Welcome, everyone, to the first event of our Healthcare Provider Genomics Education Week. My name is Donna Messersmith. I'm one of the co-chairs of the Inter-Society Coordinating Committee for Practitioner Education in Genomics, or ISCCPEG. NHGRI is proud to host ISCCPEG as well as this upcoming week. ISCCPEG, as you can see on our slides, is made up of over 250 members. We're open to individuals, organizations, and industry interested in healthcare provider genomics education. Membership is free, and we support different project groups that have a specific need, as we will see later in this webinar today. The project groups identify specific educational needs and solutions, they share best practices, and they develop educational resources. One of NHGRI's roles is to facilitate the dissemination of products from those project groups. As one of our most recent examples, the Direct-to-Consumer Genetic Testing Project Group, which is led by our co-chairs, Dr. Tracy Weiler and Dr. Haria Ayubia, who we will hear from in a few minutes, have created a new resource that's posted on genome.gov. And this is the Direct-to-Consumer Genetic Testing FAQ for healthcare professionals. You can access it here through this link, as well as through the QR code. So for more information about ISCCPEG, please feel free to visit our link to the web page for ISCCPEG. And I want to also point out that this webinar will be recorded for future use, and you can listen to it later, and your questions can be posted into the Q&A on the webinar. Okay, next slide, please. So just a brief overview, our Healthcare Professionals Genomics Education Week. This is our second year, and we will have events throughout this week, June 6th through the 10th. Our events include panel discussions, webinars, Twitter chats, and Q&As. When I last checked this website, we had over 10 different events, and we encourage you to check out the events and register and participate. Importantly, we have additional information coming through the hashtag MenGeneEd22. So keep an eye out for events and activities through your Twitter feed. The themes for each day are listed here. As you know, today is Direct to Consumer Genetic Testing, Tomorrow Pharmacogenomics, Wednesday Inclusive Genetics, Thursday Cancer Genomics, and OBGYN, and on Friday the 10th, rare diseases. You can see more information from this flyer. So please enjoy the upcoming panel discussion, and we can move on to our next slide. Thank you. Good morning all. We will be discussing Direct to Consumer Genetic Testing case studies. My name is Haria Ayubiay, I'm a clinical geneticist and an assistant professor at Texas Tech University Health Sciences Center in El Paso. Next slide. We have an amazing panel for you today, and I will ask the panel members to introduce themselves before every case. So next slide. We have no conflicts to disclose today. Next slide. So as a reminder, we actually, this project group had a seminar, a little webinar about Direct to Consumer Genetic Testing for Healthcare Professionals in 2021, where we ironed out the different details about Direct to Consumer Genetic Testing. To re-familiarize yourself with those details, please watch the YouTube video. The link is here on the slide, and we are happy to answer any questions that you may have in the Q&A. Next slide. So Nguyen is going to be taking over. Hi, my name is Nguyen Park, and I'm a PA. I'm also an NIH ACMG Genomic Medicine Program Management Fellow and the president and founder of the Society of PAs in Genetics and Genomics. So today we're going to be looking at Direct to Consumer Genetic Testing in greater depth. And we'll start off with the definition, which is a genetic test that can be completed without involving a healthcare provider. Next slide, please. So there are many different genetic testing models, and we can divide them according to three separate categories. One who orders the test, two how is consent obtained, and then three how are the results disclosed. So in direct to consumer testing, there's not a healthcare professional involved that's ordered as it states in the name by the consumer. And the consent is obtained by the written information directed to the consumer. And results go directly to the consumer. There's also provider-mediated genetic testing in which the consumer initiates it, but there is some healthcare professional involvement, and that may differ depending on the company. The consent may be obtained with or without the healthcare professional, and the results can go directly to the consumer, and they can have optional access to healthcare professionals. In clinic-based genetic testing, which is the type that most clinicians are most aware of, it's usually ordered by a healthcare professional, and the consent is thus obtained by that healthcare professional, and the results are discussed with the patient by the healthcare professional themselves. Next slide, please. In our webinar, however, we'll be focusing directly on the direct to consumer genetic testing, and the case studies will allow us to get some really great in-depth information about that. Next slide, please. So there are obviously benefits and limitations for direct to consumer testing. Obviously, we like in genetics, we like that there's more awareness about genetics. Direct to consumer testing can be much less expensive since insurance or medical systems aren't involved. People find their results frequently entertaining, or they may find that it empowers them. If they're able to look at their ancestry or look at some aspects of their health, they can also find out information about paternity, look at things like sports and fitness and nutrition, and certain benign genetic traits. However, we know that there are limitations to this, and a lot of caveats. So they're looking frequently at segments that are analyzed, and it's very targeted so you don't get full sequencing. The results then can be misleading, and because there's not a healthcare provider directly involved, you can end up having patients who have a lot of questions and concerns, and then this can cause even a potential burden to the healthcare system. Most of the time, we need clinical confirmation. And with direct to consumer testing, because it's through a company, there's not necessarily understanding about privacy and the use of that data. And again, a lot of times patients don't understand because they have either limited or no informed consent that goes into ordering the test. So, Huan, we'll be presenting the next segment. Next slide, please. All right. Good morning, everybody. My name is Huan Lee. I use she, her pronouns, and I'm a genetic counselor and assistant professor at the University of Minnesota's Genetic Counseling Program. So we'll be doing, I'm starting my video here, sorry about that. And so we're just going to be going on to the cases next. Next slide, please. So the first case about direct to consumer testing we have is DTC in the clinic. So we have a 28-year-old patient.  And she discloses she's adopted and has no known biological family history. And she also relates, she took DTC, and she mentions that her results were negative for BRCA1 and BRCA2. And so these are, have a lot of different components here, and we think about, like, what are the different issues that we should be thinking about? Next slide, please. So a few things. So first, we really want to elicit the reason why the patient is doing the direct to consumer testing and any underlying concerns. So for adoptees, many adoptees who have no biological family health history, this direct to consumer testing is the only link that they have to their genetic ancestry and family medical history. So it can be very meaningful and important to them, maybe different from people who have a bio-advantage and actually know their family history. So one of the things we want to talk about is that, you know, she had a negative result. And so we also know that negative results with DTC, it's not comprehensive, it may be a false negative. Now, let's say she had come to you and said, I have a positive result. And so we really want to say, OK, let's make sure we can actually confirm and detect and make sure this is actually a real pathogenic variant. We might need additional testing to confirm or refute the results. And then we have to also recognize that some of this testing may not be covered by health insurance. Or it might be so it's really great to kind of go to a genetic health professional like a genetic counselor, geneticist, et cetera. One of the other things is that, you know, with genetic testing and adoptees is it can bring up a lot of loss, it can bring up frustration grief about not having that biological link. So that's another the psychosocial element that's really important to consider when adoptees or people without family health history come to see you with these results. Any other kind of comments that you might want to be considering? I want I have something to think about. My name is Rachel Mills. I'm a genetic counselor and assistant professor with the UNC Greensboro genetic counseling training program. And I teach my students about direct to consumer genetic testing. And during that class, one of the counseling strategies that we talk about is the importance of not dismissing patients whenever they present with DTC results as health care professionals, you know, we know that the DTC BRCA results are usually limited to just a handful of variants and they're not clinically valid. So it might be, you know, we might feel like we just want to be dismissive and like, oh, you don't need to worry about that. It's just direct to consumer testing. But you don't ever want to be dismissive in that way, especially as this case includes for adopted patients. They may have no other way to know about their family history. So it's really important to approach these cases with empathy and openness and follow, you know, the first recommendation that he won provided here of figuring out the reason for pursuing testing and making sure that you're being responsive to that. Absolutely. Thank you, Rachel. I would like to add this is for you at UBA. You know, I I agree with both of those excellent points is that, you know, because because this person is concerned about their risk for breast cancer and we know that there are many other genetic changes in our information that can cause breast cancer in addition to BRCA 1 and 2. So discussing this person's concern with a genetic counselor directly would be useful so that they could potentially pursue clinical genetic testing. Now, from a clinical geneticist's perspective, being adopted is not necessarily an indication to see a clinical geneticist, but they could definitely benefit from talking to a genetic counselor and seeing what their options are so that they do get comprehensive testing and not just a snapshot that might give them incomplete information. That's an excellent point.  