondue!
We are already diving into our 2017 travel planning, and cannot wait to share what we will be doing with you guys! Look out for posts on all of our remainder of 2016 adventures, and feel free to send any recommendations you have for the above our way.
Where would you like to see us travel in 2017?
Pin this post for future travel inspiration!
We can't wait either! Hopefully we can make it there soon!


Earlier this month I completed another fact-finding mission: figuring out if I really truly love Portland, Oregon. Amanda and I first visited Portland in 2005 after a glowing recommendation from my brother. Since then I've been longing to go back: to explore the endless shelves at Powell's books and sample what some claim to be the best pizza in America.
When I saw that the forecast was for rain all weekend, I knew this would be the first trial of my love. Plus, we weren't renting a car, so we walked around in the chilly (40-50deg) rain all weekend. This did not dampen my spirits one bit. I really enjoy overcast weather because it cuts down on sunburn and keeps things cool. Plus there are so many wonderful green trees and lawn there.
We learned about Voodoo Doughnut on the Food Network and of course had to visit their downtown location. The first time we went there (Friday morning) the line was out the door and we would have waited for 30mins just to get our doughnuts. So we went to Stumptown Coffee Roasters (also great!) instead and vowed to return.
The second day was much less busy and gave us a chance to peruse their funky menu and order up some sugary concoctions for the days ahead. We started with a Triple Chocolate Penetration (yes, it's topped with Coco Puffs) and something that was topped with Cap'n Crunch cereal. What's amazing is how well the cereal worked by adding just enough crunch to an otherwise soft and delicious doughnut. The sugar balance was also just right.
For breakfast the next day we grabbed a blue-raspberry-cotton-candy flavored one and their namesake Voodoo Doll doughnut, which is filled with raspberry jelly that looks like blood when you bite into it. Yum!
One consistent thing we noticed is that service there was universally friendly: from the baristas to the bartenders to the servers. People were willing to take time to explain things to you and always had a smile. It certainly made our trip even more enjoyable.
We always try to hit as many breweries and brewpubs as possible, and this trip was no exception. My favorite of the bunch was Deschutes Brewpub because the food, beer, ad location were all excellent. We actually ended up going there twice.
The interior space has a modern warehouse feel to it and the restrooms have gigantic urinals. Amanda was on a venison kick so she had elk stew one day and the elk burger the next.
I had the Reuben sandwich and the Blue Bacon burger. They offer generous beer samplers and even have a special/seasonal beer menu that you can choose from. I'm really glad we didn't have to drive anywhere afterwards.
One of the surprises of the trip was running into a couple places who made their own spirits. Our first night there we went to McMenamin's Ringler's Annex which is tucked in the basement in a triangle-shaped block. Upon finishing our panini-centric meal and imbibing a couple of their house beers, we spotted their Alambic "13" Brandy and realized we had to get that. It was served warm by precariously positioning a brandy snifter over a glass of warm water, which releases the intoxicating aromas.
Our second encounter with artisan distillation happened at the Rogue Public House, where after having enjoyed a couple of their fine ales we decided to move on to the hard stuff: hazelnut spiced rum, spruce gin, pink gin, and probably some others I'm not remembering. I'm not a big gin fan, but the Rogue incarnations were amazing. I wouldn't hesitate to say that trying artisan spirits there and at McMenamins was a revelation.
After drinking at Rogue we had the munchies, and my phone told me there were cupcakes nearby. We found ourselves at Cupcake Jones where we could point-point at the ones we wanted to devour. Those first couple were gone so fast we didn't even have time to take pictures (nor can I remember the flavors), so we went back the next day just so that I could bring you this fine shot of their chocolate chip cookie dough cupcake.
What else is there to say, other than Powell's is a full city block and 4+ stories high (depending on how you count, since the stories don't cover the full block)? One neat thing is that, at Powell's, they intermix used and new books so that you aren't limited to what is still in print. They even have a rare book room. I spent a lot of time in their humor and art sections, and also scoped out some good cycling books.
One of our side trips was to do a pub crawl down Hawthorne Blvd, with the final dinner destination being a pizza place we didn't make it to last time: Apizza Scholls. We started at the Lucky Labrador Brew Pub, where we enjoyed a couple of their beers, a pulled pork sandwich, and some unshelled peanuts. The pub has a very open feel but was a little more grungy than Deschutes. The food was unadventurous and so-so but the beer was tasty.
Our next stop was Roots Brewing Company, just one block away. The food menu there looked tasty but we stayed away, preserving our appetite. They had a great selection of beers to offer in their reasonably priced sampler, including the unique heather ale and the tasty Festivus. You knew it was a working brewery because the whole placed smelled like boiling and fermenting beer. This was a great stop and certainly a place to get some food next visit.
We then hopped back on the bus and made our way further down Hawthorne. At our next stop we visited a couple shops including a mystery bookstore (Murder By The Book), Powell's Home & Garden (yes, they're so big they have specialized satellite bookstores), and a neat Italian market.
Our last destination of the evening was Apizza Scholls, which is well known for making a high-quality pizza with fresh ingredients. It had also been featured on TV and we tried to go here last time we were in Portland but it had been closed for Memorial Day weekend. This time we showed up at 4:30 to wait in a ~20-person line for their 5pm opening. Service was slow at first as they struggled to deal with the glut of people right at opening. Their beer list included a local (homebrew?) IPA that Amanda got, and I stuck with a non-alcoholic birch beer.
We ordered their sausage pizza, figuring that a homemade sausage would beat out pepperoni. It was an excellent pie, but to be honest I was expecting it to be more transcendent than it was. I'm a big fan of Blind Lady Ale House here in San Diego, and I'd say they offer just as good of pizza with more unique ingredients (love the poblano chorizo one) and a better beer selection.
In spite of 30-degree temperatures with driving wind and rain, there was an amazing array of vendors at the Portland Saturday Market. What sets this apart from other street markets is the quality of crafts and selection of booths. There is a great selection of food items, cute haberdashery, and some great art involving utensils. The only thing we bought was a catnip-filled body pillow for the cats – about as much fun as you can have for $6.
Well, I guess there hasn't been one yet. The 7.2 San Diego earthquake happened while we were still up in Portland and we returned home to a mess of tumbled CDs and some terrified cats. Actually it was interesting and fortunate that the only things that fell were my CDs – the glasses stayed put in the cabinets.
This entry was posted in Beer, Travel and tagged Beer, cupcakes, doughnuts, portland, travel. Bookmark the permalink.
My husband and I just moved to PDX a year ago and have been fun trying these same things! We love VooDoo and Cupcake Jones and the Sat. market is the best on a sunny day!
Thanks so much for mentioning us on your blog! We LOVE living here in Portland for all your reasons and many many more, too!
See you at the bakery!


