And not to all the parts of Africa, the Congolese opposition is boycotting a dialogue organized by the government ahead of local and legislative elections in the Central African country. A coalition of parties dismissed the meeting which starts today in Owando, in the country's North-Azeria stunt meant to divert attention from the various crises plagued in the country. The last match, President Danny Sassou-Ungueso and his Congo Labour Party controversially won re-election, has been in power for a total of 38 years. The government has defended the dialogue as necessary to achieve consensus ahead of the legislative vote to be held in five months. The ruling party is keen to maintain an overwhelming majority, but the opposition has demanded a structured dialogue which past sharing constitutional reforms and the release of political prisoners, key among them, General Jean-Marie Michel Mokoko, a former commander who challenged Sassou for the presidency in 2016.


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What's everybody jazzy over jazby's case breaks dot com having your release day our second you release today is 2020 Panini elite Donner's football six box half case break random teams number one is what sold out This actually is one of the first products that you'll see the new draft class in their NFL uniforms and professional uniforms for the first time So that should be pretty fun guys box break down is two autographs one pen pal autograph One memorabilia car three rookies six parallels eight inserts. So for a total I believe of 20 five cards per pack 20 packs per box so there you go and Just remember no veteran commons will ship Only all these right here will ship the inserts parallels rookies Relics and autographs and this is a early bird break guys So buy one of the first 20 spots in this break and get entered a win a free spot. So here's a dice roller Here's the early bird customers that made the list. Here's the customers all in and here's all the teams So let's use the same dice roll for this. Let's roll it and it's a three to two for five times one two three four and five Boom Five times Daniel s Congratulations, you just got you are part of the early bird and just want a free spot Let's put you in there and those five times, right? Yeah Let's go five times here one two three four and five five times John Down at Thomas five five times here one two three four Rungos down to the Cowboys John the wrong goes out of the Raiders Jordan with the Patriots Sefka Sefki a star with the 40 diners Chris you have the bills Daniel the Texans Peter with the Vikings Coleman the Chiefs Angel the Bears Chris Yeah, the Steel's last Bob module Joseph the Saints Chris with the Jets Nick with the Packers Christopher with the Eagles Chris you have the Seahawks John with the Colts Chris. You have the bangles. There you go Matthew the Dolphins just with the Giants Nick with the Bucks Donald with the Browns Raymond with the Lions Derek with the Rams Chris with the Titans Colm with the Falcons Christopher with the Chargers Justin with the Reskins Christopher with the Cardinals Daniel your free spots the Panthers followed with the Jaguars Chris You have the Ravens and Thomas with the Dallas Cowboys There you go Anybody want to trade let me know if not we will start the break in the meantime. Let me just open up this case Or we can decide which half we're gonna use in this break And we're second half random seems already on the website. I think we're done like to the low 20s So can break that still today, and that'll be Joe or Sean later tonight Raiders for Ravens TJ suggesting Chris St. Tynes dealers up Seahawks up and Chris is agreeing to the trade so Thomas and Chris confirm right Ravens for Raiders We do got one trade Well, since it's just you two guys, let's just close the trade window so We'll just get that rolling so Ravens for the raiders. There you go, Thomas. Actually, that's not use the plus sign. Let's use What time can we use? There you go. That's a trade sign right there. All right, so there you go trade with the closing guys and Six boxes to the left six boxes to the right just like a museum collection. Let's choose one two three for the left side four five six Right Let's hopefully get a good dice roll wasn't too bad. I guess four one two three four five six So let me quickly just write down here. Let's put to be to RT To RT on this for the second random teams Callie's yes, man. That won't probably won't be starting for about another hour But I do have it on the spreadsheet. I believe I put it at two twelve fifty So in about an hour Because after this we got to do a museum collection random teams number one and then pick your team number two will be after that So in about an hour get some good work done And then I'll see you in about an hour. So pretty much 20 packs Five cards per pack for a total of 100 cards per box and there's like three rupees per box eight parallels like six inserts and Then two autos one was gonna be a pen pal and one rally so three hits At least I said, you'll see the rookies in there. It's new NFL uniform here for the first time So that's always gonna be a product that people will always go back to when they say hey When was Joe Burrell's first product you started signing with the bangles jersey on? Little kid reporter That's not gonna happen this year. So after they interview a kid from not sure Nancy if it's not on the website maybe Nick Canceled it and if he did then I'm sure he issued refunds so That probably is what happened If it's not on the web, yeah, I don't see it either Yeah, so probably I think they might have cancelled it if we didn't finish up that number eight last night Yeah, check it out. But I'm sure if he might have just taken it off and I didn't even notice Oh wait, let me see broke last night both of them Number seven any oh, well, there you go, Nancy They were broke last night, then we're good Wester, what was my favorite? Tough one man, I love select But I also do love prism. I'd say it's one of those two But then again, I want to say contenders often But then I want to say contenders. I don't know any of those four Let me see.  I don't know if it was number seven or eight though But if he did break in for some reason it just did an upload I can take a look at it after this Nancy and leveled it But I want to say that Great last night at some point. Oh wait. Yeah, there is right here Was it luminance number eight what you were looking for or number seven? Yeah, number eight's right there And then we're seven there it is Yeah, they're both right there Nancy. I just so I didn't have to get refunded. There you go There's seven and eight No worse. All right, let's take a look at this guy's first three boxes. So elite company will chase young. I Don't know. I think this might be a randomizer here I'm assuming Says I would have are these all like Ohio States? Players so we'll take a look at this and if these are randomized then if anything what we'll do is we'll go like First second third or fourth, they're gonna have a bunch of these so we'll put this to the side Give those out. You know if there is multiples then we can always just give one to each each team Adam Troutman Saints Jordan loves to 399. That's a nice one Green Bay Packers Already right off the bat. Look at that turn of the century my boy Justin Herbert 53 out of 99 who has a Chargers? Already hitting it's meant to be Christopher with the Chargers and this is pretty nice I'm gonna say Ricky Rolls of you should be there DJ Dallas for Seattle Josh Allen craftsman relic For the bills going to Chris and star status Bobby Wagner to 349 It's a cool insert. I dig it Gallimore Cowboys and we got to us. This is a cool little insert I'm a dolphins Well, hey, Wester, you know what we have some actually have I think most of those as personal boxes on Jasper's calm. I don't know if you're interested in doing personal boxes, but You know that at 349 349 welcome butler And wow What a Chargers box Justin Herbert and Joshua Kelly pen pals and To Herbert autographs this time. It's a pen pal and it's an on-card autograph with Josh Kelly. I Would be hitting these Herbert's and I want them and I just can't have them though Moving into a new place rents can be pretty expensive now compared to what it used to be Chase young Michael Vic KJ Hamler. That's a cool little one right there. I'm Fitzpatrick a little of Mark Jackson Christian McCaffrey Little dyke at AJ Brown Angles Colton, this is the random team picker team is not sold out yet. We have this all that little pack break Dalton Keene Christian Fulton Steve Largent as in the Torch I Told Nick you got to have a king player Gretzky because if not, they're gonna say you're late in the backyard I don't have no Kings to a Gabriel Davis Andre Johnson Yeah, I could tell you you have really quick Yeah, the Kansas City chiefs it looks like and the Atlanta Falcons To a talk below and we got Brian Evers to 49 Christian McCaffrey and Drew Brees Field vision van Jefferson. Now. We're just getting a bunch of charges in this break Red ink Patrick Mahomes Yeah, I said you should have Gretzky because there's so many Kings players living around here No, I don't think so JK Dobbins, I thought it was just gonna be Jordan or LeBron Kobe Serena Fernando and Dickerson or something like that Herbert this is actually pretty cool. Maybe I bought one of these ones CD lamb Josh Jacobs Let's see do both Jackson. Oh Jalen Hertz to 125 for my Eagles Eagles going to Christopher Freese I think we brought him up to Nick Bosa Um, they are the only ones that they're gonna be in though is gonna be the penthouse This is where they'll be in their pro uniform fully for the most part the sticker autographs are probably most likely gonna be in their College but have logos on them, but the penthouse for sure should have