1. Introduction {#sec1-ijerph-13-00391}
===============

Multimorbidity is usually defined as the co-occurrence of two or more long term conditions within one individual, and is an increasing problem with a reported doubling of prevalence over the last 20 years \[[@B1-ijerph-13-00391]\]. It is a global phenomenon and has now become the norm rather than exception in many populations \[[@B2-ijerph-13-00391],[@B3-ijerph-13-00391],[@B4-ijerph-13-00391],[@B5-ijerph-13-00391]\]. Multimorbidity is associated with increased mortality \[[@B6-ijerph-13-00391],[@B7-ijerph-13-00391],[@B8-ijerph-13-00391]\], lower quality of life \[[@B9-ijerph-13-00391],[@B10-ijerph-13-00391],[@B11-ijerph-13-00391]\], and greater utilization of healthcare including unplanned admissions \[[@B12-ijerph-13-00391],[@B13-ijerph-13-00391],[@B14-ijerph-13-00391]\] and thus higher healthcare costs \[[@B6-ijerph-13-00391],[@B15-ijerph-13-00391],[@B16-ijerph-13-00391],[@B17-ijerph-13-00391]\]. Patients with multimorbidity are less satisfied with care provided \[[@B18-ijerph-13-00391]\], perhaps due to the fragmentation of care resulting from the single disease-focus that drives much of current health care \[[@B19-ijerph-13-00391],[@B20-ijerph-13-00391],[@B21-ijerph-13-00391]\].

The prevalence of multimorbidity rises rapidly with increasing age \[[@B4-ijerph-13-00391],[@B5-ijerph-13-00391],[@B6-ijerph-13-00391],[@B16-ijerph-13-00391],[@B22-ijerph-13-00391],[@B23-ijerph-13-00391],[@B24-ijerph-13-00391]\], although, the absolute number of individuals with multimorbidity is often higher in those under 65 years \[[@B4-ijerph-13-00391],[@B25-ijerph-13-00391],[@B26-ijerph-13-00391]\]. It is also strongly associated with socioeconomic deprivation and occurs 10--15 years earlier in individuals living in the most deprived compared with the least deprived areas \[[@B3-ijerph-13-00391],[@B4-ijerph-13-00391],[@B5-ijerph-13-00391]\]. The effect of sex on multimorbidity has been less well defined \[[@B3-ijerph-13-00391]\]. Most previous studies have shown an increased prevalence of multimorbidity among women \[[@B1-ijerph-13-00391],[@B6-ijerph-13-00391],[@B16-ijerph-13-00391],[@B26-ijerph-13-00391]\], though not all studies find this \[[@B2-ijerph-13-00391],[@B27-ijerph-13-00391],[@B28-ijerph-13-00391]\]. Although in almost all countries in the world women have a longer life expectancy than men \[[@B29-ijerph-13-00391]\], they are more often affected by a number of non-fatal chronic diseases that decrease quality of life and everyday physical ability \[[@B23-ijerph-13-00391],[@B30-ijerph-13-00391]\].

Multimorbidity is a broad concept, and can be characterised further in a number of ways, such as physical-only, mental-only, and mixed mental and physical \[[@B24-ijerph-13-00391]\], as well as by the commonest combinations of individual conditions. The typology of multimorbidity by sex has not been well documented in large primary care populations. Therefore, this study aimed to examine the relationship between sex and different types of multimorbidity across different age groups, using cross-sectional data from a nationally representative large primary care dataset.

2. Methods {#sec2-ijerph-13-00391}
==========

We obtained a dataset for 1,751,841 patients of all ages, who were alive on 31 March 2007 and permanently registered with 314 Scottish general practices, from the Primary Care Clinical Informatics Unit at the University of Aberdeen, UK \[[@B31-ijerph-13-00391]\]. This accounts for about a third of the Scottish population and is representative of it in terms of age, sex, and socioeconomic deprivation. The NHS National Research Ethics Service had previously approved the use of these anonymised data for research purposes and this analysis did not require independent review \[[@B4-ijerph-13-00391]\].

Forty conditions in total were analysed as previously defined \[[@B4-ijerph-13-00391]\] using either Quality and Outcomes Framework (QOF) register Read Code sets where available (Read Codes are the clinical coding system used in UK general practice) \[[@B32-ijerph-13-00391]\], other Read Code sets used by NHS Scotland for non-QOF conditions, or combinations of Read Codes and prescription data where coding was known to be likely to under-record important conditions. The appendix provides further detail of definitions and the 40 conditions analysed.

Multimorbidity was defined as the presence of two or more disorders in an individual. The choice of conditions was based on recommendations from systematic review for multimorbidity measure \[[@B33-ijerph-13-00391]\] as well as diseases in QOF within UK General Practice (GP) contract and important diseases identified by NHS Scotland \[[@B32-ijerph-13-00391],[@B34-ijerph-13-00391]\]. To specifically examine multimorbidity in terms of physical and mental health disorders, we defined each condition as either a physical or mental health disorder. Of the 40 conditions we classified 32 as physical and 8 as mental disorders (depression, anxiety, drugs misuse, alcohol misuse, schizophrenia/bipolar, dementia, learning disability and anorexia).

In order to characterize the prevalence and type of multimorbidity, we additionally analysed how many people had: (a) 2 or more physical conditions but no mental health conditions (physical-only); (b) 2 or more mental health conditions but no physical conditions (mental-only); or (c) 2 or more conditions including at least 1 physical and 1 mental (mixed physical and mental). We then examined the top 10 most common conditions in those with multimorbidity separately in each age group by sex.

As the current analysis focused on adults with multimorbidity, we excluded adults aged under 25 years in whom multimorbidity is uncommon (prevalence 1.9%) \[[@B4-ijerph-13-00391]\]. We divided the remaining patients into 6 age groups (25--34, 35--44, 45--54, 55--64, 65--74 and 75 and over) to reflect different stages in the life course. For each of these age groups, we calculated the number (and percentage) of patients with: no conditions; with one condition; and with two or more conditions. We used graphical display to compare differences by age group in patterns of multimorbidity by sex. We calculated the ten most prevalent conditions by age group and separately for men and women with two or more conditions by dividing the number of patients with each condition by the number of patients in the relevant age groups with two or more conditions. All analysis was conducted using Stata version 13.0 (Stata, College Station, TX, USA).

3. Results {#sec3-ijerph-13-00391}
==========

The analysis involved 1,272,685 adults aged 25 years and over, of whom 51% were women and 49% were men. [Table 1](#ijerph-13-00391-t001){ref-type="table"} shows differences in prevalence of morbidity by age group and sex. For both men and women, the number and percentage of people with multimorbidity was higher in each successive ten-year age group within each sex, however, there were more people with multimorbidity in absolute numbers under the age of 65 (201,311 *vs.* 194,996). There were more women with multimorbidity than with a single condition or no condition in all age groups above the age of 55, whereas this was only true in men above the age of 65. The prevalence of multimorbidity (two or more conditions) was higher in women than in men in every age group, although the differences were small over the age of 65. The biggest sex difference was found in the 45--54 age group (women 26.5% *vs.* men 19.6%; difference 6.9 (95% CI 6.5 to 7.2).

[Table 2](#ijerph-13-00391-t002){ref-type="table"} shows the prevalence of different types of multimorbidity (physical or mental or mixed) across age groups by sex. In general, the differences in prevalence of all types of multimorbidity between men and women were markedly small. However, whilst physical-only morbidity increased with age for both men and women, differences were small up to the age of 64 years but were marginally higher for women. After the age of 65 more men than women had physical-only multimorbidity. The most significant difference was observed in the over 75 age group (women 45.3% *vs.* men 53.5%; difference −8.3 (95% CI −7.7 to −8.7). Gender differences were greatest for mixed physical and mental multimorbidity (as compared with mental-only and physical-only) at all ages but the magnitude of this difference varied with age. Women's higher prevalence of mixed physical and mental multimorbidity was small in absolute terms at age 25--34 (2.1% (95% CI 1.9 to 2.2), increasing to around 5% between the ages 45 and 74), and highest in those above the age of 75 (women 30.9% *vs.* men 21.2%; difference 9.7 (95% CI 9.1 to 10.2).

[Figure 1](#ijerph-13-00391-f001){ref-type="fig"} shows the number of people with the different types of multimorbidity by age group and sex. It illustrates that, overall, women have more multimorbidity across the life course but sex differences are small and diminish even more after 55--64 years. It shows that a large part of this reduction in sex difference is due to a steeper rise in the prevalence of men with physical only multimorbidity compared to women.

[Table 3](#ijerph-13-00391-t003){ref-type="table"} shows prevalence (%) of the conditions which feature in the top 10 most commonly found in men or women with multimorbidity within each age group. For women with multimorbidity below the age of 55, depression was the condition with the highest prevalence, whereas above the age of 55 hypertension was the most common condition. In contrast for men with multimorbidity, drugs misuse had the highest prevalence for men aged 25--34, depression for men aged 35--44, and hypertension for men aged 45 and over. Women had a consistently higher prevalence of depression, pain, IBS and thyroid disorders across all age groups. For men under 45 with multimorbidity, compared to women in the same age group, prevalence was only notably higher for substance (alcohol and drugs) misuse. Amongst people with multimorbidity, higher prevalence's of coronary heart disease (CHD) and diabetes were recorded in men than women from the ages of 45 and over.

4. Discussion {#sec4-ijerph-13-00391}
=============

This study has examined patterns of multimorbidity by age and sex in 1,272,685 adults in a nationally representative primary care sample in Scotland. Women had more overall multimorbidity than men at all ages, although the sex differences were relatively small. From the age of 45, physical-only multimorbidity was consistently more common in men, and physical-mental multimorbidity more common in women. The biggest sex difference in physical-mental multimorbidity was found in the 75 years and over group. The commonest condition in women was depression until the age of 55 years, thereafter hypertension. Depression, pain, irritable bowel syndrome and thyroid disorders were more common in women than men across all age groups.

