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This study evaluated the effect of childhood trauma exposure and the role of resilience on both depressive symptoms and suicidal ideation.
1488 military personnel and veterans, who served after September 2001, were evaluated for depressive, suicidal, and PTSD symptoms, combat exposure, childhood trauma exposure, and resiliency. Participants were enrolled as part of an ongoing multicenter study. Outcome measures were depressive symptoms and suicidal ideation.
After controlling for the effects of combat exposure and PTSD, results revealed that childhood trauma exposures were significantly associated with depressive symptoms and suicidal ideation. In addition, resilience was negatively associated with depressive symptoms and suicidal ideation, suggesting a potential protective effect.
These findings suggest that evaluation of childhood trauma is important in the clinical assessment and treatment of depressive symptoms and suicidal ideation among military personnel and veterans.
Depression is a common cause of morbidity worldwide (Kessler et al., 2003; McKenna, Michaud, Murray, & Marks, 2005) and is associated with significant disease burden (Gadermann et al., 2012). Depression also contributes to mortality due to completed suicide(Zivin et al., 2007). Among males, deaths due to suicide are considerably higher among U.S. veterans compared to non-veterans (Kaplan, Huguet, McFarland, & Newsom, 2007). Thus, understanding the factors that contribute to depression and suicide, as well as the possible mediating factors (e.g., resilience) is of critical interest and serves as an important clinical priority in the treatment of military personnel and veterans.
Prior history of childhood trauma is an important risk factor for depression (Bernet & Stein, 1999; Duncan, Saunders, Kilpatrick, Hanson, & Resnick, 1996; Kendler, Kuhn, & Prescott, 2004; Molnar, Buka, & Kessler, 2001; Ritchie et al., 2009) and suicidal ideation, behavior, and attempts (Afifi et al., 2008; Mandelli, Carli, Roy, Serretti, & Sarchiapone, 2010; Nelson et al., 2002; Sarchiapone, Carli, Cuomo, & Roy, 2007; Sarchiapone, Carli, Giannantonio, & Roy, 2009) in civilians. This can include history of exposure to childhood physical abuse, childhood sexual abuse, and other significant childhood trauma (e.g., accidents, natural disasters, stranger violence). Both animal (Shannon et al., 2005) and human research suggest enduring psychological and biological effects of childhood trauma. One study found that peer-reared monkeys, (considered to be an analogue of childhood trauma) had a lower established serotonergic system level than maternally-raised monkeys (Mann, 2003). In humans, childhood trauma also has been shown to program the stress response systems, especially the hypothalamic-pituitary-adrenal (HPA) axis, to overreact to new stressors (Heim, Newport, Bonsall, Miller, & Nemeroff, 2001; Shea, Walsh, Macmillan, & Steiner, 2005; Teicher et al., 2003). Results from the National Comorbidity Survey showed a significant risk of depression in individuals (males: OR=1.8 [95% CI=0.9, 3.7]) and females: OR 1.8 [95% CI=1.4, 2.3]) (Molnar et al., 2001) with a reported history of childhood sexual abuse. Increased rates of depression have also been observed in childhood violence survivors (Duncan et al., 1996). Taken together, these studies suggest that childhood trauma exposure may be an important developmental contributor to depressive symptoms and suicidal ideation among military personnel.
Despite the evidence of increased risk of depressive symptoms and suicidal ideation among those exposed to childhood trauma, not all individuals who are exposed to childhood traumas develop psychological symptoms (Collishaw et al., 2007). This raises the possibility of contributory protective factors such as resilience. Resilience is defined by Connor and Davidson as "qualities that enable one to thrive in the face of adversity" (Connor & Davidson, 2003, p.76) and has been demonstrated to play an important role in PTSD prevention and recovery (Vaishnavi, Connor, & Davidson, 2007). It has also been suggested to be an important protective factor against the development of psychological symptoms in the face of adversity (Rutter, 1985). The central serotonergic function has been suggested to be related to resilience (Connor & Davidson, 2003), and in an initial study, venaflaxine was related to positive changes in resilience scores from pretreatment to post-treatment in patients with PTSD (J. R. Davidson et al., 2005). Resilience has been inversely correlated in military veterans with the occurrence of and functional correlates of PTSD (Green, Calhoun, Dennis, & Beckham, 2010). Hence, further understanding of resilience, the factors contributing to it, and its impact on depressive symptoms and suicidal ideation is warranted.
The effect of resilience on the development and severity of depression and suicidal ideation in military personnel and veterans with childhood trauma exposure is largely unknown. In the current literature, we found only one related cross-sectional study of childhood trauma exposure, resilience and depressive symptoms. In 792 adult civilians with childhood trauma exposure, researchers (Wingo et al., 2010) found that childhood trauma was significantly associated with depressive symptoms and that resilience had an attenuating effect in decreasing depression. While these findings offer insight into the negative association between resilience and depressive symptoms in a disadvantaged civilian population, results are limited by a lack of controlling for the influence of PTSD symptoms. Evaluating the relationships between resilience and other outcomes among trauma exposed individuals may be particularly important as PTSD symptoms are significantly associated with childhood trauma (Breslau, 2002), depressive symptoms (Gros, Simms, & Acierno), and suicidal ideation (Guerra & Calhoun, 2010).
Although the results by Wingo and colleagues (2010) are significant, it is unknown whether these associations hold true among military personnel. Combat exposure may intensify the burden of trauma and negatively impact mental health outcomes. Severity of depressive symptoms may also be different among military personnel and veterans compared to civilians. To our knowledge, there are no studies that have addressed these issues in a military sample.
Therefore, the first aim of the current study was to evaluate the effect of childhood trauma (as a risk factor) on the severity of both depressive symptoms and suicidal ideation in military personnel and veterans who have served since September 11, 2001. The second aim of the study was to examine the possible role and interaction of resilience (as a protective factor) on depressive symptoms and suicidal ideation above and beyond the effect of combat exposure on depressive symptoms and suicidal ideation. We hypothesized that childhood trauma exposure would be positively associated with depressive symptoms and suicidal ideation in military personnel and veterans, while higher levels of resilience would attenuate depressive symptoms and suicidal ideation.
Measures in this study were collected as part of a multisite study designed to evaluate military personnel and veterans of the U.S. Armed Forces who served in the military on or after September 11, 2001. This study is conducted through the Department of Veterans Affairs (VA) Veterans Integrated Service Network (VISN) 6 Mental Illness Research, Education and Clinical Center (MIRECC). Institutional Review Board approval was obtained at all collaborating sites. After comprehensive description of the study and prior to study enrollment, written informed consents were provided by all participants. We enrolled 1488 U.S. Iraq/Afghanistan era military personnel between June 2005 and July 2010. Study participants were recruited through fliers, advertisements, invitational letters, and VA clinic referrals. Data were collected during one or two study visits and included completion of paper-and-pencil or computer-administered questionnaires and face-to-face psychiatric interviews with a doctoral psychologist or a master level clinician. All clinicians were supervised by licensed psychologists or psychiatrists.
Demographic information related to age, gender, race, education, and marital status were collected as part of study participation.
The Beck Depression Inventory – Second Edition (BDI-II) is a 21-item, forced-choice scale of severity of depressive symptoms. Each item represents a symptom of depression and contains a list of four statements of increasing severity. Each item is rated on a 0-3 scale with total scores ranging between 0 and 63. High internal consistency reliability of the BDI-II has been demonstrated (Cronbach's alpha = 0.96 in the current sample).
In addition to the scale's utility as a unidimensional measure of depressive symptomatology, items load distinctly on two factors that capture cognitive and non-cognitive (somatic/affective) domains, (Beck, Steer, Ball, & Ranieri, 1996; Steer, Ball, Ranieri, & Beck, 1999a). Eight items comprise the cognitive dimension: pessimism, past failure, guilty feelings, punishment feelings, self-dislike, self-criticalness, suicidal thoughts or wishes, and worthlessness. The somatic/affective dimension is comprised of 13 items: sadness, loss of pleasure, crying, agitation, loss of interest, indecisiveness, loss of energy, changes in sleeping, irritability, changes in appetites, concentration difficulty, tiredness or fatigue, and loss of interest in sex (Steer et al., 1999a).Clinical cutoffs for these subscales have not been investigated, however the subscales have been identified as conceptually and statistically separate in previous factor analyses (Kumar, Steer, Teitelman, & Villacis, 2002; Speilberger, Ritterband, Reheiser, & Brunner, 2003) Suicidal Ideation. Severity of suicide ideation was assessed using the 21-item, self-report Beck Scale for Suicide Ideation (BSI) (Beck & Steer, 1991). Participants select statements that best describe their feelings over the past week. The first 19 items assess suicidal thoughts, intents, and plans. The number of previous suicide attempts and the seriousness of the attempt to die associated with last attempt are assessed in items 20 and 21. Item responses are rated on a 3-point scale ranging from 0 to 2 and then summed to arrive at a total score. The BSI has demonstrated strong internal consistency reliability (reported α coefficient between 0.90 and 0.97 (Beck, Steer, & Ranieri, 1988; Steer, Rissmiller, Ranieri, & Beck, 1993)). BSI has reasonable convergent, discriminative, and predictive validity (Beck et al., 1988) (Beck, Brown, & Steer, 1997; Brown, Beck, Steer, & Grisham, 2000; Cochrane-Brink, Lofchy, & Sakinofsky, 2000). Using survival analyses, Brown et al. (2000) determined that a cut-off score of 3 on the BSS yielded the highest hazard ratio in prediction of risk for actual suicide in a sample of almost 7000 psychiatric outpatients. This cut-off score is employed here to create a dichotomous index (≤2 OR ≥3) of "suicidality"(Brown et al., 2000). The BSI scores deviated markedly from normality in our sample, thus we employed this cut-off score to create a dichotomous index (≤2 OR ≥3) of "suicidality."
The Traumatic Life Events Questionnaire (TLEQ) is a 23-item self-report questionnaire that assesses exposure to various traumatic events (Kubany et al., 2000). Content validity and reliability of the TLEQ have been well demonstrated (Clancy et al., 2006; Dedert et al., 2009; Kubany et al., 2000). The average convergent validity with an interview one week later for the TLEQ was 85% (range of 74% - 97% for individual items). The TLEQ was utilized to evaluate childhood trauma by generating the following three subscales: childhood exposure to physical violence, childhood sexual assault, and a subscale for "other" childhood trauma. Participants were counted as having childhood exposure to physical violence if they endorsed either item 12 or 13 (Kubany et al., 2000). Participants were counted as having childhood sexual assault if they endorsed either item 15, 16, or 17. Participants were rated as having exposure to "other" childhood trauma, if they endorsed any of the items 1-11, 19, or 22 before the age of 18. "Other" childhood trauma included items such as trauma due to natural disasters, car accidents, other accidents, life-threatening illness etc. Table 1 shows the number of participants endorsing each childhood trauma category. If a particular traumatic event is endorsed, then respondents are also asked the following: 1) whether the event occurred before age 18 and 2) whether they responded with fear, helplessness, or horror (to discern whether that trauma met the threshold for DSM-IV Criterion A2 for PTSD).
Resilience. The Connor-Davidson Resilience Scale (CD-RISC) is a reliable (Cronbach's alpha = 0.96 in the current sample) and valid (Connor & Davidson, 2003) instrument for measuring resilience. It consists of 25 items, with each item rated on a 5-point Likert scale as follows: not true at all (0), rarely true (1), sometimes true (2), often true (3), and true nearly all of the time (4). The total score ranges from 0-100, with higher scores indicating greater resilience. The CD-RISC has demonstrated sound psychometric properties (Connor & Davidson, 2003) in studies of differing populations including community sample, primary care outpatients, general psychiatric outpatients, participants with generalized anxiety disorder, and PTSD. Moreover, the CD-RISC has demonstrated sensitivity to the effects of treatment with several therapies in clinical trials of PTSD patients (including sertraline, paroxetine, venlafaxine and CBT) (J. Davidson et al., 2008; J. R. Davidson et al., 2005).
PTSD severity was assessed using the Davidson Trauma Scale (DTS)(J. R. Davidson et al., 1997; McDonald, Beckham, Morey, & Calhoun, 2009). The DTS is a brief global assessment scale for PTSD symptoms. It includes 17 items corresponding to the DSM-IV symptoms of PTSD. The 17 items are rated by both frequency and severity. Reliability and validity of the DTS has been demonstrated in veterans who have served since September 11, 2001 (McDonald et al., 2009).
Experiences of wartime stressors were assessed using the 7-item, self-report Combat Exposure Scale (CES). The CES is a widely used self-report scale that consists of 7-item wartime stressors. Responses to each item are divided into 5-point scales, with higher scores indicating greater exposure to combat. Respondents are asked to respond based on their exposure to various combat situations. The total CES score ranging from 0 to 41 is calculated by using the weighted sum of scores, which is classified into 1 of 5 categories of combat exposure, ranging from "light" to "heavy" (Keane et al., 1989). The CES has excellent test-retest and internal reliability (Keane et al., 1989).
A series of linear regression equations were calculated to examine relationships between childhood trauma exposure, combat exposure, and resilience with depressive symptoms. Logistic regression analyses were conducted to test the relationships of childhood trauma exposure, combat exposure, and resilience with suicidal ideation as a dichotomous outcome. Given that demographic variables of age, gender and minority racial status have been differentially associated with suicidal variables (Crosby, Han, Ortega, Parks, & Gfroerer, 2011), all regression analyses are adjusted for these variables. Models also included PTSD symptoms, endorsement of childhood physical trauma, childhood sexual trauma, childhood other trauma, combat exposure, and interactions between trauma categories and resilience. Non-significant interactions were eliminated from the final models to reduce concerns with model overfitting. Multicollinearity statistics (i.e., VIF, tolerance) for all analyses were within the acceptable range. Statistical analyses were performed using SAS Version 9.2 for Windows (SAS Institute, Cary, NC).
We chose dimensional measure of depressive symptoms (rather than the diagnostic category) as an outcome measure to assess severity of symptoms in line with the upcoming fifth edition of the Diagnostic Statistical Manual (DSM V). The DSM V proposes that dimensional assessment "provides additional information that assists the clinician in assessment, treatment planning, and treatment monitoring" (Helzer et al., 2008). In addition, assessing depression as a continuous variable (rather than categorical) will provide stronger statistical power for analysis and will allow for better exploration of the relationship with other continuous variables.