text:
Excerpt from The Last Juror by John Grisham, plus links to reviews, author biography & more
Summary | Excerpt | Reviews | Readalikes | Genres & Themes | Author Bio
Feb 2004, 368 pages
Dec 2004, 496 pages
Legal, Medical & Corporate Thrillers
Ordinary People (Thrillers)
Mis. Ala. Ga.
1960s & '70s
Rhoda Kassellaw lived in the Beech Hill community, twelve miles north of Clanton, in a modest gray brick house on a narrow, paved country road. The flower beds along the front of the house were weedless and received daily care, and between them and the road the long wide lawn was thick and well cut. The driveway was crushed white rock. Scattered down both sides of it was a collection of scooters and balls and bikes. Her two small children were always outdoors, playing hard, sometimes stopping to watch a passing car.
It was a pleasant little country house, a stone's throw from Mr. And Mrs. Deece next door. The young man who bought it was killed in a trucking accident somewhere in Texas, and, at the age of twenty-eight, Rhoda became a widow. The insurance on his life paid off the house and the car. The balance was invested to provide a modest monthly income that allowed her to remain home and dote on the children. She spent hours outside, tending her vegetable garden, potting flowers, pulling weeds, mulching the beds along the front of the house.
She kept to herself. The old ladies in Beech Hill considered her a model widow, staying home, looking sad, limiting her social appearances to an occasional visit to church. She should attend more regularly, they whispered.
Shortly after the death of her husband, Rhoda planned to return to her family in Missouri. She was not from Ford County, nor was her husband. A job took them there. But the house was paid for, the kids were happy, the neighbors were nice, and her family was much too concerned about how much life insurance she'd collected. So she stayed, always thinking of leaving but never doing so.
Rhoda Kassellaw was a beautiful woman when she wanted to be, which was not very often. Her shapely, thin figure was usually camouflaged under a loose cotton drip-dry dress, or a bulky chambray workshirt, which she preferred when gardening. She wore little makeup and kept her long flaxen-colored hair pulled back and stuck together on top of her head. Most of what she ate came from her organic garden, and her skin had a soft healthy glow to it. Such an attractive young widow would normally have been a hot property in the county, but she kept to herself.
After three years of mourning, however, Rhoda became restless. She was not getting younger; the years were slipping by. She was too young and too pretty to sit at home every Saturday and read bedtime stories. There had to be some action out there, though there was certainly none in Beech Hill.
She hired a young black girl from down the road to baby-sit, and Rhoda drove north for an hour to the Tennessee line, where she'd heard there were some respectable lounges and dance clubs. Maybe no one would know her there. She enjoyed the dancing and the flirting, but she never drank and always came home early. It became a routine, two or three times a month.
Then the jeans got tighter, the dancing faster, the hours longer and longer. She was getting noticed and talked about in the bars and clubs along the state line.
He followed her home twice before he killed her. It was March, and a warm front had brought a premature hope of spring. It was a dark night, with no moon. Bear, the family mutt, sniffed him first as he crept behind a tree in the backyard. Bear was primed to growl and bark when he was forever silenced.
Rhoda's son Michael was five and her daughter Teresa was three. They wore matching Disney cartoon pajamas, neatly pressed, and watched their mother's glowing eyes as she read them the story of Jonah and the whale. She tucked them in and kissed them good night, and when Rhoda turned off the light to their bedroom, he was already in the house.
An hour later she turned off the television, locked the doors, and waited for Bear, who did not appear. That was no surprise because he often chased rabbits and squirrels into the woods and came home late. Bear would sleep on the back porch and wake her howling at dawn. In her bedroom, she slipped out of her light cotton dress and opened the closet door. He was waiting in there, in the dark.
Copyright John Grisham 2004. All rights reserved.
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Genres & Themes
The Fortunate Ones
by Ed Tarkington
An engrossing story of class, love, and loyalty for fans of Kevin Wilson's Nothing to See Here.
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October 13, 2009; 73 (15) Special Article
Practice Parameter update: The care of the patient with amyotrophic lateral sclerosis: Multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidence-based review)
Report of the Quality Standards Subcommittee of the American Academy of Neurology
R. G. Miller, C. E. Jackson, E. J. Kasarskis, J. D. England, D. Forshew, W. Johnston, S. Kalra, J. S. Katz, H. Mitsumoto, J. Rosenfeld, C. Shoesmith, M. J. Strong, S. C. Woolley
First published October 12, 2009, DOI: https://doi.org/10.1212/WNL.0b013e3181bc01a4
R. G. Miller
C. E. Jackson
E. J. Kasarskis
J. D. England
D. Forshew
W. Johnston
S. Kalra
J. S. Katz
H. Mitsumoto
J. Rosenfeld
C. Shoesmith
M. J. Strong
S. C. Woolley
Neurology Oct 2009, 73 (15) 1227-1233; DOI: 10.1212/WNL.0b013e3181bc01a4
CME Course
Objective: To systematically review evidence bearing on the management of patients with amyotrophic lateral sclerosis (ALS).
Methods: The authors analyzed studies from 1998 to 2007 to update the 1999 practice parameter. Topics covered in this section include breaking the news, multidisciplinary clinics, symptom management, cognitive and behavioral impairment, communication, and palliative care for patients with ALS.
Results: The authors identified 2 Class I studies, 8 Class II studies, and 30 Class III studies in ALS, but many important areas have been little studied. More high-quality, controlled studies of symptomatic therapies and palliative care are needed to guide management and assess outcomes in patients with ALS.
Recommendations: Multidisciplinary clinic referral should be considered for managing patients with ALS to optimize health care delivery and prolong survival (Level B) and may be considered to enhance quality of life (Level C). For the treatment of refractory sialorrhea, botulinum toxin B should be considered (Level B) and low-dose radiation therapy to the salivary glands may be considered (Level C). For treatment of pseudobulbar affect, dextromethorphan and quinidine should be considered if approved by the US Food and Drug Administration (Level B). For patients who develop fatigue while taking riluzole, withholding the drug may be considered (Level C). Because many patients with ALS demonstrate cognitive impairment, which in some cases meets criteria for dementia, screening for cognitive and behavioral impairment should be considered in patients with ALS (Level B). Other management strategies all lack strong evidence.
ALS=
amyotrophic lateral sclerosis;
ALS-FTD=
amyotrophic lateral sclerosis with a dementia meeting the Neary criteria for frontotemporal dementia;
ALSbi=
amyotrophic lateral sclerosis with behavioral impairment;
ALSci=
amyotrophic lateral sclerosis with cognitive impairment;
BTxA=
botulinum toxin type A;
BTxB=
botulinum toxin type B;
DM=
dextromethorphan;
FDA=
Food and Drug Administration;
FTD=
frontotemporal dementia;
NIV=
noninvasive ventilation;
PEG=
percutaneous endoscopic gastrostomy;
Q=
quinidine.
Amyotrophic lateral sclerosis (ALS) is a relentlessly progressive paralyzing disease. Most patients with ALS die within 2 to 5 years of onset. The mainstay of ALS management is symptomatic treatment and palliative care. More treatments are now available to ease the burden of the disease, and they are increasingly utilized by patients and clinicians, at least in part because of the expanding base of evidence showing effectiveness. Much more needs to be done in this regard, but there has been substantial progress in the past decade.
This is part 2 of the revision of the 1999 practice parameter on the care of patients with amyotrophic lateral sclerosis (ALS).1 Consensus-based general principles of ALS management have been developed to guide clinicians in managing patients with ALS.1 Only evidence-based recommendations based on ALS studies are included in this revision.
DESCRIPTION OF THE ANALYTIC PROCESS
We searched OVID, MEDLINE, EMBASE, CINAHL, Science Citation Index, BIOETHICSLINE, International Pharmaceutical Abstracts, OVID Current Contents, Medline-Proquest, EIFL, and INVEST from 1998 through September 2007 combining the words ALS, Lou Gehrig's disease, and motor neuron disease with the following words using AND: sialorrhea, pseudobulbar palsy, pseudobulbar affect, emotional lability, palliative care, diagnosis, telling the diagnosis, breaking the news, advance directives, botulinum toxin A, botulinum toxin B, parotid irradiation, anticholinergic drugs, amitriptyline, glycopyrrolate, benztropine, transdermal hyoscyamine, atropine, trihexyphenidyl hydrochloride, propranolol, metoprolol, dextromethorphan, quinidine, opioids, opiates, oxygen, hospice, dyspnea, pain, lorazepam, anxiety, sleep, depression, cramps, spasticity, insomnia, deep venous thrombosis, communication devices, multidisciplinary clinic, specialty clinic, cognitive impairment, dementia, frontotemporal dementia, executive dysfunction, fatigue, and constipation. We reviewed the abstracts of these articles and examined 142 articles in their entirety. The diagnostic and therapeutic classification schemes used to grade the articles are summarized in appendices e-4a and e-4b on the Neurology® Web site at www.neurology.org. Recommendations were based on the levels of evidence as described in appendix e-5.
ANALYSIS OF EVIDENCE
Breaking the news.
How should a physician tell patients that they have ALS?
Telling the patient and family the diagnosis of ALS is challenging for clinicians and patients. Two studies analyzed patient perceptions of this experience (Class III and Class IV).2,3 Patients reported lack of empathy, insufficient explanation of the diagnosis and the course of the illness, and lack of information on where to get help.
There have been no controlled trials of breaking the news in ALS.
Recommendation.
There is insufficient evidence to support or refute any specific method of disclosing the diagnosis in ALS (Level U).
Clinical context.
Useful strategies have been developed for disclosing a diagnosis of cancer (appendix e-1).4
Multidisciplinary clinic.
Does multidisciplinary management improve outcomes?
In specialized multidisciplinary clinics, patients with ALS receive comprehensive care from a physician, physical therapist, occupational therapist, speech pathologist, dietitian, social worker, respiratory therapist, and nurse case manager. Studies suggest varying degrees of adherence to the practice parameters (Class III).5 Specialized clinics coordinate care and interface with a primary care physician and community-based services. Patients who attend specialized ALS clinics are younger and have longer symptom duration than neurology clinic patients, indicating possible referral bias (Class II).6–9
Patient care and survival were examined for 97 patients attending specialized ALS clinics in Italy compared with 124 patients in neurology clinics (Class II).6 There was increased utilization of riluzole, percutaneous endoscopic gastrostomy (PEG), and noninvasive ventilation (NIV) in the ALS clinics, and fewer hospital admissions. Mean survival was longer in specialized ALS clinics (1,080 days vs 775 days, p = 0.008). Using the COX multivariate analysis, attending an ALS specialized clinic independently predicted longer survival.
Prolonged survival (7.5 months, p < 0.0001) was found for patients in Ireland attending multidisciplinary ALS clinics (Class II).9 Patients at ALS clinics were younger and more likely to receive riluzole (99% vs 61%). Multidisciplinary care was an independent predictor of survival (p = 0.02) and reduced the risk of death by 47% in a 5-year study (Class II).9 Dutch patients in multidisciplinary ALS clinics (n = 133) were compared with 75 patients receiving general care (Class III).10 Patients were well-matched and data were collected by a blinded nurse. Patients in multidisciplinary clinic received more aids and appliances (93.1% vs 81.3%, p = 0.008) and had higher quality of life (SF-36® Health Survey, p < 0.01). Beneficial effects derived from a single visit to a multidisciplinary clinic, suggesting better coordination of care.
By contrast, another Class II study documented no increase in survival from multidisciplinary clinic.11 Riluzole use was higher in multidisciplinary clinic (61% vs 43%, p = 0.02) but very few patients received PEG (6% vs 2%) or NIV (2% in each group). There was a nonsignificant 10% increase in survival in those attending a multidisciplinary clinic after 12 months. Low utilization of palliative care, case management, PEG, NIV, and riluzole, compared to the 2 positive studies above, may account for the lack of survival benefit in this study.
Two Class II studies and 1 Class III study show that multidisciplinary clinics specializing in ALS care are probably effective in several ways: increased use of adaptive equipment; increased utilization of riluzole, PEG, and NIV; improved quality of life; and lengthened survival. However, 1 Class II study with low use of treatments found no survival benefit.
Specialized multidisciplinary clinic referral should be considered for patients with ALS to optimize health care delivery (Level B) and prolong survival (Level B), and may be considered to enhance quality of life (Level C).
Symptomatic management.
Effective management of symptoms is one of the primary goals of ALS patient care.
What are the most effective treatments for sialorrhea?
Sialorrhea, or drooling, is embarrassing and is associated with aspiration pneumonia. The prevalence is estimated at 50%, and 70% of patients receiving oral medications for treatment reported benefit (Class III).12 In a small trial, amitriptyline and botulinum toxin type A (BTxA) seemed equally effective, although 3 of 5 patients treated with amitriptyline experienced side effects (Class III).13
In a double-blind, controlled trial of botulinum toxin type B (BTxB) in 20 patients with ALS with refractory sialorrhea (Class I),14 patients were randomized to 2,500 U of BTxB or placebo into bilateral parotid and submandibular glands. Treated patients reported a global improvement of 82% at 2 and 4 weeks compared to 38% in placebo (p < 0.05). At 12 weeks, 50% of patients receiving BTxB were improved compared to 14% receiving placebo. There were no important adverse events.
Radiation therapy for medically refractory sialorrhea reduced salivary production, but side effects included erythema, sore throat, and nausea (Class III).15 A "satisfactory response" was observed and saliva secretion rate diminished with a single dose of 7–7.5 Gy bilaterally (Class III).16
In patients with medically refractory sialorrhea, BTxB injections into the parotid and submandibular glands are probably effective (1 Class I study). There are inadequate data on the effectiveness of BTxA and amitriptyline (1 Class III study). Low-dose irradiation is possibly effective for sialorrhea (2 Class III studies).
In patients with ALS who have medically refractory sialorrhea, BTxB should be considered (Level B) and low-dose radiation therapy to the salivary glands may be considered (Level C).
In ALS and other diseases, anticholinergic medications are generally tried first to reduce sialorrhea, although effectiveness is unproven.1 Botulinum toxin has been effective in controlled trials in parkinsonism as well as ALS.17
What pharmacologic measures reduce pseudobulbar affect?
Pseudobulbar affect, excessive laughing or crying, or involuntary emotional expression disorder affects 20%–50% of patients with ALS, especially in pseudobulbar palsy.18 Although it is not a mood disorder, antidepressants are frequently employed.
A fixed-dose combination of dextromethorphan (DM)/quinidine (Q) (30 mg DM/30 mg Q BID) for treatment of pseudobulbar affect in ALS (Class I)19 reduced the frequency and severity of laughing and crying behaviors compared to either DM (p < 0.001) or Q alone (p < 0.001). Side effects were dizziness, nausea, and somnolence, which accounted for termination of treatment in 24% with DM/Q compared to 6% with DM and 5% with Q. DM/Q is not yet approved by the US Food and Drug Administration (FDA).
The combination of DM/Q is probably effective for pseudobulbar affect in ALS (1 Class I study), although side effects may limit its usefulness.
If approved by the FDA, and if side effects are acceptable, DM/Q should be considered for symptoms of pseudobulbar affect in patients with ALS (Level B).
What pharmacologic interventions reduce fatigue?
Fatigue may be a symptom of depression, poor sleep, abnormal muscle activation, immobility, or respiratory dysfunction. Fatigue was a side effect of therapy in 26% of patients taking riluzole vs 13% taking placebo (p = 0.07; number needed to harm = 8) (Class III).20 Asthenia occurred in 18% of patients taking riluzole vs 12% of patients taking placebo in a larger study (p = 0.004; number needed to harm = 17) (Class III).21
There are no controlled studies of pharmacologic agents relieving fatigue in ALS. Riluzole possibly causes fatigue in some patients (2 Class III studies).
In patients developing fatigue while taking riluzole, once risks of fatigue vs modest survival benefits have been discussed, withholding the drug may be considered (Level C).
What interventions reduce cramps?
Cramps have been a secondary outcome measure in ALS clinical trials of gabapentin (Class III),22 vitamin E (Class III),23 and riluzole (Class III).20 There was no benefit from these agents.
By survey, quinine was widely used for cramps (Class IV),24 but there are no studies in ALS. Recently, the FDA warned against using quinine for cramps and removed unapproved quinine drugs from the market.25
Studies of gabapentin, vitamin E, and riluzole for treating cramps were all negative (Class III). There are safety concerns about quinine.
There are insufficient data to support or refute any specific intervention for the treatment of cramps in ALS (Level U).
What interventions reduce spasticity?
Treating spasticity might improve gait and relieve painful spasms. Moderate exercise led to a small decline in the Ashworth Spasticity Scale over 3 months, compared to a worsening with no exercise (p = 0.005) (Class III).26 Vitamin E 5,000 mg daily plus riluzole had no beneficial effect on spasticity as a secondary outcome measure (Class III).27
