Well, thank you everybody for having me. I actually appreciate the opportunity to come and meet all these nurses from suburban and have an opportunity to talk to all of you about nursing practice. I'm going to tell you a little bit more about myself, sort of the little fun fact, which I think is important when we're talking about a complex area about genomics. I'm a cancer nurse, obviously, working at the National Cancer Institute, so full disclosure. And I started very early on in my career working with breast cancer clinical trials. And I can tell you when I started, I knew zero, absolutely nothing about genetics and genomics. And I mutated myself, ultimately, into learning quite a bit about genetics and genomics. Because guess what? We started looking for a breast cancer susceptibility gene.  And indeed, I thought this was just going to be one more clinical trial that we were going to launch at our institution, the University of Michigan. And lo and behold, it became my passion. And I hope to give you a little bit of passion. But the take-home message as a nurse is that, let me tell you, if I can learn genetics and genomics, you can do it too. So it's not that hard. But I'm going to start with a few definitions just to make sure that we're all on the same page. And so genetics is the kinds of things that we think about as single gene disorders, the sorts of things that are associated with an inherited predisposition to different kinds of health conditions, be they cancer conditions, cardiac conditions, or the fat that I have, the short-fat Italian gene that runs in my family. But genomics is actually where we are today. This is where we begin to move out of the domain of the genetic specialist into the domain of all of the health care that we practice, where we have the interaction of all genetic variation. And we begin to think about the interaction with personal lifestyle factors, the environment, and cultural factors, and all of this combined together and how that's influencing health. And that's really where we are today. And this is where we're beginning to see so much movement into health care, that concept of translation of the evidence that we're learning into health care. So when you begin to think about, well, how does this influence my practice, right? You know, I'm working in the OR, or I'm working in the cardiovascular unit, or whatever it is that your area of practice is. How is it that this influences my practice? And that's what I really want to speak to a little bit today. And I'm going to start with thinking about, what are the major things that cause death in our country? And when you begin to look at this list, is there anything on this list that you see that you think may not have a component that has to do with genomics? And just so you know, I'm really asking a question, right? So I expect answers. Maybe I'll call in people. Do you think there's anything on this list? So now I can't hear anybody. Unintentional injury. Right, so unintentional injury. And in fact, it's quite interesting. The National Institutes of Health has sponsored workshops over the last few years about how people heal from traumatic injuries. So the fact that you may be clumsy, that's probably very complex. I actually think it's always quite remarkable that I can get across Wisconsin Avenue or get across old Georgetown road without getting hit by a car. And so there are many things that can influence the fact that you can have these injuries. But how we heal from these injuries actually may have a role in genomics. And we're in an environment where we have this emerging science and technology. And so this is very interesting. This is a slide from the Genome Institute. And the green bar actually represents, if I can get my arrow to work, the decrease in cost of how much it costs to actually sequence a genome. Whereas the white bar is Moore's Law. So I don't know how many of you are familiar with Moore's Law, but think about the progress in sort of computerized equipment and that sort of technology and the rapidity in which that has progressed. How many of you all have your little smartphone in your pocket and your little pad or tablet at home that you utilize compared to the giant desktops that we used to use? And you can see this acceleration in this ability to sequence a genome. And why are we interested in that? If you can reduce the cost and the goal that people are really aiming for is this concept of the $1,000 genome, that this would be something that could easily be translated into healthcare because there are many things that we do that cost $1,000 or more. And that this would reach the threshold in which we could begin to utilize this kind of technology. Now that said, the $1,000 genome is, it's like we have the technology but exactly how do we utilize it? Therein lies the challenge. That's an implications for all of us in practice. And I think that this little commentary, the $1,000 genome, the $100,000 analysis, it may even be a substantial more analysis. That's the challenge that we all face. But we do have that capacity to be very close to that $1,000 genome. To put it in perspective, if you think about doing a genetic test currently for say mutations in BRCA1 and BRCA2 associated with a predisposition to breast and ovarian cancer, the current cost can be over $2,000 to $3,000. And so that actually exceeds that for a single set of tests. We're also in an environment where we're moving these tests rapidly in directly to the consumer without the interface of the healthcare provider. And these are all kinds of varied tests. They can be anything from, companies that offer testing about what your ethnic heritage may be, to anything from risk assessment to different kinds of genetic conditions or what kinds of food you should eat or who you should date or a whole host of things. And they can be very inexpensive.  A lot of them are saliva tests. And this moves outside of the realm of the healthcare provider and actually utilizing these tests. And it's interesting. We don't know a lot about how the public actually thinks about these tests, but there was an interesting study actually done looking at Facebook users. So of course you've got some people who are sort of interfacing in that public domain, if you will, because they're using Facebook. And they're very interested, right? 64% indicated that they actually would consider using a personalized genetic test that they would actually order. But there was a large number of people who thought that the results of some of these tests indicated that this was the diagnosis of a disease. So it sort of points to the fact that there are a lot of challenges in what people actually interpret from this information. And that they would consult their physician. I'd challenge you that there's a number of healthcare providers that people could consult with, not just their physician, it could be their nurse practitioner, it could be their, if they do see genetics, it could be a genetic counselor, it could be a PA, it could be any number of healthcare providers. And what I would say to you is ask yourself the question if somebody came to you with one of those reports, would you know what to do with the information? Would you know where to go to find out what to do with the information? Would you know who to refer somebody to who could actually answer the questions that your patient has? And we're at this point where we're using more and more of this genomic analysis. And in fact, you know, whole genome analysis is certainly all the rage, certainly in a wide range of research studies. And you can even order some of these clinically where you can order a whole exome sequence clinically for evaluation of given conditions, certainly something that happens in the auspices often of a genetics clinic. But it brings to light these issues of incidental findings. I'm actually intrigued in the dialogue in genetics about incidental findings because in healthcare in general, we're very accustomed to dealing with incidental findings. You do a CAT scan and you're doing a CAT scan for a given indication and you find something completely different that needs to be addressed. Those are things that we actually deal with. The distinction here is the magnitude and the scope of what you could find. Things that you may not know exactly what to do with, things that could have significant social and personal impact like what if you learned that you were at risk of having developing Alzheimer's, for example, and what kinds of things would be reported and how you would do that and the true scope of that. And how do you consent people to actually have a test like this? And so the magnitude is something that is certainly outside the realm and there's been sort of increasingly a number of organizations beginning to grapple with how do we actually deal with this? And I challenge that nursing needs to be at the table as part of the healthcare team and really thinking through this because they certainly are a big component of the care. And from a research perspective, you need to begin to think about, you know, genomic DNA is very, very stable. I spend a lot of my time chasing down tissue blocks in pathology laboratories. And we're in an environment where we do have broad data sharing of samples, of data, and we need to be thinking about do we have control of downstream use once that information or that sample is disseminated to other groups? And do we really have the capacity to keep this information private in the way that we've classically thought about it? And I've sort of mentioned the incidental findings but our duty also to re-contact people and the implications of what if your patient or research subject was deceased? And this had implications for family members and how exactly do we engage in this? These are very complex issues and the point that I bring to you all is to begin to think about how that impacts your practice either whether you're interfacing with people doing research or you're sitting on your own institutional IRB or you're doing your own research, you need to begin to think about some of these issues. I'll tell you that there is a sort of a disconnect between what the healthcare community begins to think about what kinds of things should be reported as far as incidental findings and some of the data that we're beginning to garner from our consumers about whether they feel they would want that information. And in fact, a large number of people are saying that they want as much information as possible even if that information is not something that's actionable or would change healthcare management. And so it's an intriguing thing it requires certainly far more exploration for us to really understand the scope of this but it begins to sort of open the door of what we need to consider. And one of the first things I think we need to consider is who's our patient? I've certainly been in the room where as a nurse your patient is your patient and the family. But in fact, when you begin to think about genomics and genomic information, it can be information that does not just impact your patient it impacts the family, it impacts potentially communities it could be an entire population of people. And we need to begin to rethink who it is that we're actually thinking about and how we begin to think about the healthcare implications of the movement and translation of genomics into healthcare across the entire lifespan. And so to do that, I'm gonna sort of walk us through a few examples. I'm gonna pull in a couple of clinical examples and I'll just warn you, I'm a cancer person cancer examples for the most part but I'm gonna try and give you a flavor of thinking about the use of genomic information from preconception to after end of life and to get you thinking about well what is this got to do with my own practice as a nurse, as a framework. And I'm gonna go through a little bit of the evidence that we have about what nurses are reporting to us that they know and these are studies that I have been involved in with my colleague Gene Jenkins and others. And so there's a few of these studies that I think are important to include. One is our national nursing workforce study that was done in collaboration with the American Nurses Association. We had 619 people who responded to that survey that obviously as ascertainment bias, right? People who are responding to a survey at nursingworld.org are people who have an interest in this topic. We then went to the House of Delegates which is more of a nursing leadership cohort to see if there are differences in that group. From our national nursing workforce studies we saw we didn't have enough ethnic diversity reflecting the true scope of what we know is associated with the nursing workforce. So we've done a study in collaboration with the National Coalition of Ethnic Minority Nurse Associations. And our largest project is our MINK project which is a method for introducing new competency into nursing practice. This is a study of 20 magnet hospitals where I'm reporting data from that and we have two control hospitals. This is a year long initiative. And then because we are quite interested in sort of the leadership, we've pulled out from our MINK study the administrators as a separate cohort just