Demographic and clinical characteristics are shown in Table 1. Participants (N=1488) were primarily Caucasian (45.2%) or African American (47%) and had a mean age of 37.5 years (SD = 10.1). The majority of the sample was male (79.9%), married (53.6%), and employed (65.8%) and the mean education level was 13.52 (SD = 3.3) years. Eleven percent (n=168) of the study sample endorsed a history of childhood trauma and no combat trauma. Additionally, 652 participants reported no trauma history (i.e., no combat trauma and no childhood trauma). Of these, nearly 60% endorsed experiencing other trauma event types (e.g., a motor vehicle accident).
Table 2 provides a summary of linear regression analyses examining the predictive and moderating effect of childhood trauma exposure, combat exposure, resilience, and dependent variables: total depressive symptom severity, cognitive-related depressive symptoms, and somatic-affective-related depressive symptoms.
For the regression analyses examining total depressive symptom severity, female gender, childhood physical trauma, and combat exposure were positively associated with total depressive symptom severity. Moreover, Caucasian race, resilience, and the interaction between combat exposure and resilience were negatively associated with total depressive symptom severity. The significant interaction between combat exposure and resilience is illustrated in Figure 1. As shown, higher levels of resilience attenuated depressive symptoms, particularly among individuals with high combat exposure. Furthermore, the variables in the model for total depressive symptom severity accounted for 74% of the variance.
Results examining cognitive-related depressive symptoms indicated that younger age, Caucasian race, childhood physical trauma, childhood sexual trauma and childhood other trauma were associated with cognitive-related depressive symptoms. In addition, there were significant interactions noted for combat exposure and resilience, and other childhood trauma exposure and resilience for cognitive related depressive symptoms. The interaction pattern between trauma and resilience for cognitive related depressive symptoms followed the same configuration as displayed in Figure 1. Additionally, the total amount of variance accounted for by the variables in the statistical model was 59%.
Moreover, data revealed significant main effects of elevations on the somatic-affective subscale for female gender, combat exposure, and resilience. No interaction effects were observed. Collectively, the variables in the model for somatic-affective depressive symptoms accounted for 73% of the variance.
Multivariate logistic regression analyses (Table 3) were conducted to examine the relationship between childhood trauma exposure, combat exposure, resilience, and potentially confounding variables (i.e. PTSD symptom severity) on suicidal ideation. The full model was shown to have a good fit (Hosmer and Lemeshow χ2 goodness-of-fit test [df =8] = 5.00; p = .76), with resilience, Caucasian race, and each childhood trauma type (physical, sexual, and other)significantly associated with severity of suicidal ideation. Controlling for other model variables, resilience was the strongest associated variable with suicidal ideation. Interactions between trauma exposures and resilience for suicidal ideation were not detected.
After adjusting for PTSD symptom severity and combat exposure, resilience was found to be significantly associated with all evaluated domains of depressive symptoms. Additionally, increased resilience was associated with lower suicidal ideation. Interactions with combat exposure and resilience were noted for both total depressive symptoms and cognitive depressive symptoms such that depressive symptoms were attenuated by resilience among those with higher trauma exposure. Generally, the presence of childhood trauma was significantly associated with increased total depressive and cognitive depressive symptoms. These study results confirm our initial hypotheses and suggest both resilience and childhood trauma are important in evaluating depressive symptoms and suicidal ideation in military personnel and veterans.
The current study finding that Caucasian race and female gender are positively and significantly associated with depressive symptoms is consistent with previous research in military samples. For example, a study conducted in 4,089 Iraq and Afghanistan active-duty soldiers indicated higher depression scores in Caucasians than in Blacks and Pacific Islanders (Lapierre, Schwegler, & Labauve, 2007). In a retrospective study of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans receiving medical treatment through the VA Connecticut Healthcare System (n=1,229), researchers observed a greater degree of positive screenings for depression among women than men (Haskell et al., 2010). Conversely, in non-military samples, the literature relating to gender and racial differences in depression have been mixed (Riolo, Nguyen, Greden, & King, 2005; Somervell, Leaf, Weissman, Blazer, & Bruce, 1989). The lack of consistency in reporting has been attributed largely to measurement differences across studies in depression (depressive symptoms vs. major depressive disorder; (Somervell et al., 1989)). Our research findings are also comparable to reports suggesting that resilience may serve as a protective factor in the occurrence of depressive symptoms. In a study of U.S. Iraq/Afghanistan era combat veterans (n=497), resilience was shown to mitigate to some degree the effects of higher combat exposure on the occurrence of PTSD along with potentially providing protective effects for depression and poorer functional outcomes (Green et al., 2010). A prospective study involving 475 combat-exposed, active duty Marines separating from service, found that resilience had a larger effect on individual functioning than on psychological symptoms independently (Hourani et al., 2012). Lastly, the interaction noted between combat exposure and resilience proved to be equivalent with other studies demonstrating the protective nature of resilience against high levels of trauma exposure (Green et al., 2010). Nonetheless, the current study and others have been largely cross-sectional; the directions of these effects need to be evaluated in longitudinal studies to determine causal effects.
Consistent with the initial factor analytic study of the BDI-II, no relationship with gender was revealed for cognitive-related depressive symptoms scores (Steer, Ball, Ranieri, & Beck, 1999b). The finding that all childhood trauma types were significantly associated with cognitive related depressive symptoms is consistent with current cognitive theories of depression. Trauma experienced during childhood results in a number of psychobiological consequences, which are often transposed in adulthood (Felitti et al., 1998). Moreover, these experiences substantially contribute to negative cognitions about self, resulting in negative feelings of self worth and low levels of self-esteem (Beck, 1963). These negative cognitions about self are often applied to perceptions about the world and one's future, and according to Beck (1963) are further characterized as depression (Beck, 1963; Beck, Brown, Steer, Eidelson, & Riskind, 1987).
After accounting for PTSD symptom severity, female gender and resilience were significantly associated with depressive symptoms, however, no effect of childhood trauma was detected. There are a number of possible explanations for this including 1) potential overlap among somatic-affective related symptoms with PTSD symptoms; 2) insufficient sample size; or 3) no true effect. Empirical data have supported that women generally report more bodily distress symptoms than men (Barsky, Peekna, & Borus, 2001) and that women are more likely to endorse somatic related symptoms of depression (Dekker, Koelen, Peen, Schoevers, & Gijsbers-van Wijk, 2007; Frank, Carpenter, & Kupfer, 1988; Marcus et al., 2005).
Comparable with our study findings, prior studies have consistently indicated a strong relationship between childhood trauma and suicidal ideation and/or attempts (Briere & Runtz, 1986; Read, Agar, Barker-Collo, Davies, & Moskowitz, 2001). A study of 17,337 adult outpatients in San Diego, California found that adverse childhood experiences in any trauma type increased the risk of attempted suicide 2- to 5-fold (Dube et al., 2001). After accounting for demographic variables and PTSD symptoms, severity of suicidal ideation was better associated with resilience than by race or types of childhood trauma.
The results of this study should be interpreted in light of the following limitations. First, this is a cross-sectional study; thus, study results cannot be interpreted as causative. Second, the possibility of other confounding effects could not be eliminated due to the observational design of the study. Third, suicidal ideation, not suicide attempts or completed suicide, was examined in this study. Although related, these constructs are distinct both in their prevalence, assessment and prediction (Goldstein, Black, Nasrallah, & Winokur, 1991). Current suicidal ideation is a variable included in the evaluation of suicide risk (American Psychiatric Association, 2003). Fourth, the potential recall bias of retrospective self-reporting of childhood abuse and trauma is inevitable in this type of study. However, Dube et al. showed good test-retest reliability of responses to retrospective childhood trauma, concluding that they are generally stable over time (Dube, Williamson, Thompson, Felitti, & Anda, 2004). Using documented cases of childhood trauma, inconsistencies in reported retrospective childhood trauma was shown to be largely due to under-reporting rather than over-reporting of the trauma (Della Femina, Yeager, & Lewis, 1990; Hardt & Rutter, 2004). Thus, the differences in reporting over time "would likely bias any associations found between these exposures and health outcomes towards the null" (Dube et al., 2004). As this sample included both active duty servicemembers and veterans, the results are more generalizable to the population of interest. However, given that there was a small representation of active duty servicemembers, possible military status differences could not be examined. It may be helpful to evaluate this in future research.
The study findings suggest that comprehensive assessment of both childhood trauma and resilience among military personnel and veterans can contribute to the understanding of their clinical status in terms of depression and suicidal ideation, and ultimately their clinical care. The clinical utility of these results is relevant to the following 3 areas: 1) it emphasizes the importance of clinical assessments of the degree of childhood trauma (as risk factor) and resilience (as protective factor) in military personnel and veterans with depression and/or suicidal ideation. 2) it highlights the importance of the implementation of prevention strategies for individuals with childhood trauma who are seen to be at more risk for depression and suicidal ideation. 3) it suggests that potential screening of military personnel and veterans for childhood trauma and its degrees may have implications in decreasing later depression and suicidal ideation.
While the results of our study are encouraging, further research is needed. A potential promising avenue for future research is to evaluate possible methods for boosting resilience through therapeutic interventions. For instance, initial work has shown that resilience can improve as a result of both psychological (Leve, Fisher, & Chamberlain, 2009; Stallard et al., 2005) and pharmacological (J. R. Davidson et al., 2005) interventions. Further interventional research in this area is still needed to be done. Resilience-enhancing intervention may have a preventative or prophylactic role against depressive and suicidal ideation. These data may also have implications in treatment policy. Both the Department of Veterans Affairs and the Department of Defense (DoD) have current efforts underway to potentially increase resiliency among active duty soldiers (Reivich, Seligman, & McBride, 2011) and veterans (Bates et al., 2010). Increasing resilience to mitigate the negative impact of developmental trauma on depressive symptoms and suicidal ideation is relevant to further development of psychological and pharmacological interventions. However, the empirical evidence is nascent, and it remains a question as to whether resilience (as a state, trait or process) can be significantly modified to reduce depression and suicidal ideation and improve functioning among individuals with trauma exposure. Future studies are needed to address these questions as well to replicate these findings in a prospective study. In addition, further examination of this line of research might lead to important preventative and treatment modalities above and beyond symptom control.
We extend thanks to the military personnel and veterans who volunteered to participate in this study. We also thank the research study staff members at the Durham, Hampton, Richmond, and Salisbury Veterans Affairs Medical Centers for their diligent work and essential contributions to the recruitment of participants and data collection and management of this study. We would also like to acknowledge Mr. Perry Whitted and Ms. Misty Brooks for their extensive administrative contributions on this project as well as Mr. Jeffery Hoerle for his computer expertise devoted to the project. Mr. Whitted and Ms. Brooks and Mr. Hoerle report no conflict of interest.
Funding/support: This work was supported by the Office of Mental Health Services, Department of Veterans Affairs; VISN 6 Mid-Atlantic MIRECC; and Office of Academic Affiliation (OAA), the Department of Veterans Affairs (NAY), the Department of Veterans Affairs Clinical Sciences and Research Career Development Award (EAD) and NIH R01CA081595 (JSH).
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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Extra drug and alcohol testing in Perth and WA targeted in budget
Increased roadside drug and alcohol testing in Perth and WA is one of the initiatives outlined in the recent Western Australian State Government budget.
Extra funds for roadside drug and alcohol testing in Perth and WA
The Western Australian Police, like other police forces across the country, have been conducting random roadside drug tests for several years. This is in addition to alcohol testing, which has been carried out for decades with great success. This drug testing effort will increase in the near future with an extra $5.5 million announced in the budget.
The drug testing in Perth is carried out using oral fluid samples of drivers. Drivers rub a collection implement around their mouth for a short period of time to collect their saliva. The collection implement is then placed in a drug testing unit for analysis. A printable, auditable result is produced, showing if the driver has any drugs in their system. If a positive test is found, further oral fluid or blood sampling is conducted and analysed in an independent laboratory. If this test also proves positive, the driver will face consequences such as a fine and loss of licence.
This drug testing process is very similar to that used by Integrity Sampling for its workplace drug testing in Perth, Western Australia and throughout Australia.
Extra fun'ds to target meth
The State Government has also targeted methamphetamines use in the budget, with $15 million in extra funds announced. The increased funds will be used to employ a multi-pronged attack on the drug.
This will include extra beds in dedicated meth rehabilitation centres and more specialist nurses at emergency departments. A dedicated ICE help phone line will also be set-up. In addition, a pilot clinic dedicated to meth addicts will be implemented.
Like other states, methamphetamines are a great concern in Western Australia, and its affect on communities is far-reaching. Western Australia has extra reason to be concerned about meth and ICE, however, with research suggesting the usage rates in the state are above the national average. For businesses, it's yet another reason why drug and alcohol testing in Perth and Western Australia is a necessary part of any good drug and alcohol management plan and overall work