Evidence is insufficient to recommend exercise or medication for treating spasticity in ALS (Class III).
There are insufficient data to support or refute exercise or medication for treating spasticity in ALS (Level U).
In multiple sclerosis and cerebral palsy, benzodiazepam, baclofen, dantrolene, and tizanidine are effective in reducing spasticity-related symptoms.28
What pharmacologic interventions reduce depression?
The prevalence of depression in ALS ranges from 0 to 44%,29 although systematic studies suggest 10% in advanced ALS (Class III).30
There have been no controlled trials of treatment for depression in ALS.
There are insufficient data to support or refute specific treatments for depression in ALS (Level U).
There is consensus among experts that depression should be treated in patients with ALS31; however, there are no controlled studies of benefit or harm.
What pharmacologic interventions reduce anxiety?
Recognition and treatment of anxiety in ALS can be challenging since similar symptoms can be related to dyspnea.
There have been no trials of treatment for anxiety in ALS.
There are insufficient data to support or refute specific treatment for anxiety in ALS (Level U).
What pharmacologic interventions reduce insomnia?
Insomnia is common in ALS and may be a symptom of early respiratory weakness, underlying anxiety, depression, or pain.32 There is a concern that sedative/hypnotic agents may suppress the respiratory drive in patients with ALS.
There have been no studies of treatment for insomnia in ALS.
There are insufficient data to support or refute specific treatment for insomnia in ALS (Level U).
Cognitive and behavioral impairment.
There is now considerable evidence for cognitive and behavioral manifestations in ALS. Specific ALS phenotypes include pure motor degeneration (ALS), ALS with cognitive impairment (ALSci), ALS with behavioral impairment (ALSbi), and ALS with a dementia meeting the Neary criteria for frontotemporal dementia (FTD) (ALS-FTD). FTD, as defined by Neary et al.,33 has insidious onset, gradual progression, altered social conduct, emotional blunting, and loss of insight. These criteria are required for the diagnosis of FTD, which is supported by neuropsychological abnormalities, language dysfunction, and poor self care. ALSci reflects frontotemporal dysfunction with deficits in attention, cognitive flexibility, and word generation, with relative sparing of visuospatial function and memory. ALSbi refers to changes in social interactions unrelated to a psychiatric condition.
The domain of cognitive and behavioral impairment in ALS is a rapidly evolving field and there is little consensus regarding diagnostic criteria and assessment methods.
What is the prevalence and natural history of cognitive and behavioral impairment in ALS?
Estimates of cognitive impairment range from 10% (Class III)34 to 75% (Class III).35 A population-based sample produced an estimate of 28% (Class II).36 The prevalence of impairment meeting criteria for dementia ranged from 15% (Class III)37 to 41% (Class II).38 Behavioral impairment (irritability and social disinhibition) was identified in 39% (Class III).39
Three studies (Class III)39,40,e1 documented mild cognitive decline over 6 months, while others (Class III)e2,e3 found no change over 12 months. It is not known whether patients can progress from ALSci or ALSbi to ALS-FTD. However, 15% of patients presenting with FTD later develop motor neuron degeneration (Class III).e4
A significant proportion of patients with ALS demonstrate cognitive impairment and some have dementia (2 Class II, multiple Class III studies). Neither behavioral impairment in ALS nor the natural progression of cognitive or behavioral impairments has been adequately studied.
Screening for cognitive and behavioral impairment should be considered in patients with ALS (Level B).
How is cognitive or behavioral impairment in ALS diagnosed?
Cognitive impairment in ALS is best identified through neuropsychological assessment using standardized measures and normative data. The Mini-Mental State Examination is less sensitive to the cognitive impairment seen in ALS and does not examine for behavioral dysfunction.
There is no consensus regarding the best screening tests for cognitive impairment in ALS. Two 1-minute word generation tests had 65% sensitivity, 90% specificity, and 88% positive predictive value in detecting possible, probable, or definite FTD by Neary criteria (Class II).36 A 1-minute letter fluency measure (F words) had 73% sensitivity, 88% specificity, and 79% accuracy to detect ALSci (Class III).e5 An abbreviated neuropsychological battery demonstrated 88% accuracy (Class III).37
Neuropsychological assessment is possibly effective for identifying cognitive impairment in ALS (1 Class II, 1 Class III).
Screening tests of executive function may be considered to detect cognitive impairment in patients with ALS prior to confirmation with formal neuropsychological evaluation (Level C).
What is the effect of cognitive or behavioral impairment on management of patients with ALS?
In patients with ALS with frontal lobe impairment, noncompliance with PEG (72%) and NIV (75%) was greater, and survival was shorter by 11 months, compared to cognitively normal patients with ALS (Class III).e8
Insufficient data exist on the effect of cognitive or behavioral impairment on the management of patients with ALS.
There are insufficient data to support or refute the impact of cognitive and behavioral impairment on management in ALS (Level U).
What treatments are effective for cognitive or behavioral impairment in ALS?
No studies were identified that evaluated pharmacologic treatment for cognitive or behavioral impairment in ALS. One Class III studye9 found an improvement in cognition after NIV initiation.
Data are inadequate regarding the effect of pharmacologic treatment or NIV for cognitive or behavioral impairment in ALS.
There are insufficient data to support or refute treatment of cognitive or behavioral impairment in ALS (Level U).
What treatments for dysarthria optimize communication in ALS?
Communication is fundamental to effective participation in life, especially sharing social closeness.1 Strategies for communication with patients with ALS include an alphabet board, computerized systems, Morse code, utilization of the anal sphincter, and infrared eye movements.
No controlled studies examined communication in ALS.
There are insufficient data to support or refute treatment to optimize communication in ALS (Level U).
Palliative care.
Palliative care is the holistic management of symptoms in patients with terminal illness. Palliative care does not preclude active treatment or life-prolonging interventions. Hospice is a major provider of care in the final stages of ALS. Palliative care addresses advance directives and psychosocial and spiritual issues.1
What treatments reduce pain and dyspnea in the terminal phase of ALS?
Pain and dyspnea are common correlates with suffering (Class IV)e10 and a desire for physician-assisted suicide in late-stage ALS (Class IV).e11
No controlled studies examined treating pain or dyspnea in late-stage ALS.
There are insufficient data to support or refute specific treatments for pain and dyspnea in late-stage ALS (Level U).
Do hospice care, spiritual interventions, or advance directives improve quality of life in the terminal phase of ALS?
Systematic studies of hospice, spirituality, and advance directives in ALS are lacking.
No controlled studies examined hospice, spiritual care, or advance directives in ALS.
There are insufficient data to support or refute hospice, spiritual care, or advance directives in ALS (Level U).
What is the optimal method of withdrawing both noninvasive and invasive ventilation in ALS?
Case series offer practical advice for withdrawing both invasive and noninvasive ventilation from patients with ALS (Class IV).e12,e13
There are no controlled studies examining withdrawal of ventilation in ALS.
There are insufficient data to support or refute specific strategies for withdrawal of ventilation in ALS (Level U).
Protocols based on consensus for withdrawal of mechanical ventilation in intensive care units (Class IV)e14 include counseling and symptom control with opioids, benzodiazepines, and anticholinergic medications.e15 We could find no controlled studies in any disease.
RECOMMENDATIONS FOR FUTURE RESEARCH
This evidence-based review indicates some progress in evaluating new therapies for patients with ALS. More high-quality studies have been reported leading to more confident recommendations regarding multidisciplinary clinics and symptomatic therapy for pseudobulbar affect and sialorrhea. However, future research in the following areas is still greatly needed.
Breaking the news
Validate measures that can be applied to studies of diagnostic disclosure.
Evaluate attitudes of neurologists and patients to strategies for breaking the news.
Conduct controlled studies of the effects of different disclosure strategies on patient satisfaction, preserving hope, and outcomes.
Multidisciplinary clinic
Examine referral bias to clinics.
Examine factors essential to benefits in clinics, optimal visit frequency, cost effectiveness of staff, and economic factors in care.
Symptomatic management
Conduct controlled trials of pharmacologic therapy for spasticity, cramps, constipation, sialorrhea, pseudobulbar affect, pain, depression, anxiety, fatigue, and therapeutic exercise.
Examine irradiation and botulinum toxin for sialorrhea in controlled trials.
Cognitive and behavioral impairment
Develop consensus criteria for cognitive and behavioral impairment to ensure consistency in diagnosis and research.
Identify screening tests for cognitive and behavioral impairment.
Evaluate the natural history of, and treatments for, cognitive and behavioral impairment, and their impact on compliance and survival.
Validate criteria to examine communication strategies.
Design clinical trials to compare different strategies for communication in ALS.
Design controlled trials of terminal symptom management, advance directives, hospice, and spiritual care.
The authors thank additional members of the ALS Practice Parameter Task Force: Thomas Getchius, Laura Moses, AAN staff; Gary Gronseth, MD; Sharon Matland; Valerie Cwik; Larry Brower; and Sid Valo.
Dr. Miller serves on the editorial board of the ALS Journal; received a speaker honorarium from the AANEM; served as a consultant to Celgene, Knopp Neurosciences Inc., Teva Pharmaceutical Industries Ltd., Taiji Biomedical, Inc., Sanofi-Aventis, Novartis, and Neuraltus; and receives research support from the NIH [R01 NS 44887 (PI)] and the Muscular Dystrophy Association (PI). Dr. Jackson serves as a consultant to Knopp Neurosciences Inc. and receives research support from Knopp Neurosciences Inc., Insmed Inc., Solstice Neurosciences, Inc., the ALS Association, and NIH NINDS [U01 NS042685-0 (site PI), R01NS045087-01A2 (site PI), and N01-AR-2250 (site PI)]. Dr. Kasarskis serves as an Associate Editor for Amyotrophic Lateral Sclerosis; has received honoraria from the American Institute for Biological Studies (grant reviews); served as a consultant to Acceleron Pharma; holds equity in Amgen; and receives research support from the NIH/NINDS [R01-NS045087 (PI) and 1U01 NS049640 (site PI)]. Dr. England serves as an Associate Editor for Current Treatment Options in Neurology; received a speaker honorarium from Teva Pharmaceutical Industries Ltd.; and serves as a consultant to Talecris. Ms. Forshew has served on a scientific advisory board for the ALS Association and receives research support from the Muscular Dystrophy Association. Dr. Johnston reports no disclosures. Dr. Kalra receives research support from the ALS Association of America and the ALS Society of Canada. Dr. Katz has received research support from Pfizer Inc. Dr. Mitsumoto served on scientific advisory boards for Avanir Pharmaceuticals, Knopp Neurosciences Inc., Neuralstem, Inc., Aisai Communication Technology Co., Ltd., and Otsuka Pharmaceutical Co., Ltd.; and receives research support from Avanir Pharmaceuticals, Teva Pharmaceutical Industries Ltd., Knopp Neurosciences Inc., Sanofi-Aventis, Athena Diagnostics, Inc., BioScrip, and the NIH/NINDS [DNA repository as a supplement and NIEHS Center grant]. Dr. Rosenfeld serves on the editorial board of Amyotrophic Lateral Sclerosis and has served as a consultant to Solstice Neurosciences, Inc. and Avicena Group, Inc. Dr. Shoesmith receives research support from the Muscular Dystrophy Association and her spouse is employed by Biovail Pharmaceuticals Canada. Dr. Strong serves on the editorial board of Amyotrophic Lateral Sclerosis. Dr. Woolley has received research support from Pfizer Inc., Eisai Inc., and the ALS Association (co-I).
This statement is provided as an educational service of the American Academy of Neurology. It is based on an assessment of current scientific and clinical information. It is not intended to include all possible proper methods of care for a particular neurologic problem or all legitimate criteria for choosing to use a specific procedure. Neither is it intended to exclude any reasonable alternative methodologies. The AAN recognizes that specific patient care decisions are the prerogative of the patient and the physician caring for the patient, based on all of the circumstances involved. The clinical context section is made available in order to place the evidence-based guideline(s) into perspective with current practice habits and challenges. No formal practice recommendations should be inferred.
The American Academy of Neurology is committed to producing independent, critical and truthful clinical practice guidelines (CPGs). Significant efforts are made to minimize the potential for conflicts of interest to influence the recommendations of this CPG. To the extent possible, the AAN keeps separate those who have a financial stake in the success or failure of the products appraised in the CPGs and the developers of the guidelines. Conflict of interest forms were obtained from all authors and reviewed by an oversight committee prior to project initiation. AAN limits the participation of authors with substantial conflicts of interest. The AAN forbids commercial participation in, or funding of, guideline projects. Drafts of the guideline have been reviewed by at least three AAN committees, a network of neurologists, Neurology® peer reviewers and representatives from related fields. The AAN Guideline Author Conflict of Interest Policy can be viewed at www.aan.com.
See also page 1218
Supplemental data at www.neurology.org
Appendices e-1–e-5, tables e-1–e-5, and references e1–e15 are available on the Neurology® Web site at www.neurology.org.
Approved by the Quality Standards Subcommittee on November 5, 2008; by the Practice Committee on March 8, 2009; and by the AAN Board of Directors on July 30, 2009.
Disclosure: Author disclosures are provided at the end of the article.
Received April 3, 2009. Accepted in final form July 21, 2009.
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Levitsky G. Pharmacological therapy of sialorrhea in patients with motor neuron disease. ZH Neurol Psikhiar Im SS Kovsakova 2005;105:19–22.
Jackson CE, Gronseth G, Rosenfeld J, et al. Randomized double-blind study of botulinum toxin type B for sialorrhea in ALS patients. Muscle Nerve 2008;39:137–143.
Harriman M, Morrison M, Hay J, Revonta M, Eisen A, Lentle B. Use of radiotherapy for control of sialorrhea in patients with amyotrophic lateral sclerosis. J Otolaryngol 2001;30:242–245.
Andersen PM, Gronberg H, Franze L, Funegard U. External radiation of the parotid glands significantly reduces drooling in patients with motor neuron disease with bulbar paresis. J Neurol Sci 2001;191:111–114.
Molloy L. Treatment of sialorrhea in patients with Parkinson's disease: best current evidence. Curr Opin Neurol 2007;20:493–498.
McCullagh S, Moore M, Gawel M, Feinstein A. Pathological laughing and crying in amyotrophic lateral sclerosis: an association with prefrontal cognitive dysfunction. J Neurol Sci 1999;169:43–48.
Brooks BR, Thisted RA, Appel SH, et al. Treatment of pseudobulbar affect in ALS with dextromethorphan/quinidine: a randomized trial. Neurology 2004;63:1364–1370.
Bensimon G, Lacomblez L, Meininger V. A controlled trial of riluzole in amyotrophic lateral sclerosis. ALS/Riluzole Study Group N Engl J Med 1994;330:585–591.
Lacomblez L, Bensimon G, Leigh PN, Guillet P, Meininger V. Dose-ranging study of riluzole in amyotrophic lateral sclerosis: Amyotrophic Lateral Sclerosis/Riluzole Study Group II. Lancet 1996;347:1425–1431.
Miller RG, Moore DH, 2nd, Gelinas DF, et al. Phase III randomized trial of gabapentin in patients with amyotrophic lateral sclerosis. Neurology 2001;56:843–848.
Desnuelle C, Dib M, Garrel C, Favier A. A double-blind, placebo-controlled randomized clinical trial of alpha-tocopherol (vitamin E) in the treatment of amyotrophic lateral sclerosis. ALS riluzole-tocopherol Study Group Amyotroph Lateral Scler Other Motor Neuron Disord 2001;2:9–18.
Forshew DA, Bromberg MB. A survey of clinicians' practice in the symptomatic treatment of ALS. Amyotroph Lateral Scler Other Motor Neuron Disord 2003;4:258–263.
Drug products withdrawn from sale for reasons other than safety or effectiveness: quinine-containing drug products; enforcement action dates. Federal Register 2006 Dec 15;71(241):75557–75560.
Drory VE, Goltsman E, Reznik JG, Mosek A, Korczyn AD. The value of muscle exercise in patients with amyotrophic lateral sclerosis. J Neurol Sci 2001;191:133–137.
Graf M, Ecker D, Horowski R, et al. High dose vitamin E therapy in amyotrophic lateral sclerosis as add-on therapy to riluzole: results of a placebo-controlled double-blind study. J Neural Transm 2005;112:649–660.
Abbruzzese G. The medical management of spasticity. Eur J Neurol 2002;9 (suppl 1):30–34; discussion 53–61.
Kurt A, Nijboer F, Matuz T, Kubler A. Depression and anxiety in individuals with amyotrophic lateral sclerosis: epidemiology and management. CNS Drugs 2007;21:279–291.
Rabkin JG, Albert SM, Del Bene ML, et al. Prevalence of depressive disorders and change over time in late-stage ALS. Neurology 2005;65:62–67.
Andersen PM, Borasio GD, Dengler R, et al. EFNS task force on management of amyotrophic lateral sclerosis: guidelines for diagnosing and clinical care of patients and relatives. Eur J Neurol 2005;12:921–938.
Hetta J, Jansson I. Sleep in patients with amyotrophic lateral sclerosis. J Neurol 1997;244:S7–S9.
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More Online
Practice Parameter update: The care of the patient with amyotrophic lateral sclerosis: Drug, nutritional, and respiratory therapies (an evidence-based review)Report of the Quality Standards Subcommittee of the American Academy of Neurology