4.1. Relationship with Existing Literature {#sec4dot1-ijerph-13-00391}
------------------------------------------

Several studies have reported that women have more multimorbidity than men \[[@B4-ijerph-13-00391],[@B26-ijerph-13-00391],[@B35-ijerph-13-00391]\], as reflected in a recent systematic review \[[@B3-ijerph-13-00391]\]. The level of sex difference in multimorbidity varies between studies. One study reported little difference between the sexes on the risk of being mutlimorbid \[[@B36-ijerph-13-00391]\]. This study used 20 chronic conditions and the difference in reported results may be explained by the inclusion in our study of additional conditions which are far more prevalent in women such as migraine and thyroid diseases. Moreover, most previous studies have had either much smaller samples sizes \[[@B26-ijerph-13-00391],[@B27-ijerph-13-00391],[@B36-ijerph-13-00391],[@B37-ijerph-13-00391]\] or were restricted to elderly \[[@B38-ijerph-13-00391],[@B39-ijerph-13-00391],[@B40-ijerph-13-00391]\] or hospitalised people \[[@B41-ijerph-13-00391]\], whereas the current study examined a nationally representative one-third of the Scottish population.

As far as we are aware, our study is the first to show prevalence rates of different types of multimorbidity and particular conditions by sex and across all ages in a large, nationally representative dataset.

In terms of mental health morbidity, our results show that physical-mental multimorbidity is much more common in women than men. Depression was more prevalent in women than men and was the most frequently occurring condition among women below the age of 55. These findings agree with previously published studies in both multimorbid \[[@B4-ijerph-13-00391],[@B42-ijerph-13-00391]\] and single disease analyses. \[[@B43-ijerph-13-00391]\] Whether this reflects "true" levels of depression in patients with at least one other condition, or a difference in the presentation (by patients) or recognition (by patients and doctors) of depression in people with other long-term conditions cannot be determined from these data. Experimental studies support differential recognition by doctors of potential symptoms in women and men \[[@B44-ijerph-13-00391],[@B45-ijerph-13-00391],[@B46-ijerph-13-00391]\], at least for cardiovascular disease and depression. In addition, below the ages of around 60 years, women are more likely to have contact with their general practitioner \[[@B47-ijerph-13-00391]\], and there thus may be differences between men and women of prior recording of depression which may alert GPs to be more alert to depression when they see female patients with physical conditions. Recent survey data have shown that 90% of women with depression discussed it with their doctor \[[@B48-ijerph-13-00391]\]. Underestimation of depression in men could perhaps also be explained by so called "masculine" ways of responding to negative affect, less help seeking and lack of consideration for some of such symptoms in commonly used diagnostic tools for depression \[[@B49-ijerph-13-00391]\]. This may be important particularly in older populations as previous literature has described that depression is related to negative outcomes within chronic diseases such as, e.g., coronary heart disease \[[@B50-ijerph-13-00391]\].

We also found higher rates of alcohol misuse for men with multimorbidity, particularly in the younger age groups, which have also been reported elsewhere \[[@B51-ijerph-13-00391],[@B52-ijerph-13-00391]\]. This is perhaps not surprising given the consistent finding of higher consumption of alcohol in general population samples of men compared with women in many cultures \[[@B53-ijerph-13-00391]\]. It is also consistent with the view that men's mental distress and depressive illness may disproportionately present as substance abuse \[[@B54-ijerph-13-00391],[@B55-ijerph-13-00391]\].

Although we did not examine the utilization of healthcare in the current study, increased multimorbidity among female patients, especially those with mental health problems, could explain the previous results in literature in relation to consultation rates and emergency inpatient admissions \[[@B12-ijerph-13-00391],[@B47-ijerph-13-00391]\]. A recent study using a large dataset in England reported that consultation rate among women was higher than men, which was only partially explained by reproduction related visits \[[@B47-ijerph-13-00391]\].

4.2. Strengths and Limitations {#sec4dot2-ijerph-13-00391}
------------------------------

As far as we are aware, the present study represents the most comprehensive study to date on sex associations with multimorbidity, based as it is on a large nationally representative primary care sample. The study has, however, several limitations. Firstly, it was based on electronic medical records from GP practices and thus relies on the diligence of the practitioners in coding conditions, and their propensity to do this equally diligently by sex for all conditions. We used mixtures of morbidity codes and prescribing to define and measure some conditions, firstly to ensure that coded conditions were still "active" (e.g., asthma code plus recent inhaler prescription) and secondly because some conditions not incentivised in the UK GPs Quality and Outcomes Framework (such as osteoarthritis) are poorly recorded. In addition, the physical conditions we used did not include chronic conditions that are specific to women (in order to compare men and women across conditions). The study is also not able to take account of severity of any of the conditions as these data were not available. Additionally, we did not examine ethnic differences in multimorbidity.

4.3. Implications for Policy and Practice {#sec4dot3-ijerph-13-00391}
-----------------------------------------

This study shows that multimorbidity differs between men and women in terms of types of conditions as well as prevalence, raising the potential need for a more tailored gendered approach to patients with multiple chronic conditions.

Lack of appropriate guidelines and integrated health systems creates a gap between patients' healthcare needs and experiences and its provision \[[@B55-ijerph-13-00391]\]. As reflected in previous studies, this gap could be decreased by improved integration and a generalist patient-centred approach \[[@B56-ijerph-13-00391]\]. Given the apparently large additional multimorbidity burden in women relating to sex-specific conditions, Gender sensitive services development may be important in some settings, including the implementation of sex related health and socio-economic risk factors reduction policies as suggested by WHO \[[@B57-ijerph-13-00391],[@B58-ijerph-13-00391]\]

Further research is required to understand the differing burdens and impacts of multimorbidity typologies in men and women.

5. Conclusions {#sec5-ijerph-13-00391}
==============

Our study has shown that, overall, women have more multimorbidity across all age groups, which is driven by a higher prevalence of combined physical and mental multimorbidity in women than men, with the biggest difference in this category being found among the oldest (above the age of 75 year). This warrants further study, including the severity, burden and effects of such sex differences in multimorbidity.

This work was funded by the Chief Scientist Office of Scottish Government Health Directorate (Applied Research Programme Grant ARPG/07/1), but study design, data analysis, interpretation and publication were the responsibility of the research team who had sole access to the data. The data contained herein were provided by the Primary Care Clinical Informatics Unit (PCCIU) at the University of Aberdeen. The views in this publication are not necessarily the views of the University of Aberdeen, its agents, or employees. Particular thanks go to Katie Wilde and Fiona Chaloner, University of Aberdeen who carried out the initial data extraction and management. Kate Hunt is funded by the Medical Research Council (MC_UU_12017/12).

Stewart W. Mercer and Bruce Guthrie conceived and designed the original study, and Karolina Agur with input from all the other authors including Kate Hunt conceived and designed this secondary analysis; Gary McLean analysed the data. Karolina Agur wrote the first draft of the paper, and all authors contributed to revisions and the final version.

The authors declare no conflict of interest. The founding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results.

![Per cent of people, by type of multimorbidity (physical only, mental only and mixed) and by sex and age.](ijerph-13-00391-g001){#ijerph-13-00391-f001}

ijerph-13-00391-t001_Table 1

######

Number of conditions by age group and sex.

  Age Group   No Conditions   One Condition   Two Conditions
  ----------- --------------- --------------- ------------------------ --------------- --------------- --------------------- --------------- --------------- ------------------
  25--34      78,941 (70.1)   90,806 (77.7)   −7.6 (−7.2 to −7.9)      22,701 (20.2)   18,261 (15.6)   4.6 (4.2 to 4.9)      10,911 (9.7)    7776 (6.7)      3.0 (2.8 to 3.2)
  35--44      80,309 (58.9)   99,029 (69.4)   −10.5 (−10.1 to −10.8)   32,966 (24.1)   27,805 (19.5)   4.6 (4.3 to 5.0)      23,025 (16.9)   15,859 (11.1)   5.8 (5.5 to 6.0)
  45--54      59,328 (47.3)   72,592 (56.4)   −9.1 (−8.7 to −9.5)      32,751 (26.1)   30,702 (23.9)   2.2 (1.9 to 2.5)      33,230 (26.5)   25,191 (19.6)   6.9 (6.5 to 7.2)
  55--64      35,128 (31.9)   40,715 (37.2)   −5.3 (−4.8 to −5.7)      29,120 (26.4)   29,051 (26.6)   −0.2 (0.2 to −0.4)    45,737 (41.6)   39,582 (36.2)   5.4 (4.9 to 5.7)
  65--74      14,868 (18.0)   13,794 (18.9)   −0.9 (−0.5 to −1.2)      18,567 (22.5)   16,501 (22.7)   −0.2 (0.2 to −0.5)    49,009 (59.4)   42,541 (58.0)   1.4 (0.5 to 1.5)
  75 plus     6989 (8.3)      4864 (9.4)      −1.1 (−0.7 to −1.3)      12,532 (14.9)   8058 (15.5)     −0.6 (−0.1 to −1.0)   64,491 (76.7)   38,955 (75.1)   1.6 (1.2 to 2.1)

Analysis based on 40 chronic conditions; 32 physical and 8 mental, percentages in the conditions columns relate distribution within each separate age group by sex.

ijerph-13-00391-t002_Table 2

######

Differences in type of multimorbidity by age group and sex.