We often want to do a broader panel just because we don't have that bio advantage. We don't know the biological family health history. So excellent points. Thank you so much for that discussion. We'll be going on to our next case, please. Next slide, please. All right. So this is Harie Yubi again. So we have a 50 year old man using the pronouns he and admitted to the hospital for acute exacerbation of heart failure. He has limited family history and no other chronic artery disease and that risk factors you perform an EKG and echocardiogram. And there is a pseudo infarction pattern and there is a preserved systolic function with left ventricular hypertrophy. The patient's daughter mentions that he had dark consumer genetic testing showing that he has a genetic condition that could damage his heart. His report says that he has hereditary amyrolydosis to TTR related with two variants detected. So in this scenario, we have a patient in the hospital with dark consumer genetic test results that are potentially related to his presentation. Millions of people have have undergone genetic testing and there are 30 plus million individuals who get hospitalized every year. Invariably, if you ask a hospitalized patient, they might have had dark consumer genetic testing. Most of the time, the results may not be related to the reason for hospitalization and they may not be relevant to the hospitalization. There is the, you know, the acuity of being hospitalized limits the health care professionals time and ability to ask about dark consumer genetic test results like here in this circumstance, I want to show that typically the results might be shared by the patient or their family member and you do not want to disregard them. Not all hospitals have direct access to geneticists or genetic counselors to discuss this with and to confirm the clinical genetic testing. So what I would do and I was a hospitalist in the previous lifetime, I would look up the dark consumer genetic test report, see where it was performed, was it performed at a clear certified lab? Is this a report that I can trust? And if it is, I'm going to look up this information and see if this is relevant or not. And it turns out that this could be that hereditary amyloidosis could present as heart failure without other coronary artery diseases factor in younger individuals. And at that point, I would see that the way to evaluate this would be ordinary cardiac MRI, which confirms the suspicion for amyloidosis. And there are other clinical testing that could be pursued. Next slide. So for an individual who is presenting with a positive or a variant detected for a dark consumer genetic test result that is associated with a genetic health condition, you would want to evaluate the patient for those signs and symptoms if if they are relevant to what they are presenting with. You would ideally want to order confirmatory clinical genetic testing. That may not be possible acutely during a hospitalization, but that's where after the hospitalization, you would want to refer them out to a clinical geneticist or genetic counseling so that they can proceed with this testing. In the meantime, while hospitalized, you can proceed with other clinical evaluations that are relevant to confirm or refute the result. And another test result that would be of interest and would be of concern and value in somebody who's hospitalized are for macogenomic variants. And that's when Christine Formea from D would take over. But I'll open this to to the general discussion. Any comments from the from our panel members? Doesn't look like it. So let's move on. Christine, would you like to take over next slide? That's great. Thank you so much, Rhea. Wonderful. So we're going to move on into DTC testing for pharmacogenomics results. And I'm Christine Formea. I am a clinical pharmacogenomics pharmacist and associate professor at Intermountain Health Care. And that's located in Salt Lake City, Utah. Wonderful. All right. So a 65 year old man using he him pronouns is admitted for myocardial infarction. The physician plans to discharge him on clopidogrel when reviewing discharge instructions. The patient happens to mention that he had a DTC test that showed that he cannot process certain medications. And his his results show a poor metabolizer for CYP2C19, which is a metabolism enzyme. You verify that this result is cleared by the FDA for clinical use without additional clinical validation. So the care team decides to use tocagrelor, which is not dependent on the CYP2C19 pathway. We think so. What issue should we be thinking about now? Well, some things that come to mind include being very aware that almost all directed consumer testing for pharmacogenomics are not repeat, not cleared by FDA for validation for other than CYP2C19. So in this particular patient vignette, this is OK. This has been we found out that his his test is OK to use for this purpose. However, with other pharmacogenomics results, which will be almost all other result types, the pharmacogenomic results need to be confirmed in a CLIA certified testing environment in a clinical laboratory. And I do recommend reaching out to your pharmacist colleagues for additional help and insights if you bump into questions about using a pharmacogenomics test result. Next slide, please. OK, so what are the steps we should be thinking about when patients present with a directed consumer pharmacogenomics test result? First, we should be thinking about looking into the pharmacogenomic variant specifically and looking at the effect that variant can have in that there's information you can look at using FDA approved drug labeling and also their online dated resources that are available. And we'll we'll talk about a couple of them in the next in the next slide. Not yet, though. And we look for this information where it's available from reliable sources to understand the genetic the pharmacogenetic effect with this medication, the medication in question. Next, we review the pharmacogenomics test result to determine the need for additional clinical testing in a clear certified clinical laboratory prior to any medication change. And this is really important because we should not be using in almost all cases, pharmacogenomic test results from directed consumer tests. Now, if this was a pharmacogenomic result that is not FDA cleared for use, we do need to have to order a confirmatory testing be done. Sometimes we're stuck in time sensitive situations where we don't have time to it's going to take us a while to get from confirmatory clinical genetic testing such as situations where patients get hospitalized and we have to make some quick decisions. So I do recommend that you reach out to your clinical pharmacist colleagues for information and consider using an alternative medication that is not related or are impacted by pharmacogenomics or used an adjusted dose that you do have information from the FDA approved drug label until you can get that confirmatory testing. So those are a few things that to consider when stuck in a scenario where there's an acute need to make some decisions. And that's important until you can get those results back from a clear certified laboratory. And as always, third point is to refer any questions to your pharmacists who are they are becoming knowledgeable and many are knowledgeable about applying pharmacogenomics to medications. Next slide, please. Lastly, on this slide, we have listed some resources to help interpret and apply clinical pharmacogenomic test results to your patient care. At the top, there is a list of useful pharmacogenomics variants that are included in FDA approved drug labels and they can be found on the website that is that is listed here. It's a quick reference to understand what biomarkers are matched with drugs. This is helpful. Secondly, there's an evidence based clinical practice guidelines group and that's information. Those guidelines are available through the clinical pharmacogenetics implementation consortium, also known as CPIC. These are great guidelines. I use them all the time, a bookmark, a bookmarked on my computer. Pharmacogenomics test results should always be interpreted in the context of other clinical variables that may influence drug response. It's always important to remember everything else is going on along with the pharmacogenomics test results as well. Please note that CPIC does a great job with these and their purpose in these guidelines is to help clinicians use test results that are currently available. A CPIC does not tell a clinician when to order or not to order a test. So it's when you have a test result available. And finally, the pharmacogenomics knowledge base, also known as FarmGKB, is a searchable database of curated pharmacogenomic information and includes a lot of great information, primary literature, drug labels from around the world and other guidelines besides the CPIC guidelines of the consortia. And it's very helpful and clinicians may search for drugs, genes or other drug gene combinations for additional information. And with that, I will now pass the baton to Rachel. Next slide, please. Thanks so much, Christine. There was actually a question in the Q&A about the pharmacogenetics case. If we can go back to that slide real quick that I wanted to answer before I share my case and get other folks to weigh in on. So Andy Cosgrove asked, does direct to consumer pharmacogenetic testing require counseling before, during or after the results are in? Because it seems like this could be incorporated into the medical record