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Ancient Rome: Republic to Empire
founded in 753 B.C. after Romans overthrew Etruscans
Republican Government
-Legislative Branch: in charge of making laws
-Senate: group of 300 advisors to Roman leaders (senators=Patricians, assembly members=Plebians)
-Judicial Branch: ran courts with 8 judges
-Executive Branch: carried out the laws
-Two Consuls lead the executive branch
How is this related to what you know about U.S. government?
Punic Wars
-By 275 B.C. Rome had conquered the entire Italian Peninsula
-conquered people could be Roman citizens
-could manage themselves
-had to pay taxes, and send soldiers to Roman army
-264 B.C.-146 B.C.: Punic Wars
-3 different wars against Carthage
-after 3rd war, Rome captured/destroyed Carthage
expanded from Spain to Greece
-Soldiers came back wealthy, and bought large farms w/slaves
-small farms couldn't keep up and lost their land
-gap between rich and poor grew wider=conflict between social classes
Why were the Punic Wars significant to Roman expansion?
Julius Caesar
-65 B.C. : elected as a public official
-focused on providing entertainment=very popular w/common citizens
-59 B.C.: elected to position of Senior Consul, and governed Gaul, focusing on military
-Pompey (ruler @ the time), did not like Caesar, ordered him to step down
-Caesar refused and started a civil war
-Elected Consul again, reformed government
-extended citizenship
- expanded Senate so citizens had bigger voice
- Julian Calendar
-44 B.C.: was elected "dictator for life",
-stabbed to death on March 15 of that year
Why was Julius Caesar important, and how did the Ancient Roman civilization change during this time?
Pax Romana
"Roman Peace"
-27 B.C.: Caesar's nephew, Augustus, becomes ruler
-First real emperor of Rome
-beautified Rome
-started civil service
-Controlled provinces
-Pax Romana: 200 years of peace
-Army grew to biggest size,guarded borders, built roads
-Farming and trade
-common currency
What was the Pax Romana, and how did it contribute to the strength of the Roman Empire?
Rome as a Republic
-Republic: A government in which people elect their leaders
-Early life for Romans: farmers who owned land could also be in military. They became wealthy and this caused a gap in social classes, which would later cause divisions in Roman government.
-Patricians: members of wealthy landowner class that held highest positions in the government
-Plebians: common farmers who could not hold important government positions
-Plebians resented Patricians, until Patricians created the 12 Tables (laws that set up basic rights for all Roman citizens)
How did social class influence Roman Society?
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Ancient Rome: Republic to Empire
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Kaitlin O'Melvenyon 24 January 2014
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Tories moot feed-in tariff for microrenewables
A Conservative party Green Paper on microgeneration, which puts forward a system of feed-in tariffs, has been praised as a significant improvement on existing policy.
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Make a bigger impact with the HART 3.5 lb. Axe. Outdoor striking tools haven't changed much in the last one hundred years, until now. The HART 3.5 lb. Axe is equipped with an arsenal of signature features including face cutouts, a forged head, and SureGrip over mold. With HART's superior performance and innovative signature features, you can be assured that nothing hits harder.
California residents: see Proposition 65 information
- Face cutouts to prevent sticking in wood
- Fully forged for greater strength and life
- Anti vibration for dampening the shock of impact
- SureGrip handle for maximum comfort and grip