their uniform on them And I think it's just a little difference this year from last year since obviously They had, you know Rookie premieres where they're able to take more action photos Rather than this y'all to cancel it So I think penthouse is what you're gonna look for for the full pro uniform wise T Higgins Pen pals for the bangles Chris with that one I'm not sure Tyler the checklist is out though. I'm gonna check it out Harbor Connection or group rate checklist I want to say if he is it's probably gonna be a sticker and I know We hit some on car autographs of his before he passed away, but I don't know which would have been his last product He's signed on card If there is I'm sure they might be just stickers Brady to 349 Troy Paul Malo insert Akeem Bangles little Joe Burrow Oh Little bit better Chris will get there sweet three to go so far though pretty good names The first three boxes Yeah, they probably Probably didn't put them in there. Yeah, this actually looks pretty solid the base cards look really nice, too So again guys we have these for personal boxes later tonight. Let me on Instagram in a couple hours I go around three o'clock So we can do it some personals of these I Think they're on jazzy's calm and So our museum collection baseball boxes, too. Well Tyler sometimes it's a pretty expensive case break and We feel like sometimes it's easier for someone to split it up because Again at the end of the day Tyler if you really want a full case break All you got to do is buy the teams in both and you're gonna secure your full cases, but I Think sometimes it gets a little pricey and we feel that maybe some customers rather Have a half case break and take a chance out of half and maybe buy multiple teams For a lower price than having to fully commit To the full spot, but again if you're one of the people that love full case breaks All you got to do is just grab both teams and one and two three four five six however they're linked But some people rather just spend half the money than the full spot and take that chance That's why we do it that way sometimes. We don't always do half case breaks But as of lately just because you know museum collection and this stuff happened to be a little pricey box You know sometimes it's just easier to split it up that way. You know what I mean? Like I said not everybody has Has the same size wallets So You know I'd probably stick to half half case breaks too to be honest That's true Pat But at the same time if we did full case breaks the team might not even be there at all You know what I mean? so That's all it is The team you may want may have already been taken at the time too, you know Especially they're popular teams. That's like the bangles. I don't think anybody bought the bangles in number one, right? So I think we had to put the bangles in a in a team random today So I think people should hop on that team random because actually I think it has the dolphins and it has the bangles when it comes to So even better We're talking to me. No, I know what you mean Pat. I mean, it's true. Sometimes the second half might not be there So obviously that's the risk you're gonna take but It also could be that the bangles may not even be available at all or whatever team you're looking for even in a full case break Yeah, I think it's just easier to sell half case breaks much quicker And people will commit to paying half the price. That's all if they are available That's why I always suggest to tell people If both teams are available number one and two and you want to secure hits potentially for a full case grab them Of course if they're not there then obviously that's the risk you're gonna have to take and get them in a half case for sure Yeah, I don't know what it is sometimes Pat. I think honestly, I think a lot of us are superstitious I think what it is is like their favorite numbers number two. So they rather just Get the number two team rather than number one. I really think it's something like that or you know They just they said screw it. I'm gonna grab two teams a number two and none a number one You know, I don't know. It's just something like that You know, I really think it is that like when I look at picker teams Like when I bought into a couple of anti-pigger teams at other places I bought into picker teams number six because I was like Number six my favorite number. I feel good mojo in this. Let me buy the Eagles a number six Even though they're available number one and two That's what I did But I bought them in a full case not a half case. So I was still securing them But I was just I was just shopping around numbers Nice. Well, good luck Tyler Yeah, I mean what also is to is maybe they wanted to grab two teams a number one, but You know, let's say the bangles are taking number one And they wanted the bangles and like the Eagles so that I got screwed the bangles are available number two So let me grab the Eagles a number two in the bangles So that way they stay in the same break and I feel like that's another strategy to They just want the teams they're gonna buy to stay in the same break Sometimes it goes that way. I don't know for me. This is all about super this being superstitious Obviously getting lucky, but again studying the Czechos guys. There's their strategy to case breaking too. It's not just It's not just obviously just all fully luck and Obviously trying to invest if you're trying to do this for some type of investment to flip in the future then obviously invest into players that Have a good potential, but then at the end of the day, we don't even know, right? They could have all the potential in the world, but they never make it Jared Goff No, it does hurt. It really does. I get that though. It's like it's 50-50 or sometimes both of you guys hit But it is it is a definitely a risk Show that Stafford did they have Mario in Raiders here already? Can't wait to see Mario take over for the Raiders Yon Branch who killed us in the Super Bowl Christian McCaffrey to 75 a lot of Tom Brady inserts there's some with the Patrons and some of the bucks as well and Antonio Ghandy golden the penthouse Gilmore or galleymore Herbert 799 Gabriel Davis. What is this like a one or something? I don't see no number, but it looks pretty cool Christian McCaffrey field vision little Russell Wilson Dica number 97 Nate Stanley to 99 Gabriel Davis Phil Montaigne a playmakers Thomas to a tug of a Lola 799 Miami Gonna Matthew another Herbert this time at 399 and Antonio Gibson rookie autograph for the Redskins and a Justin This one has an extra hit like extra hit or something full throttle upon Barclay and a tool tug of a Lola Yeah, you guys you just got to be you got to be snakes guys, honestly Lamar Jackson look at that double patch to 25 It's like, you know, honestly guys, some people really stock our website They really do they're up early in the morning to make sure that when are they kind of already time doing Nick Posts up these picker teams so that way when they see them posted they just snag them But again, not all of us have the time to Come look and see what's available. It does make it a little tough You just have to know that you're not the only one that wants them, you know, Henry rugs. How about that green ink? And I think by the color of the pen pal tells you how rare it is. I think Where's a ratus? Chris trade mojo getting a Henry rugs Then the raiders so actually Lamar Jackson relic Henry rugs auto so so far one hit each Danny amandola John high tower to 799 Xavier McKinney for the Giants haven't ingrown to 99 Carson Wentz Rice Perkins Kenny Galladay impact impressions anymore to 149 for the Colts Spellbound Help on the suitors CD Lions going to the Cowboys Die-Cut Jamal Adams to 24 24 to 24 for the Jets. All righty guys Last box Good luck Second half random teams is in the store guys 25 To a tug below for the Miami Dolphins and we got Tyler Boyd to 49 The King Davis for the Bengals Sam Darnold and James Morgan for the Jets turn of the century 49 Jets going to Chris. There you go, man. You got your Jets hit Caffrey Spellbound numbered every playmakers Which have at least one more autograph and it's gonna be a pen pal guys It's 99 mink of Fitzpatrick Pats their 49 for the Steelers Another one for Chris last spot mojo Steelers sit right there Jerry Judy Jonathan Taylor 799 got AJ Terrell to 399 Michael Thomas to 99 and it's Michael Pittman, Jr. Pen pal autograph for the Colts John Paul. Oh, is that right Pat? Yeah, nice. I knew the green was kind of more limited Is that 10 copies per checklist nice? So yeah, that's an out of 10 Remember they said that the color of the ink usually identifies What kind of a how short printed really is? Mates Stanley their own James Alrighty guys. Well, there you go. So we did get some nice stuff. This is actually just There's a relic. These are numbers with James Morgan auto. You got Kenny Moore So this should be out of 10 Henry rugs or short printed to 10 You got Antoni again golden T Higgins a dual autograph dual pen pals of Joshua Kelly Justin Herbert Jalen Hertz to 125 You got more for the Chargers. Oh, this is actually Jefferson Chargers to me passing the torch Steve Largens Justin Herbert 99 and Michael Pittman There's probably another couple autos in here in relics in this stack here a lot of stuff guys that'll be Paying Steve to top load these are all the inserts and Stuff that'll ship So there was these carts here I want to just look on the checklist really quick if it does show all four teams because I'm assuming that we're just gonna have to Four-way it so we'll do it like this from the front One two three or four and then whatever lands on is what team is gonna go to so if it goes Jerry Judy that'll go To the Broncos those Julio Jones. I don't go to the Falcons Jets To the grounds So I'm assuming that's what the checklist shows We'll do it for all of these right here There was a couple of them the same Either way they got to be randomized So it's quickly randomized and see who gets what For that So let's actually just pull a carbon connection that will check Red ink only we got a red so it's like the red ink like this van Jefferson or just Just something else. It just looks red because we got a red ink in there Where's football here to sir? So yeah, it's a leak company We're gonna go by the player so number one starting with chase young to the second player third player fourth player on the front to just so that way People know what we're doing load extra hit for somebody six and four ten times one two three four five six seven eight nine So ten times. Yes fourth player on the front So I don't go to the last player right here Which in this one will be Paul Warfield and that'll be for the Miami Dolphins And there you go guys appreciate elite round of teams football number one sold out in the books number two is on the website Jasper's case breaks calm


