Welcome to all of you from all over Australia, over 300 people online at the moment. And also we'd like to welcome the people who are going to watch this on the podcast later, which is often quite a number of people. MHPN wishes to acknowledge the traditional custodians of the land across Australia, upon which our webinar presenters and participants are located. We wish to pay respect to the elders, past, present and future, for the memories, the traditions, the culture and the hopes of Indigenous Australia. My name is Mary Emma Laus and I will be facilitating tonight's session. I have a background in general practice and psychotherapy. I have a particular interest in the whole person and how the mind and body are connected. I have not particularly worked with prostate cancer but I've done a lot of MHPN webinars and I'm really pleased to be facilitating this tonight. I'm actually also now training as a psychiatrist so I can possibly represent that discipline a tiny bit. And I would really like to welcome our presenters tonight. So I'll start with Jane. Now before I do, I just wanted to acknowledge that we do have a mostly female panel and most of us don't possess a prostate gland. But MHPN has worked really hard to try and find practitioners from different disciplines who have expertise in this area. So we acknowledge that it's perhaps a little bit unusual. Jane, I'd like to welcome you and I am curious to find out how you've got a special interest in prostate cancer as a female DP. Yes, well I work in suburban Melbourne but I was asked to look after men with advanced prostate cancer who are on androgen deprivation therapy or hormone therapy. And this sort of treatment has got loads of side effects, medical and psychological. And often the specialist would start a patient on this treatment that think well the GP will look after the patients and the GP will think well the urologist or radiation oncologist will look after it. So these men were falling through the gaps. And so my job was to come and bridge the gap and monitor and manage these men. Well it's great to have you on our panel. Thank you. Thank you. And Declan, so you are a specialist urologist originally from Ireland and now living in Melbourne. I wonder if you have an opinion, this may be putting you on the spot. But what do you think is sort of the biggest issue facing the health professions in regards to prostate cancer at the moment? Thank you Mary and thank you of course for the invitation to participate in this fantastic event. Well it's an enormous topic but I'll summarize it very briefly that for me the greatest challenge in managing prostate cancer in Australia today is balancing the benefits of early detection, diagnosing men early etc. Along with the proven harms as we will discuss this evening in administering treatment for men. So balancing benefits of early detection, better survival etc. along with the inevitable side effects of treatment. That's the biggest challenge. Okay and I'm sure as you say we will come back to that. So thanks very much for that and welcome to the panel. Samantha I'd like to welcome you. You're a psychologist with a special interest in this area and I understand that you've been trying a lot or have experienced using a lot of mindfulness interventions for people affected by prostate cancer. And have you found that to be helpful? Well certainly anyone diagnosed with cancer finds that their head is always hiking back to the past or is sort of thinking about the future possible consequences. So any intervention that's going to help people to feel more able to know where their head is and to get it back into the present moment is going to be a useful thing. But mindfulness is certainly the intensive mindfulness interventions and not for every man. But for men who are really keen to learn that as a skill it can be very useful. And Samantha, Jane's in rural Victoria and Declan's in Melbourne. And we're about to use. I'm in Gwyddon. Right another Queenslander. Absolutely. And welcome to everybody from all over the place. That's one of the great things about this platform. Now just coming back to the platform just for the audience information. There is a chat box down in the bottom of your screen. You can see a tab that says general chat. And I'll just move on to some guidelines around using that in a moment that you'll see that in the bottom right hand corner. There's a little file icon and that contains resources that relate to this webinar. And we will be discussing that a bit later on. There is a technical help tab if you have any problems that you can have a look at and see if you can solve them or ask for help. So there is a number that you can call in the technical help box if you're still having difficulty. We will be really encouraging your feedback at the end of the webinar. And there will be a tab that gives you access to a survey at the end. So we now have 430 people online. Welcome to everybody. Now just to make sure that everyone gets the most out of this live webinar, we just want you to be aware that it is as though you were in a face-to-face activity. So things that you write in the chat box can be seen by the participants and panellists and just keep it on topic. And if you have any technical questions, put them into the technical box because they may not be noticed if they're in the participant chat box. And that's the phone number there if you need any help and it will be repeated into the technical help box. So just to have a quick look at the learning outcome. So by the end of the webinar, we hope that you will