text:
Rob graduated from the Western College of Veterinary Medicine in 1991, where he also met his wife and business partner Elaine. After practicing as both associates and later as practice owners, Rob and Elaine came to the West Kootenays in 1997, taking ownership of the West Kootenay Animal Hospital and starting a family.
While the ensuing years of child rearing and running a practice have been very busy, Rob would tell you that there is no where else he would rather live and work. Working with an amazing team of people while helping concerned owners provide care for their animal loved ones is a privilege and pleasure.
Living here also provides Rob with ample opportunity to enjoy the mountains, woods, rivers and lakes he loves. When not at the work, Rob can be found mountain biking, cross country skiing, or kayaking, often in the company of his Cairn Terrier, Maisy, who is determined she will one day catch those squirrels on their adventures together. When not enjoying the outdoors, Rob can be found at home reading and drinking coffee in the company of Stella, his not-so-keen on adventure snuggle dog. That works too!


text:
Chapter 8 – Text Files. 8.1 Managing Text Files 8.2 StreamReaders , StreamWriters , and Structured Exception Handling 8.3 XML. 8.1 Managing Text Files. CSV Files & LINQ Review WriteAllLines Method Sorting a Text File Set Operations Seaching a CSV Text File The OpenFileDialog Control.
Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.
8.1 Managing Text Files
8.2 StreamReaders, StreamWriters, and Structured Exception Handling
New Jersey,NJ,7417,8135000
(name of state,abbreviation,area,population)
Dim states() As String =
Dim query = From line In states
Let data = line.Split(","c)
Let name = data(0)
Let abbr = data(1)
Let area = CInt(data(2))
Let pop = CInt(data(3))
Select name, abbr, area, pop
Note: The Select clause must contain two or more items in order to use a DataGridView control.
Where name.StartsWith("New")Order By area DescendingSelect name, abbr, area, pop
George Washington,57
John Adams,61
Thomas Jefferson,57
James Madison,57
Barack Obama,47
Dim agesAtInaug() As String =
Dim query = From line In agesAtInaug
Let age = CInt(line.Split(","c)(1))
Order By age
Select line
IO.File.WriteAllLines("Sorted.txt", query)
After the query sorts the file's original values, this statement writes them to a second file.
Theodore Roosevelt,42
John Kennedy,43
Ulysses Grant,46
Bill Clinton,46
Ronald Reagan,69
The tasks above are carried out with the Set operations on arrays.
array1.Concat(array2).ToArray consists of the merge of the two arrays
Dim array1() = {"Alpha", "Bravo", "Charlie"}
Dim array2() = {"Bravo", "Delta"}
Dim array3() = array1.Concat(array2).ToArray
Size of array3: 5
Elements of array3: "Alpha", "Bravo", "Charlie", "Bravo", "Delta"
array1.Union(array2).ToArray consists of the merge of the two arrays without duplications
Dim array1() = {"Alpha", "Bravo", "Charlie"}
Dim array2() = {"Bravo", "Delta"}
Dim array3() = array1.Union(array2).ToArray
Size of array3: 4
Elements of array3: "Alpha", "Bravo",
"Charlie", "Delta"
array1.Intersect(array2).ToArray consists of the items common to both arrays
Dim array1() = {"Alpha", "Bravo", "Charlie"}
Dim array2() = {"Bravo", "Delta"}
Dim array3() = array1.Intersect(array2).ToArray
Size of array3: 1
Elements of array3: "Bravo"
array1.Except(array2).ToArray consists of the items in array1 that are not in array2
Dim array1() = {"Alpha", "Bravo", "Charlie"}
Dim array2() = {"Bravo", "Delta"}
Dim array3() = array1.Except(array2).ToArray
Size of array3: 2
Elements of array3: "Alpha", "Charlie"
Note:LINQ queries can be used in Step 2 for greater flexibility.
Dim states() As String = IO.File.ReadAllLines("USStates.txt")
Dim query = From line In states
Let name = line.Split(","c)(0)
Let abbreviation = line.Split(","c)(1)
Where abbreviation = mtbAbbr.Text.ToUpper
Select name
If query.Count = 1 Then
txtName.Text = query.First
Dim str As String = " is not a valid state abbreviation."
MessageBox.Show(mtbAbbr.Text.ToUpper & str, "Error")
End If
Determines what appears in the boxabove the Open button, and what types of files will be displayed. The setting has the general form
text for box|*.ext
Example: Text Files (*.txt)|*.txt
Text Files (*.txt)|*.txt
Private Sub btnSelect_Click(...)Handles_
DimtextFileAs String
textFile = OpenFileDialog1.FileName
lstOutput.DataSource =
lstOutput.SelectedItem = Nothing
End Sub