  Age Group   Physical only Multimorbidity   Mental only Multimorbidity   Mixed Physical and Mental Multimorbidity
  ----------- ------------------------------ ---------------------------- ------------------------------------------ ------------ ------------ --------------------- --------------- --------------- -------------------
  25--34      3185 (2.8)                     1925 (1.6)                   1.2 (1.0 to 1.3)                           1847 (1.6)   2172 (1.8)   −0.2 (−0.1 to −0.3)   5879 (5.2)      3679 (3.1)      2.1 (1.9 to 2.2)
  35--44      7785 (5.7)                     5455 (3.8)                   1.9 (1.7 to 3.0)                           2367 (1.7)   2620 (1.8)   −0.1 (−0.0 to −0.2)   12,873 (9.4)    7784 (5.5)      3.9 (3.7 to 4.1)
  45--54      13,999 (11.1)                  12,643 (9.8)                 1.3 (1.1 to 1.5)                           1659 (1.3)   1479 (1.1)   0.2 (0.0 to 0.3)      17,572 (14.0)   11,069 (8.6)    5.4 (5.1 to 5.7)
  55--64      25,175 (22.9)                  24,596 (22.5)                0.4 (0.0 to 0.7)                           891 (0.08)   735 (0.07)   0.01 (0.00 to 0.06)   19,671 (17.9)   14,251 (13.0)   4.9 (4.5 to 5.1)
  65--74      31,711 (38.5)                  30,825 (42.3)                −3.8 (−3.3 to −4.3)                        420 (0.05)   245 (0.03)   0.02 (0.01 to 0.03)   16,878 (20.5)   11,471 (15.7)   4.8 (4.3 to 5.1)
  75 plus     38,088 (45.3)                  27,824 (53.5)                −8.3 (−7.7 to −8.7)                        459 (0.05)   127 (0.02)   0.03 (0.02 to 0.04)   25,944 (30.9)   11,004 (21.2)   9.7 (9.1 to 10.2)

Analysis based on 40 chronic conditions; 32 physical and 8 mental. Percentages are the % in each age group by sex.

ijerph-13-00391-t003_Table 3

######

Differences by age and sex in the top 10 most prevalent conditions for multimorbid patients.

  --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  Rank Order of Conditions       Age 25--34 (Women)\              Age 25--34 (Men)\         Age 35--44 (Women)\       Age 35--44 (Men)\         Age 45--54 (Women)\        Age 45--54 (Men)\
                                 % (95% CI)\                      % (95% CI)\               % (95% CI)\               % (95% CI)\               % (95% CI)\                % (95% CI)\
                                 *n* = 10,911                     *n* = 7776                *n* = 23,025              *n* = 15,859              *n* = 33,230               *n* = 25,191
  ------------------------------ -------------------------------- ------------------------- ------------------------- ------------------------- -------------------------- -------------------------
  1                              Depression\                      Drugs Misuse\             Depression\               Depression\               Depression\                Hypertension\
                                 52.9 (51.9--53.8)                38.5 (37.4--39.6)         53.7 (53.1--54.3)         36.9 (36.1--37.7)         46.5 (46.0--47.0)          36.0 (35.4--36.6)

  2                              Asthma\                          Depression\               Pain\                     Pain\                     Pain\                      Depression\
                                 27.6 (26.8--28.4)                36.4 (35.3--37.4)         28.4 (27.8--29.0)         23.5 (22.8--24.1)         32.0 (31.5--32.5)          28.5 (27.9--28.0)

  3                              Pain\                            Alcohol dependence\       Asthma\                   Drugs Misuse\             Hypertension\              Pain\
                                 21.4 (20.6--22.1)                22.8 (21.8--23.7)         22.6 (22.0--23.1)         22.4 (21.8--23.1)         27.0 (26.5--27.5)          26.4 (25.9--26.9)

  4                              IBS\                             Asthma\                   IBS\                      Alcohol dependence\       Thyroid\                   Alcohol dependence\
                                 19.9 (19.1--20.6)                22.1 (21.1--23.0)         20.2 (19.7--20.7)         21.8 (21.2--22.4)         19.5 (19.1--19.9)          19.0 (18.5--19.5)

  5                              Anxiety\                         Anxiety\                  Anxiety\                  Asthma\                   Asthma\                    Dyspepsia\
                                 19.5 (18.7--20.2)                20.4 (19.5--21.3)         18.2 (17.7--18.7)         19.2 (18.6--19.8)         18.7 (18.3--19.1)          18.9 (18.4--19.4)

  6                              Drugs Misuse\                    Pain\                     Thyroid\                  Dyspepsia\                Dyspepsia\                 Diabetes\
                                 16.9 (16.1--17.6)                16.0 (15.1--16.7)         15.7 (15.2--16.1)         19.1 (18.4--19.7)         18.1 (17.7--18.5)          17.8 (17.3--18.3)

  7                              Thyroid\                         Dyspepsia\                Dyspepsia\                Anxiety\                  IBS\                       Asthma\
                                 11.0 (10.3--11.5)                12.4 (11.6--13.1)         14.6 (14.1--15.1)         17.2 (16.6--19.8)         17.8 (17.4--18.2)          14.4 (14.0--14.8)

  8                              Dyspepsia\                       Schizophren/Bi-polar\     Hypertension\             Hypertension\             Anxiety\                   Inflammatory arthritis\
                                 9.0 (8.5--9.5)                   8.8 (8.1--9.4)            11.6 (11.2--12.0)         16.6 (16.0--17.2)         15.5 (15.0--15.8)          12.6 (12.2--13.0)

  9                              Alcohol dependence\              Hearing loss\             Drugs Misuse\             Diabetes\                 Diabetes\                  Anxiety\
                                 8.6 (8.1--9.1)                   7.9 (7.3--8.5)            9.5 (9.1--9.8)            10.5 (10.0--11.0)         10.7 (10.4--11.0)          11.2 (10.8--11.6)

  10                             Hearing loss\                    IBS\                      Alcohol dependence\       IBS\                      Inflammatory arthritis\    CHD\
                                 6.2 (3.2--4.0)                   6.7 (6.1--7.3)            7.4 (7.1--7.7)            8.0 (7.6--8.4)            9.5 (9.2--9.8)             10.9 (10.5--11.3)

  **Rank order of conditions**   **Age 55--64 (Women)**\          **Age 55--64 (Men)**\     **Age 65--74 (Women)**\   **Age 65--74 (Men)**\     **Age 75&over (Women)**\   **Age 75& over (Men)**\
                                 **% (95% CI)**\                  **% (95% CI)**\           **% (95% CI)**\           **% (95% CI)**\           **% (95% CI)**\            **% (CI 95%)**\
                                 ***n* = 47,727**                 ***n* = 39,852**          ***n* = 49,009**          ***n* = 42,541**          ***n* = 64,491**           ***n* = 38,955**

  1                              Hypertension\                    Hypertension\             Hypertension\             Hypertension\             Hypertension\              Hypertension\
                                 46.6 (46.1--47.0)                50.8 (50.3--51.2)         59.3 (58.8--59.7)         57.1 (56.7--57.6)         64.4 (64.0--64.7)          57.9 (57.3--58.4)

  2                              Depression\                      Pain\                     Pain\                     CHD\                      CHD\                       CHD\
                                 34.7 (34.2--35.1)                27.8 (27.4--28.2)         33.5 (33.0--33.9)         33.2 (32.8--33.7)         26.6 (26.3--26.9)          38.8 (38.2--39.2)

  3                              Pain\                            CHD\                      Depression\               Pain\                     Pain\                      Diabetes\
                                 34.5 (34.0--34.9)                22.2 (21.8--22.6)         23.5 (23.2--23.9)         25.9 (25.5--26.4)         26.3 (26.0--26.6)          19.9 (19.5--20.3)

  4                              Thyroid\                         Diabetes\                 Thyroid\                  Diabetes\                 Thyroid\                   Stroke-TIA\
                                 21.8 (21.4--22.2)                21.8 (21.3--22.3)         22.4 (22.1--22.8)         24.1 (23.7--24.5)         21.5 (21.2--21.8)          19.2 (18.8--19.5)

  5                              Dyspepsia\                       Depression\               CHD\                      COPD\                     Depression\                Pain\
                                 18.5 (18.1--18.8)                20.3 (19.9--20.7)         19.9 (19.6 --20.3)        15.1 (14.8--15.4)         20.7 (20.4--21.0)          19.1 (18.7--19.5)

  6                              Asthma\                          Dyspepsia\                Diabetes\                 Inflammatory arthritis\   Chronic Kidney Disease\    Hearing Loss\
                                 14.7 (14.3--15.0)                15.6 (15.2--16.0)         18.4 (18.1--18.8)         14.1 (13.8--14.5)         19.4 (19.1--19.7)          18.0 (17.6--18.4)

  7                              Diabetes\                        Alcohol dependence\       Dyspepsia\                Dyspepsia\                Constipation\              Chronic Kidney Disease\
                                 14.2 (13.9--14.5)                14.6 (14.3--14.9)         18.0 (17.7--18.4)         13.5 (13.1--13.8)         18.0 (17.7--18.3)          16.8 (16.5--17.1)

  8                              Irritable bowel syndrome\        Inflammatory arthritis\   COPD\                     Stroke-TIA\               Dyspepsia\                 COPD\
                                 13.3 (13.0--13.6)                14.3 (14.0--14.6)         14.2 (13.9--14.5)         12.9 (12.6--13.2)         16.4 (16.1--16.7)          16.6 (16.2--16.9)

  9                              Anxiety\                         COPD\                     Inflammatory arthritis\   Depression\               Anxiety\                   Any Cancer\
                                 13.1 (12.8--13.4)                10.7 (10.4--11.0)         13.4 (13.0--13.84)        12.7 (12.4--13.0)         15.9 (15.6--16.1)          15.5 (15.1--15.8)

  10                             Inflammatory poly-arthropathy\   Asthma\                   Anxiety\                  Hearing Loss\             Diabetes\                  Constipation\
                                 12.5 (12.2--12.8)                10.2 (9.9--10.5)          13.1 (12.8--13.4)         12.2 (11.8--12.5)         15.5 (15.2--15.8)          15.2 (14.8--15.5)
  --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Abbreviations: Coronary Heart Disease (CHD); Chronic obstructive pulmonary disease (COPD); Irritable bowel syndrome (IBS).