In the last segment, what we did is we came up with the idea of thermal resistances and it is basically a bit of a shortcut technique for calculating conduction problems. So what we're going to do now, we're going to work an example problem involving thermal resistances and heat loss through the wall of a house. Okay, so there is our problem statement. What we have is we have a house wall that consists of two 1.2 centimeter layers of fiber insulating board and then there is 8 centimeter layer of fiberglass pink on the inside between those two walls. So we have a layer, a layer and then inside here we have fiberglass pink and then what we have is we have a layer of brick on the outside. So there would be brick on the outside and then what we're told is that we have convective environments on either side. So we have this layer of brick and then we have two convective environments. One is at minus 20 degrees C, so that's pretty cold and I assume that is on the outside of the brick, so the outside of the house minus 20 degrees C. We have convective environment. We're told the convective heat transfer coefficient is 15 watts per square meter degrees C and then we also have another environment on the inside of the house and so you might have forced air heating or where you could have radiators, but in any event you'll have air circulating inside of the house and the temperature inside the house we're told is 15 degrees C and H is equal to 8, H outside was 15. So that is what we have for this problem and now what we want to do, we want to be able to figure out what is the heat loss, the rate of heat loss through this system. And so you can see we're going convection, conduction, conduction, conduction, conduction and then convection. So we've got a lot of stuff going on, but this is an ideal problem that you can use thermal resistances on and it's a series problem and so what we'll do, we'll work that and we'll begin like all the other problems, let's write out what we know. Okay, so there is all the information that we were given in the problem.  So that is our unit area and the problem, we're looking for the rate of heat loss or the heat transfer rate, so we're going to assume this is one dimensional and looking at the problem, all of the assumptions that led up to the thermal resistance technique will work and those being we have steady state, one dimensional conduction, there is no internal generation in the wall and the thermal conductivities will assume or not functions of temperature. So with that, what we'll do, we're going to come up with a schematic that has the coordinates and the information in terms of lengths and things on it. So let me write that out. Okay, so there is the schematic for our problem. We have the convective environments on either side and then the wall and just like I said earlier, we will assume the things that are required in order to apply thermal resistances and that was steady state, one dimensional conduction, no internal heat generation and the final thing is K is equal to a constant for all of the materials that we're dealing with. So given that, what we're now going to do, we're going to perform the analysis using thermal resistances and this is a series problem. And so what we'll begin by doing is writing out what our resistance network looks like and we're going to have the number of resistances that we're going to have, there'll be one here, there'll be two there, there'll be three here, four, five and then finally we're going to have six out here. I probably should have used different numbers because that's going to mess this up with the widths. Let me erase that. So for thermal resistances, I will do A, B, C, D, E and F. Each of those is going to have a thermal resistance, although we're going to have a different symbol for it. But anyways, that shows you the number of thermal resistances. So let's take a look at the analysis of this problem. So what we do when we're constructing our network, we begin with the temperature at the one side and that was T infinity i and then we move along and you'll notice we first get to the convective environment. So that has a thermal resistance associated with it. So we put a thermal resistance in and the value of that is going to be RT for thermal resistance and then convection and I'll do an I to denote that that is on the inside. And then we move along looking back at our schematic. The next one that we hit is going to be the wall board, which is on the outside of the wall. So that will have another resistance and that will be due to conduction. So it will be thermal resistance conduction and I will give it the number one because that was the length scale that we had for that one. Then we move into the fiberglass pink insulation and that had length scale two. So that will have its own thermal resistance and that will be RT again due to conduction three. Looking back at our schematic, we then go through another wall board, length L three and so that is going to have another thermal resistance. RT conduction four. Next one, we're going to have the brick, which is on the outside of the wall. And so that is going to have another thermal resistance. Again, it's going to be due to conduction. And that will be five. Oops, sorry, I missed the number here. It should be one, two, three, four. And then finally, what we're going to have is the last one right here. That is convective heat transfer. So we have a thermal resistance to end it here. And that is due to convection and it is convective heat transfer on the outer surface. So I'll put a zero there. And then finally, just like with voltage, you have a voltage drop here. We have a change in temperature and we're going to have a temperature drop. And we then get to T infinity outer. So that is our problem or the scenario that we have. And now heat flux is going to be flowing in this direction. That is Qx and that's what we're after. And the neat thing about thermal resistance is, although we're not going to do it in this problem, once you solve for the heat flux Qx, you can use the equation for thermal resistances in order to figure out intermediate temperatures. And so that's kind of a quick way of computing temperatures at intermediate points. And you'll use the equation for the thermal resistance, basically the equivalent of Ohm's law that we have. And that's how you could evaluate those, which you would do if you're doing electrical circuit analysis as well. You could calculate voltage at intermediate points. Well, here we can calculate temperature. So with that, what I'm going to do, I'm going to write out all of the different thermal resistances. We're going to sum them up because this is a series circuit. We'll put them in the equation and we'll solve for Qx. Okay, so those are all of our thermal resistances. What I'm now going to do, I'm going to sum all of those. And so the total thermal resistance is going to be equal to sum of each individual component because this is a series circuit. And we get 2.5757. And with that, we can now put it into the equivalent of Ohm's law that we have for thermal resistances. So let's do that on the next slide. And what we have then is Qx is equal to, and it's going to be the temperature change from one part of the circuit, from the start of the circuit to the end of the circuit. So looking back at our circuit, we're going from here. Let me do that in red. We're going from there to there. So that's going to be the temperature change over all of the resistances that we've computed. And when you do that, we'll divide by the total of the thermal resistances for all of the individual components. And if we recall, the inner temperature was 15 degrees C. The outer temperature was minus 20. And then that's going to be divided by the sum of all of the resistances, which was 2.5757. And with that, we get Qx is equal to 13.59 watts per meter squared. And so there, what we've done, we've calculated heat loss through this wall using thermal resistances. It's quite a simple technique. It's straightforward. You're just putting these resistance values together. And like I said, if you wanted to go in and evaluate the temperature at one of the intermediate points, you would just use this equation again. But the end points would change. And the resistance values that you're working with would be different. And that would then enable you to determine the temperature at one of the intermediate points within the circuit. So that is an example using thermal resistances provided that the four assumptions apply, that steady state, one-dimensional, no heat generation, and constant thermal conductivity, you can apply this. And you can do this also for cylindrical or spherical coordinate systems. And so it's a pretty quick and efficient method for doing conduction analysis.