without complicated discussion. And I agree that counseling for pharmacogenetics is not usually as intensive as counseling for other types of genetic tests. But I think that there is benefit to some level of counseling for pharmacogenetic testing, if nothing else to help set expectations. There are some limitations to the clinical utility of pharmacogenetic testing, particularly among non-European or individuals without European ancestry. And so having a discussion upfront about what a pharmacogenetic test result can actually say and how it can actually impact clinical care would be helpful to do during the consent process for pharmacogenetics. So again, not a super labor intensive counseling process, but still helpful to kind of set some groundwork in under understanding expectations for the test. Did anybody else want to weigh in on that question? Absolutely. Yes. This is Harie, a UBA. Thank you for this question. As Christine pointed out, doctor's tumor genetic testing that includes for macogenomic testing may not. Well, one, it you in most situations, you still need to clinically validate the results before you do any any medication change based on that result. So I would not incorporate that into the medical record and perform any medication change before it is actually clinically confirmed through clinical genetic testing, except for one caveat, and that's for CIP to C-19, where it was actually FDA approved for use. And I will ask Christine to comment on that as well. The other aspect of it, it's not just that you need to confirm clinically at a clinical in a clinical lab. The other aspect of it is that for a specific drug, the dark symptom genetic testing variants may not be adequate. They may not be all the variants that we would test for clinically for that medication. So that is why if you're if if you're patient or an individual is is interested in for macogenetic testing or the health care professional is concerned about for macogenomic effects of a certain medication, I would review the FDA labeling and see if there is a specific for macogenetic testing that should be pursued and then clinically ordered that test rather than ordered our consumer genetic testing for the patient. So, Christine, would you like to comment on the CIP to C-19? Nitta is asking, do any DTC companies offer other FDA approved PGX genes other than CIP to C-19? Thank you. Actually, there's not currently it's only the only FDA cleared test is for CIP to C-19 and two drugs, clopidogrel and citaloparam, and that is specifically for 23 and me direct to consumer testing. Everything else needs to be all other results, all other tests should be confirmed through a clear certified clinical laboratory. And this is really important because just as just to highlight some of the things that hurry and Rachel said, absolutely. I mean, we we need to understand the different diversity of genetic variants that could a patient could have. It's especially important in our patients with diverse ancestries and this is there may be some fall some false negatives that are present with our with these test results. So it is if we're going to be managing medications, we really do want as much genetic information pulled into the test and that is useful for managing medications as possible. And it is really difficult because our patients do often go have these direct to consumer testing done. And at that point, it's really difficult because there's no one there to help counsel them for medications. And for this reason, FDA has been very, very vigilant and is really looking out for our consumers in that they do want they do have they do encourage and you want us to be using confirmatory testing to make sure that we are looking at a diversity of genetic variants and applying this in the best possible way to manage medications. And it's really important to also mention to our patients that they should not be using direct to consumer testing or pharmacogenetics results in general to manage their own medications. They need to be talking to their health care providers about this and getting more insight. And I always do recommend talking with pharmacist colleagues to to gain more insights, especially looking into some of these drug gene interactions. Thanks. I'd like to add a comment to if that's possible. This is when I'm just letting you know that we want to emphasize, I think you've heard it ad nauseam, but just to make sure you are not putting any direct to consumer genetic testing results into a patient's medical record unless you have confirmed it. And so it's not just with pharmacogenomic testing. It is with all other tests as well. And so because patients are not aware and if you're not looking at the direct to consumer genetic testing results specifically, as previously mentioned, if your patient doesn't fall within the ancestry group in which the variants apply, then you could be making and also people who come after you who see this result in the medical record could make judgments and medical decisions that is that are based on information that has not been confirmed. Thanks so much for all of the wonderful questions about PGX and we'll certainly take time to answer more at the end if they come up. But we'll go on to the next case. If you'll go to the next slide, please. So for this case, we're going to be talking about third party interpretation of direct to consumer genetic testing results. And before I go over the case, I want to give you a little bit of context of what I mean by third party interpretation in case that's something that you haven't heard of before. So third party interpretation refers to tools that are outside those provided by the direct to consumer genetic testing companies that customers order from. So you can go into your direct to consumer genetic testing company account and download your raw data from that company and then upload that file with your raw data to a separate interpretation tool. Most of these third party tools are online. A lot of them are free or fairly inexpensive, but there are some that has these comparable to the cost of testing originally. These third party interpretation tools gained popularity back around 2008 or so whenever the FDA began restricting the types of results that direct to consumer genetic testing companies could return. And they've just continued to remain popular since they provide that additional information beyond what's returned to the direct to consumer genetic testing company platform. And I'll talk a little bit more about what that means, but wanted to provide that context because in this case, a parent has had direct to consumer genetic ancestry testing for their two year old. He's generally healthy, but he's got some speech delay. So he's seeing a speech therapist. They decide to run those direct to consumer genetic test results through a third party interpretation site and it identified four variants that are all considered pathogenic variants with a variety of conditions, a couple of tumor suppressor genes, Ehlers-Danlos syndrome and gene for cystic fibrosis. So what should we be thinking about in this case? You'll go to the next slide, please. First of all, I'll get on my soapbox here and say, please do not ever order direct to consumer genetic testing for a child. The reason that this is is, first of all, it violates the terms of use agreement for almost all direct to consumer genetic tests. They specifically say that testing is only for individuals 18 and above. And these terms are in place in part to acknowledge a child's right not to know. This concept of a right not to know is an ethical concept that allows individuals to control whether or not they receive genetic information and what type of information they receive. So by testing children for adult onset conditions, it takes away their ability or it violates their option. They're right not to know. I think for us as health care professionals, it's it's easy for us to see how genetic testing information can be really helpful for understanding disease risk and putting early interventions into place. But some patients may prefer not to know their risk, particularly if it's for conditions where there aren't any good treatment options, things like Alzheimer's or Huntington's disease, for example, patients might actually see genetic knowledge to be a burden in cases like this, something that just induces stress and anxiety. It's not actually helpful to them. So anytime we're thinking about genetic testing for a child and treatment or surveillance in childhood is not available, providers and parents should consider this idea of a children's right not to know and potentially postpone testing until the child can decide for themselves when their adults, whether or not they want to have testing. Next slide. Since this case, though, is focused on the direct to consumer third party analysis, I want to talk a little bit about considerations if someone shows up with results from a third party tool analysis. This first point about results being false or uninformative, third party tools are not regulated the way that direct to consumer genetic testing or clinical genetic testing is regulated. So there's no FDA oversight. There's really no oversight from anyone, really. So because of that reason, there's not really any assurances that the results are going to be accurate. For the second point about a positive test may be a false positive. In 2018, Stephanie Tandy Conner and her colleagues from Ambrie published a paper where they conducted genetic testing to confirm results identified by a third party interpretation of direct to consumer genetic testing results. And in that analysis, 40% of variants that were reported in the raw data were actually false positives. So you have a pretty high chance that a result identified by these third party tools might be a false positive. And we've kind of talked about this already, but a negative test can be uninformative because direct to consumer genetic testing companies usually use genotyping tests that only look at a small subset of all of the genetic variants that are available. So a negative result could mean that the patient truly is negative or it could mean that the patient is positive for a genetic variant that was not covered