be able to identify some challenges, tips and strategies for building appropriate referral pathways and implementing a collaborative response to help men with mental health difficulties after surgery for prostate cancer to identify the key principles of providing appropriate therapies and communication approaches for men with these challenges and also their families and carers and describe the general principles of providing a safe and supportive environment for men experiencing mental health concerns after surgery for prostate cancer. The way in which the webinar will proceed for those of you who are new to this platform is that each of our panellists is going to give a response to the case study and then we'll be facilitating a discussion between the panellists. You are very welcome to submit any questions or things you'd like addressed into the general chat box and we will do our best to incorporate that into the discussion. I've also been provided with all the questions that you submitted on your registration. We can't ever cover everything but we'll do our best. Now, all of you have been sent the case study in advance and I suppose the thing that struck me about it was just such a human story and I think all of us can imagine ourselves in one or other or perhaps as the practitioner or any of the people in this story and it's a very real story. So I would like first of all to invite Jane to come and give her a response to how she would think about Peter if he was to be her patient as a DP. Thanks, Jane. Thank you. So to sum up, Peter has prostate cancer and is not coping very well. So my first slide is basically looking at the general aspects of general practice care and how that relates to a patient with a cancer diagnosis and then how it relates to Peter. So the first thing is to establish a rapport so that he sees the GP as a first port of call. He can be confident to come and see the GP for any medical or psychological issues. The second one is try and keep involved in his care as part of his treatment team. Regularly review him and ask him about side effects of his cancer and the management he's having and try to help manage him through that. The other thing is reassurance and try and put his cancer into perspective. Of course, cancer diagnosis is a very challenging, worrying diagnosis for most people. So sign up with the fears. As soon as you say it might be death or chemo or not working or family issues. So find about their fears, try and put into perspective and give him hope. A lot of people with cancer can still do work, still have good quality of life and can get through this with help and support. The other really important part for GP is to coordinate his care and help him navigate the healthcare system, especially with the use of the EPC items so that the, so PETA can access Medicare-rebatable psychological counselling or referrals for allied health sessions too. And the other thing is to manage the rest of PETA's health.  Is he smoking? Try and look at his lifestyle factors, getting him exercising, have a healthy diet. So just look at the holistic side of that. So in PETA's case, I've actually divided him into three stages. And the first one is stage one where he has an elevated PSA but there's no diagnosis of this stage. And he's very anxious about this, about what this means. And so this resulted in delaying his treatment and his wife is quite frustrated and they're starting to argue. So what's the role of the GP? The role of the GP is at the outset when you're talking and counselling a man about PSA testing is to put it into perspective. Let him know that there are lots, PSA can be high for many reasons, not just cancer. If it is high, we do repeat it with six weeks to three months. And if it still remains elevated, then we would routinely send him on to a urologist for sorting it out. So try and set the scene that if it is high and it stays high, it does not mean cancer. It might be needs sorting out so that hopefully it doesn't freak out on that after that first test. The other thing is to manage its expectations, educate them about, well, if the PSA is elevated and we do, I do refer Peter to onto Declan, what might happen, maybe an MRI or what a biopsy entails. And what happens if cancer is found that biopsy and explained there may be very high grade ones or very low grade ones, many don't need treatment. But whatever the outcome is, there's lots of treatments, lots of hope, lots of help available to him. So reassurance and perspective.  Plenty of good quality of life ahead if cancer is diagnosed. Keep reassuring him. But at this stage, I'm a little bit concerned about his level of distress already before the diagnosis. And I wonder if, I think he will need a psychologist at some stage. He may not accept it at this stage. So also because he was ignoring the reminders for his PSA, I'd just be ringing him up and trying to contact him and talk to him and say, look what's going on and try and reassure him and keep him in the therapeutic loop. So at this stage, Peter has high grade prostate cancer diagnosed and he is about to undertake a radical robotic prostatectomy. And from the GP side, often we're not part of the picture for Peter at this stage. He's often very busy with admission and surgery and recovery and nurses and catheters. And so the GP is kind of a bit too busy, not much energy for us. But if you could always ask if he wants to come in at any stage, but I often just ring him up to see how's he going. Just keep engaged in his care. What are his expectations? I mean, how long will he be