The ISCCPEG Nursing Genomics Project Group has convened a group of experts to create a set of frequently asked questions for nurses at three levels of practice. Entry level nurses, advanced practice nurses who are nurse practitioners, and advanced practice nurses who are nurse educators. The following video will expand upon six of those answers, two from each FAQ in the series. We hope that you enjoy learning more about these areas of nursing genomics. Please share your thoughts in the comments thread of this video. Entry level nurses, why is genomics important for nurses and in which practice settings can it be used? This is a great question because genomics is just so very important for nurses for many reasons. Genomics is a rapidly developing science and we're already seeing improvements from the use of genomics in various sectors, including our health, environment and the economy. In healthcare, we see genomic knowledge from bench science being translated into direct clinical care with improvements in the screening, diagnosis, treatment and prevention of disease. Improvements in health related to the incorporation of genomics can be seen at individual, family, community and population levels. The integration of genomics into healthcare has led to the development of a new approach to care called precision healthcare. Precision healthcare combines a person's unique genomic information with other relevant biological, social, environmental and behavioral determinants of health to develop a care plan tailored to the individual. Genomics can sometimes seem like it is outside the scope of practice for nurses. However, with this shift to precision healthcare approach in clinical care, nurses should consider genomics to be fundamental to nursing. Nurses should be reassured that not only is genomics not outside their scope of practice, but the precision healthcare is very similar to the personalized care approach historically taken by nurses. Precision healthcare combines the holistic approach to care embedded in personalized care with an individual's unique genomic information. Vital aspects of precision healthcare that are already foundational to the personalized care nurses provide include advocacy, equity, access, ethics, patient autonomy, patient education and family relationships. Nurses can take small steps to learn about how genomics can be integrated into their current practice. One example is by learning what genomic factors to ask about and be aware of when obtaining a family history. A family history that includes this information is commonly referred to as the most cost effective genetic tests and can be crucial to appropriate and timely diagnosis and risk assessment. It is vital that nurses integrate genomics into their nursing practice and increase their capacity to provide precision healthcare because nurses are the largest group of healthcare of the healthcare workforce and spend the most time with patients and their families. No other group can make as big an impact on the accessibility quality and effectiveness of precision healthcare. Nurses are key members of the healthcare team and need to have foundational genomics knowledge to help with the team approach to precision healthcare. Additionally, nurses can and should be leaders in precision healthcare. Parallels between personalized nursing care and precision healthcare make this an area with many opportunities for leadership from nurses. Nursing's voice is critical to ensuring a holistic person and family centered approach to the implementation delivery and evaluation of precision healthcare. I'm so excited for the future of nursing as more and more nurses integrate genomics into their practice. In terms of which nursing practice settings genomics can be used in to reference an Oscar winning movie genomics can be used in every nursing role every setting all at once. As we learn about how health outcomes are influenced by genomic variations, as well as interactions between the genome and the environment, we are seeing applications of genomics that are relevant across the lifespan and in all practice settings. Nurses need to be prepared to integrate genomics into the nursing process, including gathering important information about the patient's environment. And nurses in all practice settings need to be prepared to provide patient education and be patient advocates in this new precision healthcare era. Nurse practitioners. What is the role of a nurse practitioner as it relates to genetics and genomics? Nurse practitioners are critical to providing genomics informed care to individuals, families and communities. As advanced practice providers, how nurse practitioners integrate genetics and genomics into their role builds on what registered nurses do. The nurse practitioner scope of practice related to genetics and genomics includes assessing, diagnosing and creating care plans based on precision health principles, ordering genetic tests and providing pre and post test counseling, providing individual and family risk information, and following risk based screening guidelines. Genetics and genomics informed care also includes taking and continually updating a comprehensive family history to identify those at increased risk and ensure they receive appropriate care. Based on the information they collect, nurse practitioners can provide genetic counseling to educate individuals and families, refer them to genetic counselors, if necessary, and implement tailored screening approaches for those at increased risk. Nurse practitioners are key members of the healthcare team and are critical to implementing precision healthcare for all. They should work with their colleagues to incorporate genetics and genomics into clinical care. These colleagues include other healthcare professionals who may be able to provide genomics related information and guidance. Although some nurse practitioners in practice may have received limited content on genomics during their graduate education, there are widely available resources to support lifelong learning, including local genomics experts, continuing education courses and webinars. Nurse practitioners should use these resources to support integration of genomics into their practice. Because of their involvement in every aspect of patient care, nurse practitioners play an extremely important role in implementing genomics informed precision healthcare for all. Nurse practitioners. How can nurse practitioners be prepared to respond when patients share DTC results? Consumers who have undergone some type of direct to consumer genetic test or DTC testing is expected to surpass 100 million very soon. DTC genetic tests are readily available, often marketed as gifts for family or friends, and can be purchased quickly online. Patients bringing DTC genetic test results to primary care providers, such as nurse practitioners, has and will become more frequent. Nurse practitioners should be aware of what these results mean, where to go for assistance, and recommendations for next steps. Patients trust their healthcare team and are counting on you for the most sound and educated advice. In these cases, it's up to you to remain knowledgeable about how to interpret these results, as well as keeping an updated list of genetic specialists who may be able to help you. There are nurse practitioners with clinical genomics nurse credentials, or those who may be working in a genetics clinic. Additionally, there are physicians who work as clinical geneticists, as well as genetic counselors to name a few. While DTC genetic tests can provide details about ancestry, traits, and some health risks, they do not test for all known variants that can be disease causing. This means they should not be used to rule out or screen for a particular condition. Even if the DTC genetic test results show an abnormality that may be clinical actionable, these results typically need to be confirmed with a clinical genetic test. While DTC tests look at some genomic information, clinical genetic tests are more comprehensive and are based upon current genomic information known for a certain disorder. Due to this, DTC genetic test results should not be used for clinical decision making. It is important to communicate with patients about the risks of a false sense of security if the results in fact come back normal. As mentioned, all known variants are typically not tested, which means that the patient may still be at risk and patients should really understand this. For instance, if a DTC genetic test result identifies a single gene high risk variant, such as those we see with the BRCA gene variants for breast cancer, clinical genetic testing should be initiated and or referral or further discussion with a genetic specialist should occur. In the meantime, it's your duty as a nurse practitioner to maintain and update a thorough family history. And then depending on the results of the clinical test, patients, family members and close relatives should be educated about their risk and offered any screenings, treatments or other interventions as indicated. For patients with a low risk variant or one considered to be multifactorial involving genetics plus the environment, such as with type 2 diabetes, the provider should be prepared to explain that this may indicate increased risk for condition, but does not mean that they have or will even get the condition. Patient education in this case should focus on lifestyle management, as well as ongoing screenings. However, DTC genetic testing has been approved for a few variants for medication management via pharmacogenomics tests that are FDA approved do not need to be confirmed with a clinical genetic test. Currently, there are just a few medications for which this is approved. However, one caveat here again is that patients may not be tested for all known genetic information and may only get results for a handful of the variants that are known for drug metabolism specifically. You always want to remember your chemist, also known as your pharmacist, as someone to seek professional guidance from as well. With the increase in DTC genetic test access as well as the increased use, interpretation of these results will fall on nurse practitioners or other health care providers who are trusted to provide the most sound advice. In order to do this, nurse practitioners are expected to remain knowledgeable and up to date just as they would with any other clinical practice update in order to provide the best evidence-based care for every patient. Nurse educators, where is Genomics included in the American Association of Colleges of Nursing, AACN Essentials? So you want to know where Genomics is included in the Essentials. The American Association of Colleges of Nursing, the AACN, released a new version of the Essentials document in 2021. And the Essentials document is intended to provide a framework for the preparation of nurses at four-year colleges with specific guidance about developing and revising nursing curricula at specific degree levels. A very important document for academic nurse