to begin to look at that. So I'm gonna use those studies to sort of give you a framework of sort of what do we know as we go through sort of the healthcare continuum. So I'm gonna start with sort of preconception and prenatal genetics and talk about this. And certainly I know we have a genetic counselor in the room. That's one of the areas where they really started an Excel ad, I'm always like I know who to call. But you begin to think about testing for carrier status in that circumstance, especially when you begin to think about recessive disorders. And then prenatal testing, being able to do testing as a component of thinking about people who may have risks for certain kinds of conditions in their trial or their fetus because either advanced maternal age or family histories of certain kinds of conditions or particular ethnic backgrounds. The Genome Institute in collaboration with others has done these nice sort of posters called Do You Know? And I don't know how many of you have seen them but there are nice things to utilize on a unit-based education initiative. And this particular Do You Know poster is about Tay-Sachs disease. And it's just sort of a way to begin to think about those kinds of implications and how you may use this information. Newborn screening is probably the area where we have the largest use of genomics. And that's a public health initiative, right? Newborn screening happens in every state. Now the scope of the test will be different but there are approximately four million newborns who are screened in this country annually for different kinds of health conditions. They are done with that little heel blood spot and it can result in a wide range of different diagnoses as a result of those particular tests. And there is a committee used to be called the Secretary's Advisory Committee on Heritable Disorders in Newborn and Children and now it's the discretionary advisory committee and I don't know what that's all about but they changed their name. And that particular committee is associated with really thinking about what's the level of evidence to recommend that a particular test be integrated into the newborn screening and that the benefits would outweigh the harms and that there will be the capacity within the state to actually deal with the consequences of that particular test. This is the kind of thing where it's certainly family members can also derive benefit from this information because it may not necessarily benefit the newborn, although it certainly is intended to do that but it could also benefit the family members where there may have been something going on in a family that people were uncertain about and it could facilitate some of the assessments that need to go on, it could facilitate future reproductive decision making in certain families. So there is a wide range of applications for newborn screening. Now newborn screening is not perfect. Newborn screening can have false positive results, false negative results or ambiguous results and that's where the assistance of the genetic specialist and really having partnership with all members of the healthcare team become very, very important. And then there's an interesting thing about, well what happens to the dried blood spot? I sort of feel like all of us should go back and watch that movie Jurassic Park with the rebuilding of the dinosaurs because the extraordinary capacity of even the smallest amount of a biospecimen and the capacity of what we can do with it and how valuable those dried blood spots are. And I'd ask you in the state of Maryland which was where we are now, what happens to dried blood spots in this state? Do you know? And what would you answer to somebody who asked you that question? Could I have my baby's dried blood spot to take home and maybe do other testing on it? An interesting question. And so we're at this point though where certainly on a research basis people are beginning to explore the concepts of do we begin to think about integrating whole genome analysis as part of newborn screening and how would we handle that information? What would we do and how would we consent people? Is it really something we should even consider? And so that's really the infancy of exploration but it's something that's really an intriguing concept and one that we don't actually have an answer for. So let's move on to risk assessment. And so here we are, cancer again. But think about risk assessment, the value of risk assessment. Nurses are all about health prevention, health promotion, trying to reduce risks, healthy eating, the kinds of sort of core fundamentals that drive some of what we do in our profession. And the ability to identify people who may have an inherited predisposition to serious cancer illness and be able to intervene to try to ameliorate that risk is an intriguing concept that actually has been moved widely out in some cancers like breast cancer, colon cancer, thyroid cancer and so forth to be able to be truly effective. But of course the key is being able to find those people. And that's one of the big components is how do you find those people? And one of the simplest ways to find those people is to take a family history. So what do we know about what people in our profession do with family history? And so the very first question we asked was in the past three months, in nurses who actually are actively seeing patients, how often were you rarely or never assessing a family history? So three months, did you rarely or never assess a family history? And it's astounding to see that the majority of nurses in our profession do not assess family history. They rarely or never assessed a family history. When you then asked if you did assess a family history, did you assess the age of diagnosis? One of the key indicators for what it is that we should be looking for to identify someone who may have an inherited susceptibility, that could be anything from cardiovascular disease to cancer to other conditions. Is it occurring earlier than when it would be expected in the general population? And the answer to that is there's a large segment of our group who aren't doing that. One of the key and important questions. When they took a family history, did they assess both maternal and paternal lineages? Anecdotally, I can tell you working in breast cancer almost my entire career, that it's astounding to me that even at this point, I have both patients and healthcare providers who say that they never assessed the paternal family history. And there's a robust evidence that that continues to persist. And people who've actually studied that. And indeed, we see a large segment in anywhere from 50 to 75 or more percent of people who are not assessing maternal and paternal lineages that have equal weight when you begin to think about genetics. But what is intriguing is that a large segment of the nursing population feels this is important. And so this is really good because one of the first steps is thinking that this is a value to your practice. And to think about then how do we fix what is a challenge here? When we kind of drill down into this challenge and we say, are you confident in doing any of this stuff? And the answer is that more than half of the people say, no, I'm not, I really don't have confidence. That says we need to do more from an educational perspective to get people up to speed. And what's even more worrisome is that 64% of people in our MINK study said that they don't actually know what patients, if they did the family history, that they would refer. I'll actually tell you, they also don't know who to refer to. So key points of opportunities to actually intervene educationally, put policies in place to think about doing this. I will say that one thing that's important and is one of the foundational concepts of our MINK project is that you can't say, take a family history, do all of this stuff, refer, and have no place in your electronic health record to document it. And so our MINK project includes both educators and administrators and the dyads that are leading this because those are key concepts that everybody needs to understand because the person who's making those decisions has to understand the implications for this. So I wanna tell you a little story. And this is a story that's close to home here at the hospital that we're in because it was at the time, the Naval Hospital, it's at Walter Reed. It's a colleague of mine who's given me permission to use her case. Her name is Barb Ganster. She's a case manager in the Breast Care Center over at the Naval Hospital, now Walter Reed. And she was taught how to take family histories as part of my work in that particular program of integrating genetics into their breast center. She was taught how to identify the key red flags. She was taught how to identify a referral. And so she went in and the particular patient that she was seeing had come with someone who was a breast cancer survivor, her support person. She did the family history, blah, blah, blah, took all this history, came out of the room, and the support person came out of the room and said, oh, don't go yet, I have a question. And her question was, why did you ask about ethnicity? And why did you specifically ask about, was there any particular heritage of Ashkenazi Jewish heritage, which is Eastern European Jewish heritage? And why did you assess the father's family history?  I've been a survivor for many years now.  No one ever told me that my Ashkenazi Jewish heritage was important. And so Barb said, well, I think you need to see a genetic specialist and where do you live? And she gave her a referral. And I can tell you that Barb is someone who is like tele-calzone. Anything that's significant, she calls me on the phone. Right, well, Barb never called me on the phone about this patient, never. This was so inconsequential. It was just, you know, I'm busy, I got other stuff to do, right? Never came up. Well, I can tell you that several months later, Barb called me on the phone in a panic because she heard from this woman who went to the genetic specialist, who got a genetic test, who found out that she had a gene mutation, who decided to have her ovaries removed, had her ovaries removed, and it just heard from her surgeon with a pathology that said she had pre-cancerous cells found on her specimen. So what's the take-home message, right? There are so many people involved in this person's care. And it's the concept of interprofessional care. It's what we do, right? But there was one person who made a difference and it wasn't even her patient. And all of us know, right? As a physician, as a nurse, whatever you are, right? They're like, oh, I have a question. It doesn't have to be your patient. Do you know who you'd refer to? Do you know what your resources are? Do you know what the red flags are? Just sort of core key concepts. Barb didn't take a big, full, fancy three-generation pedigree. She took enough to know that this person needed to see somebody and she knew how to make a referral. And it's the single most powerful thing in her practice that she said I saw something and, oh my god, it's made such a huge difference. Now, does it make a big difference in this patient? I would argue the answer to that is yes. Long-term health outcomes will tell us. But right now at face value, it appears she made a huge difference. And she didn't do that much. And she didn't take that much time. So what about screening, right? In cancer, we certainly do a lot of screening tests. There are certainly screening tests for other kinds of conditions. Anything from diabetes, cardiovascular disease, and so forth. And the scope of screening tests can be guided based on genomic information. What would you do differently if you knew that somebody was at an increased risk for a particular condition? And the use of genomic information to supplement screening tests. So in cancer, for example, we may use risk models, like the breast cancer risk assessment tool. Also known as the GAL model, where they've been studying being able to look at different kinds of genetic variations called single nucleotide polymorphisms and whether that can add an additional piece of information that could be informative about people's risk. Or could we develop tests like tests that look for genetic variation in the stool that could be indicative of an indication of a colon polyp or colon cancer? Colon cancer is actually an extraordinary disease that can be prevented. But getting people to do the colonoscopy, and people aren't afraid of the colonoscopy, they're afraid of the prep. So could you come up with something that people would actually do is sort of the step that we're kind of aiming for? And if you're in cancer, but certainly this is moving out into other diseases, can you use genomic information to actually help you get a more accurate diagnosis, to establish a prognosis? In cancer, we're using tumor profiling to guide things. And breast cancer, for example, they're using tumor profiling in certain kinds of breast cancer to guide whether or not people may benefit from additional therapy to reduce their risk of a recurrence. And this is something that, as nurses, we've known all along that, oh, goodness, why did this person recur when stage for stage they were the same as the