by the test. So it's hard to know exactly what the risk is there. Also, it's important to keep in mind that direct to consumer genetic testing and these third party interpretation reports include a lot of results like pages and pages. A patient will come into your office with like a stack of papers if they print everything out. So it's not really possible for us to discuss or conduct confirmatory testing on every single variant. So it's helpful to kind of engage in some discussion with the patient at the outset to understand what results they're most concerned about. So if we use the case that I presented a second ago, the parental concerns about speech delay, none of the variants that were detected are related to speech concerns. So we could potentially defer any confirmatory testing until the child is older, maybe until they're 18 and can consent themselves. But you might inquire about family history to see if there's any familial risk of a hereditary cancer syndrome, considering some of those variants in tumor suppressor genes. The cystic fibrosis gene, like that's on newborn screening in all states. So you can assume that that is a false positive or double check their newborn screening results just to confirm. So this kind of use of triaging all of these results to address the most significant concerns first can help you address a lot of information in a short time and make sure you're really focusing on the the needs and concerns of the patients. So with that, I'll check in with my other panelists and see if y'all have any other thoughts or comments about this case. Thank you, Rachel. This is Haria EVA. I think this is a great case. We often, you know, this this brings back the the the the question, why did the parent do this third party analysis? Right. What are they concerned about? And it's possible that their main concern is that the their child's delayed speech. And that's where formal evaluation can be perhaps done to evaluate if this significant should we be looking into genetic causes? Are there other features that are concerning other developmental delays, other features such as autism spectrum disorder or something else that might actually warrant clinical genetic evaluation and clinical genetic testing for the child for something that is relevant to what the parent is concerned about. But I completely agree with you for the other variants. It's not uncommon for me to see in clinical genetics, a child, unfortunately, a child who had clinical genetic testing for an adult onset cancer risk because their parent had it and their parent is concerned. So if, for instance, the the the the mother had a BRCA variant, she would ask that her child gets tested for it when the child is only five or six.  But in in in certain situations when the cancer onset is in adulthood, where the oldest screening recommendations are begin during adulthood, you really want to give that child the option to decide for themselves if they want to get genetic testing or not. So thank you so much for bringing up this important ethical issue. Of course. Any other thoughts or comments? All right. Well, I'll pass it on. Next slide, please. So key takeaways. And I want to thank everybody who's been putting questions in the Q and A's. We will make sure to address the ones that weren't addressed already. I I want to start with answering one question that dark consumer genetic testing while there is a fine print when you for consent, right, with everything that you sign up for online, if you want to sign up to the for. Anything you're going to have a long list of the disclosures and agreements and do the patients go through that? I know that I wouldn't. I just came through things and signed at the end. So although informed consent is supposedly in there for dark consumer genetic testing, it's not true informed consent. They are not really going understanding what are the benefits and risks of obtaining this type of testing. That being said, if your patient comes in with dark consumer genetic test results, start with the first start the conversation. Why did they pursue genetic this type of testing? What are their concerns? Once they once you look at those results, determine was this actually a report generated from the dark consumer genetic testing company? Is this company? Does this company have a clear certified laboratory or was this a third party analysis report? Remember that the third party analysis report may be false and the ones that you really want to focus on are those that are directly attained for the dark consumer genetic testing company. Then look at those results. What is clinically significant? Do I need additional medical information, additional medication history, family history? And is there clinical genetic testing that could be ordered to confirm those results? Remember that the for for a positive result, if there is something that could be confirmed clinically, that's that's the right you want to take. And you want to discuss that with your patient. And if a patient is reassured that their dark consumer genetic test results are negative, that is where you want to remind them that this is not comprehensive testing. And this is for you to to recognize that this is not comprehensive testing. And that's where you go back to your clinical evaluation and deciding does this patient need additional clinical evaluation, maybe genetic counseling referral or clinical geneticist referral for proper clinical genetic testing? Or do I need to talk to the clinical pharmacist about from our progenomic testing for this patient? Next slide, please. If the patient is hospitalized and it's a time sensitive situation, clinical genetic testing, confirmatory clinical genetic testing is not feasible or readily available. You want to evaluate for the genetic condition and you would want to research any pharmacogenomic result to determine if you need to adjust medication dosing. Remember that there are always ethical issues when it comes to genetic testing, especially in minors. And clinical, so dark consumer genetic testing is not covered by insurance, right? And any clinical genetic testing may or may not be covered by insurance depending on the clinical indication. So having a dark consumer genetic test result is not necessarily a reimbursable clinical indication for clinical genetic testing. But if the patient does have a significant personal family medical history, then that would be reimbursable in most situations. Next slide, please. I want to remind you all that we are we're going to be answering your questions. So please feel free to put them in the Q&A. This is how you could find a genetics professional. You could go to the National Society of Genetic Counselors website. We've had fantastic genetic professionals, genetic counselors with us on this panel today. Even as a clinical geneticist, I use their expertise about genetic counseling issues. So please reach out to a genetic counselor if you have questions or concerns. And if you need a clinical geneticist to evaluate for a clinical genetic condition, reach out through the American College of Medical Genetics and Genomics. And for macrogenomic results, I strongly encourage you to talk to your clinical pharmacist about any FDA recommendation in terms of... FDA labeling in terms of for macrogenetic testing for a specific medication. Next slide. As a reminder, we have a dark consumer genetic test frequently asked questions, resource for healthcare professionals that's on genome.gov. And you can reach that through the QR code. Many of the discussion points that we highlighted today are actually in that FAQ. And it was created by members of the IACC PEG, DTCGT Project Group, any of them are presenting today. And if your patients have questions about dark consumer genetic testing, you can provide them with information from Medline Plus that uses less medical jargon and is more patient-friendly. Next slide, please. We'll go through your questions in the Q&A. And next slide. And I would like to leave this slide up with the QR code to evaluate our webinar. So please feel free to do that anytime. We look forward to your feedback. So the first question that we got, do all states require informed consent? And for clinical genetic testing, as far as I know, informed consent is required. And I'll ask our genetic counselors to chime in. Hi, Huria. This is Wynn. And so I would like to talk about it from a clinician standpoint in terms of being a clinician who's worked in all different fields of medicine. I worked in cardiology, nephrology, environmental medicine at the VA, and now in genetics. And I don't know that there's a specific requirement by states in terms of informed consent. However, from a clinician standpoint, ethically, you would not order a test without obtaining informed consent and without discussing it with your patient first, no matter what field of medicine that you're in because you would want to be discussing the results. And one of the things that were taught in school is that you never order a test that you don't know how to deal with the results. And so in the same way, you would need to prepare your patients when you're ordering tests of any kind. And especially when it comes to genetic testing, you wanna be thinking about all the different people that are affected because genetic testing doesn't just affect the patient, it affects their family members, generations before and after and within their own family. So I don't know specifically in terms of legal, there's not a lot of, I think specific regulations about it, but from an ethical standpoint, just to reiterate, all clinicians would obtain informed consent. Hopefully that answers your questions. Absolutely, and in their position statement, the American College of Medical Genetics and Genomics stresses that consumers should be fully informed regarding what the test can and cannot say about his or her health or their health. And so we have, we just don't have, we have a lot of laws about DNA privacy, but not specifically about informed consent for genetic testing. Go ahead. Sorry, and I was gonna say in all research studies, informed consent is required, but from a clinical standpoint, I don't know that it's mandated, but definitely recommended. Right, I