educators. So to answer the question, where is Genomics included in the Essentials? It's everywhere in the Essentials. Each one of the 10 domains includes competencies and sub-competencies for which Genomics-informed nursing has relevant and concrete applications. Genomics is referred specifically several times in the document, but you won't always find the elements related to Genomics simply by clicking and entering a search on genetics or genomics. I'll give you just a couple of examples. So the first domain in the Essentials document talks about foundational knowledge that nurses need to practice. And the competency 1.2A states that entry-level nursing education should enable nurses to apply or employ knowledge from nursing science as well as natural, physical and social sciences to build an understanding of human experience and nursing practice. Advanced practice nurses need to take this idea one step further, and in sub-competency 1.2F, it's noted that they should be able to synthesize this knowledge from nursing and other disciplines. Notice that in these two sub-competencies, the word genomics or genetics does not appear. However, biology is one of the natural sciences, and the study of genomics is essential for understanding the fundamental biological processes that make up human physiology, anatomy, including growth development, and the maintenance of homeostasis. Domain 2 is another example. Domain 2 of the Essentials document focuses on person-centered care with applications to individuals and families. What gets more genomic than that? One of the sub-competencies in this domain discusses the importance of being able to apply individualized information, specifically genomic information for the delivery of personalized healthcare. Both entry-level and advanced practice nurses must understand that personalized or precision healthcare is taking into account individual risk levels, screening decisions, and treatment plans. For example, if a woman has a lifetime risk for breast cancer that exceeds 20%, guidelines recommend that she receive annual screening MRI in addition to mammography. The Nursing Genomics Project Work Group from ISCCPEG has developed a frequently asked questions page, and on that page, we provide a table that maps a few important nursing learning objectives and activities that will help nurse educators teach students the application of genomics-informed nursing care. So final answer, nursing genomics is everywhere in the Essentials. Nurse Educators. How can genomic competency be assessed? It's my opportunity to provide some additional information on how we, as nursing educators, can assess genomic competencies. With the publication of the new Essentials by the American Association of Colleges on Nursing, our profession is moving towards a new model of competency-based education. Competencies are the knowledge, skills, attitudes, and behaviors that contribute to a nurse's performance. Transitioning to this new model presents an ideal time to ensure nursing students have the foundational genomic competencies needed to enter the practice environment. In nursing education, we must also consider the novice-to-expert model developed by Dr. Patricia Benner. Assessment of genomic competency acquisition can also be viewed through the same five levels of proficiency, novice, advanced beginner, competent, proficient, and expert. Teaching and assessment strategies for each of these stages can be scaffolded to help students gain skills and knowledge as they progress through each stage. Let me illustrate how we can map course objectives to the AACN Essentials domain of person-centered care while keeping in mind levels of proficiency as students demonstrate competency attainment. Gerald is a second-year nursing student who is taking his first clinical course, health assessment. In this course, students must show competency by utilizing interviewing skills and assessment skills to elicit a comprehensive health history. At the novice level, Gerald was able to identify and gather essential components of a person's individual health history. Meanwhile, Sophia is in her fourth and final year of her undergraduate nursing program and enrolled in a leadership course where students must apply strategies for increased collaborative practices. At a competent level, Sophia was able to obtain a full patient and family health history and discern a relative hereditary risk. She was then able to advocate for genetic counseling for this family. Monique is a family nurse practitioner student about to graduate and take her licensure exam. Monique is enrolled in the transitioning to advanced practice course. One course objective requires students to evaluate healthcare clinical process and practice problems and identify possible solutions. Monique works alongside her preceptor in a rural clinic located in parts of Appalachia. Most of their patients hesitate to obtain genetic testing when warranted. Monique demonstrates expert communication skills to gain trust and develop a variety of modalities to improve the genomic literacy of the patients that she serves. Whether your school of nursing has a concentrated genomic course or genetics and genomic information is threaded throughout the curriculum. These examples identify ways that genomic competency skills can be observed and assessed in the clinical setting. As you can see, competencies mature over time and become more sophisticated with ongoing practice. Within the classroom, we can also assess proficiency levels for baseline and advancing competency attainment through case studies, simulation activities, and even validated assessment tools. See other FAQs in this section for more details on resources and ideas on ways to map and assess genomic competencies within this new model. And I encourage you to explore all the FAQs that encompass rich information for practicing nurses just entering the field or have an advanced degree.


Hello everyone. Welcome to People's Health Dispatch. Today we are joined by Chihan from Third World Network and he's also the co-convener of People's Health Forum Malaysia. Chihan is here with us today to speak on the issues of health and healthcare that have been faced in Malaysia and give us a description of what has really happened there. Welcome Chihan. Thank you Gagaya and thanks People's Health Dispatch for the invite. I'm happy to share with you about the situation in Malaysia. Whenever we talk these days, we are starting with the issues of COVID and I think maybe let me start there. What is the present situation of pandemic there and how was the response in the last two years towards the COVID pandemic in Malaysia and is there something that you want to say about this? Yeah, I think currently the government is doing a good job, especially after they ensure that the vaccine supply is sufficient to give the overall population and even the booster doses. So this half of the population has at least been given second, the first booster dose. So that means, and also for the first two dose, we have more than 80% of the coverage. So for a vaccination campaign, you can say it's a huge success and actually this is the foundation for successful control of the pandemic and transition to the pandemic currently. But for the past two years lessons have been learned, especially when the time before we receive any vaccination, I remember the delta virus trend actually devastated our public health care system and caused a lot of deaths and hospitalization. And many actually have to even wait around in the hospital compounds even to sleep outside the camp, the temporary can set up by the government just to accommodate the large amount of infected patients at the time. This means that there are definitely some deficiencies in the public health system there. I think Malaysia is one of those countries with a mixed system where you have both the public as well as private. Could you speak a bit about, you know, the public health system there. How is it one, you know, how, how does it function, but also you know how strong or how weak it is because I think in your recent report, you have detailed a lot of things on the issues faced by public health systems in Malaysia, and how is the response of the government for these demands to. The question. Yes, Malaysia has gained independence from the British in 1957, and we actually inherited some kind of a structure and system from the UK, especially when the NHS is getting popularized in UK and there's some spirit and some fundamental values in views here in Malaysia. So, so in Malaysia we have, there's a two tier healthcare system, of course, a government become the main provider service health service provider, and also the single payer for the public health system. That works similarly as the UK, at least before, or at least before, I mean, the contemporary UK. Yeah. We have a sizable private sector here, but they function many on the market system. So, besides the standards of operation and infrastructures are being regulated. Other than that, even health data, even the pricing of the services are all determined by the market. There's not too much of a cross talk between the public and health private health system. And that's actually created some kind of attention, especially with the limited healthcare resources, especially the manpower especially the health practitioners, the labor for that. Yeah, but all in all, I would say our relation health care public health care system or the structure is pretty much intact. We do, we have three levels. The first level is the primary care, and then we secondary care and tertiary, tertiary being the hospital and primary care we do have lots of health clinics run by the government. It will have a ruler clinics. So, the statistic pose that 92.6% of population live within five kilometer radiance of a public health center. So it's quite a achievement if you look at the Malaysia geography. The distribution there will you know that there's a vast land in the East Malaysia. And with the kind of record 92.6 is actually kind of achievement for the government but it's not easy. There's still a lot of problems. And we do have a very good primary care in terms of immunization. There's something that we learned from the British time. We do have we do boost about 98.4 to 1.5 of infants born in 2018 administered with BCG. This is a very high, especially when even before pandemic there's already a lot of vaccine skeptic or anti-vaxxer kind of campaign in Malaysia still in 2018 we have this 98.4% of the coverage is considered very good. And the government did spend on health, totally from the taxpayers money, I mean from general taxation, we spend about 1123 per capita is equivalent to 260 USD per person per year. But one big problem for Malaysia is that the society and the population are not actually really healthy. The health trend is actually going down. There's a lot of reason, especially when you look at the major indicator such as overweight population, this comes close to half one in two are considered overweight. And I would