Rawalpindi Development Authority has restarted the 'One Window Operation Centre' to provide relief to the citizens. According to RDA spokesman, Hafiz Irfan who is also In charge of the Centre, the One Window Operation launched earlier was abolished five years ago.
He said, the Centre has been made operational once again, as per the instructions of Director General (DG) Rawalpindi Development Authority (RDA) Rana Akbar Hayyat to facilitate the citizens. The officials at the Centre have started receiving the applications and addressing the public complaints, he informed. According to him the objective of the one window operation is to facilitate the RDA clients and save their precious time.
He said the DG is taking keen interest to solve the problems being faced by the citizens and the One Window Operation would prove a great facility for them. Meanwhile, Director Metropolitan Planning and Traffic Engineering (MP&TE) Jamshaid Aftab informed APP that the Authority has directed the owners of five illegal housing schemes identified as Safari Green Farm Housing Scheme, Adyala Road, Mahmood Town, Dhamyal road, T&T, Extension, Defence Road, Kohsar Extension, Taxila road and Al-Miraj Garden, Chakri road, Rawalpindi to stop illegal advertisements and development work. Jamshaid Aftab said, RDA has declared the housing schemes illegal and unauthorized. Notices have been issued to the owners of the housing schemes under sections of Punjab Private Housing schemes and Land Sub-division Rules 2010.
The owners have been warned of strict action in accordance with the law if the development work and advertisements were not stopped immediately. RDA would also seal their site offices, he added. He advised the citizens in their own interest not to investment in any illegal and unauthorized Housing Scheme. He informed that RDA has also requested the Utility Services Departments not to extend services to the illegal housing schemes.