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Chapter 1 : A Silent Favour
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|Chapter Reviews: 15
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James, Sirius, and Lily had invited him to take part in one of their newest adventures that evening, but he wasn't really in the mood for it. As a prefect he was hardly able to go and cause an uproarious scene, and as a friend he didn't want to be the one to have to call it all to an end. Besides, it would just be one more occasion to watch James and Lily flirt with one another. He looked at the way his robes hung off of him in the mirror. He was very thin, and looked so much like he was longing for a life, unlike James who always seemed so full of life. He stared at his face again for another moment, and then stretched his face into a smile. The beauty of his smile was lost on Remus, he could not escape the scars on his face. He put his hands over them and started scrunching his face up, trying to making different expressions. This time he tried to look distinguished. He put his chin up, and puffed out his chest.
"Oh it's no use," he said, slinking back into his normal posture. "James and Sirius are off playing heroes, Lily proudly at James' side, and here I am, worn out robes, a strange face, and an affliction that will certainly keep me from having girlfriends."
"What are you doing, Remus?" asked James, coming up behind him. "Making sure your hair is parted on the right side?" He laughed and nudged his friend's arm.
"No," he frowned. "Just, trying to retie my tie," he fidgeted with the knot of his tie, which seemed to be tighter around his neck.
"Are you coming with us tonight?" James asked, pulling his sweater over his head. "Come on, Sirius really wants you to come, too."
"No," he answered sternly. "I have too much work to do."
"Your loss," James grinned at him again and went out into the commons room to meet with the others.
Remus came out of the bathroom and went to get a book from his bag before sitting down in one of the large chairs by the fire. The boys were laughing about something, when Remus saw Lily come over to him. She was so beautiful in Remus' mind. The perfect compliment to James' handsome nature, Lily was delicate and kind. Just being in her presence made him feel even more loathsome.
"I'll be along in a second," she said to James.
James gave Lily a quick kiss on the cheek before following Sirius out of the commons room. Remus had his face hidden in his book, reading the same sentence for the fourth time.
"Are you really not coming with us?" she asked, looking over the top of Remus' book. "You'll miss all the fun."
"Not tonight, no," said Remus, shyly. A feeling in his stomach was rising, a feeling that had been burgeoning for quite some time now. He had always adored Lily, if only as a friend, and could not deny being jealous of her and James' relationship. "I've got a few chapters to finish."
"You could finish them later, Remus," she said, a tone of disappointment in her voice. When she was looking at him with those green eyes he couldn't help but feel like he had to give in. He already let pass so many of James and Sirius' nonsense, but it was even harder to say no to Lily.
"Could you just go, it's alright," he said, returning his eyes to his book.
Lily shrugged and turned to leave, but then stopped short. "Remus, can I ask you a question?"
"Do you have a problem with me?" she looked concerned as she knelt down to look him in the eye. "It just seems to me that you enjoy spending time with James and Sirius, but not when I'm around."
Remus shifted in his seat. "Look, Lily, I don't have a problem with you...it's just, you know," he could feel his face flushing red. He crossed and uncrossed his legs nervously.
"I know what?" asked Lily.
"That you're a girl, and you spend lots of time with James, and I spend lots of time with—"
"—with no one, is that it?" she asked, putting her hand on his knee.
"I suppose, yes, I suppose that is a way you could say it," he moved his knee so that her hand would fall off of it.
Lily thought for a moment, and then stood up. "I understand," she said. "Stand up, Remus."
Remus sat there shaking for a moment, and then he pushed himself from his chair and stood facing her. She was just as tall as he was, but he barely noticed. He stood there, unmoving, his breathing had stopped. Lily took one of his hands in hers. Remus looked down at their hands clasped together, and then looked back to Lily's face with a frightened look.
"I take it you've never been kissed by a girl, have you?" She smiled, kindly.
He stiffly shook his head, "well look at me!" He looked her in the face, his eyes sparkling with fresh tears. "Look at my face, my scars." He could feel his tears streaming down his face and running over those same scars, burning his skin. He struggled to ignore his embarrassment at being seen like this by Lily.
"Don't cry, Remus," said Lily. "It's alright." She leaned in to him slowly and kissed him gently on the lips. Remus closed his eyes and didn't even notice once she'd pulled away and let go of his hand. When he opened them, she was standing there, tracing over the scar on his left cheek with her finger. "Your scars are not who you are, Remus. The man you are is here," she put her hand on his chest, "and here," her other hand she placed on his temple. "Your scars are just physical proof of how strong you are." She slowly took her hand from his face. "Just be patient."
With that she backed away slowly and turned to go catch up with the other boys.
Remus stood watching her leave before slumping back into his chair.
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Mamma's Current MoansFriday, November 13, 2015
Hello Lovelies,
If you are a reader of my blog and also a subscriber of my YouTube channel you will know that I have or should I say had since I'm not currently making YouTube video's, a series of video's called "Mamma's Monthly Moans" and each month I would sit down and speak about all the things from the previous month that had really got my goat or peeved me off, it was all very light hearted but some things were serious and for some reason the video's were popular amongst my subscribers, recently a lot of people have told me they miss me on YT which is so nice and it got me thinking that maybe I could try and do a "moans" on my blog so that's what I have for you today, but not a monthly moans a "current moans" today's moans are actually some things from as far back as August and up to today so my current and past moans I suppose, anyway enough of the waffle, I'm going to crack on with my moans.
✿ My 1st moan is about something I noticed whilst on holiday but not just my summer holiday this year which we went on at the end of August, but something I've noticed on previous holidays too, why is it that when some people are on holiday they cease to look after their children properly? Now I am not for one minute saying I'm a better parent than anyone or they are bad parents but some people just sat or should I say lay sunbathing whilst their children who were babies/toddlers toddle around the complex and dangerously close to the edge of the pool, leaving everyone else to watch them. It was the same at night, the doors to the entertainment part of the hotel were open meaning access to the pools, so many parents would sit drinking whilst their children left the entertainment to go outside and play and sometimes dangerously close to the pools, it is very dark in Greece at night and the area we go to isn't well lit, but never mind the pools, anyone could abduct these children, there were certain families who just did not watch their children meaning other people had to keep fishing their small children out of the pool after they'd fallen in, no harm was done but it isn't the point, they are sunbathing and not watching their children properly and on a previous holiday we've seen a baby who was just 13 months fall in the deep end of the swimming pool whilst it's parents were sat in the bar watching a football match!!! But every year when we're away on holiday we see the same thing, parents lying around sunbathing whilst their small children run around dangerously close to the pools and are sometimes really far away from their parents, maybe it's me but it's something I've noticed more and more over the last few years and it drives me mad!!
✿ As you know I have a medical condition, well rather a few conditions but I need assistance with a lot of things and if I go out which is quite a rare thing for me I need to use a crutch and or hold onto Simon for numerous reasons which I won't go into, a few weeks ago I had been to an appointment and got there via train, Simon and Lissy were with me and we got on and it was very busy, I had my crutch with me so people could see I needed assistance, there were 3 families with around 3-4 children each ranging from ages around 5 to 12 and all had a seat, not one of the parents asked their child to let me sit down or maybe put the younger one on their knee so I could sit down, they just all sat there letting me struggle, now I'm not saying I've got more right to sit down than them and if I was able bodied and in perfect health it wouldn't have bothered me but I'm not, an elderly gentleman offered me his seat which I didn't take and then someone got off and I sat there, but surely it's good manners to teach children than if someone is in more need of a seat than them then it's nice to offer your seat? My daughters always offer their seats up when necessary, and I am very proud of them for that, it's different I suppose if I am using Simon and not the crutch as my illness becomes very much an invisible one, but on this occasion it wasn't, I know I'm at risk of sounding like Victor Meldrew here but it really peed me off!!!
✿ I've spoken before in my moans about bizarre things I am offered from companies and pr companies mostly sports equipment and sports wear which does still continue by the way but recently I have had 2 things that stood out as more bizarre than that, the 1st thing being only a few days ago. I was offered a pram, buggy or pushchair but call it what you will I was offered a device to push a baby around in, now correct me if I'm wrong but the last time I looked my children were 18 and 24 and a little bit old for a pram!! It made me laugh so much, a pram???? And the email said "we love your blog so much" really??? You love it so much you missed reading the parts where it never mentions I've got a baby?? Oh dear!!! The second comical thing I was offered was also an invitation to an event, I was invited to go and preview the item or should I say an event showing me how to use the items and then offered items to use plus an outing to use them, sounds good right? An event with lunch and drinks, plus an outing to use some new things, a great offer is it not? Well when I tell you the event and items were all regarding fly fishing you may think differently, yep you read that right FLY FISHING, what the actual? I didn't actually know what fly fishing was so googled it and at the time I was with Lissy and my friend Jodie and we were howling laughing, if you don't know what fly fishing is it's basically fishing but using a fake fly type thing, well that's what I could fathom from google anyway, but honestly why on earth would anyone offer a beauty blogger something to do with fly fishing?? I know I do blog about lifestyle things too but fly fishing, come on!! Deary deary me!!!
✿ My next and last moan is about fake bloopers on you tube, I was watching You Tube videos a few weeks ago and the bloopers in one persons video's were obviously fake, fair enough if you forget words or say the wrong thing, drop things etc etc but these were soooooooooo fake, why? When making you tube video's there's usually enough mistakes made in at least some video's to add bloopers in, but I've noticed that this person will include bloopers in almost all their video's and they are all put on, it's very obvious and I've noticed more and more other people noticing and unfortunately I don't think I can watch the person much longer because it annoys me so much, their content isn't bad but the bloopers are, other people had commented about it too so it isn't just me, I love a good blooper and some things are really funny especially if filming with someone else but sitting on your own in a room which most people do when filming these things were clearly set up, I'm not going to say what I mean because it may become obvious to some people who it is and I wouldn't hurt someones feelings for anything, I like the person, I enjoy their video's but cannot bare the fakeness at the end of each video, there's no need and it spoils it. A lot of people do it and I've mentioned it in the past in moans and a lot of you agreed with me, it is really needless and annoying and I wish it wasn't done, but unfortunately me moaning isn't going to change that!!
So those are my moans for this post, I know in a video I usually have a couple more moans than in this post but I didn't want the post to be too long, let me know if you enjoyed my moans post and if you'd like more of them, and if you did enjoy it would you like a couple more moans next time? I really hope you've enjoyed this post it's different obviously from seeing me sit and talk on a video but I do hope you've enjoyed it all the same.
Let me know in the comments if you have had anything to moan about lately, it always makes me feel better when it's not just me!
Thank you for reading, much love as always
Zoe x