was gonna chime into, this is humanly informed consent as a part of our job as a genetic counselor, with every patient and with every test. Just as far as legal and mandates, again, different states have different requirements, especially for even third party, some require more than others. So it's not a blanket policy that all states have to do X, Y, Z. So there are different sites. I was looking at some governments and CGC and some of them are a little bit out of date, but it seems like there's 10 to 24 states requiring different levels of consent from third party, but absolutely from what Wyn said and from the rest of us from clinical perspective, we always have to go through an informed consent and that's just part of our ethical, moral and legal, I would say as well, process to make sure that our patients are well informed and have an idea as well as the clinicians themselves. Thanks. So the next question that I'd like to pause to our audience, R of U.S. is regularly reported in dark consumer genetic testing. And as far as I know, variants of uncertain significance are not reported in dark consumer genetic test results. The reports depend on the company that is releasing it. Typically they either say variant detected or variant not detected or result positive, result negative. They do not typically report out variants of uncertain significance. And for our other audience members who may not be familiar with this term, variants of uncertain significance is that when there is a variation in the sequence of a gene of a specific genetic instruction, but we don't know if this variation is just normal variation in the population that is not related to any genetic condition or clinical condition as far as we know, or it may be related to a genetic condition but we just don't have enough information about it. And when we order clinical genetic testing, we can get three types of results. In a clinical genetic test, we can get a positive result, a variant detected that is associated with a disease. This is called a pathogenic variant. And with variations of it, likely pathogenic, we could get a negative result or no variants detected. And we could get a variant of uncertain significance, which means that there is variation in the sequence but we don't know what it means in 2022. And we would want to reevaluate those results in the future in a year or two to see if there is updated information about that variant. Any other comments from the panel about variants of uncertain significance in dark somogenetic testing? Have you encountered any dark somogenic testing results that report out variants of uncertain significance? I have not and I wanted to share like kind of a different way to look at it. Most direct to consumer genetic testing use a technology where they know what they're looking for. So they have a predetermined list of variants that they are searching your genome for. And so it's a checklist of like, yes, they have this variant, no, they don't have this variant.  I did, I do think that this is relevant to the other question about full genome sequencing being available direct to consumer for around $100. And I certainly have mixed feelings about it. You know, and on one hand, I think that it could continue to promote awareness of genetics and get testing into the hands of consumers more readily and more easily since it is challenging to get a referral to genetics or genetic counseling because of the number of practitioners in the U.S. My concern would be the question of what they're returning and how they're gonna return it. The large cost for genome sequencing actually has, my understanding has less to do with the actual technology of the sequencing and more to do with the amount of time and effort that it takes to interpret those results. So my concern would be if they are just giving you raw data and then expect you to run it through a third party interpretation tool, use another resource that costs extra money. So I would be looking really closely at the fine print of what you're actually going to get for $100 and how you can use that information. There's also a question of, is it truly full genome sequencing where you're getting things like variants of uncertain significance or are they using sequencing technology to still return a checklist of findings similar to genotyping? So I am interested to see, I've also heard that this is on the horizon and I'm interested to see what it looks like. But those are some of the questions that I would be asking before I dive in and start using that test. Does anybody else have thoughts about that question about the whole genome sequencing for 100 direct-to-consumer? That is a great question. Clinically, I have not had the opportunity to actually order full genome sequencing for my patients. One, because one, it's still very expensive and two, the interpretation is, we don't understand everything about our genome just yet. So in many circumstances when we are doing whole genome sequencing, it's really done on a research basis and potentially in the future it will become a clinical genetic test but at present time, it is not going to be reimbursed by insurance to order whole genome sequencing. What we do order clinically is something called whole exome sequencing. And what that is is that we are just checking on the sequence of the actual genes that we know of at present time. So the genome is huge and only about less than 3% of it consists of genes that we know of. And of those, these are the ones that we can order clinical genetic testing for and that's called whole exome sequencing. So ordering whole genome sequencing, if it's truly whole genome sequencing on your own, it is worrisome to me because we don't know how to interpret that outside of the research setting at present time. And that information, how we interpret that's going to change dramatically as we learn more and more about our genetic information. So many of the companies that say they are doing whole genome sequencing are in fact just performing genotyping which is what Rachel Mills talked about just kind of seeing if somebody has a variant or not. Another issue with genome sequencing if it is truly genome sequencing is the technology that is used. What is the depth of coverage? So in clinical testing, we need to make sure that every sequence is covered so many times, right? We want to make sure that we truly, that if there's a change that we saw it see it consistently throughout and the depth of coverage is valuable. And when I've looked at into some of those dark genetic testing companies that offer whole genome sequencing looks like the depth of coverage is not adequate. Then again, when you get a report you get lots and lots and lots of pages of information that is not, it is not the same quality as the clinical report. It does not report things out as you would get from a clinical report. So I would not encourage my patients at present time to pursue dark consumer genomic testing, whole genome sequencing. I don't know if the other panel members have a different take on it but that's my personal opinion. I just want to acknowledge that we are at time and we do have a couple of more questions in the chat. I think for the purposes of the event we need to wrap things up but if folks want to hang on so that we can respond to those questions via the chat we would be happy to do that and appreciate everyone being here today and asking such great questions and being engaged. Donna, would you like to close us out? Sure. Again, just to repeat your comments. Thank you so much everyone for coming and we do plan to post different aspects of the webinar on our website and please check back to see additional resources and do consider checking out our events page for additional events during the whole week and follow the hashtag MedGNED22 on Twitter. Thank you so much everyone and thank you so much to our panelists who provided excellent cases and responses to questions and overviews. Thank you to all.


And like duo together For cool Valentine Cousins go to r slash Valorant 34 r slash Valorant 34 nah, I'm kidding you guys thought I was gonna do it I Don't like that they could have crossed a short though. I'm kind of gambling that they did Graham was really cool. I'm gonna play like really aggressive here There's two here and then fate was long to they're hitting C pretty hard.  I could I can try to grab spike No, just wait 10 seconds No, it's fine. I'm gonna get the spike. I'm gonna TP back to be they have a lot of old by the way Nice guys, I'm holding elbow if you want to hold side side. I'm holding up. Oh, so one one's it now But here I just saw I'm gonna flash this out of the smoke. I'm gonna flash out of the smoke He was up a side. I'm gonna stick. I'm gonna stick he was ever said There's two pushing out two pushing out one one two lower two lower like in the flower spot. Nice two here, too I know we're five second here, but my clone is the garage player. I'm gonna flash back side and flash him back side Two be two two be two. Let's go. Let's go. Let's go. Take site. Take site. Take site Hey, I got my three like sure you can do with the door there for sure What's up mid still I'm gonna flash Oh my god that flash was so sexy Slipper was mid two right? Wait right now. Yeah, yeah. Oh she's dinked. She's dinked He's fine. He's fine. He's fine. Left side of six Coming out here one's three side He's left side, I think I think she's pushing top mid I know Cutting through he's close. He's close. He's close. He's close lower lower lower lower lower Back up back up back up back up. He has no idea. He has no you're here


Well, BSU men's hockey fans of 2017 and 18 regular season is set in stone on paper. This afternoon the Beavers unveiled their schedule for the upcoming year. A 36 game slate features the season opener with a home and a way with frozen four participant Minnesota Duluth, October 13th and 14th. Coach Sera Torres reunion against his son Matt and Air Force on October 20th. The conference home opener October 27th with Ferris State and also a home and a way series January 12th and 13th with North Dakota. If you've enjoyed this segment of Lakeland news, please consider making a tax deductible contribution to Lakeland Public Television.