The phone's case is one-of-a-kind, but the charger can be yours, Hero of Hyrule with a low battery.
Powerhouse GAN demonstration even has tech giant Elon Musk applauding its awesomeness.
These plucky little bots use AI to generate comedy bits on the topic of your choice.
You'll never be lonely with Kosaka by your side.
Month-long modding project lets him go back to the 32-bit past on the go.
We get to take a Tesla Model S luxury EV for a spin around the historic capital of Japan.
The day when human singers get replaced by A.I. inches that much closer.
They aren't just creating armies of fictional smiling girls for the fun of it!
Self-controlled robo guard scans for dangerous individuals and suspicious packages, would probably look adorable with a police officer's uniform.
In other words, now's probably a good time to get all that valuable data onto removable physical media.
It's nice that it can make omelets by itself, but it's certainly not a threat to human existence.


text:
Vanderbilt University Medical Center job cuts officially over
By Shelley DuBois;
The Tennessean;
The layoffs at Vanderbilt University Medical Center are officially over and the final tally was smaller than officials had previously feared, according to Jeffrey Balser, the head of Vanderbilt University's Medical Center.
"I want everybody to go home for the holidays understanding that we've been through this, and we're turning the corner," Balser said at the winter Clinical Enterprise Leadership Assembly earlier this week at Vanderbilt's Langford Auditorium.
Since July 1, the medical center has cut 400 people. The workforce reduction strategy is part of Vanderbilt's larger plan, called "Evolve to Excel," to cut $250 million from its $3.3 billion operating budget by the end of the 2015 fiscal year.
In September, Vanderbilt notified state and local government officials that it could let go of at least 1,033 employees by the end of this year.
However, Balser said that VUMC's choice to eliminate 1,100 open positions as part of its overall review kept the actual number of job cuts lower than expected.
"That's a big improvement over the initial estimate," said Benjamin Eagles, a 24-year organizer for a labor advocacy group called Organized & United for Respect at Vanderbilt, or OUR Vanderbilt. "We're committed long term to work towards better wages for employees on campus," Eagles said, but the end of this particular issue comes as a relief. "Employees having a sense of job security in this business environment is a big plus."
The university has been rolling out news of its workforce reduction plans since this summer. The week that VUMC reported its 1,033 estimated job cuts with government officials, the medical center let go of 275 people. Also as part of the plan, 250 employees opted to take Vanderbilt's early retirement package.
Vanderbilt cut costs in other ways besides laying people off, Balser said. He said the overall review helped the medical center cut about $70 million of the $250 million target through non-labor expenses.
4 reasons for cuts
In November, Balser announced that the medical center also would reduce the number of incoming medical and doctoral students by 10 percent, which should amount to about 10 students per class, according VUMC spokesman John Howser. "We are capping the number of trainees in our residency and fellowship programs to assure we can continue to provide the meaningful research and scholarship training experiences that are signatures of the nation's leading clinical training programs," Balser wrote at the time.
Balser has repeatedly said that there were four main reasons that academic medical centers were facing major budget cuts: the price pressure of caring for an aging population, lower reimbursement rates from insurers and the federal government, Tennessee's choice not to expand the Medicaid program and reductions in available federal research grant money.
Before "Evolve to Excel" began, Vanderbilt Medical Center had cut 300 jobs earlier in 2013.
Contact Shelley DuBois at 615-259-8241 or sdubois@tennessean.com. Follow her on Twitter
@shelleydubois.