This training grant will support 17 graduate students usually for their first two years. The goal of this program is to give the students the widest possible education in genetics and provide opportunities to work in many of the major areas of genetics research, including plant, microbial, yeast, Drosophila, C. elegans, Zebrafish, human genetics, genomics and bioinformatics and other areas. The Training Grant sponsors regular genetics research presentations by more senior graduate students and three student-invited outside genetics seminar speakers. Students are selected for the grant before matriculating on the basis of their interests and their agreement to take an introductory and an advanced genetic course. Their progress is followed by faculty advisors who are members of the Training Grant and by the Director this Grant. These students will be part of the Biological and Biomedical Sciences program which includes the following components: 1) Advising throughout their graduate career by a faculty member of the Training Grant; 2) a set of four core courses in genetics and other core subjects, a critical reading course, and advanced courses. The total required number of courses is 8; 3) a regular fall poster session, regular faculty talks, student-organized fall retreat, Mini-Symposia on specialized topics and Departmental activities all of which introduce students to the range of lab research subjects available; 4) a program and course in Conduct of Science and a seminar speaker on social issues in genetics; 5) laboratory rotations during the first 12 months allowing students to try out three labs; 6) forums on careers in academic science and in alternative careers; 7) a qualifying examination and a thesis advisory committee to follow the progress of the student; 8) regular seminars on genetic subjects in Medical School basic science Departments.


Stats

Lockscreen:~ Wallpaper by Obeythe10: mod of [link]~ Clock by Patrick Muff: mod of the Analog Clock~ Unlock Tweak by Max Katzmann: JellyLock (beta) (used an Icon from the same Icon Pack that i used in the HS Dock)

Homescreen:~ Wallpaper by ether: [link]~ Sarif Theme by White-Baron: for the textuel weather and time [link] (used SarifMod-HS time, SarifMod-HS weather and SarifMod-dock hide <- all included in the Theme)~ Icons by lajalousie: [link] + some selfmade with included psd~ Dock Icon by pk1st: [link]~ Weather widget: used DashboardX and the standart NC Weather~ Font: BytaFont Tweak with Geo Sans Light


1. Introduction
===============

Breast cancer is the most common type of cancer among women worldwide and ranks as the second most common cancer among women in Korea.^\[[@R1]\]^ Owing to the advances in systemic therapies, including intensive local treatment, chemotherapy, endocrine therapy, and targeted therapy, overall survival rates of breast cancer have increased; however, these therapies have not produced significant changes in the prognosis of patients with breast cancer accompanied by distant metastasis.

The main sites of metastasis for breast cancer are the bone, lung, and liver, whereas metastasis to the gastrointestinal tract is relatively rare; reported incidence rates are 2% to 18% of breast cancer cases. Importantly, gastric metastasis from invasive lobular breast carcinoma is reported to occur at a higher rate than the metastasis from invasive ductal carcinoma.^\[[@R2]\]^ Gastric cancer has high incidence rates in Korea,^\[[@R1]\]^ and differentiation between primary gastric cancer and metastatic gastric cancer based solely on clinical findings may be difficult. Inappropriate diagnosis can lead to unnecessary surgical procedures.

In the present study, we report a case of gastric metastasis from invasive lobular breast cancer, which can be misdiagnosed as primary gastric cancer. We also report the effectiveness and applications of immunohistochemical analysis in the differentiation of gastric metastasis from breast cancer and primary gastric cancer.

2. Case presentation
====================

The study was approved by the institutional Review Board of Chungbuk National University Hospital, Republic of Korea. The patient agreed to authorize us to share the figures and the experiences during her treatment procedure in our department. Informed consent was obtained.

A 39-year-old woman visited the clinic because of the presence of a palpable mass in the right breast that had developed 2 months ago, and discomfort in the upper abdomen. The patient was on medication with antacid for chronic gastritis that she had been diagnosed with at a private hospital based on her upper gastrointestinal endoscopy results. A solid mass in the upper outer region of the right breast and enlarged ipsilateral axillary lymph nodes could be palpated on physical examination. Ultrasonography and breast magnetic resonance imaging (MRI) results showed single masses on the upper outer quadrant of the right breast, as well as multiple axillary lymphadenopathy (Fig. [1](#F1){ref-type="fig"}A). The patient was diagnosed with invasive lobular breast carcinoma after a core needle biopsy. Blood test results, including liver function measurements, were all normal. The hemoglobin, carcinoembryonic antigen, and carbohydrate antigen 15-3 levels were 12 g/dL, 4.36 ng/mL, and 34.59 μ/mL, respectively. No abnormal finding was observed on abdominal ultrasonography other than bilateral hydronephrosis. Positron emission tomography (PET) results showed lesions in the right breast and axilla, and no evidence of distant metastases (Fig. [1](#F1){ref-type="fig"}B--D).

![Breast magnetic resonance imaging (MRI) (A) and positron emission tomography-computed tomography (PET-CT) (B--D) findings showing irregular enhancing mass in the right breast with axillary lymph node metastasis. There was no evidence of distant metastasis.](medi-97-e0258-g001){#F1}

Right breast conserving surgery and axillary lymphadenectomy were performed. A biopsy performed after surgery confirmed the presence of invasive lobular breast carcinoma, measuring 2 cm in the right breast (Fig. [2](#F2){ref-type="fig"}A). Metastasis was observed in 5 out of 20 dissected axillary lymph nodes (Fig. [2](#F2){ref-type="fig"}B). The breast carcinoma was immunohistochemically positive for estrogen receptor (2+, 90%) and progesterone receptor (2+, 60%), and negative for E-cadherin and C-erb-B2 (Fig. [2](#F2){ref-type="fig"}C and D). An additional immunohistochemical analysis identified the breast carcinoma was positive for gross cystic disease fluid protein-15 (GCDFP-15), and negative for caudal-type homeobox 2 (CDX-2) transcription factor, mucin-2 (MUC-2), and mucin-5 (MUC-5).

![Histopathology of breast at the invasive front showed invasive lobular carcinoma, morphologically resembling signet ring cell carcinoma with poorly adhesive cancer cells (hematoxylin and eosin staining × 400) (A). Single-cell invasive pattern was prominent in metastatic lymph nodes (hematoxylin and eosin staining × 400) (B). The primary breast carcinoma was immunohistochemically positive for estrogen receptor (C) and negative for C-erb-B2 (D).](medi-97-e0258-g002){#F2}

Two weeks after the surgery, gastroscopy was performed again because discomfort and pain in the upper abdomen were persistent; a diffuse scirrhous mass was identified at the prepyloric antrum with pyloric obstruction (Fig. [3](#F3){ref-type="fig"}A). Abdominal computed tomography (CT) scans showed hypertrophy of the gastric wall of the pyloric region accompanied by pyloric obstruction (Fig. [3](#F3){ref-type="fig"}B). No evidence of lymphadenopathy or metastasis was found, whereas bilateral hydronephrosis was observed. Based on these findings, the patient was diagnosed with T3N0M0 gastric cancer according to the 7th edition of the AJCC staging system. Poorly differentiated adenocarcinoma partially resembling the morphology of signet ring cell carcinoma was observed on gastroscopic biopsy. The aforementioned lesion was positive for estrogen receptor (2+), progesterone receptor (1+), and GCDFP-15, and negative for CDX-2, cytokeratin (CK) 5, CK14, MUC-2, MUC-5, and E-cadherin. Finally, the lesion was diagnosed as metastatic gastric cancer originating from invasive lobular carcinoma. A difference in the level of C-erb-B2 expression was found between the gastric lesion and the primary breast carcinoma; overexpression of C-erb-B2 was observed in the metastatic gastric cancer (Fig. [4](#F4){ref-type="fig"}).

![A diffuse, scirrhous mass at the prepyloric antrum with pyloric obstruction was identified on gastroduodenoscopy (A). Abdominal CT scan with contrast demonstrating pyloric obstruction with diffuse gastric wall thickening (B).](medi-97-e0258-g003){#F3}

![Histopathology of gastric lesions. Gastric biopsy showed poorly differentiated adenocarcinoma with signet ring cell morphology and intact normal gastric mucosa resembling the primary breast lesion (hematoxylin and eosin staining × 100) (A) and (hematoxylin and eosin staining × 400) (B); immunohistochemistry was positive for estrogen receptor (C), C-erb-B2 (D), and GCDFP-15 (E), and negative for CDX-2 (F). These findings demonstrated that the gastric lesion was metastatic from breast carcinoma.](medi-97-e0258-g004){#F4}

During a medical examination, the patient stated that she had no family history of breast or gastric cancer, had never been diagnosed with lobular carcinoma in situ, and had never undergone hormone replacement therapy in the past. After a multidisciplinary team meeting, it was determined that no additional surgery would be performed for the metastatic gastric cancer, and a duodenal stent was inserted under the guidance of endoscopy to relieve the patient\'s symptoms (Fig. [5](#F5){ref-type="fig"}A and B). Systemic chemotherapy with combined administration of paclitaxel (80 mg/m^2^) and trastuzumab (2 mg/kg) at 1-week intervals was initiated. Pyloric obstruction was moderately reduced and evidence of reflux was found on gastroscopy performed 6 months after the diagnosis (Fig. [5](#F5){ref-type="fig"}C). Moreover, 7 months after the diagnosis, small bowel obstruction occurred as a result of stent displacement. A laparotomy for stent removal, and resection and anastomosis of the small bowel were performed.