person sitting next to them? And so why is it that this person recurred in this one didn't when they had an overall good prognosis? So this adds an additional piece of information that in certain circumstances can be informative in terms of health care management. And then we're using more and more targeted therapies in cancer. And this is actually a PET scan. So think about PET scans and glucose metabolism and sort of the red and the green and yellow or sort of these abnormalities. And this is a person who has metastatic melanoma. And just to remind you that in the brain and the bladder, you'll see some of that green and yellow because that's a natural component of that function. And we're looking at before treatment with widely disseminated disease to during treatment and the rapidity of the response when you're actually targeting a particular genetic defect associated with that person's cancer. And we're in this environment, and this is something that I'd encourage you to sort of upload, where we have a huge range and platform of targeted therapies. And they can be from all sorts of diseases in cancer, from lung cancer to thyroid cancer, to breast and colon malignancies and so forth. And the Genome Institute hosted a New England Journal of Medicine series where they've gone through a wide range of different health conditions and provided evidence reviews. All of those papers are on genome.gov and are open access. So you can go in and actually upload these papers and read them. They're very useful platform to sort of begin to get you up to speed. And I have a mutation in my technology gene and let me tell you, if I can understand these papers, you can understand them, so. And what about pharmacogenomics, right? Pharmacogenomics is sort of using genetic variation to begin to look at would somebody respond the same way to different treatments? Would they be able to absorb the medicine in the same way? Do they metabolize it in the same way? Would the medicine work in the same way? And in fact, we know that there are variations in that. And then in addition to the target, which I sort of mentioned before, are there other things that you take, sort of the classic concept of contraindications that could change some of this? But that it's based on the genetic underpinning of how a drug is metabolized. And we begin to look at that and we think about phenotype. That's sort of the observable trait, if you will, so that if there are different genetic variations, you can see a wide range of different variations in phenotype in terms of drug metabolism overall, where you can have limited responses to recommended doses. You can have what's expected and begin to think about, how do we do drug discovery? We take a bunch of people, we do a bunch of studies, we may randomize them, and we say for most people, this is what works. And we've all seen somebody who took a particular medication and it didn't work, somebody who took a serious toxicity and is in your emergency department upstairs because of that toxicity. And so this wide range is what we're after. And think about the component of healthcare savings that could be derived if we could understand this complex phenotype a little bit better because then the trial and error approach may perhaps be diminished to a certain degree. And I really focus on inhibitors and inducers because nurses are a key component of drug administration. If you're in an advanced practice role, you may actually be ordering drugs. But nurses are a big driver also in terms of symptom management, talking to people about their medication history. What else are you taking? What else are you doing? You know, the sort of litany of vitamins and supplements that people may or may not take and how does that influence medications that they may be on for particular conditions? And you begin to think about symptom management and oncology, I can tell you, the oncology nurses are the drivers of symptom management. And so those kinds of things can have huge implications. Think about the fact that in breast cancer, for example, one of the anti-estrogens that's commonly used is tamoxifen. Tamoxifen is predominantly a pro-drug so it needs to be metabolized into its active form to actually do its job. That active form is a doxifen. And that happens through a complex mechanism but one of the big driving genes is CYP2D6. And what happens with people who take anti-estrogens? They get hot flashes. So what do you do?  Estrogen, right? You're sort of shooting yourself in the foot. And so we give them SSRIs, low dose anti-depressants. But some of those can be inhibitors of CYP2D6. And so those are the kinds of things that we need to begin to understand. And it's a complex area, right? If you never had pharmacogenomics when you learn pharmacology, this is the kind of thing that is a complex area to begin to understand. And the evidence base that continues to emerge and the complexity associated with it. But there are a number of excellent resources to help people get up to speed, including those developed by our pharmacy colleagues like Farm Gen Ed, where there's a lot of online resources to actually help people learn more. And I'm gonna tell you a story and this is not a cancer story. This is a family story. Kind of, if you're paying attention, you'll see there's me. This would be my dad. See the bald head? That's the, we have a lot of similarities. This is my brother with the beard. That's why we all look the same. So my father's in a wheelchair. And I'll say that up until his dying day was cognitively intact.  But so my father was a diabetic, an incidental pickup, incidental finding, right? On a physical for life insurance in his 30s. And he was very robust in terms of following his diet, but diabetes catches up with you in terms of vascular disease. And indeed it did in his case. And he had an MI, and then he developed lower extremity vascular disease. And after multiple operations and multiple complications, he ended up with bilateral amputations. But what's the story here? So the story is, is that he started at his local community hospital because old Italian man, right? This is where I get my care. I'm never going anyplace else. I was born here.  Ended up in the ICU. Had no pain relief from the morphine that they gave him. Reason for the transfer in the ICU was respiratory depression, right? Then he decided, you know, I think I need to go someplace else. So we went to the other major medical center in the region where he lived. And he ended up having a few additional operations at that healthcare facility. And after the first incident, it became clear to me because he had difficulty with pain medication as an outpatient in managing his vascular disease for quite a long time. And it was difficult to know what that was about. But with his hospitalization and his surgery, it became clear to me that this was somebody who really was either a poor metabolizer or had some other kind of underlying genetic component that was not allowing him to metabolize morphine in the same way as other people. And that he was getting no pain relief but he was getting associated respiratory toxicities. So long story short, he ultimately decided I'm going to the big academic center in the sky and we went to the major academic program there and he had more surgeries there. In the length of his illness, over two years he had 15 operations. He had 15 trips to the ICU. And let me tell you, I am no shrinking violet, right? There were 14 trips that I made to the anesthesiologist to the surgeon. I'm very resourceful. I can find your recovery room. I can talk to those nurses just like anybody else. And not a single person could understand that morphine was not the drug for him and the reason for it. And that stock answer was, well, it should work. Works on most people, right? So it's a fascinating thing, right? It's because people just didn't understand the underlying basis and they don't see that relevance and getting people to understand some of that could have saved bazillions of dollars and could have certainly taken care of many trips to the ICU and the stress that was associated with my other family members who really didn't understand what was going on despite my best effort to communicate because they just weren't listening. ICU. And there's more than that that runs in a family, right? Because my brother is clumsy. So somebody said something about clumsiness early on. And my brother is clumsy and he fell and he broke some ribs and he got no pain relief from the medication. And what was his first thing that's calling me up and he's going, hey, do you think that this thing that dad had runs in families? And do you think I could have the same thing?  I'm just gonna live with it. But do you think this could be it? What if I have to have an operation someday? And what's the answer to that? Yes, he answers yes, absolutely. And I'll just say one little fun fact. So there's my little brother with a beard. Here's my dad. You don't see my uncle there, this is his wife. My uncle had his first MI before the age of 50, had diabetes. My dad had diabetes. My brother's a pre-diabetic. What do you think my risk is for diabetes? I spent the last two years really focusing on my weight because when I heard my brother had the pre-diabetes, my first reaction was one that was very mature. So I'm not actually thin yet, but I do wanna look like some movie star someday. So there you go. So we're at this cusp of the quest for personalized healthcare. And you can call it what you want, right? So some people call it personalized medicine. I think it's broader than just medicine. I think it's healthcare in general. You can call it precision medicine. I don't care what you call it. It's the same concept. Can we do better by integrating genomic information into the healthcare that we deliver? And I think that the point of that is we may be able to do that. It's getting us up to speed to be able to integrate it in a safe and effective and appropriate manner. So what is it that nurses need to know? And the answer to that is we actually believe we know what nurses need to know and we establish competencies that are applicable to all nurses. It doesn't matter what your academic preparation is, where you work or what you do. These are competencies for all nurses. These are not competencies for genetic specialists. I don't need every nurse to be a genetic specialist. I'd need nurses who are going to be able to do their work to the best that they're able in the area that they are, but be able to recognize when genomic information has relevance to their practice and to utilize it when it's appropriate. One of the first things we heard from educators was, well, if we're gonna try and teach to this, we don't know how to teach to this, right? Nobody's ahead of the game here. And so we establish specific areas of knowledge that support the competencies and outcome indicators that are suggestions of what kinds of things you could measure to see if somebody was achieving a competency. And then the next thing we heard is, well, we need to level these for advanced practice. And so that work has been done by another team of people and those have also been published. So we have tried to address the question of, well, what is it that I need to know? These are open access documents and I'd encourage you to upload them because they're very useful and valuable in terms of thinking about your own work. Now, what do we know objectively about what people say? And it's not a surprise. The proportion of nurses overall in our major studies are who think that their amount of knowledge of the genetics of common diseases, excellent or very good is really very poor, right? The majority of people don't know. We thought maybe our cancer nurses may know more. Well, they know maybe a little more. Nobody's winning the game here. We don't know enough. And what's informative for us is that even with our ascertainment bias from our National Nursing Workforce study with ANA, we still have a lot of people who don't know about the competencies and aren't utilizing them. In our mean study, we calculated a total knowledge score, taking some core concepts on simple things like family history that could be integrated into anybody's practice and sort of beginning to look at that because I would say in my practice, I have never met a nurse who can't tell me about sickle cell and recessive transmission.  You're just not recognizing it as such. And so is there a way for us to tease that out?  So the maximum score was 12. And then we began to look at who was able to get those things right. And we found that in general, people actually do know a little bit more than they think they do because on average, it's between eight and nine out of 12, which was not as bad as you'd think when people self-rate their scores is so low. Now, is this really a valid measure? And the answer to that is no, but it gives us a snapshot to begin to think about it. But what we did see is that people do recognize that some of this has relevance to common health conditions like family history and cardiovascular disease.  I think it could be due to a single gene variant. And so some of that specificity is where we need to build. So what is it that we need to do?  