At an awards ceremony on Thursday, September 15, 2016, at the Maine Hospital Association in Augusta, Maine, the Breathe Easy Coalition of Maine celebrated the efforts of Maine hospitals to address smoking and tobacco use on their campuses. The event highlighted the 2016 Maine Tobacco-Free Hospital Network Gold Star Standards of Excellence Program award winners including Spring Harbor Hospital. Thirty-three (33) Maine hospitals and four individual champions are being recognized for their achievements in advancing their organization's smoke and tobacco-free policies as well as promoting tobacco-free lifestyles in their communities.
The annual Gold Star Standards of Excellence program recognizes health care organizations for their efforts to address best practice standards around tobacco use, exposure and quitting supports. Spring Harbor Hospital was recognized at the gold level in the 2016 program.
Tobacco use continues to be the leading cause of preventable disease and death in the country and a major contributor to health care costs. "Meeting these standards requires hard work and commitment from these health care organizations, and the Breathe Easy Coalition of Maine is pleased to be able to honor their dedication," said Mayberry.
Located in Westbrook, Maine, Spring Harbor Hospital is southern Maine's only nonprofit, private psychiatric hospital and a comprehensive provider of inpatient services for individuals who experience acute mental illness or dual disorders issues. Our 100-bed facility is set on 50 private acres in greater Portland and offers children, adolescents, and adults a comfortable and pleasant environment for psychiatric treatment. We provide 24-hour information and referral, voluntary and involuntary hospitalization and comprehensive discharge planning.
The Breathe Easy Coalition of Maine's mission is to reduce exposure to secondhand smoke through the promotion of strong voluntary policies that lead to reduced tobacco use and increased tobacco-free living throughout Maine. With funding and support from the Maine CDC Partnership for a Tobacco-Free Maine, the Coalition works in four targeted environments: behavioral health, colleges/universities, hospitals and multi-unit housing. For more information visit www.BreatheEasyMaine.org or contact us at 207-874-8774.