![A duodenal stent was inserted to relieve pyloric obstruction (A, B). Pyloric obstruction was moderately reduced and evidence of reflux was found on gastroscopy performed 6 months after the diagnosis (C). Forty-one months after initial diagnosis, gastric wall thickening was improved without any new lesions (D).](medi-97-e0258-g005){#F5}

Currently, 41 months after the diagnosis, the patient is still undergoing the same therapy and has been experiencing tolerable grade 1 peripheral neuropathy and changes in the nails. Gastrointestinal symptoms, including discomfort in the upper abdomen, have mostly been relieved. No recurrent lesion has been identified in the breast and evidence of a partial remission of gastric wall thickening has been observed on follow-up abdominal CT scans (Fig. [5](#F5){ref-type="fig"}D). Lastly, no evidence of new metastasis has been observed.

3. Discussion and Conclusion
============================

Gastric metastasis of malignant breast carcinoma is relatively rare. Clinical symptoms include loss of appetite, feeling bloated soon after eating, upper abdominal pain, bleeding, and vomiting.^\[[@R2]\]^ In the present case, the main symptoms were indigestion and upper abdominal pain resulting from pyloric obstruction caused by the mass. As observed in this case, metastatic gastric cancer is often presented as linitis plastica, which spreads to the muscular layers of the stomach and gastric mucosa, whereas it is rarely accompanied by external pressure or separate nodules. According to Taal et al, invasive lobular carcinoma accounts for 83% of all the metastases from malignant breast tumors and it often spreads throughout the stomach.^\[[@R2]\]^ The most common site of metastasis from invasive lobular carcinoma is the stomach; gastric metastases are observed at rates of 6% to 18% during a biopsy. Most gastrointestinal metastases present as one among multiple distant metastases several years after breast cancer surgery, and the mean time from the primary diagnosis of breast cancer to metastasis is reported to be 6 to 7 years.^\[[@R3]\]^ Therefore, the case observed in this study, in which a metastasis occurred only in the stomach at the time of primary diagnosis of breast cancer, is extremely rare.

In the present case, gastric metastasis was not detected during a systemic examination performed at the time of breast cancer diagnosis. PET scans obtained before surgery did not show any evidence of gastric tumors; tumors were observed only in breast and axillary lesions. The sensitivity of PET is reported to be relatively lower for the diagnosis of gastric cancer compared with that of other cancer types, and this is attributed to issues associated with physiological absorption of F-18 fluorodeoxyglucose and involuntary movements by the gastric wall. Gastric cancer morphology is also associated with sensitivity of PET. Although the sensitivity of PET is high for papillary or ductal carcinoma and poorly differentiated solid adenocarcinoma, high false-negative rates are reported for signet ring cell carcinoma and poorly differentiated nonsolid adenocarcinoma.^\[[@R4]\]^

In general, it is difficult to differentially diagnose primary gastric cancer and metastatic gastric cancer based on gross endoscopy results alone. Because gastric metastases are mostly localized to the submucosal and seromuscular layers, endoscopy results may present as normal in 50% of the cases.^\[[@R5]\]^ In the present case, the patient was not appropriately diagnosed even after multiple rounds of endoscopy and biopsies, possibly because a biopsy of the deeper gastric layers, including the submucosa, was not performed.

Although diffuse gastric adenocarcinoma and metastatic gastric cancer from invasive lobular carcinoma may exhibit a single-cell invasive pattern or morphologically resemble signet ring cells, they have different methods of treatment and prognoses.^\[[@R6]\]^ In such a case, a detailed immunohistochemical analysis can be of great help. Connel et al compared immunohistochemical results between gastric metastases from breast cancer and primary gastric cancer.^\[[@R7]\]^ The results demonstrated increased expression levels of estrogen and progesterone receptors, GCDFP, and CK5/6 in gastric tumors metastasized from breast cancer, compared with those in primary gastric cancer; 72% for estrogen receptor, 33% for progesterone receptor, 78% for GCDFP-15, and 61% for CK5/6 in metastatic cancer, whereas zero expression levels were observed for estrogen receptor, progesterone receptor, and GCDFP, and 14% for CK5/6 in gastric metastases from primary gastric cancer. Estrogen receptor, progesterone receptor, and GCDFP-15 were characteristics pertaining solely to gastric metastasis from breast cancer.

Various markers whose primary origin is the breast have been used in clinical practice. Among these, estrogen receptor is the most influential and sensitive marker for differentiating metastatic breast cancer. However, they have low sensitivity (∼50%) for other metastatic cancers, as well as low specificity because they can be expressed by other types of cancer aside from endometrial, ovarian, and breast cancer. Although there are rare reports on expression of estrogen or progesterone receptors in gastric adenocarcinoma, estrogen receptors are reported to be almost never expressed in gastrointestinal adenocarcinoma, especially in colorectal cancer. A gross cystic disease fluid is a pathological secretion released by the breast and is characterized by increased levels of the GCDFP-15. This protein has been used as a breast-specific marker with sensitivity of 11% to 73% and specificity of 93% to 100%. GCDFP-15 is known to be expressed in not only breasts, but also malignant tumors originating from the salivary gland, external genitals, eyelid, and apocrine duct of the bronchial tubes, and in certain instances of gynecologic adenocarcinoma (5%--10%); however, it is almost never expressed in gastrointestinal cancer. Other breast-specific markers include mammaglobin and GATA-binding protein, with sensitivity of 26% to 84% and 32% to 95%, respectively.^\[[@R8]\]^

CK7 and CK20 are useful cytokeratin markers that can differentiate distant and metastatic gastric tumors. Although CK7+/CK20− are usually expressed in adenocarcinoma of the breast, lung, and ovary, CK7−/CK20+ is more commonly expressed in intestinal adenocarcinoma. In addition, homeobox protein CDX-2, which is necessary for intestinal formation and encodes transcription factors that are involved in the differentiation and proliferation of intestinal epithelial cells, is mostly expressed by malignant gastrointestinal tumors, specifically at a rate of 61% for gastric cancer and 96% for colorectal cancer.^\[[@R9]\]^ Although the levels of expression of CK7 and CK20 were not measured in the present case, GCDFP-15, estrogen receptor, and progesterone receptor positive, and CDX-2 negative results alone suffice in the differentiation of metastatic gastric cancer from primary gastric cancer.

Curtit et al compared immunohistochemical results of primary and metastasis sites of breast cancer before and after treatment, and found differences in the levels of expression of the estrogen and progesterone receptors at 17% and 29% of the sites, respectively. A significant change in the level of expression of the estrogen receptor was found at metastasis sites after chemotherapy, and specifically anthracycline-based chemotherapy.^\[[@R10]\]^ In the present case, although estrogen and progesterone receptors were expressed at both the primary and metastasis sites of breast cancer, C-erb-B2 was only expressed at the metastasis sites. The level of C-erb-B2 expression may differ between primary and metastasis sites of breast cancer in 5% to 10% of the cases, rates that are lower than those of estrogen or progesterone receptors.^\[[@R11]\]^ The expression of C-erb-B2 in the metastatic gastric tumor observed in the present case demonstrated the potential for C-erb-B2-targeted therapy as an addition to chemotherapy and endocrine therapy. The present study is also meaningful in that a patient was maintained in partial remission through prolonged targeted therapy that was planned based on the immunohistochemical results, and in doing so, demonstrated the usefulness of long-term targeted therapy.

Chemotherapy, endocrine therapy, or combined therapy, which are treatment options for gastric metastasis from invasive lobular carcinoma, have remission rates of 32% to 53%, and can prolong survival time by 2 to 3 years.^\[[@R12]\]^ Treatment decisions can be made based on clinical symptoms of an individual patient, and the role of multidisciplinary teams, including those in charge of the gastrointestinal tract, is crucial in the decision-making process. Although resection of liver or pulmonary metastases is reported to increase survival rates in selected patients, reports of resection resulting in a significant increase in survival rates for gastric metastases are rare. In limited cases, prolonged survival has been reported for patients in complete remission from primary breast cancer with solitary gastric metastases, who underwent gastric resection, relative to those that did not undergo resection; survival time of 38 months versus 14.38 months, respectively.^\[[@R12]\]^ However, because gastric metastases are accompanied by metastases of the gastric wall and other regions of the gastrointestinal tract in most cases, surgical treatment of gastric tumors is not recommended as a primary treatment option. Surgical treatment, such as bypass surgery, may be used in cases of complete intestinal obstruction or in emergencies, such as perforation of the gastric wall. McLemore et al treated some patients with gastric metastasis using conventional surgical procedures for symptom relief, and reported no increase in survival rates after surgery. Specifically, they reported that the patient\'s history of undergoing chemotherapy or hormone therapy is an important prognostic factor, whereas old age and the presence of gastric metastasis are poor prognostic factors.^\[[@R13]\]^

In conclusion, we have reported a case of invasive lobular carcinoma with gastric metastasis, which can be misdiagnosed as primary gastric cancer. Accurate diagnosis and patient-tailored treatment can be achieved through clinical suspicion, repeated endoscopy, and accurate histological examination including disease-specific immunohistochemical analysis.