Our first time was the biggest thing in the world for us like it was this moment of our lives much less winning three times and Coming from such like a small community and such a small school Like you never thought that you would have this many talented girls to accomplish something like that And it just means so much. It means the world to me I can't believe that I won one time more than less three times And it means so much more doing it with the group of girls that we did because they're like my best friends and It means a lot to me that they're part of this too


This is Witch Based News for Friday the 4th of March 2022, I'm CMDR Buur In Elite Dangerous News this week, the Thargoids continue their assault in the bubble, there's unique rewards in the Colonia Bridge finale CG, our thoughts on the future of Elite following the Frontier community meet and the latest Frontier development news and what to expect from Carrier Interiors and Update 11 which is arriving early next week. To make sure you don't miss any of our videos hit like and subscribe and remember to click the little bell icon and select all notifications and if you'd like to help directly support this channel you can also join our Patreon via the link in the video description. The regular Thargsday server tick this week saw the resumption of Thargoid attacks inside the bubble, currently there are two systems under Thargoid incursion in the bubble and one station on fire and in need of evacuation with a further two systems under incursion in the Witch Head sector. Check your Galnet newsfeed in ship for information on what targets to head to and to get involved with the communities that deal specifically in anti-Xeno operations, station repairs and station evacuations you'll find links in the video description. It's too early currently to determine any pattern to the Thargoid bubble incursions if indeed there is one but we'll be watching closely to see if the intergalactic monster marigolds get any closer to Sol. With the Thargsday tick they're also arrived at the final part of the Brewer Corporations Colonial Bridge Community goal this week and being the finale it comes bundled with multiple special rewards. The top 75% of participants in the goal this week will each receive a unique single engineered overcharged 3A power plant. This power plant is engineered to such a degree that it's not possible via any means in game to replicate the engineering that's being applied to it even with experimental effects. The top 75% will also receive what Frontier are calling emissive exploration decals in red, white and blue. And there are Brewer Corporation themed decals in bronze, silver and gold for higher tiers of participation for this week's commanders. And further to all of that Frontier announced that anyone who has participated in any part of the Colonial Bridge Community Goals up to this point will receive a special commemorative decal with which to adorn their ships. As of this recording the community goal is proceeding at quite a dramatic pace and it's highly likely that it will not last the weekend so if you're going to jump in don't wait. As we reported last week, last Friday Frontier hosted the Elite Dangerous Community Meet and Greet event in Cambridge which saw around 100 commanders, us included, meeting up with the Frontier Community Management team as well as a cluster of the game's developers. We talked about the event and what went down on our regular Monday livestream this week, the specific point in that livestream you'll find linked below, but in summary, whilst no one from Frontier was able to speak about anything specific happening behind the scenes right now, after chatting with Arthur Tolme, Dav Stott and Derin Halil, we left the event much more confident about the future of Frontier and Elite Dangerous than we went in. Elsewhere in Frontier News this week, David Braben was quoted in a Financial Times article lamenting the current vogue for game development and publishing houses to be swallowed up in large acquisition deals, saying that allowing Frontier to go that way wouldn't make sense at the moment and adding that the shares held by both himself and his wife act as a natural barrier to such actions. Another positive move this week saw Fdev appointing a new non-executive director to its bald with the arrival of Ilsa Howling. Non-executive directors don't get involved in the day to day running of a company but instead act almost as a consultant providing impartial criticism and guidance contributing more to an overall strategy for a company. And it's worth noting that Ilsa's background comes from time spent as the head of digital marketing and communication at the BBC and she led the free view terrestrial digital television platform in the UK as the managing director. Ilsa is bringing some strong consumer facing experience with her according to the stock market announcement which is encouraging to hear. So given her background in TV, J. Michael Strasinski penned Elite Dangerous Netflix series When, asking for a friend. Alongside this Frontier still has a recruitment call out for a senior game designer to work on Elite Dangerous. The job posting states quote the role will involve designing, planning and ensuring the smooth delivery of events and content that can help bring the story arcs of Elite Dangerous to life for our players. Learning how to make a story well told using in game events will push for high quality content that matches short term goals and aligns with the long term vision for both the game and the universe of Elite. It's clear from that statement alone that as far as Frontier is concerned Elite Dangerous is not going away anytime soon and they clearly have plans for more story going forward and to use their words quote a long term vision for both the game and the universe of Elite. Whatever the reason for F. Devs continued mostly silent approach to all things Elite Dangerous currently it's worth noting that at the start of every week Frontier produces a weekly schedule publicising their live streams. They stream a different game from their stable every afternoon except Thursday the slot that is traditionally taken up by Elite Dangerous. That slot is still left blank in the schedule we assume waiting for Elite Dangerous to have its ducks lined up and ready to return. One further point of note it's possible that the continued silence from Elite Dangerous is linked to the release of the company's financial results to the stock market. If that's the case and it's a big if then we'd anticipate that they may be looking to return to the megaphone proper around mid April 6 weeks prior to the end of year results being published to the stock market. That being a fairly standard lead time to prep those results for publication. Frontier announced this week that the much anticipated update 11 is currently scheduled to arrive in the game next week on Tuesday the 8th of March. As Frontier are continuing their policy of mostly not talking about Elite Dangerous we know next to nothing about the patch or what versions of the game it will or won't be touching. It was the plan before Christmas to include fleet carrier interiors for Elite Dangerous Odyssey in patch 11 and community manager Bruce Guerrido did note this week on the forums that he was looking forward to seeing carrier jumps from inside the carrier so we can deduce from that at least that the long awaited fleet carrier interiors do seem to be part of update 11 still but we assume until the patch notes arrive on patch day Frontier aren't saying anything else. At the beginning of February we highlighted in a dedicated video what to expect from fleet carrier interiors but in case you missed it here's a rundown of what we expect to see introduced to Elite Dangerous Odyssey next week. Carrier owners will have the opportunity to host a pioneer supplies franchise on their fleet carrier. This carrier specific version of the galaxy's favourite arms dealer will be guaranteed to supply at least one of everything they're capable of selling with the carrier owner having the option to disable the selling of restricted items like e-breaches. A Vista Genomics outlet is further being made an option for carrier owners it's thought that this outlet will operate in exactly the same way as the Starport and Station version of the Interstellar Fungus Obsessed Science Shop and the shipyard module will be an interior version of whatever exterior shipyard services the carrier offers but it's the bar area that perhaps holds one of the more radical and intriguing additions to carrier functionality. The barkeeper will act as a host for some form of player to player Odyssey on foot material trading. Exactly how this system will work or what specific materials will be tradable is a complete unknown at the moment as Frontier aren't yet saying. However it certainly has the potential at least to make the engineering of Odyssey's suits and weapons more accessible to more people. Carrier owners and their teammates will have exclusive access to the bridge and ready room lounge overlooking the huge panoramic windows that look out over the carrier landing pads and the jump sequence will be fully viewable from inside the carrier. Carrier interiors will also feature your own NPC crew members and we believe functional seating will now operate onboard the carriers both away from and during a jump. Further, the carrier interior space and lighting can be themed in some regard by the owner we're assuming this customisation will be an ARC's purchasable feature but again it's not been specifically stated either way. Now all the new features are added to existing carriers remains a mystery currently if they are required to visit a dry dock system as is the case with external upgrades to services then adding something like a Vista Genomics for example will prove extremely problematic at the very least for those carriers at permanent anchorage in the deep black. Exactly the same carriers that would make best use of a feature like Vista Genomics in fact. After things turn out we don't have long to wait as of this recording we have just three full days before carrier interiors are due to arrive. How are you feeling about the future of both the game and Frontier at the moment? Are you planning on pitching into this week's community goals? Are you helping clear out the Thargoids from the bubble? Let us know in the comments below. That's it for now, thanks very much for watching, we'll be back later this week with more videos, until then 07 commanders follow the greens on the way out and do keep clear of the toast rack, we very much look forward to seeing you next time.