text:
Narcolepsy: Forgotten No More?
The old diagnostic cliché about "listening for zebras" is well suited to the realm of narcolepsy. Primary care physicians (PCPs) hear the figurative hoof beats of "sleepiness" and naturally gravitate to a host of possible causes before considering narcolepsy.
"PCP docs are thinking chronic fatigue syndrome, auto-immune disorders, sleep apnea, and more," says Jed Black, MD, a consulting associate professor at Stanford University Medical Center, Stanford Center for Sleep Sciences and Medicine, Palo Alto, Calif. "The list of things that cause fatigue and sleepiness is long, and that is what makes diagnosis difficult."Factor in the sheer number of patients who complain of sleepiness and it's no wonder that the far less common ailment of narcolepsy is rarely diagnosed. "If someone has two conditions simultaneously, such as sleep apnea and narcolepsy, then it is really easy to just pick up on the sleep apnea and miss the narcolepsy altogether," explains Black. "That even happens at highly sophisticated narcolepsy centers such as what we have at Stanford."
A poster presentation at SLEEP 2013, the annual meeting of the Associated Professional Sleep Societies LLC in Baltimore, entitled High Rates of Medical Comorbidity in Narcolepsy: Findings from the Burden of Narcolepsy Disease (BOND) Study of 9,312 Patients in the United States", showed that the consequences of missed diagnoses can be high. Black and six co-authors determined that narcolepsy patients had significantly higher frequencies of respiratory, musculoskeletal, endocrine, and circulatory conditions across a 5-year period when compared with control subjects.
As part of the Burden of Narcolepsy Disease (BOND) study, the poster helped to demonstrate that people with narcolepsy face significant health and economic burdens. In addition to the comorbidities, sufferers generated more than twice the mean annual medical costs compared with the general population.
No Small Task
Far beyond the simple data collected at clinics, Black and his colleagues gained access to a huge database that admittedly took a long time to sift. For Black, who also serves as vice president of Sleep Medicine at Jazz Pharmaceuticals, the task involved multiple validations of the data. Ultimately, he believes the conclusions were "relatively representative of the insured population."
Black reports a "lot of interest" thus far in the research, a reaction that amounts to pent up demand for a frequently misunderstood condition. With additional hard numbers to back up the serious effects of narcolepsy, Black expects the poster to spark follow-up research by academics and commercial interests.
Many who observed the poster's conclusions did not expect the economic consequences, and Black puts himself in this group. "I was incredibly surprised," says Black. "We know that there is an increased risk for certain comorbid conditions. We know they have to be getting medication and seeing their docs occasionally, but what really surprised me were the inpatient hospital costs and the ER department costs. Every aspect of health care utilization increased."
The sheer breadth of comorbidities also took researchers by surprise, with Black reporting that he and his colleagues expected to see things such as sleep apnea and depression—even anxiety disorders—but narcolepsy touched even more than that. "Across almost all of the major diagnostic categories there are significant increases in comorbidity, and that I did not expect," he says. "That lead me to think, 'Ok something is systematically wrong with the data here,' and so we went through and did a number of internal evaluations just to convince ourselves that there was not some systematic bias within the data set.
However, the information is solid."
"Infinite" Follow-Up Possibilities
Despite the sizable work completed by the BOND studies, the University-of-Utah-educated Black confirms that there is still an "infinite" amount of work to be done to better understand narcolepsy. "I think the next step for us is to do a regression analysis to find certain associations within the database," adds Black, who completed his internship at Yale and his Fellowship at Stanford. "We also want to do a full characterization of the comorbidities."
The loss of hypocretin is the known cause of narcolepsy and/or cataplexy, but still more can be known. "It's particularly the loss of hypocretin cells in the brain," says Black. "Are there some other variety of secondary effects there that lead to health consequences? There are many ways to look at it, and it's almost overwhelming to think about the process required to start something up and gain these answers."
The prospect is daunting, but Black believes additional basic research is necessary to counter what he calls the "very low knowledge" level among PCPs and non-sleep specialists when it comes to narcolepsy.
"It's fair to say the overwhelming majority of primary care docs know that narcolepsy is a condition of sleepiness, and that's all they know about it," says Black. "They know it's pathological sleepiness that can be severe, but if someone comes in who is sleepy, they don't know how to differentiate it from anything else. They have no capacity to make the narcolepsy diagnosis, and therefore it goes unrecognized. We need to change this, and we can through additional education and research."
Narcolepsy As Defined by The Burden of Narcolepsy Disease (BOND) StudyNarcolepsy is a serious, chronic disorder of the central nervous system characterized by symptoms of excessive daytime sleepiness (EDS), muscle weakness (cataplexy), disrupted nighttime sleep, hypnagogic hallucinations and sleep paralysis. People with narcolepsy experience abrupt shifts between wakeful and REM-like states that are thought to be caused by a loss or impairment of hypocretin-producing neurons in the hypothalamus. The disorder affects approximately one in 2,000 Americans, yet approximately 50 percent of patients remain undiagnosed. Symptoms of narcolepsy often start between the ages of 15 and 25.
High rates of medical comorbidity in narcolepsy: Findings from the Burden of Narcolepsy Disease (BOND) study of 9,312 patients in the United States; Black J, et al, SLEEP 2013.
Should You let Your Pet Sleep with You?
FDA Brings Awareness to Driving and OTC Drug Dangers
Is There Room for Two Sheriffs (AASM/BRPT) in the Sleep Certification/Credentialing World?
Documentation of Bite Changes with OAD


text:
Die Saison 1977/78 war die 43. Spielzeit der polnischen Eishockeyliga, der höchsten polnischen Eishockeyspielklasse. Meister wurde zum insgesamt zehnten Mal in der Vereinsgeschichte Podhale Nowy Targ. GKS Tychy, KS Cracovia und Polonia Bydgoszcz stiegen in die 2. Liga ab.

Modus
In der Hauptrunde absolvierte jede der zehn Mannschaften insgesamt 36 Spiele. Der Erstplatzierte der Hauptrunde wurde Meister. Die drei Letztplatzierten der Hauptrunde stiegen in die 2. Liga ab. Für einen Sieg erhielt jede Mannschaft zwei Punkte, bei einem Unentschieden gab es einen Punkt und bei einer Niederlage null Punkte.

Mannschaften

Hauptrunde

Tabelle

Sp = Spiele, S = Siege, U = unentschieden, N = Niederlagen, OTS = Overtime-Siege, OTN = Overtime-Niederlage, SOS = Penalty-Siege, SON = Penalty-Niederlage

Weblinks
 Spielzeit bei hockeyarchives.info (französisch)

1977
Eishockeysaison 1977/78

redpajama_set_name: RedPajamaWikipedia


CMS introduces a new ACO program that it is calling the Next Generation ACO Model, that will allow providers to assume a higher level of risk than either the Pioneer ACO or Shared Savings Program, and will generate a larger financial return for providers that successful manage those risks.
FDA efforts to create a medical device ID numbering system have received political pushback from CMS administrator Marilyn Tavenner, who says that adding a medical device ID number on claims forms would require significant work from her department and would result in significant unanticipated costs.
Louisiana's state health information exchange will rollout a state-wide patient portal, providing patients with a centralized portal with medical information from all care settings.
Antelope Valley Hospital (CA) is challenging claims made by a local nurses union after the group claimed that unplanned EHR downtime forced the hospital to close its ED. The hospital acknowledged redirecting some patients to other hospitals during the downtime, but reports that it still treated 900 ED patients during the event.


We all know that Kiss member Gene Simmons is known for making wild comments but the aging rocker just might have crossed the line. Simmons suggested that those who suffer from depression should kill themselves during an interview last month with songfacts.com.
Simmons's remarks surfaced as the world was mourning the death of Robin Williams. The actor/comedian took his own life after years of struggling with depression. The Simmons interview had been given a couple of weeks before Robin Williams passing. Simmons tweeted "RIP a kind and generous man" along with a suicide prevention hotline number on the day that Williams died.
Radio stations Power97, BobFM in Canada, Australian station Triple M, and New York's WPYX DJ Uncle Vito has jumped on the ban wagon and will no longer play Kiss musc after learning of the fire breathing demon's comments.