I know, go ahead, ground, that's okay. But I think it's important to think about how do you take something that's so complex and think about how you can move this out in a way that's gonna be effective? And some of that has to do with the healthcare system that people work in. Some of it has to do with knowledge. Some of it has to do with what they think about this information. And then once you get people there, they have to be supported to be able to learn more and to adopt it. And so one of the first things are attitudes. And overwhelmingly, people think this is really important. They just don't think they know anything about it. And so that's the first hurdle is that people think this is important. And what's interesting though, is that when you say, do you think that senior staff, and we've asked people, who do you think senior staff is? Well, those are line managers, right?  And the answer to that is no, they don't think that senior leadership thinks it's important. And so that's actually interesting because then when you pull out your administrators and they say, well, from your perspective, your leadership, do they think it's important? And the answer is no. So everybody thinks that everybody up above them doesn't think it's important. And as a consequence, that influences some of what people are doing. But here's the most interesting thing. Would they attend a genetics course on their own time? And overwhelmingly, we're seeing that people would have interest in doing that. Now, what people say they think they might do on what they do are always two different things, right? But I'd love to find somebody who'd fund me to take that out for a spin because I'd love to see if we can make it go. We have a lot of clues about what people need to know. We know that people think that people are gonna be discriminated against and that they don't know anything about the Genetic Information and Discrimination Act. We know that people think this is really gonna make people really crazy and frantic and anxious. And in fact, most of the behavioral studies say that that's not the case. They don't think it's reimbursable and it's too costly, but in fact, I've showed you the evidence that this is going down in costs. And a lot of insurers when there's a clinical indication are covering the costs. And so there are lots of opportunities for key things that we can do to influence. We know that education in an academic setting makes a difference. And so we looked at total knowledge score based on level of education from doctorate all the way down to diploma. And we did see that there is a trend that the higher your level of education, even if you're not studying genetics like I did, the more likely you are to have an understanding and to get some of these questions right. So education potentially can make a difference in sort of improving some of the competency in our profession. And we know that when we look at after you've gotten your licensure, if you then went to a genetics course, we do see some differences in people's knowledge about the competencies in what they're reporting about their self-professed knowledge about genetics. And so this is your prior genetics education, no genetics education. This is from our MINK study. We had a lot of statistical power and all of these are p-values that were significant and younger nurses, right. Think about it now, right. Our science teachers in high school have embraced genetics. We've got students going into the academic programs who are really eager and open to genetics and technology and all of this sort of thing. And so we need to capitalize on that. And we've seen that the younger people are, the more they're sort of embracing some of this. It's really our challenge to sort of step up to the plate. There are a lot of policy implications and I can't go through them all here. I can tell you that in our MINK project, people are working drastically on policy work that can be associated with their institutional regulatory bodies like their IRB. It can be setting up competencies on an institution-wide basis. Pathways for referrals, really documenting what it is that you need to do so that people have a place to go to look to see, well, what do I do? I found something and I need to refer. Some nurses are saying, well, they don't even know if it's something that they're supposed to do to refer. So what do you do in that situation? Just pretend it didn't happen. People are really challenged about how you document family history because it's not been well integrated into electronic health records and we have groups working about that. So there are lots of strategies that our MINK hospitals are working on. And I wanna bring home the point that there is no one group that's sort of ahead of the game here. Everybody works together for the benefit of the patients. This is an interprofessional problem. This is something that we should be thinking about how we can partner with our interprofessional colleagues to move this forward better from an educational perspective, from a healthcare delivery perspective, from the way we begin to think about our quality initiatives at our institution, the evidence that we need. And there's a lot of things about data, data, data, data, data. I will say that I'm delighted that our colleagues from the National Institute of Nursing Research have really embraced genomics very early on with their summer of genetics institute and other initiatives and recently have partnered to work with us on a state of the science initiative to sort of define a nursing research blueprint to sort of guide some of this evidence space. And I'll say, I don't wanna get into the details. You can certainly read the paper about that, but we had an excellent advisory panel that was pulled together of experts in the field. And this was interdisciplinary. We had colleagues from other professions engaged in this effort. And then we sent our blueprint out for public comments. So we tried to get as much input as we could. And there are a couple of things that they said. One is our definition of the client or the patient should be as broad as possible. And that we need to do research focused on the client, but also focused on the context in which healthcare is delivered. And there are key cross-cutting themes. And in August of this year, the National Institute of Nursing Research is sponsoring another workshop to really begin to drill this down, to begin to even refine the blueprint a little further. And it is available both on genome.gov and on the NINR website where you can go in and actually see the blueprint itself to help get your thinking going about research that you may be doing in your area or things you may consider. So we have a lot of challenges and opportunities, not the least of which in today's fiscal climate is funding, but I think it's an extraordinary opportunity to really effect change in healthcare. And there are lots of resources to help you. We just finished a Journal of Nursing Scholarship Genomics Special Issue, which is all open access, and we're grateful to Susan Genaro and Wiley Publishers for actually doing that with us. My colleague Jean Jenkins has been working with a wide range of health professionals to establish the Genetics and Genomics Competency Center for Education because we all know we can do a Google search and find 13,000 hits for genomics, but which ones are accurate and current and reliable resources for you to use. And right now they have nurses, genetic counselors, PAs, the pharmacists are working, and I understand our physician colleagues are beginning to think about how they can build their platform of resources into this infrastructure. The CDC has excellent resources on their public health genomic site, including a listserv to keep you up on the current literature. And if you wanna join our competency listserv, which I moderate, email me, and I'm happy to put you on it. It's a way to disseminate current resources. I'm gonna also say that we have a website that's under development, which is an online unfolding case studies because everybody says, well, I learned best by seeing patients who had this. And so this is filmed with real actors. It's unfolding, pick your pathway, pick your disease, pick your condition that you wanna learn more about. And in fact, today we're filming some of those cases across the street, so if you wanna see real actors, they'll be the people wandering around lost. Probably the resource I'd say, if you picked anything to do right now, I would go to the Smithsonian and see the Smithsonian Collaborative Exhibit with the Genome Institute. It's absolutely fabulous. They worked very hard on this. It's fun, it's exciting, it's interactive, and it's a fabulous way for you to learn more about genetics and sort of whet your appetite. At a hospital-based level, get a field trip, going is all I can say. It's really worth it, and it's a great platform to get you thinking about learning more. And then in October, the International Society of Nurses and Genetics, where you'll see people from all over the world coming to talk about their studies and their evidence, will be here in Bethesda, just down the street, and I'd encourage you to take the opportunity to attend that meeting, because it's an extraordinary chance if you're in this particular area. It's one of the greatest nursing genetic meetings that you could attend. So what's a take-home message? What does genetics have to do with your practice? Only you can answer that, right? I don't know what you do. And utilize your leadership to begin to think about how you can be a change agent in your own environment. Recognize your opportunities. Are there policies that need to be changed? Are there things we need to do differently? How do we creatively think about, on an institutional level, what we do and how we can move it forward? And how can we leverage the resources that we have to move this forward? I can tell you, the things that our main hospitals have come up with to move this out are absolutely extraordinary. And people in the trenches, you've got fabulous ideas.  So I'm happy to entertain any questions. I have a question about the Amazon. While you're thinking, when you go to the Smithsonian, it's room 23, and I guess we put it there because there are 23 rooms on it. Is there a comment for... Yeah, I am gonna do that because I know she's filming it. Yeah, so the comment is really about the role that nurses can play in facilitating decision-making about the referral to genetic services. And I absolutely wholeheartedly agree that nurses can play a role in that and that we do see people who are referred who don't go and don't come. And some of that is indeed misconceptions. And I'd encourage you to partner with your genetics referral teams because they're all enthusiastic to partner with you and work with you to think about ways that you can help and make sure that you as the nurse is making that referral know what that's about. Who is a genetic counselor? What do they do? What role do they play? What would happen in a counseling appointment? People have all kinds of misconceptions about what that is about. And there are unique and distinctive opportunities for nurses in that realm. So the question is about the American College of Medical Genetics guidance on what kinds of incidental findings reach the threshold of evidence that they should be reported out. And Anne Cashin's comment is about the number that should be reported out. And who does whole exome sequencing? It's important to understand so the acronym is ACMG and it's actually a very important paper for you to sort of read through. But this is clinical exome sequencing. It's done predominantly in environments where you're dealing with a genetic healthcare professionals really trying to diagnose something and they don't know what it is, that it didn't hit any of the things that would be classic and they're trying to do some discovery about what could be the underlying cause of a particular condition. There are challenges in the literature coming out in regards to this because how do the laboratories report that out? But there are a number of laboratories that you can order including one right here down the street where you can order a whole exome sequence. And so it can be done but it is often done with the counseling and support of the genetic healthcare professional. But this is a challenge that will continue to emerge isn't really the right thing but will continue to translate itself into the general healthcare community as we identify people who may not reach the classic phenotype, right? That observable trait associated with a condition but you found something on a particular genetic test that warns some kind of interaction. One of the co-authors on that was our very own rescue center who runs the clinic C study here in the desert and I mean many of you know that I'm a participant and the reason I think he did it is he's sitting over there finding things there's a big fight that's going on what you should do with it so if you get into it. Are there other comments or questions? Well, we'll be on time I'm sure that Alzon would be happiest to pick around and answer any individual questions. All right, thank you. It was a nice presentation to have. Thank you. Thank you.