text:
Yeah, I am going to put the CPU max speed back down to 768, and add some more governors.
I think 800MHz is a bit crazy, 768 is good.
Does anyone know how to do an update.zip? I have an idea to make a script that fetches the kernel and wifi module, then shoves it in a zip with an updater script and binary.
Currently looking at CM7 updater script in the zip to try and learn how to do these things.
|arco, buzz, cm kernel, infinityplay, kernel
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text: Kids and adults alike love spooky things. The latest release of the animated movie Hotel Transylvania was directed by Genndy Tartakovsky, known for his work on the animated shows Dexter's Laboratory and Samurai Jack. The movie received favorable reviews from families but much worse reception from critics. The same might apply to the video game on 3DS that shares its name. Movie tie-in games have created a separate standard for themselves. Most games encounter rushed production, indefinite parameters, and small teams. In most cases, movie tie-in games fall back on the tried and true format of platformers, which is what happens in the case of Hotel Transylvania. The game garners some comparisons to Castlevania, which are most likely due to the supernatural castle atmosphere and genre of game. Level advancement harkens also to that found within titles like Castlevania and Metroid. The player begins the story as the movie's protagonist Mavis. A teenage girl who is the daughter of Dracula. Dracula runs the resort for monsters, but apparently there are still many dangers found within the castle. Mavis' human friend is in danger, so this sets the pace for the small amounts of game plot. The levels of the platformer are rooms within the castle, and they work both forwards and backwards. This is due to the game not having a linear map progression. Progress is measured in small tasks performed for various family members throughout the castle. The plot is thin, which is pretty common in many games geared toward children or based on movies. Story and level progression are based on micro fetch quests which send the player to different rooms. Expect to visit the same rooms in a varied order after acquiring new powers. The levels, while accessible from many different starting points and potentially created with the style of older games in mind, can grow repetitive after the fourth or fifth time of passing through a corridor or stairwell. The bulk of game enemies become available in early gameplay, which can add to the stale feel of levels, as well. Instead of finishing a room and being done with it as most games treat levels, there are places within rooms that are only available after gaining specific powers. These powers include the ability to freeze enemies or run up walls. Remembering and unlocking these hidden areas later in the game serves as a majority of the fun and challenge, which is where this game shares the most in common with its predecessors. Since the game takes place within the same castle, the appearance is mostly unchanging. The 3D options are fine, but they offer very little to the game. There is really not much difference in playing the game with 3D turned on due to the shallow depth. Considering the game is in a 2D side-scroller setting, this is almost to be expected. Soundwise, characters do not speak, and you'll likely grow tired of hearing the same moans and groans from the seldomly changing minions. The music works well with the atmosphere, though. Controls are fluid and accurate enough, though the oversized main character creates the added challenge of sometimes navigating past enemies on more than one level at the same time. Levels are not particularly hard for older kids or adults, but for younger children, there may be many requests for help. The main issue here is that while the movie attempts to provide entertainment for younger and older children, the game only offers one difficulty level. Carrying on through levels is not as intuitive as most games that contain multiple exploration options. This might be novel for older children but frustrating for less experienced gamers. Movie tie-in games do not often sit at the forefront of praiseworthy games, and if this sounds like I'm making excuses for the game, I'm not. As a throwback side-scroller, this game has some issues with repetitive level design and sound variety. There were no major bugs or glitches that I encountered, but the story was nearly as absent. This game can be recommended for children who are fans of the movie, but it doesn't seem to carry much intrigue as a stand-alone. I'm not even certain how much it would add to the overall Hotel Transylvania experience for fans. [raw] [row_box style="grid_8 wpc_verdict"] The TotallyGN Verdict [col_1_3] [bullets] Exploratory gameplay does its best to recapture the expansive levels from earlier titles. 3D sets it apart from other games in its genre. Lack of variety in levels can drag out playing experience. [/bullets] [/col_1_3] [col_2_3] Summary: Hotel Transylvania 3D doesn't set itself apart from the movie or the movie game genre due to underwhelming level design and supporting gameplay elements that are as barebones as the skeletal minions. [note class="alignright"]5[/note] [/col_2_3] [divider_space_thin] [/row_box] [list] Format: 3DS Developer: WayForward Publisher: GameMill Release Date: September 18, 2012 [/list] [clear] [/raw]


text:
New Bally Mocc Plus Women's Golf Shoes - Size 8 US
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Shipping | Payment | Checkout | About Us | Contact Us | Our Other Listings New Bally Mocc Plus Women's Golf Shoes - Size 8 US (99 Additional Shipping Terms
Canadian and international customers who live in extended delivery areas are subject to higher shipping rates and will be contacted accordingly. Some of the more commonly affected Canadian areas include British Columbia, Alberta and New Brunswick as well as addresses that have a 0 in the second position of their postal code (i.e. L0G 1N0). Other areas may be affected as well.Due to the shape of many of our items our packaging is large and oddly shaped resulting in dimensional weight billing. Consequently our shipping rates may seem higher than would be expected from other items of a similar weight but with different sized packaging to certain areas, especially internationally. International buyers (outside the US and Canada) are responsible for any importing tariffs/taxes. We do not ship to Brazil, France, Puerto Rico, South Africa or any Southeast Asian countries and reserve the right to decline shipment to other destinations outside of the US and Canada. FAQ: Shipping
Q: When will my order leave? A: Your order will leave our warehouse via UPS within 48 hours (excluding weekends and holidays) once we receive cleared payment. Q: When will my order... read more


text:
Endocrinology of the Testis and Male Reproduction
Part of the series Endocrinology pp 1-46
Gonadotrophin Receptors
- Livio CasariniAffiliated withUnit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia
- , Ilpo HuhtaniemiAffiliated withFaculty of Medicine, Department of Surgery & Cancer, Imperial College London
- , Manuela SimoniAffiliated withUnit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia
- , Adolfo Rivero-MüllerAffiliated withDepartment of Physiology, Institute of Biomedicine, University of Turku
The two gonadotrophin receptors (GnRs), luteinizing hormone receptor (LHCGR) and follicle-stimulating receptor (FSHR), belong to the glycoprotein hormone receptor subgroup of type A G protein-coupled receptors (GPCRs). LHCGR binds specifically the two structurally similar gonadotrophins, luteinizing hormone (LH) and human chorionic gonadotrophin (hCG), and FSHR binds follicle-stimulating hormone (FSH). The receptors reside on plasma membrane and transmit the gonadotrophin signal to target cells using the classical Gs/adenylyl cyclase/cyclic AMP/protein kinase A signaling cascade. Other signaling pathways (e.g., inositol phosphate, calcium) are activated at pharmacological hormone concentrations or at high receptor density. LHCGR is expressed in testicular Leydig cells and in ovarian theca, luteinizing granulosa and luteal cells. FSHR is expressed in testicular Sertoli cells and ovarian granulosa cells. LHCGR activation stimulated Leydig cell steroidogenesis, in particular testosterone production, while FSHR maintains Sertoli cell metabolism, thereby indirectly stimulating spermatogenesis. Recent basic research, using GnR, expressing cells in vitro and genetically modified mice in vivo, has elucidated novel aspects of the molecular mechanisms of gonadotrophin receptor function. The crystal structure of GnRs has also been partly resolved. Numerous inactivating and activating GnR mutations that have been discovered in patients have unraveled the molecular basis of hypogonadism and other aberrations of reproductive endocrine functions. The purpose of this chapter is to review the recent trends of GnR research and how it has elucidated the molecular mechanisms of GnR function and the role of GnR in human reproductive physiology and pathophysiology.
KeywordsFSH Gonadotrophins hCG LH Polymorphism
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Date: 2016 (Latest)History
- 2016 (Latest)
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- Title
- Gonadotrophin Receptors
- Reference Work Title
- Endocrinology of the Testis and Male Reproduction
- Pages
- pp 1-46
- Copyright
- 2016
- 10.1007/978-3-319-29456-8_4-1
- Print ISBN
- 978-3-319-29456-8
- Online ISBN
- 978-3-319-29456-8
- Series Title
- Endocrinology
- Series ISSN
- 2510-1927
- Publisher
- Springer International Publishing
- Copyright Holder
- Springer International Publishing AG
- Additional Links
- Topics
- Keywords
- Gonadotrophins
- hCG
- Polymorphism
- Industry Sectors
- eBook Packages
- Editors
- Manuela Simoni (3)
- Ilpo Huhtaniemi (4)
- Editor Affiliations
- 3. Dept. of Biomedicine, Metabolism and Neural Sciences, University of Modena and Reggio Emilia
- 4. Dept. of Surgery and Cancer, Imperial College London
- Authors
- Livio Casarini (5)
- Ilpo Huhtaniemi (6)
- Manuela Simoni (5)
- Adolfo Rivero-Müller (7)
- Author Affiliations
- 5. Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- 6. Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
- 7. Department of Physiology, Institute of Biomedicine, University of Turku, Turku, Finland
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on May 16, 2013 8:29 PM by 1009440
Analyzing core dumps generated by JVM
May 16, 2013 8:29 PM
I have an application written in Java that is crashing with JVM core dumps. All debug symbols have been installed but since the default build of JDK doesn't have Java binary with debug information, it is difficult to nail down the problem. gdb shows ?? for method calls. Are there any debug builds available for JDK 6u33 on Linux? From what I understand, the code base for OpenJDK 6 is different from Oracle's JDK releases so the chances of openjdk debug build having same symbol information are fairly low. Any help or direction is greatly appreciated.
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There's a lot more to prescription sunglasses than meets the eye (pun intended), yet, thankfully Nike has been developing the innovative technology wearers need to reach their peak performance outdoors. Nike's prescription sunglasses selection includes options for both athletes and casual wearers; either way, consumers will enjoy the benefits of the technology behind Nike prescription sunglasses.
Lens Technology
Nike Max Optics is the lens technology found in all of Nike Vision's prescription eyewear line, including the semi-rimless sunglasses model, designed, specifically, for athletic use. The technology in Nike Max Optics comes from the lens materials, the way they are cut and shaped, and the coatings.
The lenses are made from polycarbonate and nylon materials and are made to be impact and shatter resistant, as well as lightweight. They provide 100% UVA/B protection, and consumers can choose between specific tints depending on the use, such as polarized, golf, speed, or outdoor. The main benefit of this technology is to shield wearers' eyes from different shades of sun glare and provide consistent vision when in the shade away from sun glare.
Nike teamed up with Transitions Optical to develop the different lens options for wearers to choose from. The main idea is for the lenses to be adaptive to different environments and light conditions, to dim the sun and brighten the shadows by manipulating the spectrum of colors coming through. Each type of lens is made for specific uses, for instance: the Speed Tint is engineered specifically for runners on road surfaces, Outdoor Tint for natural environments, Golf Tint enhances the green's contours and the white ball, etc.
Another aspect of the technology behind the development of Nike Max Optics is the way the lenses are cut. Instead of cutting from the center of the blank (like inferior lenses), Nike Max lenses are cut from the position in the blank that aligns best with the eyes – this method optimizes the lenses around the typical line of sight of wearers.
Another important aspect of Nike Max Optics technology is the hydrophobic coating on the lenses. This coating is very useful in practical applications, as it repels: dust, perspiration, dirt, sand, fingerprints, liquids, etc.scratch resistant; also, this coating is what scratch-resistant and easy to clean. For athletic, work, casual, or general active users, this innovative coating technology makes the difference in being able to see clearly or not.
Frame Technology
The Nike Vision Prescription eyewear line includes many different types of frames, such as high-quality metal, full nylon wrap around, metal rims with nylon arms, and semi-rimless. These all have their benefits and qualities, including breathable nose bridges, thickness levels, rubber arm ends, lightweight, and differing styles, yet, the semi-rimless interchange frames are the most innovative when it comes to technology.
The Nike Interchange frames allow for wearers to use different lenses in them, simply, by switching them out when desired. Every part of these frames are adjustable and interchangeable from the other parts, such as the: Cam-action hinges, temple, silicon rubber arm ends, main nylon frame, ventilated nose bridge, and the Nike Max Optics lenses of choice.
With Nike Interchange frames, wearers have the ability to match the appropriate lenses with the environment they'll be in for each day; this type of innovative technology, uniquely, belongs to Nike sunglasses, giving wearers more options and flexibility when choosing their sunglasses.
When consumers choose Nike prescription sunglasses, they'll benefit from the innovative lens and frame technology behind their development. The science of the light spectrum, precision in design, innovative partnerships, and quality materials, all work together in creating the best lenses and frames for athletic use on the market today.