say, probably including myself, that I have to take care of, and then one in five, having diabetes, and about a third of the population, they don't do regular exercise. So you can see there's a lot of health problem and the trends actually getting worse. So, if government cannot control at the primary care level, that's what the People's Health Forum reform is about we want to strengthen the primary care. So there's a lot of linkages problem, especially when you're talking about continuity of care or health promotion. There's a serious lack of effort on the ground, especially utilizing the private sector resources, because at the primary care, more than 80% of the DPs actually belong to the private sector. So it's a kind of resource for the public sector to handle. There's a lot of demand for the primary care. So they couldn't deliver because also they lack of budget to work with the private sector to take care of the population health at the primary care level. So the statistics told us that there's 2.8 million of hospital admission in the government hospital alone have very might that Malaysians has only 33 million of people. So it's about close to 10% of hospital admission per year and 48 million of outpatient attendance in the government clinics. That means there's a lot. So there's a lot of demand and this demands keep on palling on the government and yet the government budget does not really increase fast enough to keep up with the demands. So basically this big volume about the Malaysian health care problem and challenges right now. Because the private sector do have more hospital than the public one, they have 202 private hospitals and government only has 156 in 2020. But in terms of the admission is about 70%. The government has to take care of in terms of our outpatient is close to 90%. So all the burdens with government is kind of expected because in Malaysia, we provide the care as one of the social welfare services as with education is for free, or at a nominal sum. Because this is a fundamental right to the services for the population. So we still retain that unlike Singapore, they have already met for us to another system where people always have to pay this nothing for free in Singapore. So they also gain dependence from British. They don't do the same. So in Malaysia we are proud to say we still maintain that very cheap system where you only need to pay one ring it to see a doctor. This affair is with us since 1980s. So for close to 40 years, the rig doesn't change when you get to see a doctor firing it to see a specialist. You can find it anywhere. So it's close to close to free of charge. But there's a lot of challenges because the private sector is driving before the pandemic. One thing they are driving on is the medical tourism is a selling of the health services. Because they dim the Malaysia market is small enough, but they can attract in good proposition to attract a lot of Western and rich Gulf Arab countries, people to come to Malaysia to use the health service and we, Malaysia boost our health care standard and quality on par with Singapore and any Western countries. Yeah, so that actually costs a lot of strength because when you need to operate a private hospital with specialist, then you have to get it from somewhere. The usual place for the private sector to push specialist from the public sector or even within different private hospitals. So with the kind of growth in the medical tourism and the private health care sector, you can see that actually more and more government resources stream. And that's why you see there's a lot more private hospital. Before we go into a bit of the private health sector, I would like to ask you more about that in a while. Okay, you've been saying how important the public health system is because you're saying there is this huge demand budget, you know, does not always meet the demand the infrastructure is, I mean we have seen in the pandemic and all through that the resources are tight and there's always beds are low, the number of doctors are low, and nurses and so on. So, and, you know, globally we see there is a onslaught on this understanding of provision, we call, we say public provision of health care. So, is there any such thing and is there any, I mean, what is it that civil society or organizations and activists in Malaysia. You know, what is it that you, you have been demanding the government for one improvement of the existing public health infrastructure. And two from, you know, privatizing or from, you know, because we see in many countries, hospitals are slowly decreased or they're privatized and so on. Are there such issues in Malaysia. If so, how is it that, you know, are there any discussion with the government and debate and so on. So very good question about is a difficult one for the government government treats health sector as economic sector. That's the first problem that we face. Once they have this policy proposition that means they would actually not do much to actually stop the sector from growing, then the problem just excerpt it. But we want to actually from the civil society, often we want to go on to rectify the problem, actually to strengthen the public sector by investing more. Because currently, the public spending on the public health is very inadequate in Malaysia in 2018 before the pandemic. It's been 3.8% of GDP on health that includes the private spending, but it's, it's actually below the world's average 6.6 is not because we are healthier just that there's a reason for that. If you look at another indicator is the public's government expenditure on health in a total of government expenditure Malaysia only spend 8.5% of the government total government budget on health. If you look at the world's world average is 10.4 but if you compare with the similar economic social economic development country, the upper middle country such as South Africa and Thailand, you will see that they spend 13.3% and 15% on health. Obviously Malaysian does not spend enough on health. And this actually is the source of a problem, because if you say we do not build enough of the clinics and the hospital, then you need money. If you don't recruit enough specialists or don't trade enough, you also need money. And if you think about the private, the primary care that we do not have enough service to really take care of every citizen that also needs money to run. You can also have a program to outsource it to the private to join the program. Since you know we have a 70 to 80% of a GPS in the private sector. So that's what how I look at the problem. If a government thinks that health sector is for money making, then there will be inconsistency. I think this clash of looking at it as a right and looking at it as a market commodity is always the clash and a lot more in the health sector. So, I, from there I'll you know I'll use this into looking at you know, you're also saying, in addition to the public sector there is a vast private health sector there. So both in the code pandemic and in general, what is the analysis of this private sector, is it actually able to cater to the needs of the people and first of all, is it accessible, because you know in many countries we see the private sector is a lot more costly, because people have to spend a lot from their pocket to an extent of you know even selling their assets and so on. So, there is this always a conflict with private sector, many of us, you know, you and I find it a bit difficult. So, yeah, how do you see the private sector. And what is your analysis of critical critical comments. I have a question I think just like there's one additional point I focus to mention is that our society actually demand the government to spend close at least 4% of GDP on public health. So you just combine with a private expenditure you reach the 4% public expenditure alone has to be 4% and above. And that's what the former government when they took power defeating the long standing government before that. And they actually promised 4% in five years. So, in two years of their governments they feel they, they, they, yeah, the, there's, there's the collapse of the government. So they couldn't fulfill and we didn't see that they have the political view to fulfill the promise. The expenditure is coming to the general election time period again and this time the three main political coalition promise, they try to outbid each other they say 5% five years. So, the all three big one, they promise 5%. So, actually I hope, and we from the civil society we definitely will push the government to actually realize that, because it's actually a quite a steep increase in terms of the real money term, they really commit to getting 5% of GDP in five years that means every year they have to increase at least 10 billion we get Malaysia for the health budget. It's not the small feed. But anyway, so what the pandemic told us is that we, they exposed the public health system in terms of infrastructure, like I say just now in the beginning. There's a lot of demand for beds, because people seek is because due to COVID need special kind of environment to keep to contain the virus. So actually that time, simply the public hospital couldn't cope with that many search of demand for the base. And even that time, the private hospitals were not cooperative. They were into negotiation with the government talking about money terms. They refused to take COVID patients. They just want non-COVID. So they asked the government to decay in the non-COVID patients to their hospital, but don't want anything to do with the COVID because that will actually scare of other local patients, because if they will have a COVID section, then people will be afraid to go. There's one reason and then the maintenance of a COVID hospital condition is also quite strict and costly. So from that you know the system is not working when we have two tier system and not cross talk and the private sector only think about their profit, their reputation and public opinion about them. Then they're not, they don't put people's health as a priority. And don't think about people's benefit. So that's what we always wear when negotiating with the private sector. And in the last year, government even declared public emergency in Malaysia, partly due to political reason, but also they use a pandemic as a reason. I won't say excuse, but it's a legitimate reason to force the hospital, hospital to to to cooperate, to to accept COVID patients. There was the moment that they started to actually admit COVID patients. So you even have to use the emergency law to force them. So, so if the gap is now now we are into the endemic period, and the private hospital currently trying to going back to the normal days, and the doors open already for medical tourists. And in the latest government budget also they, they allocate budget for the development of this sector. So I would expect this problem will go on. And of course, to your, for your understanding, the specialist in Malaysia's are usually trained by the public sector, private sector never