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Hello, welcome to the session on precision rectifiers. Learning outcomes are at the end of session students will be able to explain the working of precision rectifiers and they can sketch the output waveforms for the rectifier circuit for given input signal. Contents are like this. So, what are the precision rectifiers and what is the need for this? As you know due to the voltage drop across the diode, we cannot get the characteristics of diode as ideal diode. The drop across conducting diode of 0.7 volt, but when we connect the diode in the feedback path of the opamp that is operational amplifier, we can get the diode as a ideal diode. So, these characteristics are called as super diode. So, where we get the rectification of the signals less than 0.7 volt which is not possible with the ideal diode. So, which will eliminates the error in the output signal. So, it can give you the rectification of the signal that is VD upon the voltage gain of the opamp that is in terms of lakhs that is VD upon AOL that is open loop gain. Even the signal is in the millivolt or microvolt we can rectify that signal. Therefore, this is called as precision rectifiers. So, there are two types of precision rectifier that is half wave and full wave based on the signal we are connecting to the inverting or non-inverting terminal we have the types as inverting half wave rectifier or non-inverting half wave rectifier. Figure shows the circuit diagram for precision rectifier that is half wave rectifier where the diode is connected in the feedback path and signal is applied to the non-inverting input of the opamp. So, it is called as non-inverting half wave rectifier. As you know you are connecting the signal to the non-inverting input when input voltage is greater than 0 that is positive half cycle then diode D1 gets conduct. When diode D1 get conducts we can say it is act as a short circuit. So, as input signal increases output signal will also increase. So, in this way we will get this transfer characteristics of the half wave rectifier. In the negative half cycle what happens diode will not conduct as negative signal is at the positive terminal of the opamp. So, diode D1 will be reverse biased and therefore, we will get 0 voltage at its output. So, what will be the equation and the waveforms for precision half wave rectifier during positive half cycle as D1 conducts we will get the signal same as the input signal and during negative half cycle D D1 not conducts therefore, you will get the 0 over here. So, this is the equation that is V out equal to plus V in and opamp is now acting as a unity gain buffer when negative half cycle is applied diode does not conduct and it acts as a ideal opamp switch therefore, output voltage will be 0. But here when you go for the higher frequencies sometimes it will not give you the precise rectification therefore, we will give one more diode connection in the same circuit. So, this is called as modified precision half wave rectifier where signal is connected to the inverting input of the opamp and non-inverting input terminal is grounded. So, you can assume now positive half cycle is there at the input signal D1 conducts, but diode D2 will not conduct because as you know this terminal is the inverting terminal and therefore, you will get the condition that is D1 is on, but D2 is totally off therefore, you will not receive any signal at the output of the opamp or output of the circuit. But in the other case where negative input is applied to the inverting input terminal at that time diode D1 will not conduct, but diode D2 conducts and therefore, you will receive the positive half cycle over here because as you know inverting input terminal will give you the phase shift in the signal. Therefore, you will get this positive half cycle for the negative half of the input signal. So, this is the waveform for the inverting precision half wave rectifier. Now the circuit for precision full wave rectifier is like this, input signal is connected to the inverting terminal of the opamp A1 and here both the diodes are connected. Now assume input signal is greater than 0 that is during positive half cycle. During positive half cycle diode D1 conducts, but D2 will not conduct. So, this complete part will be like a open circuit there will be no connection over here, but now you see this act as a short circuit. So, you will see here opamp A1 and A2 both are in the inverting amplifier configuration. So, at that time you can say both will give you the gain of minus 1. So, both are connected with the input signal. So, V out will be minus 1 into minus 1 into V in. So, output voltage is equal to plus V in over here. This is during positive half cycle. Now in the negative half cycle this will be the equivalent circuit. In the negative half cycle diode D1 will not conduct. So, it is like open circuit and diode D2 conducts. So, this path will be in the closed loop path. So, D1 is off, D2 is on. Now just see input signal is applied to the inverting input terminal and here current flowing through these three paths. So, we can apply case here to this node A because we are interested to find the voltage V at this terminal for the opamp A2 and that will decide the output voltage of this rectifier circuit. So, we can say I1 plus I2 plus I3 equal to 0. So, I1 will be V in minus 0 just apply the concept of virtual ground, non-inverting terminal is grounded. So, this terminal is also assumed to be at 0 volt. So, this is V in minus 0 divided by R. See V minus 0 divided by R as this terminal is 0 we can say this voltage is also 0. So, next is V minus 0 divided by 2R. Just see here in the previous case these two registers are connected in series when D1 is open circuit condition then we can say here these two will be forming the value of 2R. Therefore, if you find the equation for V it will be like this it is minus 2 by 3 times the value of input voltage. Therefore, this is the amplifier closed loop configuration. So, it is gain as you know 1 plus R by R1 that is 1 plus Rf is the feedback resistor R divided by R1 that is at the input terminal that is 2R. So, 1 plus R by 2R into V, but when you put the value of V. So, that will be 2R plus minus 2 by 3 times V in. So, here this comes 3 by 2 and this comes minus 2 by 3 that will get cancel out. So, output voltage is equal to negative of the input signal, but now see we are dealing with the negative cycle. Therefore, when input is negative over here this negative and this negative comes positive over here. Therefore, output voltage is positive for the negative half cycle. Thus we will get this waveform for the precision full wave rectifier that is in both the half cycles we will obtain the positive voltage over here, but if you change the directions of diode over here we will get the negative signal at the output. We can write and sketch the waveforms for the transfer characteristics of precision full wave rectifier. So, as we have seen the transfer characteristics for half wave rectifier thus pause this video and sketch the transfer characteristics for precision full wave rectifier. Yes and you will get the linear relationship between input and output voltage for positive as well as in the negative half cycle. Thus this will be the transfer characteristics for full wave rectifier circuit. These are the references. Thank you.