Author contribution
===================

**Data curation:** D.H. Kim, S.-M. Son, Y.J. Choi.

**Formal analysis:** S.-M. Son, Y.J. Choi.

**Investigation:** D.H. Kim.

**Methodology:** Y.J. Choi.

**Project administration:** Y.J. Choi.

**Supervision:** S.-M. Son.

**Visualization:** D.H. Kim, Y.J. Choi.

**Writing -- original draft:** Y.J. Choi.

**Writing -- review & editing:** S.-M. Son, Y.J. Choi.

Abbreviations: BCS = breast conserving surgery, CDX-2 = caudal-type homeobox 2, CK = cytokeratin, CT = computed tomography, GCDFP-15 = gross cystic disease fluid protein-15, MUC-2 = mucin-2, MUC-5 = mucin-5, PET = positron emission tomography.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The authors have no funding and conflicts of interest to disclose.


The incidence of congenital penile curvature.
To determine the incidence of congenital penile curvature a group of 500 consecutive male neonates at our institution were examined for this anomaly. In this group there were 3 cases of congenital penile curvature, for an incidence of 0.6%.


"I want to be a Great Witch Huntress of that Fairy Tales, like Shiny Chariot"

- Rubykko catchphrase based on both characters.

BASIC INFORMATION

Name: Atsuby "Rubykko" Kagarose

* (Name can be different, share your own Fusion Name)

Fusion Between: Ruby Rose + Atsuko "Akko" Kagari

MEDIA

1st Half: RWBY

2nd Half: Little Witch Academia

CHARACTERISTICS

Gender: Female

Race: Human

Hair: Brown w/Red Stripes

Eyes: Silver

Age: Teen (16, Both characters have 16 years old)

Height: 1.59m (The middle between Ruby's and Akko's height)

- Ruby [1.57m]

- Akko [1.61m]

WEAPONRY AND SKILLS

[Special] Crescent Rod

Fusion Between:

- Crescent Rose (Owned by Ruby)

* A Scythe designed by Ruby who can turn in a Sniper with different types of ammo.

- Shiny Rod (Owned by Akko)

* A Rod originally owned by Shiny Chariot, who can turn in a Magic Bow.

Special Skills:

- Magic Manipulation (by Akko)

* Akko is a Witch Student who originally can't use Magic being Human.

- Speed Semblance (by Ruby)

* Ruby uses the Speed, who can travel like a Tornado with Rose Petals.

VOICE COMBINATION

Japanese:

- Saori Hayami (Ruby)

- Megumi Han (Akko)

English:

- Lindsay Jones (Ruby)

- Erica Mendez (Akko)


Q:

Removing dynamic component from jQuery messes up the ViewContainerRef container

I have an angular 2+ app in which I am creating a bunch of dynamic components like so -
@ViewChild("containerNode", { read: ViewContainerRef }) cardContainer;

const factory = this.ComponentFactoryResolver.resolveComponentFactory(CardComponent);
const ref = this.cardContainer.createComponent(factory);

I'm using jsPlumb (jQuery version) with which I am drawing these created components on to a canvas. Once these elements are part of the jsPlumb instance, jsPlumb provides options to remove the elements, add endpoints, etc.
Now, on a user (click) event, I am removing the element the user clicked on, like so -
this.jsPlumbInstance.remove(ref.location.nativeElement);

Internally I assume this is just a jQuery remove. The problem I am facing is, after I remove this element using the above code, I'm not able to add any new components using the ViewContainerRef. After this line has executed, when I do this
const factory = this.ComponentFactoryResolver.resolveComponentFactory(CardComponent);
const ref = this.cardContainer.createComponent(factory);

the ref.location.nativeElement's parent nodes are null. I suspect that removing a component using the jQuery remove is somehow messing up the container and does not add new components properly to the parent. Note, I HAVE TO do a jsPlumb.remove as there are several other related events that will be fired internally by jsPlumb which must all execute when a component is removed from it (like all edges connected to it should also be removed, etc.)
Does anyone know what is happening here and how it can be fixed? Any help is appreciated.

A:

As mention in the above comment. One way to manipulate DOM element created by Angular in Angular way is using detach() method of ViewContainerRef class. Something like this:
@ViewChild("containerNode", { read: ViewContainerRef }) cardContainer: ViewContainerRef;

...

// To remove/detach component in Angular way
this.cardContainer.detach();


This invention relates to awning windows, and is directed particularly to protective covers for the individual window sashes of awning windows for security and wind-storm protection.
It is common practice to enclose or "board-up" windows from the outside of a building to afford security protection against forced entry or break-in when the building is unoccupied, and to protect against breakage by flying objects during severe weather conditions such as occur during hurricanes and tornados. Plywood and sheet metal window covers heretofore used for this purpose are deficient in many respects, principally in that they are costly, difficult to install, and usually unsightly in appearance.


Tag: featured

This is actually my 150th post on Rediscover Fukushima! It seems fitting that the timing worked out like this, but I actually have an exciting announcement to make. I started this blog in September 2016 because there wasn’t a lot of information available online in English about Fukushima Prefecture, which meant people around the worldContinue reading Fukushima Travel: New Website!→

I recently got to try my hand at making awamanju (a local delicacy from Yanaizu Town, Aizu) and really enjoyed the experience! This activity is suitable for people of all ages, and staff can even instruct you in English! But first things first… What is a manju? Manju are a type of traditional Japanese confectioneryContinue reading Making Awamanju in Yanaizu→

This autumn, I visited Showa Village, in rural Okuaizu region. (I wrote about Showa Village in my last post as well.) One of the places I took a trip to was Michi-no-Eki Karamushi Orinosato Showa (Roadside Station) – pictured below – where I was able to try traditional ramie weaving! From shirts to bags, decorationsContinue reading Trying out Ramie Weaving in Showa Village→

Autumn at Kuimaru Elementary School in Show Village is like something from a postcard. Kuimaru Elementary School closed in 1980 after years of population decline in Showa Village. This beautiful building was due to be torn down in 2012, but was bought by the village and reopened in 2018 as a museum and community building,Continue reading History Paused in Showa Village→


Sunday Services

Me and White Supremacy

This sermon is an invitation and education about recent events at the UUA as well as an exploration of terms such as “white supremacy” and “white privilege.” This is not about guilt, shame or blame but looking to ways we can move forward in our understanding of the racialized landscape of our culture and denomination.


Q:

Python Graphing on linux system without xserver

I am new to python and trying to explore graphs, could you please help me understand if I can plot graphs on the console using matplotlib on a linux system that has no XSERVER running?
Thanks.

A:

You can use matplotlib with no X server by setting the backend to Agg, PS, PDF or SVG, Cairo or GDK (depending on what kind of file you wish to create). You can set the backend in your matplotlibrc file, which, depending on your installation, may be in a directory such as ~/ or ~/.matplotlib or ~/.config/matplotlib/.
Alternatively, you can set the backend in the script itself.
Be sure to set the backend first, before importing other modules such as pyplot:
import matplotlib
matplotlib.use("Agg")

See this SO question for examples.


Q:

List Drush specific add ons, plug ins, extensions, or modules to use drush dl in automated script

I'm writing a really basic bash script and want use drush dl to download the Drush extras add on.
drush dl drush_extras
But I need to check whether drush extras is installed before I try to install it (and then use it) because it prompts the following text.

Install location C:\cygwin64\home\USER/.drush/drush_extras already exists. Do you want to overwrite it? (y/n):

How do I determine whether a drush add on/plug in/module (not sure what you call it) exists? So I handle that use case?
I'm trying to automate configuration, starting with assigning blocks to regions, and I have to make it work on Windows (first) and Linux. So I'm using Cygwin and Drush on Windows. There's probably different approaches, but this seems OK.

A:

I would personally lean towards simply installing with -y. Adding -y onto the command you've listed will return Y accepting the default on any prompt that comes up (like the one you mention).
drush dl drush_extras -y
If you still want to check if it’s installed, you can check if the directory exists,
if [ -e $HOME/.drush/drush_extras ]; then
  # some logic here
fi

This won’t help you if the directory is empty though.
Another option is checking the output of
drush someCommand -h

Where someCommand is a command provided by drush_extras. You can compare the output of a valid one to an invalid one. If they match, it’s not installed.


Superior mesotympanic sinus.
This study of the posterior tympanum was performed to better define the anatomy of this complex area of the middle ear. A sinus previously not described was examined. The posterior tympanum of 49 temporal bones was studied by microscopic techniques. The sinus depth, the opening into the sinus, and the relationship of the facial nerve to the sinus were documented. A sinus lying in the superior part of the posterior tympanum was discovered: the superior mesotympanic sinus. The depth of the sinus was from 0.5 to 2 mm, and it was present in 42 of the 49 specimens (86%). The superior border of the sinus is the facial nerve, which was dehiscent in 9 cases. The surgeon can remove disease with more confidence from the tympanum if he or she knows that disease may harbor in this sinus, and that injury to the facial nerve must be avoided.


Related Media

Vail Resorts Inc. this week reported comparative ski season metrics from the beginning of the ski season through Jan. 5.

The metrics have been adjusted to reflect data had Vail Resorts owned Canyons Resort in Park City, Utah, during this time last year, a Vail Resorts release stated. Data from Afton Alps in Minnesota and Mount Brighton in Michigan were not included in the analysis.

Total season-to-date lift-ticket revenue at Vail Resorts’ eight mountains, including an allocated portion of season pass revenue, was up approximately 3.9 percent compared with the same period last year, the release stated. Season-to-date lift-ticket revenue at Vail Resorts’ five mountains in Colorado and Utah was up 11.7 percent.

At Colorado and Utah resorts, season-to-date ski school revenue was up 7.5 percent, dining revenue was up 13.1 percent and retail and rental revenue for resort store locations was up 7.7 percent.