text: Overview -- U.S. gaming services provider Scientific Games plans to issue $250 million of senior subordinated notes due 2020. -- We are assigning the notes our 'BB-' issue-level rating, with a recovery rating of '5'. -- The stable rating outlook reflects our expectation that credit measures will remain at a level we believe is in line with the current rating. Rating Action On Aug. 15, 2012, Standard & Poor's Ratings Services assigned its issue-level and recovery ratings to Scientific Games International Inc.'s proposed $250 million senior subordinated notes due 2020. The notes were rated 'BB-' (one notch lower than the 'BB' corporate credit rating on parent company Scientific Games Corp.) with a recovery rating of '5', indicating our expectation of modest (10% to 30%) recovery for lenders in the event of a payment default. Proceeds from the notes offering will be used to redeem or repurchase the $200 million 7.875% senior subordinated notes (including accrued interest and the applicable redemption premium), and for general corporate purposes. All existing ratings, including the 'BB' corporate credit rating on Scientific Games Corp., are unchanged. The rating outlook is stable. Rationale Our 'BB' corporate credit rating on Scientific Games reflects our assessment of the company's financial risk profile as "aggressive" and its business risk profile as "fair," according to our criteria. Our assessment of its financial risk profile as aggressive reflects our expectation that our measure of leverage will remain below 5x over the intermediate term. It also reflects the company's substantial acquisition activity and investments through joint ventures, its "adequate" liquidity profile, and our expectation for interest coverage to track around 3x over the near term. Our assessment of Scientific Games' business risk profile as fair reflects competitive market conditions in the lottery industry for contract renewals and for new contracts, which often result in pricing pressure; the mature, capital-intense nature of the lottery systems industry; and the company's limited business diversity. Offsetting factors are Scientific Games' leadership position in the instant ticket lottery segment of the gaming industry, a diversified customer base, and substantial recurring revenue and cash flow, given long-term contracts with renewal options that are typically exercised. Our rating factors in the expectation that Scientific Games' revenue and EBITDA will grow in the mid-single-digit percentage area in 2012. Our revenue assumption incorporates an expectation for continued weakness in instant ticket revenue, largely the result of a weak macroeconomic environment in Italy. We are currently incorporating an expectation that declines continue at the same level as the second quarter for the remainder of 2012. (Instant ticket revenue declined 8.3% in the second quarter.) Our expectations for the Italian instant ticket business are largely driven by our European economist's baseline forecast for a 2.1% decline in GDP in 2012 and 0.4% decline in 2013 in Italy, and for unemployment to increase to 10% by the end of 2013. We are factoring in high-single-digit revenue growth across Scientific Games' service and sales revenue (excluding the acquisition of Barcrest). Our forecast also factors in a modest level of incremental revenue associated with the company's acquisition of Barcrest last year. Our performance expectations for the company's lottery business factor in our U.S. economist's forecast for modest consumer spending growth and changes in various lotteries, including the Powerball price increase and the ability to sell some lottery products through the Internet channel. We expect growth in the lottery segment in the remainder of the year to be more moderate than first-quarter sales levels, which were aided by strong jackpot activity. Additionally, we believe economic uncertainty in many European markets could dampen international growth. In addition to the revenue drivers above, our EBITDA forecast also factors in an expectation for about $55 million in cash distributions from joint ventures in 2012, slightly higher than distributions received in 2011. (We include return of capital payments in our measure of cash distributions.) Under our performance expectations, we believe leverage will remain in the high-4x area in 2012, and that the company will continue to improve leverage in 2013, building in additional cushion relative to the 5x maximum leverage threshold. We view some cushion relative to our threshold as necessary to provide Scientific Games with flexibility to pursue additional strategic growth opportunities without meaningfully impairing its financial risk profile. While revenue growth has somewhat exceeded our expectations in the first half of the year, EBITDA has performed in line with our expectations. In the six months ended June 30, 2012, Scientific Games' revenue increased 11%. EBITDA (which we adjust to include cash distributions and return of capital payments from joint ventures) increased about 6%. At June 30, 2012, leverage and coverage were 4.8x and 2.9x, respectively. Scientific Games is a leading integrated supplier of instant tickets, lottery gaming systems and services, and server-based interactive gaming terminals and systems to lottery and gaming organizations worldwide. While the company remains a distant second in the lottery systems segment, behind industry leader Lottomatica SpA, Scientific Games is the leader in the instant ticket segment of the lottery industry, which has grown more rapidly in recent years. Liquidity Based on the company's likely sources and uses of cash over the next 12 to 18 months and incorporating our performance expectations, Scientific Games has an adequate liquidity profile, according to our criteria. Relevant factors in our assessment of Scientific Games' liquidity profile include the following: -- We expect the company's sources of liquidity over this period to exceed its uses by 1.2x or more. -- We expect that net sources of liquidity would be positive, even if forecasted EBITDA declined 15%. -- We believe that Scientific Games has sufficient covenant headroom, such that a 15% decline in forecasted EBITDA would not result in a breach of financial covenants. -- We believe Scientific Games has a sound relationship with lenders and a satisfactory standing in credit markets. Liquidity sources include a $250 million revolving credit facility, a moderate cash balance, and internally generated cash. As of June 30, 2012, the company had approximately $212 million in availability under its revolving credit facility (after accounting for letters of credit outstanding) and a cash balance of $112 million. In the 12 months ended June 30, 2012, Scientific Games generated about $157 million in cash flow from operations and spent about $98 million on capital expenditures. We expect that operating cash flow generation in 2012 will be sufficient to cover our expectations for around $150 million in capital expenditures and that the company will generate a modest amount of free operating cash flow (FOCF) that it could use for debt repayment, modest-sized acquisitions, or possible additional strategic growth opportunities. The company's credit facility includes several financial maintenance covenants. The total leverage covenant is set at 5.75x through Dec. 31, 2013, 5.50x for all of 2014, and 5.25x thereafter. The senior leverage covenant is set at 2.75x, and the interest coverage covenant is at 2.25x. Under our forecast assumptions, the company maintains adequate cushion with respect to these financial maintenance covenants. The proposed $250 million senior subordinated notes offering, which will refinance the company's $200 million senior subordinated notes due 2016, improves Scientific Games' already strong debt maturity profile. Over the next few years, debt maturities consist primarily of amortization payments under the term loan until the company's term loan and revolver mature in June 2015. Scientific Games has a $200 million share repurchase authorization in place through the end of 2012, with roughly $172 million remaining as of June 30, 2012. While the company has built in some flexibility to complete a modest level of share repurchases, we generally expect the company will use its resources for growth opportunities as they arise and have not incorporated any meaningful share repurchase activity. Outlook Our rating outlook on Scientific Games is stable, reflecting our expectation that credit measures will remain at a level we believe is in line with the current rating. Furthermore, we expect the company will continue to gradually improve its leverage profile over the next two years. This should allow Scientific Games to build in some cushion relative to our 5x maximum leverage threshold, which would provide it flexibility to make additional strategic investments without meaningfully impairing its financial risk profile. For 2012, we have factored into our rating a mid-single-digit revenue and EBITDA increase. Under our performance expectations, we expect leverage to be in the high-4x area at the end of 2012 and EBITDA coverage of interest around 3x. We could lower our rating if the company does not demonstrate organic growth in its existing businesses or if the company embarks on larger-than-expected investments for acquisitions or other strategic growth opportunities, such that we no longer believe the company has the ability to maintain leverage below 5x. A higher rating is unlikely over the next two years, given our expectation that Scientific Games will pursue investment opportunities and that leverage will remain in the mid- to high-4x area, on average. Related Criteria And Research -- Methodology And Assumptions: Liquidity Descriptors For Global Corporate Issuers, Sept. 28, 2011 -- Criteria Guidelines For Recovery Ratings, Aug. 10, 2009 -- Business Risk/Financial Risk Matrix Expanded, May 27, 2009 -- 2008 Corporate Criteria: Analytical Methodology, April 15, 2008 Ratings List Scientific Games Corp. Corporate Credit Rating BB/Stable/-- New Ratings Scientific Games International Subordinated $250 mil sr sub notes due 2020 BB- Recovery Rating 5