Well, let's get some reaction from the bad his name has been on everybody's lips this week Miloš Nikovic is with Scott McKinnon Scott That's right Miloš Nikovic here in a Derby in a different Jersey here tonight It was all about you in the build-up to this one. What does it mean to come here? Rain supreme and get the victory here tonight It's been amazing to I said even before the game. This is my favorite stadium. Obviously. I had so many great memories here, you know But it's all about the team tonight, you know, obviously I said I'm gonna give Everything I can tonight to help my teammates to get three points and I think we deserve To have that exist to to Yangi does that make it extra special for you? Especially when you had the chance moments before I had a chance before that obviously probably I should have scored but Doesn't matter obviously we won the game. That's for me most important team, you know For you mate, I know like the booze every time you touch the ball the stuff from your old club about trading in your Jersey I know you tried to bat that stuff off But it was that a bit of disrespect did that take it to heart look? I understand fans obviously, you know because I made decision I made obviously I understand them I am gonna live with that, but I was in support as I said On the club, you know, obviously I spent seven years if that came from from the fans I will understand but from the club obviously I spent seven years one six trophies and I said before the game I still have all seen FC jerseys Pictures awards and I'm gonna keep it all my life for you here You've got your beautiful family here that you hug before you've got your new family all these fans here Who absolutely love you this must be an extremely special moment for you to celebrate with a win And I'm sure you believe that you can do something special with this team this year Yeah Even before I came before I signed for this club Obviously I asked them what their plans plans are if they want to fight for something big then I'm gonna come if not Then it's better me to not come, you know, and they said to me Yeah, we want to do something big this year. Obviously we start where we have few injuries Obviously we have break now and I think after the break We need to start even better mate. I can see the emotion charging through you. Enjoy this Enjoy going and soaking it up with your new fans. Well done. Thank you


Welcome to The Metal Voice. It's been 11 years. Yeah. We've we've had Wolfon. Don't get in us wrong, Mark. We've had Wolfon many, many, many times. Tons of times that we go, you know, we got to go back to Mark. We haven't had him in 11 years. Mark Spanillo accept. One of my favorite interviews was, you know, over 13 years we've been doing the shows with you and Mark, or you and Peter, sorry, that they styling grad tour here in Montreal. There's a great interview and you guys are a great bunch of guys. And now we're talking, you know, 14 years in the band, your sixth LP with them. Wow. Yeah. Can't believe it. Humanoid. Humanoid to be released April 26 on Napalm Records. This is the 17th. Can you believe it? The 17th studio album. Roll it out and begin. Go ahead, Alan.  What a job on the lyrics. You know, they're topical. They're, but there's some, you know, sometimes you're just universal. It just every, every album you write the lyrics, it just, it just enjoy, enjoy to listen to. It's a, it's a challenge to find things to write about, you know, anymore. You try not to rehash the same thing over and over again. But, you know, we, luckily we seem to come up with these topics. So. I know in the past, when we used to speak to Gabby, she used to always, always have her hand in there, right? Like sort of, and I think you even told us that, but now you're completely free of that. So do you feel that you have a lot more space, less of an editor looking over your shoulder? I've always enjoyed Gabby's input.  Yeah. Yeah. And really well read. You should see her library saying how she comes up with all these things.   And it's the same for them, you know, for everything that we do, every, everything's ever finished until it goes to press can always change. It's okay. That's okay too. That's all right. Well, let's talk about some topics. Me and Alan, we're just talking about the topics on the new album. All right. Let's, let's AI seems to be the big thing today, right? Humanoid. I mean, are we talking about the Terminator here? What are we talking about? iRobot? An AI cleaning machine to clean our vacuum or house? Well, that's what I said. I was, I was thinking more like the Borg actually. I was a big Star Trek fan.  So, but where the whole idea was just, you know, this was Wolf's baby when he came up with the title for the song and wrote the music and put the ball in my court. And I had to come up with a way to, way to make it palatable, you know, but yeah, I tried to incorporate as many ideas into it without making it too crazy.  This whole AI thing that's going on is insane. Where are we going? Who knows? Well, we've got Elon Musk just put a implant in somebody's brain. Now he can play chess without moving his hands on his computer. What's next? You have programs that write lyrics, you have programs that write music, you have AI programs that will mimic your voice, and you don't have to sing anymore. Like, yeah, where are we going? What are we going to do? It'll be Mark Danilo sings Taylor Swift songs. AI version. Well, that's the collective, right? The Borg is the collective, right? Yes, you there the collective. Resistance is futile. Resistance is futile. What about, you know, and it's interesting because you talk about the humanoid, but then you have Frankenstein, which was probably AI in its infancy, right? In its original form. Taking a brain and putting it to someone else's body. Whose idea was that? Well, it was a working title. And we tried a couple of different ideas, but nothing seemed to sound as good as Frankenstein. I came up with a couple of different things.  So I said, screw it. It's going to be Frankenstein, but I want to tell the story from the, from the point of view of the monster, not the people that are scared, and not the doctor, not Igor or whoever. I want the monster's point of view. And what does he know? He didn't know anything.  Who made me? Where am I? What is this? And why is everyone hate me? Like AI, like the AI boring terminator, whatever you're going to call it. Yeah, I see that as a kind of a sister song to monster man off a Russian I mean, that's a song that I can't wait to hear live. I think this is going to go down. We're definitely going to do it live. So it should be a lot of fun. And then, you know, diving into sin, us being here in Montreal, Quebec, I heard that the Putin drives you insane, but it's the routine drives you insane. So yeah, routine, the routine drives you insane. Very well. What about a man up? This to me, this sounds like that classic gang vocal except vibe, I guess. Yeah. Well, that was a kind of a, I was one of the, I think it was the first thing I wrote. I wrote the lyrics and I just sent it to Wolf. And it was more of a pep talk if anything else for me, get back on the horse and let's get this going. Yeah, lyrically, I could see where it's a follow up to, you know, sex to be you or holding the head. I mean, it's one of my faves on the album. I mean, life's hard. It's an age old truth. Man makes plans that God laughs, you know. Yeah, man. And that's the truth. How would you describe the album, the sound for all the people who haven't? Of course, most people haven't heard it, but how would you describe it to somebody? Okay, this is my new album. This is coming out soon. It sounds like classic, except that's my classic Mark Tornillo, except or classic auto, except. Well, a little of both, I think. All right. I don't think the band is strayed that far from from what it was in the 80s, you know, different members, obviously.  There's no, there's no doubt about it. So, but I mean, you know, it's a classic metal album without trying to be too redundant, you know, and try to make things interesting. Keep it's an ain't broke. So don't fix it. Just refresh it. And a song like Ravagers of Time even takes me back to the earlier, except for the late 70s. So it's got that kind of feel to it. Yeah. Yeah, Breaker album. Yeah, around there, earlier. Straight up Jack, I mean, that's, what's that except answer to ACDCs have a drink on me? Yeah, that could have been a TT quick song, I think. I'm trying to think what alcohol was not mentioned in that song. I think you covered them all. Yeah.  Give it to me straight.  Yeah. I mean, it's natural.  But you know, you could look at it that way. I'm sure some people do. So people be saying that now about KK's priest and Judas Priest. Same thing. Yeah. And we just saw that we saw KK and Ripper on the Monsters of Rock crews, man. They were amazing killing it. I think that's a great point. I mean, that's a great analogy because priest's new album is incredible. KK's new album is incredible. And it seems like that competition is just creating better music. And I think it's the same case for you guys with you and Odo. Like it's just going now. So yeah, yeah, yeah. And the song Unbreakable, I mean, you talk about One United Force metal soldiers, or you wire metalheads so, so loyal, maybe now more than ever. They just are, man. It's amazing. It's probably the only genre of music that you don't grow out of. You know? Yeah. I think we're the living proof. Yeah.  It's it. And no matter where we go, on this planet, you know your people when you see them. Yeah.  And as you get closer, you just see more and more black shirts and long hair and tattoos and, you know, band shirts. And it's like, it's my people. And you get out of the car and people. I always said that the safest place you could ever be is at a heavy metal concert with true fans because everybody knows each other feels the same. They're there for the music. Yes. Exactly. We're all, you know, one big happy family, man. Yeah. When I was a kid, you know, I didn't want to go to the punk rock clubs. I wanted to go to the metal clubs. I didn't because they were too violent on the punk rock side, but I really took care of each other at the metal clubs. Yeah. Now you go in the mosh pit. Well, I don't go, I don't go in the mosh pit. I'm too old and brittle at this point. Yeah. We'd have to call an ambulance. What has always been your challenges to tour the U.S.? Wolf is based in the U.S. You're based in the U.S. You would think it'd be that much easier, right? To tour the U.S.? You would. It's just, we don't have that kind of following in the U.S. that we have everywhere else in the world. So, you know, the money's not there. It's, it's, it's rough, but we are, we are going to make a run this year and we'll see how it plays out. Yeah, that's what we're wondering. It is in the works. Okay. So, North America or just U.S.? North American. Okay, good. So, U.S. and Montreal. Or Toronto. Or Toronto. I have not seen the final schedule yet, so I'm not at liberty to say anything. And none of that's been announced. So, I got you. We'll play that by ear. Right now we're working, you know, we have South America in May, summer festivals in Europe, and a European headline tour starting in October. So somewhere between the summer festivals and October, we should be doing a U.S. run. Okay. And, you know, not only the great lyrics on this, this album, but how the voice, you know, you, you explained to me it's a muscle, you got to take care of it. But, you know, we're all aging and you sound just good as ever on this album. Well, thank you. I appreciate that.  