Season-to-date skier visits at the company’s eight mountain resorts were down 0.7 percent compared with the same period in 2013, but were up 7.4 percent at resorts in Colorado and Utah.

Total skier visits at Vail’s Tahoe resorts declined approximately 23.4 percent compared with this time last year.

“We are pleased that, in addition to the strong 16 percent increase in season pass sales we discussed in early December, we saw very strong performance at our five destination resorts in Colorado and Utah in both lift ticket sales and in capturing ancillary guest spending in our ski school, food and beverage and resort retail/rental operations,” said CEO Rob Katz in the release. “Unfortunately, conditions in Tahoe have been very poor with snowfall down approximately 85 percent relative to prior year resulting in visitation and guest spending well below our expectations, which negatively impacted our overall revenue growth.”

Despite challenging conditions in Tahoe, Vail Resorts officials are confident they can remain within their fiscal year 2014 guidance range, saying they incorporated the potential for adverse weather in their estimates, the release stated. However, Vail Resorts’ confidence would require more normalized conditions returning to Tahoe by the third quarter.

Vail Resorts Inc., through its subsidiaries, operates the mountain resorts of Vail, Beaver Creek, Breckenridge and Keystone in Colorado; Heavenly, Northstar and Kirkwood in the Lake Tahoe area of California and Nevada; Canyons Resort in Utah; Afton Alps in Minnesota; Mount Brighton in Michigan; and the Grand Teton Lodge Co. in Jackson Hole, Wyo.

“We are pleased that, in addition to the strong 16 percent increase in season pass sales we discussed in early December, we saw very strong performance at our five destination resorts in Colorado and Utah.” Rob Katz Vail Resorts Inc. CEO


This invention relates to optical apparatus for creating an image against a background, which is particularly suitable for use as a training aid for a golfer.
It is desirable in various situations to have an image which is superimposed against a background view. For example a golfer, addressing a ball, can be assisted in his stroke if an image, which is visible only to the golfer, is superimposed on his normal field of vision. This type of situation is described for example in the specification of international application No. PCT/IB02/00953.
This international application describes a system wherein light is concentrated by a collector element and then passed through a reticle (a light grid) which directs an image onto a reflector which is in the nature of a beam splitter and which reflects light from the reticle towards an eye while at the same passing light in a direction from a normal field of vision. Normally the fabrication of a beam splitter, in the type of application referred to, requires the application of a light reflective coating to what may be referred to as an internal surface of a lens ie. a surface which faces an eye. The application of this type of light coating can be expensive and, if the coating is not of a satisfactory material, the coating can be easily damaged by scratching, abrasion or the like. A further factor with this type of lens is that the user's second eye, which does not receive the image from the reticle, is directly exposed to the general field of view. In other words one eye, which receives the image, views the general field of vision through a lens while no lens is positioned between the other eye and the general field of view. To some extent this imbalance is compensated for by an external lens or visor which covers both eyes but the overall appearance of the end product can be unacceptable to certain users. Also, the different light intensities on the eyes of a user can be disturbing and affect the user's vision and balance.
U.S. Pat. No. 3,498,293 describes a system which is used to orientate a person. Use is made of a lens which is mirrored or a beam splitter which is wavelength dependent ie. selectively reflective, and a gravity dependent device.
The problems encountered in orientating a user are quite different from those encountered in addressing a golf ball. In the specification of this patent reference is made to golf but there is no disclosure however of how a ball is to be targeted. The lenses in one embodiment are semi-transparent but there is no disclosure as to the further nature of the lenses.
It is known that semi-transparent lenses can generate ghost or secondary images but the problem associated therewith is not identified in the aforementioned American specification nor addressed.
U.S. Pat. No. 4,806,011 discloses a system wherein a small secondary lens, which is partly reflective, is used to project an image onto an eye of a user. The position of the secondary lens and its size can be problematic and can present a source of physical danger to a user.
In providing an optical apparatus which can be used as a golf training aid it is desirable to have a system which, as far as is possible, has the appearance of a normal pair of spectacles or sunglasses, which is not unreasonably bulky and which is relatively easy and inexpensive to manufacture.


Renal carcinoma with a solitary synchronous contralateral adrenal metastasis: a case report.
A case of synchronous contralateral adrenal metastasis of renal cell carcinoma occurring in a 64-year-old male is reported herein. The patient underwent a left transperitoneal nephrectomy for renal cell carcinoma and right adrenalectomy. The postoperative course was uneventful. To our knowledge this is the 14th case of contralateral adrenal metastasis of renal cell carcinoma in the international literature.


using System;
using System.Collections.Generic;
using System.Linq;
using System.Text;
using NUnit.Framework;
using Simple.Data.Ado;
using Simple.Data.Mocking.Ado;

namespace Simple.Data.IntegrationTest
{
    [TestFixture]
    public class RangeAndArrayFindTest
    {
        static Database CreateDatabase(MockDatabase mockDatabase)
        {
            var mockSchemaProvider = new MockSchemaProvider();
            mockSchemaProvider.SetTables(new[] { "dbo", "Users", "BASE TABLE" });
            mockSchemaProvider.SetColumns(new[] { "dbo", "Users", "Id" },
                                          new[] { "dbo", "Users", "Name" },
                                          new[] { "dbo", "Users", "Password" },
                                          new[] { "dbo", "Users", "Age" },
                                          new[] { "dbo", "Users", "JoinDate"});
            mockSchemaProvider.SetPrimaryKeys(new object[] { "dbo", "Users", "Id", 0 });
            return new Database(new AdoAdapter(new MockConnectionProvider(new MockDbConnection(mockDatabase), mockSchemaProvider)));
        }

        [Test]
        public void TestFindByWithIntRange()
        {
            var mockDatabase = new MockDatabase();
            dynamic database = CreateDatabase(mockDatabase);
            database.Users.FindAllById(1.to(10)).ToList();
            Assert.AreEqual("select [dbo].[users].[id],[dbo].[users].[name],[dbo].[users].[password],[dbo].[users].[age],[dbo].[users].[joindate] from [dbo].[users] where [dbo].[users].[id] between @p1_start and @p1_end".ToLowerInvariant(), mockDatabase.Sql.ToLowerInvariant());
            Assert.AreEqual(1, mockDatabase.Parameters[0]);
            Assert.AreEqual(10, mockDatabase.Parameters[1]);
        }

        [Test]
        public void TestFindByWithIntArray()
        {
            var mockDatabase = new MockDatabase();
            dynamic database = CreateDatabase(mockDatabase);
            database.Users.FindAllById(new[] { 1, 2, 3 }).ToList();
            Assert.AreEqual("select [dbo].[users].[id],[dbo].[users].[name],[dbo].[users].[password],[dbo].[users].[age],[dbo].[users].[joindate] from [dbo].[users] where [dbo].[users].[id] in (@p1_0,@p1_1,@p1_2)".ToLowerInvariant(), mockDatabase.Sql.ToLowerInvariant());
            Assert.AreEqual(1, mockDatabase.Parameters[0]);
            Assert.AreEqual(2, mockDatabase.Parameters[1]);
            Assert.AreEqual(3, mockDatabase.Parameters[2]);
        }

        [Test]
        public void TestQueryWithNotEqualIntArray()
        {
            var mockDatabase = new MockDatabase();
            dynamic database = CreateDatabase(mockDatabase);
            database.Users.Query().Where(database.Users.Id != new[] { 1, 2, 3 }).ToList();
            Assert.AreEqual("select [dbo].[users].[id],[dbo].[users].[name],[dbo].[users].[password],[dbo].[users].[age],[dbo].[users].[joindate] from [dbo].[users] where [dbo].[users].[id] not in (@p1_0,@p1_1,@p1_2)".ToLowerInvariant(), mockDatabase.Sql.ToLowerInvariant());
            Assert.AreEqual(1, mockDatabase.Parameters[0]);
            Assert.AreEqual(2, mockDatabase.Parameters[1]);
            Assert.AreEqual(3, mockDatabase.Parameters[2]);
        }

        [Test]
        public void TestFindByWithDateRange()
        {
            var mockDatabase = new MockDatabase();
            dynamic database = CreateDatabase(mockDatabase);
            database.Users.FindAllByJoinDate("2011-01-01".to("2011-01-31")).ToList();
            Assert.AreEqual("select [dbo].[users].[id],[dbo].[users].[name],[dbo].[users].[password],[dbo].[users].[age],[dbo].[users].[joindate] from [dbo].[users] where [dbo].[users].[joindate] between @p1_start and @p1_end".ToLowerInvariant(), mockDatabase.Sql.ToLowerInvariant());
            Assert.AreEqual(new DateTime(2011,1,1), mockDatabase.Parameters[0]);
            Assert.AreEqual(new DateTime(2011,1,31), mockDatabase.Parameters[1]);
        }
    }
}


IN THE CIRCUMFERENCE OF HIS PRESENCE – I carry the Holy Ghost; spoken word; samkleezy

My first goal as I commence is to stress the awareness that
the Lord is presently present to present presents to those presently within the
circumference of his presence because the essence of his presence is the
emergence of a glory with a difference whose awesomeness produces a conscience
void of offence which serves as our fence of defense against the fierceness of
Satan’s pretense

The totality of our identity’s reality as entities of
humanity through the authenticity of our connectivity to the trinity’s divinity
lies in the practicality of our heart’s sincerity of the humility of Christ’s
personality in entirety.

Our divine connection to the God of creation has placed us
in a position of ministration for the implementation of reconciliation through
the demonstration of God’s impartation which breaks the condition of limitation
that’s upon the nations of humanity, bringing a portion of solution to the
situation of confusion in this generation through the power of regeneration.