Chris and Tammy live from the collard, Valley Cook kitchen. You haven't seen me in a while. I burnt my finger and it's been really bothering me but we are in here tonight and I got me some rubber gloves so when I'm washing the dishes it's going to help me. So be careful with your grease because I burnt my finger frying chicken. All right we're going to get started making my mama's Saturday waffles. It says mama's Saturday waffles. Mama would make these sometimes should pull out this old thick green cookbook and make them. This is in my third cookbook and I remember how excited we get should beat up those egg whites and fold them in there, make these light beautiful delicious waffles and that's what we're going to do tonight. We're going to be using our white lily flour to make our waffles and you do use all purpose. I hardly ever use my all purpose so I'm going to open a new bag and put it in here and we're going to use a new bag of white lily all purpose flour tonight to mix up our waffles. And everybody always asks about these. These are these are containers that we have on the website and then the stickers on them came from white lily. Everybody asks where can I get these containers.   You can go through amazon through one of our links but the the white lily on both of these items are actually stickers from their website. If you go to their store and click on sticker set they're only four dollars for a set. All right so we're going to get this in the trash and this is 2022 in case you watch this years later. All right so we're going to drop some swaggery sausage in our frying pan so tonight we're having the best of both worlds sausage and waffle. So this is just swaggery sausage you can find it at Walmart. Yum yum it's our favorite and so I got that on a medium heat and we're going to start getting these waffles ready. Now the first thing you do I didn't melt that yet is you melt a half stick of butter in your bowl that you're going to mix your waffles up in you. And so we've already got this waffle iron it's an old-fashioned round waffle iron it's hot and steaming so it's preheated so go ahead and preheat it. I like my waffles dark and crunchy so I got it on five. You can also get these through our website they're the old-fashioned just an old simple quesnaart I do not I'm so funny but that's not quite melted but I don't like what they call those deep waffles. Oh the Belgian waffles? Yes I'm not crazy about those and that's because I don't like real deep pockets in my waffles because to me it makes the waffles soggy when you put your syrup on there. So I'm a real fan of old-fashioned this thinner waffle type. Okay I guess because it's what I grew up on I don't really know for sure but we're going to go ahead in this and we're going to start mixing up our waffles. First thing we're going to do is separate three eggs you can come on over here Chris. So we're going to separate eggs because you're actually going to beat egg whites and that takes a few minutes so it takes at least three minutes to beat the egg whites. So be patient with that today since we're live I could have beat them up before I came on but then it wouldn't have been like mama was really making them with it. Lord I didn't get a good side to get that. You put the whites in the yellow. I did didn't I honey. Well I can take them back out. Okay it's what I do when I talk I just don't even pay attention to what I'm doing. It's what happens when you get to be any 50s young ladies. Okay if you're wondering. All right there's one yellow, two yellows and three yellows. Good. Look at there. Well there's a wheel there's a way. Right daddy? I guess. You reckon? I reckon so. All right let's mix up these waffles.  Let me turn these down on low. So we're gonna add our egg yolks. Let me get me a whisk. We'll put those in our butter. Our buttermilk is two cups. So we got two cups of buttermilk and everybody's always asking me about their buttermilk and I use mine past the expiration but of course I can't tell you you can because then what what if something happens but I'm gonna tell you I always do. Mama always said I use it until I get done with it. Now if you don't use buttermilk that often you don't need to wait forever but mine's actually a little past the expiration date now. And if you want to know a guide I would say two weeks. How's that? That's not I would go longer personally but I can't tell you to go longer than that. All right so now we're going to put in two cups of flour, uh, baking powder, baking soda. Let's put in our vanilla first. Now Cathy Williams from Alabama made me some vanilla y'all and I ain't even opened it and showed it on the show yet so I want to say special thanks to Cathy Williams and tonight your vanilla's going in my mama's.  Well that means you got to measure it. You're gonna have to measure it for once. No actually that was just a little thing in the thing. Oh I don't mean nothing. Okay I'm gonna measure I'm just gonna pour it in here. There you go. Mmm smells so good Cathy. Okay so there's our buttermilk, our eggs, and our butter and our vanilla and now we're going to put in our flour and we're going to use two cups of this wonderful all-purpose flour. There's one. I gotta give me a full work. I can't do this now with this or I'm gonna make a mess. Or I'm wild in the kitchen ain't I baby. Two cups. Let me flip this right here right quick. Y'all come on here we'll flip the sausage. Pretty sausage. Smells good don't it? Wish y'all could eat with us. This is such a simple supper. I remember being a kid we get so excited when mama pulled out the waffle iron. Did your mama make them like this Chris? No. No? Nope. Oh my mama did. We got excited when mama pulled out the egg-o's. All right so we're mixing that up so there's our flour in there and now we're going to beat up an egg and fold it in there and that's going to be our waffle. Y'all we got to add just a little bit of sugar to it. Did you add your bacon soda and baking powder? No. Salt and all that? No. I got the exact same thing on my baby. Okay salt. Two tablespoons of sugar. I'm just gonna throw some sugar in here ready? Yep. There you go. Sugar. A teaspoon of bacon soda. No course. I'm looking for a teaspoon. A teaspoon of bacon soda. There you go. And how much salt? A half a teaspoon of salt. There you go. And teaspoons of bacon powder. This is brand new bacon powder. I just opened it tonight y'all. Brand new. Clever girl. Bacon powder. All right so let's mix it up good and now all we have to do is fold in the egg whites and drop a waffle. That looks good. Looks like cake battered on there. It's pretty much what it is. Yeah. For real. For real. Pretty much what it is. All right so there you have it. Now we're going to beat up our egg whites. We're going to put them in this four cup measuring cup so that they eat a little quicker because they'll be in a taller area and it's probably going to still take at least, it usually takes three minutes so we'll see how long it takes for this. All ready. For your waffles to be fluffy and light that's the biggest difference in waffle mix and pancake mix is using the egg whites and folding them in. Last measuring cup to do egg whites in. I think it worked good. I'm going to flip this up and then we're going to drop a waffle simple dinner. We haven't had waffles in forever have we? No. We haven't had them since those years. I don't think we have. About time I got out the waffle iron magnet. Yeah. Coffee y'all. Some whole city right here because we're going to pour some kind of coffee. Now I got some pancake syrup at Sam's Club and it's called Pearl Milling Company. Now I did not get real. What do you call it? Syrup. Yes. Maple syrup. Maple syrup. We don't use maple syrup. We just use this bad for you kind. The kind we grew up eating down here in the south. We didn't have the maple trees like I did with the maple syrup up there in the upper states. We used to have some dairy farmers actually that used to live down here in Georgia. I'll tell them the story right quick while I'm finishing up my sausage. There was some dairy farmers that we knew that were from up north and they lived in the states here in Georgia where they lived in Georgia. Okay. And they moved back up there. They had maple syrup and daddy would get some maple syrup from them ever once in a while. He would do that. Daddy liked it. Daddy liked real maple syrup. Okay. I'm going to open this up. Oh wait. Let's fold these in first. We don't want to cool it down. And then we are going to drop one. Okay.  And my hometown this week is the Fair. I remember when I was young we'd go to the fair.  And tonight's the cattle show. And daddy will probably go to the cattle show tonight. There at the fair. It says place a half cup of batter in your waffle iron and make it as dark as you want it. So we're going to get out a half cup spoon. And that's what we're going to use in our waffle iron. Okay. Now if you use too much of course it runs out the side. So let me scoot over just in case. And we're going to pick up a half cup this beautiful batter. See how light and fluffy it looks. And we're going to place it right in here. Y'all I didn't spray it. It's not supposed to stick to this thing. But I think I typically spray it anyway. But it's too late now. Let's close it. Too late now. You're gonna power plate right here. Now the way it works as you can see that the light is red boy it smells so good. The light is red and when it turns green you can get it out. And I've got it on the darkest setting. I swear I like it. I like them dark and crudgy. You like them Chris? Dark and crunchy. Dark and crunchy. I'm always trying to pick up as I go. Made waffles and actually beat egg whites and put it in the batter. I want to know how many mamas cook that way. Or did she just mix up pancake mix out of a box? Y'all let me know because I'm going to tell you if you've never had a fresh waffle like this y'all grab my third cookbook and try it. It's good. It's great. It's great. Here we go. It's great. Nobody think. Perfect. There it is. Now if you want to make a lot of them and you don't want them to get soggy you can take them and you can cook them and you can keep them hot in the oven or you can put them in your air fryer and crunch them up some. So I'm going to show you. I'm going to put a little butter on this and I'm going to give it a try and we're going to pour us. Swaggeries actually sent me this beautiful coffee cup. Ain't it pretty? And so I'm going to pour me some coffee in it. I already got sugar in there. Pull my seat back. Have me a swaggery sausage. A white lily waffle. Can't get any better than that can you Chris? Nope. So we're going to put a little butter on it. Get us a piece of sausage out. And you can also actually and I've done this before. I've cooked them on light and then turned around and put them back in there and cooked them again. It's just toward how crunchy you want it. Seriously. Let's put some syrup on it. Now I'm not a big big syrup fan. That's plenty for me. And I didn't drop Chris's because waffles are best fresh. Aren't they Chris? Yep. More video. We want to show y'all. Let's beat the waffle house now. If you like waffles this is your waffle. Yummy. Just like mama made. Tim is going to be ready to watch cartoons now after she eats this waffle. Oh that's so good. That is so good y'all. Yummy. Just like being a kid all over again.  Yummy. Whoo. What a supper. Y'all have a wonderful and blessed evening. And we thank you so much for watching Collard Valley Cooks where we cook like our mama's did. Remember this one's in our third cookbook. Y'all come back and see us and tell me if your mama made them just like this. Love you. Bye.