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It has already been a week since our last blog update and a lot has happened within these few days. The past week has been a busy period for everyone at crypto-games. Starting from adrenaline fueled bets to ending of the monthly wagering contest – this sure has been an exciting week for every individual gambler at crypto-games.
September has been a wild month. We have seen contestants trying their best to beat each other to reach the top of the leaderboard. But, alas, only the most deserving ones were able to reach the crown and bag in their rewards.
Bitcoin: User BananoCoin was able to reap in most of the rewards by being the number one top user at the leaderboard. The user managed to wager an astonishing amount of 248.72 BTC and claim 0.547 BTC along with 300 lotto ticket entries (worth 0.03 BTC) as a reward for being the top wagerer. BananoCoin was followed by Pepepu35 who stood second on the leaderboard by wagering 237.05 BTC. As a reward he won 0.45 BTC and 200 lotto ticket entries! Our most notorious high-roller, Juan placed in third by wagering 205.22 BTC at the leaderboard winning 0.3 BTC and 100 lotto tickets. Our top three user had a close call with each other. They were followed by Kelsie080, brewdog2018, rowalce, Ingui550, spcm, winner11 and Bruns428 each winning 0.167 BTC, 0.128 BTC, 0.069 BTC, 0.023 BTC, 0.02 BTC, 0.012 BTC and 0.008 BTC along with massive amounts of lotto tickets. A total of 1.8 BTC and 828 lotto tickets were claimed by the users as their reward!
Ethereum: As expected, no one was able to beat Aylmer555 who placed in first by wagering an impressive amount of 24,175.485 ETH! Aylmer555 was able to claim the maximum reward of 5 ETH and 300 lotto tickets (worth around 0.45 ETH)! Sealey841 was placed second with a total wager of 8,885.825 ETH and won 3 ETH with 200 lotto ticket entries. The third position was taken by Jermane821 by wagering only 1,164 ETH and was rewarded 1.5 ETH and 100 lotto tickets for his achivement. They were followed by cj7even, BananoCoin (also won the BTC wagering contest), Salamon538, tmills, Mannton456 and Amans056 and was rewarded 1 ETH, 0.8 ETH, 0.6 ETH, 0.41 ETH, 0.31 ETH, 0.2 ETH and 0.14 ETH respectively. Each users were also rewarded with lotto tickets based on their position. The top 6 users were able to claim the maximum reward available. This time a total of 12.96 ETH and 828 lotto tickets were claimed by the users for being the top 10 wagerers!
Litecoin: The top 7 users were rewarded with hefty amount of Litecoins and lotto tokens for their effort. Killer1984 placed in first by wagering 2,293.581 LTC and gained 4.587 LTC along with 300 LTC lotto ticket entries. Klokan22 failed to secure the first position by a small margin. The user placed 2,161.714 LTC worth of bets and claimed 3.891 LTC together with 200 LTC lotto tickets as a reward. Third place was filled by YouPayNow by wagering 1,762.574 LTC and cashed in 2.643 LTC along with 100 Lotto tickets. The rest of the places were taken by Mitsuteru, Jeff140, juristksz and LowLow881. They were rewarded 1.189 LTC, 0.716 LTC, 0.49 LTC and 0.335 LTC respectively. A total of 13.851 LTC and 790 Lotto tickets has been dealt.
Dogecoin: User Kothari12 made it to the top by wagering 45,015,591.23 DOGE and by placing only 7,179 total bets! The user managed to claim 90,031 DOGE in total along with 150 doge lotto tickets. The second and third place was taken by Randee88 and Gawain493 each placing 18,775,753 DOGE and 13,289,096 DOGE. They were rewarded 33,796 DOGE and 19,933 DOGE respectively including 80 and 40 doge lotto tickets. They were followed by tmills, Nico0808, Goobersmooch and Case820 eaching being rewarded with 15,375 DOGE, 10,626 DOGE, 7,081 DOGE and 4,486 DOGE along with few doge lotto tickets. A total of 181,330 DOGE was rewarded to the top winners along with 335 lotto tickets!
Bitcoincash: Claudio513 became the top leader by wagering 107.07 BCH and was rewarded with 0.214 BCH. The user was followed by XPEH, randreo, hale490 and Jermane821, each receiving 0.168 BCH, 0.137 BCH, 0.063 BCH and 0.041 BCH. A total of 0.623 BCH as a reward was dealt to the winners.
Dash: Top place was taken by Edwardo561 who waggered 253.289 DASH and received 0.5 DASH as a reward. Rest of the winners were spcm, Eliana7, acexpress and Vazriel getting 0.1 DASH, 0.07 DASH, 0.02 DASH and 0.01 DASH. Total rewards distributed among the users summed up to 0.718 DASH.
Ethereumclassic: Amans056 ended up being the top user by wagering 3,434.2 ETC. The user was rewarded 6.86 ETC for his effort. Grav, Carda443, Adkyn566 and Aguisel935 took over rest of the places and were rewarded 5.7 ETC, 3.69 ETC, 2.46 ETC and 1.4 ETC each. A total of 20.12 ETC was dealt as a reward.
NeoGas: Our top 5 players were Bebolinz, Lutpin, Kekie, Townlee242 and XPEH where Bebolinz wagered 3,510 GAS receiving 7.02 GAS as a reward. A total of 11.7 GAS was claimed by the winners out of 220 GAS.
Peercoin: DemiGod made it to the top by making a staggering amount of 115,465.6 PPC bets in total. She received 230.9 PPC as a reward. LanMachine, Skyelar, Haunebu and Paecga129 occupied rest of the slots on the leaderboard. A total of 249.33 PPC reward was given out to the PPC wagering contest winners.
Stratis: User holzfritte wagered 38,470 STRAT which led him to the top of the leaderboard allowing him to claim 76.9 START as a reward. Torrey112 ended up being second by wagering 32,528 START claiming 58.5 START. Itibor, Sheru144 and Shahista each being awarded with 42.93 START, 32.86 START and 25.1 START. A total of 236.29 START has been given away to the winners.
Monero: This month there weren't many competitors in Monero. Top user Bruns428 wagered 583.035 XMR and has managed to grab 1.16 XMR as a reward. Mannton456, Shahista, Demason334 and spcm followed Bruns428 has claimed rest of the spots. A total of 1.6 XMR has been given to the winners.
All rewards have been dealt to the players within few hours. Along with the rewards, the top five users for each coin have received the [VIP] tag. They now have access to all the VIP exclusive features. The tag will last until the end of the next wagering contest. October's wagering contest has already been started with almost 24 days left for users to fight for the top position and claim in those sweet rewards.
No new dice Jackpots has been hit since our last update. We expect to see some jackpots being hit soon enough within the next few days. But still, one of our anonymous user managed to hit the Slot jackpot and win 0.199 BCH by just wagering 0.0002 BCH!
Last week's lotto was filled with many entries, most of them coming from the wagering contest. The BTC lotto (Wednesday draw) had a dazzling amount of 0.1209 BTC pot. Surprisingly, user Jackthenife won the first place at lotto with just 1.323% of win chance and claimed 0.0967 BTC. Second place was taken by Bananocoin wining 0.018135 BTC with a win chance of 24.814%. Another lucky user Ingui550 placed in third and won 0.006045 BTC with a small win chance of 2.481%.
Lotto has been lucky for users with low win percentage. The first place of Ethereum Lotto has been luckily captured by tmills who won 1.168 ETH with just 2.053% of win chance. The second place was occupied by Jermane821 winning 0.2192 ETH. Unluckily, Alymer555 with a win chance of 30.8% got in third and got 0.0731 ETH.
User Skyelar, Killer1984 and klokan22 placed in first, second and third respectively at the Litecoin Lotto each winning 5.648 LTC, 1.059 LTC and 0.353 LTC.
This week's Doge coin lotto round is about to close soon within 12 hours. The first place winner will receive 66,400 DOGE, second place will win 12,450 DOGE and the third place will be getting 4,150 DOGE. That's a lot of DOGE to be won. You still have time to join in the pot and win those amazing numbers of Dogecoin. Each doge lotto tickets cost only 100 DOGE. So hurry up!
One of our anonymous user managed to hit (Slot BetID:24,627,425) 5x fruit in slots winning 0.149 BTC by placing a small bet of 0.001 BTC.
User Sealey841 placed a 41.6 ETH bet (Roulette betID:8,678,823) on roulette and won an amazing amount of 107.2 ETH.
Lucky user Skyelar won 14,678 DOGE by managing to hit x6613 multiplier on dice (Dice BetID:2,638,373,569) by wagering 2.22 DOGE.


Craig is a corporate services partner at the London office. His portfolio mainly comprises UK and international owner managed businesses with a concentration of clients operating in the arts, entertainment, information technology, biosciences and investment advisory sectors. Craig often works closely with the owner manager personally and the business itself providing a full range of assurance, accounting, business outsourcing, tax compliance and tax advisory services. Having spent time out of professional practice and with his wide technical knowledge, Craig is able to bring a different dimension to client relationships and is regularly tasked with finding creative solutions to difficult problems that they may bring to him.
Craig joined Rawlinson & Hunter in 2008, bringing with him extensive experience in both industry and professional practice firms, including Ernst & Young and Smith & Williamson.
Craig is a Fellow of the Institute of Chartered Accountants in England & Wales and an Associate of the Chartered Institute of Taxation.