If you want success, you’ve got access to the key of
progress not just through what you confess but what you profess since we have
total freedom to harness wisdom from the kingdom of the author of wisdom.
That’s why it is impossible for a barrier to stop the career of the Holy Ghost
carrier.

Finally, in case you couldn’t get a testimony out of the
test, then try getting a message from the mess because while it’s not utterly
wrong to be wrong, it’s totally wrong to remain wrong.


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As Democrats gather after the close of polls in Columbus Ohio, they do so in a mood of cautious optimism. The mood has been lifting perceptibly since the beginning of the weekend, as volunteers from all over the country flooded into the Ohio field offices. To German Village office, which was honoured by a Presidential visit the day before the election, came several people from New York, a painter from Boston, a lady from Texas who’d already been volunteering for months, people from California, Pennsylvania, Washington, Tennessee and of course Britain, to join the many locals in knocking on doors. On my canvassing route on election day I met, at various times, three others from the office also canvassing on criss-cross routes. This was saturation volunteering. Every potential Democrat voter had their door knocked and literature left at least 3 times on election day.

So, nobody is taking anything for granted, but we know, in Columbus at least, that the majority are with us, because we’ve spoken with them several times in recent days. At the President’s eve of election rally in Columbus, Ted Strickland, the Governor of Ohio up until 2011, said that there were two reasons to be happy about living in Ohio. One was that you got to live in Ohio, and the second was that every four years you got to select the President, as no Republican had ever won the White House without winning Ohio.

No pressure, then.

The optimism grows from the first exit polls at 7pm EST, as Joyce Beatty is elected to congress, then Senator Sherrod Brown is re-elected, in spite of the $40 million campaign run against him. The Electoral College count swings backwards and forwards in a nail biting fashion for 4 hours until a sudden rush of calls after 11pm sees Washington, California, Hawaii, Oregon, Iowa and finally Ohio all called for Obama within 25 minutes and the room erupts with joy tempered by relief. There’s a slight hiccup as a rumour emerges that the Republicans will challenge the Ohio result, but this fizzles out as the margin widens. Ted Strickland speaks again. This is a vote for hope not hate and the people of Ohio have proven that their vote is not for sale. By the time the President speaks, we’ve all calmed down a bit; lots of people are now sitting, cross-legged, in front of the huge TV screens, like a Kindergarten class waiting to be told the next chapter of the story (well, most of us have been on our feet for over twenty hours). We’re all very happy with our newly re-elected president’s speech, with its echoes of Kennedy’s “ask not what your country…….”.

The two things I’ll take away from this campaign will be that Obama’s belief that the more people feel connected to you the more likely they are to vote for you is probably true and that therefore one of the most productive strategies for a Labour victory in 2015 is simply for Labour party members to talk to people on their doorsteps for the next two and a half years. Also, his strategy of focussing on the middle classes as the backbone of the country, but insisting that entry to them should be wide open to everyone and backed by adequate government safety nets for life’s exigencies, is demonstrably a winning combination.

At the moment the Tories are heading up the same fantasy cul de sac as the Republicans.

Also there are various snippets showing the Fox News initial reaction to reality. Beyond satire.

The thing is though, Mitt Romney should have walked this against a President struggling with high unemployment and a weak economy.

However, what Republican’s did well, like a lot of the Tory party here, is identify group after group in society to hurl abuse at.

Labour need to aviod making the same mistakes just because the Tories are so inept, because the Tories need a crushing defeat to make them wake up and smell the coffee. It doesn’t help if one of the main parties likely to form a government are divorced from reality.


Very nice, size 10, black in color, Steve Madden sandals. The uppers are synthetic black fur, and soles are a hard rubber. I won this from on Listia and paid $10.00 shipping~they really weigh. The shoes in-step is too high for me, or they wouldn't be listed! Good Luck!


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Q:

Java java.util.regex.MatchResult counter problems with Scanner

I'm using a java.util.Scanner to scan all occurrences of a given regex from a big string.
Scanner sc = new Scanner(body);
sc.useDelimiter("");
String match = "";
while(match!=null)
{
    match = sc.findWithinHorizon(pattern, 0);
    if(match==null)break;
    MatchResult mr = sc.match();
    System.out.println("Match string: "+mr.group());
    System.out.println("Match string using indexes: "+body.substring(mr.start(),mr.end());
}

The strange thing is that after a certain number of scans, group() method returns the correct occurrence while the start() and end() methods return wrong indexes like the scan has restarted from the beginning of the file.
The regex is multiline (i use this regex to discover a line change "\r\n|[\n\r\u2028\u2029\u0085]").
Do you have any hint? Could it be related to the "horizon" parameter (I've tried differend combinations for that value)?
For more details, it seems related to the dimension of the file (more than 1000 chars), after about 1000 the counter restart from 0 (e.g. the first wrong index occurrence after 1003:1020 becomes 3:120).

A:

Scanner uses an internal buffer with 1024 characters. Use Pattern instead:
Matcher matcher = Pattern.compile(...).matcher(body);
while(matcher.find()) {
    int start = matcher.start();
}


Endoscopic dacryocystorhinostomy to treat congenital nasolacrimal canal dysplasia: a retrospective analysis in 40 children.
To investigate the therapeutic effectiveness and safety of endoscopic dacryocystorhinostomy (EN-DCR) to treat congenital nasolacrimal canal dysplasia (CNCD). Forty children (50 eyes) with congenital nasolacrimal duct obstruction (CNLDO) and lacrimal bony dysplasia, including 8 children with bony atresia (10 eyes) and 32 with bony stenosis (40 eyes), were recruited in this retrospective study. Standardized EN-DCR was performed in all cases. The postoperative observations included relief of symptoms, fluorescein dye disappearance test (FDDT), syringing of lacrimal passages and anastomotic patency under nasal endoscopy. Patients were followed up for 8-18 months. Standardized EN-DCR surgery had a success (cure and improvement) rate of 100%, including a cure rate of 82% and an improvement rate of 18%. The cure rate among 40 cases of bony nasolacrimal duct stenosis was 82.5%, while that of 10 cases of bony nasolacrimal duct atresia was 80%. Statistical analysis showed that nether the receipt of other treatments before surgery nor the type of bony nasolacrimal duct dysplasia affected the cure rate. No significant complications were observed during postoperative follow-up except for four cases (4 eyes) that suffered middle turbinate and nasal mucosal adhesion and two cases with sinusitis. CNCD is a type of CNLDO that does not respond to conservative and conventional treatment. EN-DCR represents a safe and effective treatment for children with CNCD. In addition, the combination of EN-DCR with lacrimal CT scanning provides advantages over traditional lacrimal surgery in that it has a high success rate with a low incidence of complications.


The glyph chart in the Font Window (and in the Font Map panel) is a visual representation of all the glyphs in the font. To modify the font you have to learn how to use the glyph chart: navigation, selection of glyphs and selection of commands.

One of the glyphs in the Font window is always the “current” glyph. It is selected (although there may be other selected glyphs), and is specially highlighted:

You can see the current glyph name and its Unicode codepoint in the footer:

To view different parts of the font in the Font window, you can either use the vertical scroll bar, or the auto-scroll mode: press the mouse button while the cursor is very near the bottom, or move the mouse cursor above the top or bottom of the chart, and it will scroll up or down while selecting additional glyphs.

If you have a wheel on your mouse you can use it to scroll the Font window vertically.

Alternatively you can use the keyboard keys to navigate in the font chart:

Keys

Action

Arrow keys

Moves the current glyph highlight one cell right, left, up or down, according to the key used

In addition to the current glyph, you can select sets of glyphs in the font chart. These selections behave similarly to selected text in a text editor. You can copy selected glyphs to another place in the font or to a different font; you can apply different effects to the selection; open them for editing, etc. Selected glyphs have inverted colors. One of the selected glyphs is the “current” glyph:

To select one or more cells, press the mouse button on the first or last cell of your selection and drag the cursor across the cells you want to select. You will see the selection highlighted. If you drag the cursor outside the visible part of the chart, it will scroll accordingly. To cancel your selection, click on any glyph cell. To select additional non-continuous glyphs, let go of the mouse button, and then press the Cmd key before clicking again. If you prefer using the keyboard, you can using the navigating keys on the keyboard, set the current cell highlight on the first (or last) cell of a selection, then press the Shift key. Move the current cell highlight (as described earlier) to select the cells.

Selection does not have to be continuous; if you press the Cmd key, you can select and deselect cells in any order and combination.


Israel Tours For The Tourists

You should take out some time from your busy schedule in order to travel and enjoy the beauty of this beautiful world. You can take any travel packages in order to relax and unwind. Every place you visit may leave you with a lot of new things to experience. But some travel destination places alter your life in a completely miraculous way.

Israel tours offer you the same life-changing experience. Christian tours to Israel ignite the Christian faith of the person visiting there. Tour to Israel enhances one’s knowledge of the holy book. It also strengthens person spirituality. You even get private tour guides in order to enjoy unforgettable travel experience.

Image Source: Google

If you feel lost, alone or trying to find the meaning of life then Christian tour to Israel will give the life-changing experience of life.

There are wide ranges of an option during your Israel visit. Israel tour includes:

Israel Holy land tour: This tour is centric around holy places of Israel.

Israel classic tour: Here tourists are taken only to the well-known places of Israel.

You can also visit only specific places of interest in Israel. This kind of tour includes Jerusalem tours, tours to the Dead Sea and Masada.

Image Source: Google

Your trip to Israel is not completed my visit to Jerusalem. It is one of the most popular places in the country. Here you get a chance to see Old and New Jerusalem from the Mount of Olives. You can click here to know more about Israel.

The Western Wall is one of the holiest sites in Israel. It is located in the Jewish Quarter.