Sam, dyna'r gweithio. Can you give us an update on the squad in particular, Shamus Coleman, how close is he? Shamus is a considerable away-away at the moment obviously because of his long-standing injury. He's been introduced back to training with the First Team squad on a regular basis and we monitor that training on a daily basis to see how not just the injury part wydd i ddech chi'n gwybod gyda'r unrhycri, ond mae'n gweld yn cael ei bod yn cerddurod okol. Felly mae'n gweithio ddiddordeb o'ch привyd, ac mae'n bydd yn bwysigiofa ffasgfodol i'w chyfgrifio ar eich gweithio yw'r peth. Oherwydd mae'n gweithiol i'r cyfr Bunai pan yn ymddangos, rhai'r cyfrifio, gan gydigio'r gyfeirioneddau', gyda ni'n rheinydedd ar y gweithiol. Felly, rydw i mi i ddarparu uchydig Nadwgol yn ychydigorio a i mi i ddweud hynny ond a i hynny, dystod. Rydw i dda nhw rwy'n wedi gweithio'r hyn oes Rydw i ddweud ychydigol mwy gydag wrth eich rai i chi ddiwyddillysgol gynyddoedd mor hynny, dyna ym hynny'n bod yn ddod. Ond yn hayf am rheiniu o'r g seminoedd a'r gwybod, fel yna gweithio yn teimlo, ond iawn o'u bod yn y gymhau cyntaf o ddweudr y pwyllfa'n cyfrifiad yn cael i'r golygu. Wrth myfnwyd, mae'n mod i'r ffordd yw'r sefydling. Are any other updates, Michael Keanau? Michael's not back, Michael's the Stend Day nasty gasch on the top of his foot, which reopened an old one that had occurred before. Unfortunately for him and also in exactly the same place as the old one, and also it's taken a little bit longer and a little bit more cautious in the healing process. mae'n meddwl i ein wybl er mwyn. Fi'n meddwl mwych ar siis Faswr, mae'n meddwl i'r sefydlieth? Mae'n meddwl i amddangos i'r awdurd. Mae'n meddwl i'n meddwl i'r sefydliadau. Felly mae'n meddwl i'n meddwl i'n meddwl og ydy hynny a nedol i'r bydd ac yn i'r dron. Felly yn ei geffin i'r dweud beth yna, rydyn nhw'n meddwl i gweithio ffaswr. Ac oeddennydiol gwybod hynny ddim uchosol yn gennym i gweithio a gweithio yw beth sy'n bod y nifer i gynigol o'r llyfe a that dyna y gallu'n ddim uchosol o'r gwybddau ond mae'n hyn yn gyffredin iawn, ac yn byw'r llyfe cymdeithio o'r mosfaro wahanol i gael o'r gweithio o'r gweithio. Rydy y gallai gallu gweithio eich ei wneud gwahol chi'n sicrhau mae'n gweithio? No doubt about that. The service provided in the final third is one of our weaknesses, which is why we're not scoring enough goals or we don't have enough natural goalscores in the squad at the moment. So we have to try and improve on that without losing our defensive qualities. Are you looking to try and bring in any more attacking players in general? Well, I think you're all aware of our interest in Theo, but if that's possible to get over the line, I'd be delighted, but obviously there's negotiations that are happening at the moment. And if that can be all sorted out, which is one of the most difficult things to do today, then that would be a great addition, in my opinion, to come and join us from the attacking points. Two or three reasons, really, goalscoring, threat, pace, experience, and his good on assists from wide areas in terms of his crossing ability. So I think that if that's at all possible, that would be very nice, but it's not imminent at the moment, but I think some negotiations are going on. Is that for a permanent deal or a loan deal, do you understand? It's permanent, I don't think there's any chance of a loan, so I think it's a permanent deal. We're hoping to negotiate. And how optimistic are you that that can come on? I don't get optimistic, otherwise I get disappointed, so we'll wait and see. I'll be very excited and enthused once somebody, if it's not Theo, somebody else has actually signed on the dotted line in this window or in any window now, you don't get too optimistic, so so many things can happen in just a short space of time that you'll never think a player's coming in until somebody tells you he's actually signed on the dotted line. And is he the only target at the moment? At the moment, yeah, because it's called one at a time. But you'd like more? Well, I think that players that have to go out, I think we'd have to move players out. I think there's a big squad and I think that moving players out is essential to bringing more players in. And that's me talking, not the club. I think that's essential that we trim the squad down to bring more players in to adjust the balance of the squad and adjust the numbers. So we would be open, I think, to some negotiations for some of our players if that became a possibility where the club was satisfied with what had been offered by other clubs. And we've had a number of inquiries for some players, but none of those inquiries have hit anything where our valuation might be. And just finally on transfers and on those inquiries, have any players come to you wanting to perhaps go and have an opportunity elsewhere? Well, even if there is, I wouldn't tell you. So I think there are a number of players that were not satisfied about the position that they're in at the moment. I think that's only natural to say that when they're not getting a regular game. Or in fact not sometimes even getting on the substitutes, Ben Snare, which shows you the size of the squad at the minute. So, like I said, we will take a natural process that, while this window is open, if there's offers for players to move out. And you have to get the player to want to agree as well, obviously. It's not a task where we just say, right, you know, you can go, the player has an option to say yes or no, like you mean so. But we will be open to some negotiations on moving players to other clubs. We understand the FA is aware of some historical and allegedly homophobic tweets from Mason Holgate. Is that something you're aware of, and is it something the club has spoken to him about? Well, I think that in terms of awareness, yes. In terms of when it happened years ago. So he's fully aware and didn't need to be reminded of what the situation was. Because they already know the players. Because historically we go through meeting after meeting from all areas through the FA, through the PFA, that all are shown what to do and what not to do. So this is an historical tweet from many, many years ago. So he doesn't need any reminding because he's already, and the players, all the players have already been made aware I would have thought for more than this year. I think it's been going on for years that we've pointed out to players about what they do and what they don't do, and they're fully aware of that. So it's obviously not in my hands whatever the situation is now, but it moves on. We will find out if and when the course of action or what course of action might happen we'll find out. And just finishing up on the game itself, Tottenham and Wembley as well. We've got a question about the game. You might have thrown one or two. The prospect of playing Wembley for both yourself and the players, is it special or is it, how do you try and treat it like a league game? Or do you try and treat it like something different? Because you're playing at the national stadium I think it's special. I think that any opportunity to play there is one that you should really look forward to. There's lots of our players who've played there quite a few times I think. And I think that in its status and in its iconic status I think you should look forward to going to play there. For me Tottenham have overcome their problems they had with that stadium in the early stages of when they played there in the Champions League particularly. And then in the league earlier in the season they've completely overcome those negative vibes that everybody seemed to have about them. And they're a big force there now. So it will be a tough game to play because of the quality of their side. And Wembley you always hope to bring the best out of our players by playing on such an iconic stadium or in such an iconic stadium. Sam, just on Towson, how easy is it to bed in players in January when obviously they've had no pre-season with you? It's not easy at all. It might not work. It might not happen. I mean the factor is it's a massive problem in terms of your hoping really rather than being guaranteed that it can hit the ground running. We can only hope that it can hit the ground running. All its key performance indicators suggest it can. But that said, when you look at the number of players that have been brought into this country from abroad even in the summer and not worked particularly up front it's a risk. But like I said, good deal for the club. Quality player in all key performance indicators. Desperate to come here, desperate to play in the Premier League, left a Champions League qualified team to come and play in the Premier League. I think that says it all for the commitment of the player and hopefully that commitment will get onto the field as quickly as possible and show us what is shown everywhere else he's been, particularly in Bersictus in the Champions League this year. Along those lines in with Walcott, what does that say about the sort of attraction of the club that you're trying to play as that in hope of bringing players like that in? It's not as risky because he's proven he's got 100 goals for Arsenal from wide positions as well as many assists. His pace is one of his key strengths which we lack in this squad. His assists are pretty good as well as his goals and we're short of goals. So to add power in our goalscoring ability would be very important for me if we can negotiate that transfer. And he's only 28. In terms of bringing him to Everton, it's not a stainless switch but you know, Everton, Red Bull and the sign Arsenal players that often is bringing him out of London bringing him up here. Well I wouldn't have thought a player today would be any qualms about where he moves now. If it's improving his career I wouldn't have thought that he'd have a mentality where that's not the place to go wherever the right place is to get regular first team football. You know, our boots will travel now, foreign players will travel all over the world so our players or one of our players or one of our British or English players moving up the road shouldn't be a problem.