spend a cent on training specialist. And when they approach this, nothing like, like a football market you need to pay a transfer fee or something that's nothing like that. So they just coach. So there's a design, actually there's a 50% of. Retrition rate. What do you call attrition rate attrition rate. Okay, sorry. That's a 50% attrition rate from the government specialist. Among the age 30 to 39 50% with average three years of a post specialization experience, they just just leave going where or one, one they could go to Singapore or other overseas country but mostly they just cross over to the private. So it's like the government doing something for the profit of the private sector, this is not right. So, I'm happy to see that in one of the major political coalition in the manifesto in the generation current period. Now, they say they asked, they will want the private sector to train their own specialist I think it's a good proposal. At least they should be responsible for what they want to groom for their own specialist not to push from the public sector anymore. You know you're telling. Of course, taking away the train doctors these all some of the issues we have been facing. Another 10 days also but what about the patients, how is there this thing I mean, you know, you're saying that initially they were not admitting patients property and so on. Has there been any issues of overcharging of patients and you know, patients going to courts and something like that. Equitable financing issue in Malaysia, where 35% of doctor expenditure on health, which is come out pocket OOP, that means people should pay with their own money. When you know most of public healthcare services, you don't even need to pay much. This, this portion of OOP expenditure 1676% actually coming from the private. And there's one statistic told us that, tell us that about 30 or 43% of the population actually cannot afford private insurance there's a main cost of a lot of OOP in Malaysia. I won't say this is equitable because when you have a serious health issue such as cancer. This can really cost you the catastrophe financial catastrophe. They really have to sell house assets, just to finance the medicines the treatment to survive and there are some they knew they wouldn't want to cause this situation to the family they choose to die. This is the saddest thing for us in Malaysia because I think if we do believe in right to hell, we believe in solidarity in the care of every unfortunate people, including the cancer patients, and we shouldn't have this system at all, we shouldn't have people left to die because they couldn't afford. So there's one very big, we'll say it's motto slogan for people's health column, we say health for people not for profits. The other thing is that we shouldn't differentiate people by the ability to pay, because we believe firmly believe in right to hell. So I think if we can restructure the financing issue. Probably we can take care of everyone. There's no need to choose whether you want to live for money. So the financing thing is the major contention, because before the resolution of the parliament, the previous government already called for health white paper. They asked the civil society and patient groups and stakeholders to have the discussion and they drafting the health white paper. So the major issue is that they look into the health financing. So I'll say they have the difficulty in getting more financial resources from the finance minister from the government. So every year they keep at about 2% of GDP, although in the real term you see the money actually getting more and more for a year but it's not sufficient to keep up with the demand and the population growth, they couldn't keep up. So there are many different views about how to get more money. So some people actually want to go for social health insurance. So we changed the whole financing system to social health insurance. That means from the paper's health column point of view we think that this is additional tax. So if you say you want to have this social health insurance and asking everyone in the formal sector working, you want to take some kind of like 10% or some kind of tax from the working people, I would say this additional sum is a tax, where you previously would not have to do it. And once you have this social financing system, that means you need to have more layers of administrators, you have to enroll people, you have to check whether they are in the program. So all this actually making the system less efficient. So let's talk about how the government control the pandemic is a very good example, why we need to keep the current government general taxation system is that government being the regulator, fund the payer and the provider when they make decision, especially when the pandemic comes, you need fast decision you need a coordinated actions. So for the first two ways of pandemic government actually can keep it down within specific time and it was a success story. If when before the Delta, when alpha came, then the government succumbed, but I think that was also the same case for many governments in the world at the time. But for the first two ways to do government control it very well. One thing is that the public civil servant in the health ministry, they are very well coordinated they work together very closely, and it was the public sector will handle the pandemic. So, if we have some situation like the NHS, the current NHS in UK, they have to negotiate with many service providers. When the negotiation was not going well, then you have a lot of delays and miscommunication or lack of coordination. And then some western countries fail to really contain even in the very beginning. I think Malaysia show a very good example how we can do it, because the common lines are intact within our system. So, so we actually do not agree with social health insurance transition because I think it's just a political view that it's not the government do not have the money to pay for additional demand for the public expenditure just that they do not have a political support now, because after the pandemic, everyone asked for the increase, and all the competing parties right now they promise 5%. What does it show that means when people actually after the pandemic people do see there's a real need and people appreciate and start to prioritize health. That's when the government and political parties and politicians changes and say oh yes, we need to invest more everyone say so. And this thing about you know, going into social health insurance is also a bit tricky because it opens doors for privatization and somewhere like you're saying it's inefficient way of spending also because we are giving a lot of people's hard earned money to the sector, which actually takes its own profit and a lot of like you're saying administrative and managerial levels, excessive levels, and instead government can just build more hospitals, recruit more doctors and give the services. I think in India also we are having a similar, you know, argument all the time. But what happens is that when you argue against the health insurance model, it becomes like oh you are against welfare because but this is a double edged welfare where the welfare goes to the private sector at the cost of the public finances.  So, how do you see the immediate demands and how is it that you know groups in Malaysia are organizing themselves, not just on health but also different welfare, you know, safeguarding these welfare measures.  So we will keep on engaging with the government and also we will put out our narrative in the media in public to convince the public that the way forward is for the government to show political view to try their best first to inject more money into the badly needed public sector. So that's one way before you consider other other financing methods like social health insurance, we do not wish to stay here. But after the pandemic, like you say is people talk about the social determinants for health. It's not just about health care. To move away from the notion of when we talk about health care is about sick care. Now people really want to prioritize about how to stay healthy the wellness part, and how that we can strengthen the primary care. That's the focus of our blueprint on health care, a health reform in Malaysia, published by People's Health Forum. I do think that the fundamental is with the primary care. We urge the government to set up a family doctor system where the family members would have their own dedicated doctors so that the doctor would know the medical history of your family and know about your families, probably every year they could see you once. And this additional income for the private GP as well if they enroll in that system. It's not something very farfetched because Malaysia already have one such program called B40 is to take care of the bottom income 40% of the hometown families to do health screening for them. It's already there just government has to expand it beyond the 40 and go up to the medium, medium, middle 40 and then a top 20. So to cover everyone because I don't think rich families are immune from health problem. They probably also have a lot. So it's nothing about the income level. So that's what we call for the reform to put more resources on health promotion and primary care health screening. And especially, we have one call for government to put a monitor of building new private hospital we think that 202 is already way more than enough, and we do not want them to expand the hospital beds. Yeah, so there's one call in our blueprint. People will say there's a bit socialist but I'll say is they have actually the current capacity to use more because on the bed of beds occupancy they roughly score about 50% also where the government hospital, most of the specialist major specialist hospital already more than 80% of the bed occupancy, very, very resource straps. So we hope that there's a more kind of a collaboration between the private and public hospital government actually can purchase respect a strategic purchase from the private sector at a cost price or at a price that government can agree. So it's a very tough thing to blow into but I think it's actually major beneficial if a gun the private hospital will purchase any very expensive equipment, they will actually want to have more usage. I if government is do not have enough of such a equipment and it has a long queue for those. Why not you just do some kind of arrangement. I think that's one thing we also call for strategic purchase, but must be on government's turn on the private sector's turn. Yeah. So basically, this is it roughly about what we think about how to take care, take care of the major problems in Malaysia on health. Thanks a lot, I think the complexities and you know the way forward. I'm sure that the people's health forum in Malaysia is able to, you know, increase its advocacy and activism and we wish you all the best in advocating for universal healthcare and the issues of patients and people in general.