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Explore our exclusive St. John's hotel deals for your next trip to the heart of Newfoundland & Labrador's capital city. Overlooking St. John's historic harbour, we are at the centre of a thriving community and offer travellers a wealth of amenities all within easy reach of the historic city's myriad attractions.
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Book online, or call 1-877-782-0108 and ask for "Our Biggest Sale of the Year."
Allow us to take care of the details for your next stay at Sheraton Hotel Newfoundland. Fuel your day with a nourishing breakfast, then leave your car with us as you explore the best things to do in St. John's just steps from our doors.
Book online, or call 866-716-8101 and mention rate plan LAPKG1.
Take time to explore the sights of our city, from the historic harbour to scenic hiking trails to whale watching to local dining and museums in downtown St. John's. Plan your visit to St. John's this November with our exclusive offer:
Book online, or call 866-716-8101 and mention rate plan LBPKG1. Valid for stays from November 1-30, 2017.
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Memories of Me Trailer (1988)
"Abbie Polin never told anyone the terrible secret about his father... he's alive and well and living in Hollywood." 28 September 1988 Drama, Comedy 103 mins
After a heart attack, Abbie Polin (Crystal), a New York doctor, goes to Los Angeles to see his father, Abe (King), who works in Hollywood as the "king of the extras." Their relationship has been strained for several years. This was the first movie directed by Henry Winkler, and much of it was filmed inside the MGM Studios in Culver City, California, only a few miles from Hollywood. Lisa, the romantic interest in Abbie's life, also comes for a visit and bonds with Abe, who gets along famously with everyone but his son. Abe begins having memory loss and eventually is diagnosed with a brain aneurysm. He and his son grow closer in time and, before it's too late, Abbie tries to get Abe a speaking role in a film.
Watch the official Memories of Me 1988 trailer in HD below or find more Memories of Me videos on Vidimovie.


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Let there be no doubt, Obamacare is a good thing
As a journalist I get annoyed by the influence of lobbyists on the mainstream media. I think it's right for the media to try to tell all sides of a story, but sometimes, because bad news sells better than good news, the negative lobbyists get their story told more often. This seems to be the case with Obamacare. And it feels like the lopsided negative media affects American attitudes more than, for example, Canadian attitudes. Ten years from now there will be few who will regret that Obama achieved this, but at the moment, all you hear about are the problems with the web sites or the polls showing more Americans think they are against this than support it. Maybe it's time to read some of the good news stories, not surprisingly, provided by the Obama administration; but nonetheless, they strike me as what's important on this issue.
Almost everything he was doing was legal in Canada
Am I the only person who thinks this is crazy? Collecting all these guns without registering them was perfectly legal, until he tried to sell some. Is this the kind of country we want to live in?


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MMM Unfreeze all Confirmed Mavro in January 2017 says Nigerians - While Nigerians wait for their Money to be unfrozen from the popular MMM Ponzi Scheme, MMM goes ahead to advertise for new guiders school in Nigeria for those people who are still interested to make $450 USD from the scheme monthly as salary for being a guider in MMM Nigeria. This advert has gone a long way to encourage Nigerians that the scheme will unfreeze all the Confirmed Mavro that was frozen on 14th December 2016. See the advert / news below;
This was published on 19/12/2016
MMM say if you want to:
- Join MMM guiders and know more about MMM, its community and about the way it works!
- Become a guiders and gain experience from the top leaders of MMM!
- Help others to find better and more effective ways of inspiring people to join MMM!
- Be your own boss as you work as a team with like-minded people!
- Become a super guider and grow as an MMM leader!
- Finally, become Financially Free!
Remember it is absolutely free of charge! All it is needed to graduate the school is your desire and time.
Sign up here: https://goo.gl/J6Wx5f
Do you want to Join MMM & Get 50% Mavro in of 30%?
If yes click http://www.nigeria-mmm.net/
Just few days ago, the MMM founder "Sergey Mavrodi" wrote to Nigerian Journalists & Bloggers telling them to leave MMM alone because they do not know how the MMM system works. He cautioned them to desist from writing negative articles about MMM that has been paying Nigerians its promised 30% Mavro since the ordinary people has been in pain due to the Nigerian recession.
Are you aware that MMM is still working in South Africa, Kenya & Zimbabwe?
He went ahead to advise participants of MMM to give deaf ears to all posts, news and articles spreading negative and false news through their media platform just to gain popularity and cause panic in the heart of Nigerians.
MMM Guider School: MMM Nigeria to Unfreeze all Confirmed Mavro in January 2017
Sergey Mavrodi also told Nigerians that offices always goes on break during festive and holiday seasons to rest and plan for another session. "MMM is doing thesame and we are coming back better and stronger". The Mavrodi Mondial Moneybox (Mavrodi Mondial Movement as called by many people) is not a Ponzi scheme, it is not fraudulent and did not crash as published by several journalists and bloggers. All participant of MMM who has provided help and their Mavro(s) confirmed will receive their money by "Getting Help" from the MMM Office accessible at www.mmmoffice.com.
MMM to Unfreeze all Confirmed Mavro in January 2017 say Sergey Mavrodi. Go ahead and register with the MMM Guider school and make more money while others waiting for it to crash. You will be glad you did because you will surely smile to the bank come January 2017. Share it to your friends and family to uplift their spirit and increase their positive hopes.


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Thank you Sheela for your time to talk about SOLIDARITY21, if there's anyone who has the heart for what we do and understands us, it's you
Those who have been following my work will know that I am part of the collective RSCLS, and that we created SOLIDARITY21– a platform for urban cultural exchange which we receive support for from the NAC. Those who've known us from way back would know that we would initiate plenty of street initiatives for the community out of our own pockets in hopes of progressing local street culture. It has always been about the community, by the community, for the love of the community. In recent times, we decided to take it a step further to make bigger progress in this area, and we knew that what we earn as artists isn't going to be able to fund all that we wanted to achieve. As such, we went through paperwork, an intense interview (imagine two would-be convicts presenting an idea in a boardroom of easily 20 directors, artists and the like) and were awarded a seed grant to realise our goal- to progress urban art culture in all 21 East Asian and South East Asian countries.
I would just like to say, legal or illegal- what matters is the message, the intention, the initiative. SOLIDARITY21 is created to progress the art form through solidarity of all Asian urban artists to raise the profile of the discipline collectively; encourage better understanding through shared experiences; researching and documenting Asian urban art culture from different walks of life- and if doing all this for the love of the art is going to be questioned and judged based on legality or illegality of it, then let that serve as a reflection of the mindset of today. Be discerning, not assuming.
You can read the article HERE.


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TestFunda FIFA World Cup 2010 Challenge. VINEET26's choices for 03-Jul-10 recorded in database through the TestFunda FIFA World Cup 2010 Challenge Submission Page.
1) Which player will score the most number of goals in the day?: Carlos TEVEZ
2) Which team will score the maximum goals in the day?: Argentina
3) Which team will be the quickest in scoring its first goal the day?: Germany
4) Which team will receive the most Yellow Cards during play?: Argentina
5) Which team will score the most goals in the second half?: Argentina
6) Which team will score the most goals in the first half?: Spain
Tie-Breaker Question
Which player will be the Man of the Match?: Lionel MESSI


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Mon 21st Jan 2013 11:36amFlow Surf School Saltburn's Saltburn Beach Surf Report
Howling onshore east swell around 10ft+. Nowhere worth going in really today. Cheers, Richie
View the Saltburn Beach Surf Report and Forecast. Flow Surf School Saltburn's Reports have received a total of 347178 views.
This report has received 455 views since 21/1/13.


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4204 North Brown Avenue, Scottsdale, AZ 85251Request info Add to list
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Back problem rules Owen Farrell out of Saracens' Aviva Premiership opener
Saracens fly-half Owen Farrell will miss the start of the Aviva Premiership season with a back problem that director of rugby Mark McCall insists is only minor.
Farrell, who was instrumental in England's 3-0 series whitewash of Australia in June, sustained the injury during pre-season more than a month ago and has been managing it since.
The 24-year-old will sit out at least the Premiership opener against Worcester at Twickenham on September 3 and possibly additional matches, but McCall insists the prognosis is short term.
"Owen has a little bit of a back niggle, but it's nothing serious. We'll have to see how it is at the start of next week," McCall said.
"It isn't related to the England tour, it's something that has been picked up in the last five weeks. We don't expect him to miss too much though."
Farrell was a central figure in Saracens' march to a Premiership and Champions Cup last season and, on the strength of his displays against the Wallabies in June, is knocking on the door of world class status.
Alex Lozowski, a summer recruit from Wasps, will deputise at fly-half in Farrell's absence, while Alex Goode is also an option in the position.