And I think that's, that's the key to it right there. If you keep continuing to sing and pushing yourself to do it, then it'll continue to work, hopefully, you know, I mean, it sounds wonderful. Let's hope that's the truth. So far, so good. What are the toughest songs for you to sing today live? Are you still? Oh, boy. There are some tough ones, man. Breakers always a challenge. Zombie Apocalypse has been the opener for the last couple of years. And that's coming out of the gate with that is a tour. But you get it done. So I'm really glad we do it that way, that we have done it that way. But now that'll be changing up now, I'm sure that Humanoid Albums out, we'll see what wonderfulness they're going to make me do first. So what's dynamic with you and, you know, Wolf, how does it go about the songwriting process? It's totally, every song is different. Like some of the things on these, especially these past two albums, Humanoid and To Mean, a lot of times I just wrote lyrics to nothing and sent him the lyrics and the song would come back. Or he would send me a piece of music with nothing but a title, and I'll write the lyrics and send it back. So it could be, you know, and then Martin Mott next been involved in the songwriting on the last two albums. Thank goodness. And these comes up with some good ideas as well and lyrical ideas. So it's a collaboration, you know, that's all I could say. And it's not done until it's printed, you know. We will tweak things right to the very end until it goes to mastering. So that's great. Yeah, Wolf also offered jokes that, you know, being German, it's almost near perfection has to be achieved before something's put put away. Yeah. Yeah. Especially with Andy, man. He is a perfectionist, you know. I just watch his face when I'm singing and I know when he's going to go, I think you got that one in you, mate. Oh, God. Do you miss Peter Bautas as a songwriter? I mean, he was a fixture for so long. Yeah, he's a great guy. As I said, though, you know, Martin Mott, Nick has stepped up and become that guy right now that we, you know, it brings in ideas and we bounce them off of him as much as each other. So it's it's just tough shoes to fill. I know all about that, you know. Yeah. It's tough shoes to fill, but, you know, you got a man up and do it. Hands man up. And let's take a big high five for nobody gets out alive. I mean, I think that's probably the most 80 sounding song on the album. Yeah, I really like that song too. That's that's another one I wrote the lyrics before the music. And I was really, really happy with the way it came out. You know, it's amazing. You've become the classic era now. You've been in the band so long, right? Because there's usually about it on a steady run. I've been in the band longer than Udo ever was. Yeah, unbelievable, unbelievable. I remember, you know, when you guys were you guys first started off, it was it just it doesn't seem like yesterday, but it seems like a long time ago. It just really does in a good way in a good way. I don't mean yeah, but I mean, it's 15 years went by pretty damn fast. I imagine. So yeah, that's for sure. Lots of trips around the world and, you know, crazy. Still doing electricity. Last year. Oh, congratulations. 2023. I called it called it quits just basically for more more reasons than not is just too much to handle with the logistics of getting work and and benefits and you know, I'm retired now. I don't think about benefits anymore. I got health insurance for life. Oh, that's good. That's great. I didn't as long as I was still working because if you're not, you don't have enough hours, then you had to pay Cobra and Cobra payments now are up over $1,000 a month. I'm like, yeah, why don't you pay me instead? I'll stay home. How's that? Yeah. So there you go. So in other words, union-wise, you officially retired at that age where you could keep on collecting, right? Yes, you could have enough and have enough years in. Yeah. So I collect the pension from them now and and I still have my health insurance on my Medicare, obviously, because I'm a freaking old man. But that's my secondary and they cover everything that Medicare doesn't. So when you get to concentrate on music, that's great. That's great. That's a nice problem to have. Well, it's a nice problem to wake up in the morning and go, no, I really don't have to go there today, do I? I'm going to stay home and do interviews. I'll drive a few lyrics down. Do you guys still have any contact with Gabby? My wife and I do. Okay. She okay? She good? She well? My wife and Gabby are very good friends. Sorry, Gabby and myself, we're all good friends. Good, good, good, good. She used to like, you know, she was a huge supporter of the show. You know, I don't know that she's retired now and just give her her best wishes. That's all. Yeah, I think I most certainly will. Lovely lady though. Yes, she is. No, just, you know, we're talking about all these albums and you say it's a little bit harder.  Has there been a little load that's making it a little difficult to tour North America or? It's always been difficult to tour North America. It's mostly promoters and the fact that, you know, we need to play at least a big enough room where we're going to make some money, but to get out the turnout to do it, you know, so, but we're going to make it happen this year, no matter what. I know that we've all decided that, you know, if we have to take a cut, we'll take a cut, but let's we got to play. We got to play for the fans. So, you know, we, we interviewed Blackie Lawless and they were telling him for decades that there's nobody there. Nobody's going to turn up. It's no interest yet.  So, hopefully that'll be the case. We've been away long enough. No trouble selling tickets in South America. No trouble selling tickets in Europe or elsewhere else. So, it's, I think it's just that the United States is just not metal territory anymore. Whoa. I don't know why. Adrian Vandenberg, we had him on a couple of weeks ago. He was saying the same thing. It was kind of a test drive for him going around this tour, but the reaction was so strong that they're going to do a full tour down the road. His agent believes in it now. Oh, let's hope so. I hope they prove, I hope they prove me wrong, you know. I mean, I would love nothing better than to tour the U.S. You know, every year, but we'll see how it plays out.  Like, I mean, Canada has always been a strong hold for, except in general, your era, Uduz era. So, hopefully the promoters will see some value in that and book you guys. I hope so. Well, as I said, there's definitely going to be a run in, I'm going to say, late August through October. So, and I can't really say any more about it right now. It's not confirmed and it hasn't been announced, obviously, but there's, it's going to be going to be very interesting bill.  I was more sick for a few days. I had RSV. Oh, wow.  I'm telling you. And I was singing through it. I had sang four shows already with it. I mean, we had been out on that run for a few weeks already. But I got sick, I think in Colorado. And I sang that show. And I sang two more after that. And I woke up on the bus in Toronto and I couldn't breathe. Oh, seriously. I literally was laying in the bunk on the bus and I had to cough.  I know it's what's going to come up. But okay, go ahead, cough. I went to take a breath and nothing went in.  I jumped up out of the bunk and I'm like, calm down, dude. If you couldn't breathe, you would have died in your sleep. Oh, yeah, that makes sense. So just calm down, breathe through your nose. Okay, that works. That kind of works. I couldn't talk. I went up to the front of the bus and I, and they're all sitting in the lounge. I walk up to the front of the bus.  It's not going to happen.  Don't do it. It's just your vocal cords are like this big. That's why you breathe this morning. Oh, so crazy. So I missed that show. Then there was a show in New Jersey two days later that they canceled and then Jason did the Pence peak show in Pennsylvania. And then we were supposed to do, there was three shows, there's two in New York and one in New Jersey, all the same promoter. And the second the promoter got wind of what was going on. And he calls the management goes, if Tornillo doesn't show up to these shows, I'm canceling them. I'm like, you, and I came home. I was home by then. And my wife's an emergency room nurse, or she was at that point. And went down, went to her emergency room and they ran a full panel on me.  And I had you, I had RSV. It was, I don't wish that on no one. I've had COVID three times.  Oh, this was, this was nasty, man. And they were going to cancel the shows. And I said, well, I can't let that happen. Can I?  And Jason and I split the night. And we did the same thing in those three shows like that. There was two in New York, there was one in North Jersey. And then he went back to Texas and I played the New York show, New York city show. It was, it was nasty. Yeah. The court of zone usually, the court of zone usually takes about five days to kick in. Yeah. Well, I was going to take the swelling down, hopefully, but boy, I wouldn't wish it on anybody, bro. And trying to sing with it is even worse.   That's how Robert Plant lost his voice completely. He was sick during the Led Zeppelin tour. And he kept going out, he kept going out. And he just, to the point where he just abused his vocal cords. Well, I did that in the early days of TT quick. I was really sick. And I didn't want to cancel any shows. You know, I'm putting 10 guys out of work if I cancel the show. So I'm not going to do it. So we played, we played, we played, and it turned out I had walking pneumonia, went to a party, smoked something I shouldn't have after a show, had a coughing fit and my lung collapsed. Oh, so I was in intensive care for 10 days, damn near died. And of course, I'm night people on intensive care, and they keep bringing it. I'm awake all night. I can't sleep. They're everybody they put in a bed next to me died.  I need a beer. But it worked out. That's how that's what made me quit smoking. Actually, it was, that was 1980.   Everybody's out of work. The band's losing money. And that's where and that's where they pushed the singers to use backing tracks to go, look, just fake it, fake it. You know, we're not going to lose it. And that's that's the that's the pressure that's the pressure on singers. But it's not fair. It's not it's not fair to the audience to be doing that. It's not. It's not. And and yeah, it is a lot of pressure. And the thing is, too, is, you know, the guitar player breaks a string, you can change it. Somebody changes it for him, drink a drink a drumhead, put another drum on there, you break the shit, it don't come back until it heals. So there was no permanent damage, or do you find any notice to your voice? No, no. I think it usually comes back stronger when something like that happens. There you go. Wow. It sounds like it on this album. The whole thing would collapse long when I left the hospital.  I go, yeah, you guys, you don't sing anymore. I go, oh, my beer. Like 45 years ago. Yep. On that note, you are definitely a humanoid, my friend, you are definitely or you're heading that way or Frankenstein. I don't know what or the other. Frankenstein. It's going to be, it's going to be released April 26th. Napalm Records, is there any closing remarks you'd like to add, Mark? The second single, which is The Reckoning. The Reckoning. Reckoning comes out Wednesday, day after tomorrow. Okay. There we go. So video and single. So by all means, check that out. The album is on April 26th. And other than that, we'll see you on the road. Mark, finally letting go. Finally letting go. Let's book, let's book this in the calendar. 11 years from now, we are going to have this. Okay. That's a, that's a, that's a plan. Always a pleasure. And I'm glad you're feeling good. I'm glad you're looking good. You're strong. This album is unbelievable. And the voice sounds great. And it just another, another quality release from Accept, what everybody expects from you guys in your delivery. Thank you so much. I really appreciate it. And hopefully we'll see you guys. Yeah. We'll keep our fingers crossed. All right. Thanks Mark. All right guys.