Graphene is a single-atom thick two-dimensional carbon nano-sheet with outstanding chemical, electrical, material, optical, and physical properties. The use of graphene alone is correlated with certain limitations, such as irreversible self-agglomerations, less colloidal stability, poor reliability slash repeatability, and nonspecificity. This review focuses on the fundamental features of graphene, the multi-dimensional synthesis, and multi-purpose applications of graphene on nanocomposites. This article was authored by Ebrahim Khalil, Narene Atchileli Mujal Kapli, Weiji Aheehee, and others.


Hey everyone, Ken Ross here and I'm a business consultant that specializes in reducing costs for companies by looking into their essential expenses but today it is the final installment of my four-part series of my breakdown of how to save you money today right I'm gonna put that in the description on this side of the screen up here at the top if you haven't seen that go ahead and check that out as well as the other three parts of the more expanded look of that video I've talked about all the the relevant steps the first thing is a pre-step which is you need to catalog all your vendors right every major person that you pay in your business you should know who they are what their costs are how much you're paying them on a monthly basis that's the first step the second step is one that's fairly simple it's the first step of my process which is ask other people what they're paying for that business for that same service that same business that same class of business right and if you can get a breakdown from them ask them if they can provide you with some more details right because this is really gonna help you in this last step but I'm kind of getting ahead of myself I want to explain what step two is step two is calling the vendor yourself right the person that you're paying or the entity that you're paying in the case of telecom and I've been using telecom in this whole example it's Verizon wireless calling Verizon saying hey look I really want to negotiate this rate I can't afford this I want to do this with my business I want to do these things you're trying to establish a relationship and not just get a discount on step two step three is one that involves a lot more care and a lot more time right and that is I'm gonna find another vendor and I'm going to get their price for what it is that I'm paying for with the current vendor and this takes some very big care right because if you looked at my spreadsheet what you need is you need a breakdown of the service you need an understanding of everything they're offering for that price because what you don't want is you don't want to get in this the situation of hey I switched AT&T from Verizon and my level of service is different or my coverage area right isn't the same and that's certainly something that is going to be the case if you switch wireless vendors because of the technologies and that's the other thing that you'll want to make sure you understand is how the technologies work right if you are a Verizon wireless customer for example and I like to pick on Verizon because I do a lot of I've done a lot of business with them I have a pretty good relationship with them in this particular use case and in the guide that I'm going to provide in the description you can go ahead and click it down below you'll see some examples of how this all works you'll see an example of every step and what I've done during this process and what I've used as an example is my experience with Verizon wireless I haven't really kept everything the same right I've changed certain people's names the phone number and the contact information is there and I would also if you contact me I will also provide you with a copy of my Verizon wireless business bill I love giving that to people because that's that's really what step one is about right step one is ask me what it is that I pay for my service and I'll tell you and I'll actually give you a breakdown so that's that's step one right and that that's really something that you really need to understand is if you have done step one correctly and you're actually doing all the steps for each category to save the most money you are going to this this particular step is going to be very useful that you've done step one correctly because step one is hey give me the breakdown and I have my breakdown of your breakdown I can compare apples to apples in some sense or maybe run apples to oranges because in some sense you'll find out that what certain vendors are offering is a different level of service than what you have or the service that you have is far greater than maybe someone else's service for that same vendor and that's something that's really important that you understand right because you don't want to just say well this one's cheaper so I'm going to go with that right if you go with that like I said and in this step you were you are possibly signing up for more pain right and that is once I get to this vendor or I get to this new solution finding out that it's not what I asked for it's not what I thought it was and then begging my previous vendor or finding another vendor to go back to that has better service and getting fluffed into their bigger price for that right because you're desperate at that point and they know you're desperate they know the level of service you were offered was not as good as the service that that you had so now they're going to give you that service back and they may not give you a discount for it and they may give you a deal that sounds like a good deal but really it's laden with a lot of other issues and so that's why this is an important step right calling other vendors you need to do the same thing that you did with in step two which is you need to record everything that they're saying you need to know who it is that you're talking to you need to try to establish a similar relationship that you have with your current vendor and you need a breakdown so once you've had had the opportunity to get a couple of event vendors let's say four or five right different options then you can decide based on all of those factors if it's if it's worth it to switch vendors or not or if you should take the current vendors deal or if you should really look hard into what your friends in business have and see if what they have is something that you're worth investing into and saying hey look I'd rather just have this service so I'm gonna call you know AT&T and I'm gonna ask them for what what Jim is getting at you know at his restaurant that's that's the key to saving the most money and that's why this is so important right it's why I wanted to share this information and it's something that I really feel like as a business owner and as people in general right if we can share information the power that's in the information is so valuable right that you can save money today so I would really encourage you now that you've gotten through all these steps now that you've listened to me ramble for for hours or I guess maybe not even hours for minutes maybe more than a little more than an hour if you've watched all these videos invest some time in really trying to skinny down some of your expenses you will find that there's great value in knowing that you have the lowest cost for your services and that you're not overpaying for those things and and that's something that I I really enjoy it's something I really like to bring to people and in another video I'll talk about how each one of these steps I can put these on steroids so that's something I want to want to get into I'm gonna talk about how that really works for me and how that's a different for me than it may be for you but that's something I know that you'll find some value in as well and so that's what I have for today I really want to know if you've done any of these steps I really really want to know if you've saved any money doing any of these steps please put that in the comment section below in this video please subscribe to my channel because I am going to spend a lot of time investing in other topics to bring you good information to share information with you that can help your business and that's something I really want to do for you so please subscribe to my channel please tell your friends about my channel have them subscribe like this video comment down below like I said and I am Ken Ross I'm I am very passionate about this I want so desperately to see the power of business and our relationships be leveraged in such a way that we don't overpay for anything that we invest in what the right things are in business and so that's what I got for today please visit my website I am Ken Ross calm and until next time see you around


I'm Levi Newhearth and my wife Crystal. We run Prairie Paradise Farms in Central South Dakota. We have about 2,300 acres of farm ground and 3,000 acres of pasture that we custom graze cattle. We have goats, chickens, horses. We like to farm with soil health in mind. We have been in no-till for 27 years and it has really helped our soils become more resilient. We've also done rotational grazing for the last 8 or 9 years and that has really helped our pastures in getting more diversity and being able to have a longer grazing season than we have in the past. With our soil health practices that we do it helps use our water more efficiently as well. It helps us conserve our water in the dry years and helps us use moisture in the wet years to kind of keep our infiltration going as best as we can. Resilience with our farm means that we can help recover quicker and more efficiently and we can handle the extremes a little bit better than we could in the past. We had a drought one year and it seemed like most of the different wheat crops were failing but we actually had a decent to almost above average yield. So I would have to say that our soil health practices are the reason that we actually had a very good yield in that wheat crop. I don't know as much as the person is more stressed but the ground is definitely more stressed in the conventional system because it has to overcome more obstacles on the heat or the wind or the rain, the erosion. It's comforting to know that we're doing what we can and what we can't do we just try not to let it weigh on us as much. We're going to be able to make it a profitable year by spreading out our risks and not just having one or two things that we get our income from and if mother nature would take out that one or two things then that would be a very hard thing on an operation but we have spread our risk out over many different entities.