Washington calling counter-spire. Washington calling counter-spire. Washington fighting against enemy spies within our borders. Senate hates more army of men and women highly trained to protect us from professional enemy spies within our borders. Imagine chief counter-spire them all. All in the dark, swampy, sustaining coupons show a forgery of nearly a minute up to crack, Mr. Harding. Half a million forged gasoline coupons. Bud counterfeiting or altering gas perhaps worse. Here goes that deep, Mr. Harding. Mr. Harding, concerning those hundred counterfeit gasoline coupons, Mr. Harding, they were printed on Wilson's day company out west. Check every one of those companies, Mr. Harding. I want the names and addresses of all ships, Mr. Harding. Yes, Bud. It does. Well, passing these counterfeit gasoline coupons are under Mr. Bixby for ink analysis. He has some very interesting reports. Good. What is your ink analysis of these counterfeit gasoline coupons, Mr. Harding? Well, Mr. Harding, an analysis shows the ink was compounded with hydrochloric solutions of galic and tannic iron salts, with the usual sugar and gum maramic presence. Applying a reagent of 3% of phallic acid, may the counterfeiters ink disappear? Well, let me go at any gink of the genuine coupons were unaltered. How many concerns the manufacturer of this certain type of ink, Mr. Bixby? Three. One is a very small one, and sells almost entirely in northern New England. Mr. Bixby, cover all of these compounded hydrochloric... Yes, sir. Check all of their shipments over the past nine months. Give me the address of every shipment that they've made. Yes, sir. Bud, pack your suitcase and meet me at 11 tonight at the base airfield. Yes, sir. Close for a warm climate or a cold, Mr. Harding? Hot. What did you find out from those statistical reports? Well, our statistical department has reported, Bud, that a number of shipments of gasoline have been made by six different companies to a certain gasoline-launched supply station along the main road in the Everglades. We also found out that a certain shipment of Willis and Paper was also printed on Willis and Paper. Yes. And also each, similar to that used on the counterfeiters coupons, was also shipped to this gasoline station. Hey, that's hot. Exactly what kind of a filling station is it, Mr. Harding? Are you familiar with the Everglades, Bud? Oh, no, I'm not. Well, there's one main road which has been 40 different little islands. On a few of these are gasoline stations. This gasoline station in question is just about 100 feet off the main road. It services automobiles and also fishing boats. Yes, but how could it service any enemy submarine? People are driving over that road constantly. There must be some neighbors down there. That's the catch. That's what you and I've got to find out about. If anything wrong is going on down there, a mighty clever device is being used. What's your plan, sir? Well, in the morning, we'll land in Miami. We'll get an oil truck, fill it full of gasoline, and find out when the delivery is supposed to be made to this gasoline station. Then you and I will make the delivery. Did we deliver the gasoline at night? There's no sense in surmising or guessing, Bud. Just got to wait and see what they're looking for. Let's see if we can see ours. Go from the native oil refinery in Miami. That's us, buddy. Drive out on the dock. Well, that little door? Well, that holder? They've got trucks than yours that have been out there, buddy. Go ahead. Okay. If we go through it, it'll be off here, but not yours. Make quick time. Yeah, we've got it all the way from Miami. Man, it sure is dark out here. I'd use my flashlight. Put this there. We've got a tank under the dock. That's the pipeline to your left. Okay. I need a drink? No, you can have two to cap at your hand. Yeah, okay, Bud. I've got the holes coming up. Come on, Rob, hold it. Come, Paul. Yes, you are. The thing to film, do you want a drink, mister? Sure. I'm not supposed to touch it while I'm on duty, but I guess the little one wouldn't hide in the hand. Here's a bottle. Help yourself. Thanks. I think I always carry two bottles. One for a friend and one for myself. I'll take a little nip out of mine. Here's to you. Here's to you guys.  What'd you do? Drop your bottle? Yeah, more slug it here on the top of this iron stanchion and bust it. Yeah. You'll have to have a nip out of this other bottle then. Oh. Come on, do you understand it living down here? Nobody for five miles on either side of you. Oh, yeah? Got it spinning. What's that? Alligator. Just one of the Nathans. You get contact. Harding calling J-8 Palm Beach. All counter-spires on Florida, East and West Coast to investigate all ocean-going tugs. Check the last five or six feet of their rope harvors. I broke a bottle of nitric acid on iron hemp fibers of harvors. Notify immediately of any tug having harvors burned at end. Return 535 to Ms. 14 Miles. We'll have to get from her home to the gasoline station. She was going 10 hours. That leaves six and a half hours of her time to be accounted for. That's right. Six and one half hours. The Navy and a tug which makes 14. That means in two and one half hours a tug could cover 25 miles. Beautiful deduction, Mr. Harding. Good reasoning, but where does it get us? What makes you think she did pick up a 10,000 gallon barge at the gasoline station in question? Where was the barge? Oh, but I haven't been into the gasoline hose in 45 minutes. The pipe was full of a dock with a floating tank that went up and down with a flasher. Exactly. But under the dock again. Well, through the counters by headquarters of Washington. Have the contact relay to our field testers. You're starting to get apart. The whole inside is spurned as if there were acid in the gasoline. That cannot be. I'm afraid, sir, it is beyond repair. And the other mode is giving us trouble. That's not possible. Who turned off the lights?  It still appears having the same trouble with our gasoline generators. Switch the colors to the batteries. You must repair them. We'll get the mercy of the Americans. Are you sure it's trouble from the gasoline? Yes, sir. The carburetor and filters in the gasoline lines have always been eaten away by acid. Dumb and lewd. Notify Herr Himmler once. Tell him we're rules. Notify Herr Pitchman in New York. It's his fault. German submarine of Florida Coast. New Herr Himmler Berlin. Submarine also trying to contact the stop-o-agent in this country. But Canada's yet locate contact point. That means it gets to notify Florida police. New York License Bureau, as you requested. Your call is being relayed directly to me. This is Harding. I'm Phil and Ma'am. Harding, Clay. Listen in to our conversation. I'll check in on Pitchman. And you should hear from him within the next two minutes. Excellent, Baxter. I'm using your head. That's like piling clerks. If you're listening on this wavelength, come in as soon as possible. Time's an important hour. Turn to state. August 24th, 1940. Bachelor, sworn in Gestapo at Hamburg, 1937. Check his operators of that gasoline. Gestapo settles those imbeciles.


안녕하세요 여러분, 저는 메스타 유입니다. 미국의 대한민국의 당무도 연습생입니다. 이 시간에 제가 도움을 드릴게요. 여러분도 유의 기능과 위험을 할 수 있습니다. 유의 기능과 위험을 할 수 있습니다. Also, you will improve the strength of your lower back and quads and along with your shin muscles. Once you have a limitation on your hip joint and knee joint and ankle joint, you have the difficulty to bend down or sit down even the rotation. Because this is the old rotation squat and sitting, relying on your lower body. You can easily do it with your hands even turning, turning, picking up. But bending forward and back, stepping turning, you have a limitation. When your body condition is poor, check yourself which part you feel uncomfortable with. Mostly on your legs. Leg is heavy and leg is stiff and tight. Those are the results from the stagnant energy on your hip joint, knee joint. The joint is holding more stagnant energy than your muscles. When blood flows close to the joint, the blood arteries are getting tender to be narrow. Due to this narrowing may attract the many stagnant energy on your knee and hip joint by stimulating with proper posture and respiration and supporting with your guidance. We can say the concentration. You may expect some of the benefits. But please use your caution if this is too much intensive and you can use gently. You need to modify yourself. Prior to practice this training, we have to do one thing to stimulate your Achilles. Put your heels together, toes apart just a little. Here should be sealed. Pick up your heel up in the sky. At that time, try to grip the ground by using the tent toes. You may feel a little weakling. Instead of the step to catch the balance, try to use more your toes and shin muscles and thigh and abdomen and back. That is the muscle usually work together to get balance. Now slowly down, but don't touch the heel on the ground and up. Squeeze your kneecaps by using a partisan muscle and then slowly down and up and down. You may feel some of your toe joint replaced with some of the cracks and up and down. Stimulating your shin muscle along with your Achilles. Great. You can use this one about 20 to 30 times. Then prepare for this training to strengthen and stimulate your shin and knee joint. Feel for shoulder width apart. Great. Next, dragging your right side big toes behind of you. You see the one side leg is the heel is on the ground. The other one is the heel is up. All the way. All the way is better. Not this way. You have to shift your body way all the way to your left. Okay. Now hide top your right side knee behind of the other knee. Now slowly open your left part. From there, turn your core. Now you start to feel the high stimulation on hip joint on your knee joint. But if this is too difficult to you, you may narrow the distance from the heel. Do not overdo it. May result in a difficult situation for you. If that's okay, you can step further. Squats. Now from there, turn your body to your left. Little more. We pass this motion about 10 seconds. Now bring your palms in. Return your right foot. Yes. Okay. You start to feel the high stimulation. Also strengthening your cross abster and your shin cast. Actually say as well. Next one. Other side. Bring your right toes. Left toes behind of you. Depending on your condition, the further you can challenge it. But if you have difficulty, let me narrow it like this. Okay. Return. Place your right palms away. Relax your shoulders and elbow. Then do your wrist as much as you can. Now from there, turn toward the right side. From there, sinking a little bit. Start to feel the hip joint. And this one. We can palms little bit. 10 seconds. And bring your palms in. And return. Great. You can repeat this one about 3 times this side. And 3 times this side. If 10 seconds is too long, don't overdo it. Maybe hold 5 seconds. Even there is 2 hold 3 seconds. Start with a small piece of the lats. When these lats gathering together, you can create a big mountain. Okay. So start with a small effort. Improve your condition along with your confidence. Then you can challenge it little by little. Once you're getting better at it, you can use this as a flowing motion. Okay. You can follow me slowly. 1, 2, 3. Backings. As it comes, otherwise 1, 2, 3. As it comes, another goes. 1, 2, 3. Back in. Switch side. Relaxedly down. And round. Back in. Relaxedly down. Your feet and hands goes together. And back. Stand. Float. Same. Return. One more. Return. Last one more. And return. Yes. You can repeat this training with a little bit holding pose. About 10 seconds. And then once you feel the accumulate of the energy. And then use the second method to supplement your energy side to side. Okay. Great. I hope you gained some benefits from this year. Keep joint, de-joint, strengthening and stimulation training. Thank you for watching.