in hospital? And what have you been told about continence and erectile function recovery and how much time off work? And is he having his physiotherapy with continence? And does he know about pain or rehabilitation? And just tell us the other things in his life. How's his family? What's happening with work? Is he losing much money through this? Is he okay? And has he been offered a referral to a psychologist if he needs it? But I know some specialists in town do often get psychology in at this stage. It's just because of the impact it has on the patient and the partner. So the main aim is to manage expectations and ensure or encourage allied health in court at this stage. So then there's stage three, which is the recovery and survivorship side. I mean, Peter has had his prostate removed and his PSA is now undetectable, which is a good outcome for him. But he's depressed. He has existential issues. He has significant bladder and erectile issues, intimacy and relationship problems, and Anne is highly distressed. So he's got the full hand of side effects. So Peter and Anne need help. And this requires a multidisciplinary team care approach. And part of the GPS is to navigate which allied health, or which person would you refer to first? When are they ready to see one to the other? So navigating through this. But the options are first of all psychology for Peter and Anne, and as a couple to try and work through the distress and the relationship and intimacy issues. He has erectile dysfunction, and so this might mean medication or there's treatments with different devices or injections, and often psychologists and sexual counsellors might be required. Then there's the continence management, which may involve a physiotherapist, a continence service, medications, or refer back to deco-myrologist. And exercise description. Exercise physiologist is fantastic to help. They can help with mood. They've been showing us better cancer outcomes, can improve sexual dysfunction, and overall health. So the GP for this day just to review and facilitate and manage the mood, relationships, sexual and continence issues, and to coordinate the care. The other thing is to clarify the post-cancer treatment surveillance protocol and ensure adherence via recall and mind systems. Keep encouraging. Have your PSA. Go back and see Declan, that sort of thing. And also just be there and maintain hope. That's it. Thanks very much for that, Jane. I just wanted to clarify before we go on, what does EPC stand for? That was on one of your slides. It's an enhanced primary care program. So there are Medicare items available to the government where a patient can access a rebase with the Allied Health. They can access five sessions per year in access to Medicare rebase. Those five sessions with an Allied Health, for example, a physiotherapist, exercise physiologist. And the GP mental health care plan where a patient can access up to 10 sessions a year with a psychologist and receive a Medicare rebase. Thank you. Most of our audience would be familiar with the mental health item numbers, but maybe not have been aware of the EPC. So thank you very much for that. And I guess I just wanted to comment that in many of the people who are in rural and regional areas, there may not be a psychologist available, but there may be other counselling professionals who are well-equipped to be the referral person for PETA as well. Yep. And thank you, Jane. And I'd like to move on to Declan. And I have a technical question for you, Declan. So, Julie, Jane was speaking about robotic prostatectomy. So could you just briefly explain what the robotic bit means? Because we've got a lot of mental health professionals who may not understand what's the difference between robotic and open prostatectomy, that sort of thing. I know that may not have been on your agenda, but just to clarify that. It's a common question, Mary. I'm very happy to dispel the myth that when we describe robotic prostatectomy to some sort of machine, you know, running around the operating theatre like something out of Terminator. So it's not quite so elaborate. In fact, the term robotic is a little bit of a misnomer because there is not a machine autonomously doing surgery. It's more of a robot assistance approach. Briefly, it's just a form of keyhole or laparoscopic surgery. So instead of making a big cut in the tummy to go and take the prostate out, it's in a very difficult location down behind the pubic bone. We instead put small holes into the abdomen. And through those holes, we put in a telescope, a 3D telescope, which gives us an amazing view inside the body. And then we attach some robotic surgery arms to the patient, which allow us to put tiny telescopes about the size of my finger and instruments the same size, deep down into the pelvis, and to do the surgery. So we get a great view, an amazing view, and we get beautiful instruments that we can't normally use to do the prostatectomy to take out the prostate.  But nowadays, by using a robot approach, that's the way the majority of prostatectomies are done around Melbourne, certainly. It allows patients to go home the next day. So the three I did yesterday went home this morning. The two I did today will go home tomorrow morning. And patients get back to work really, really quite quickly. So it's quite delicate. It allows a really delicate surgical procedure and also a much smaller cut in their tummy so they get better much quicker. Is that basically it? Yes, that's right, but that's not to overstate the impact of a prostatectomy, as you've just heard already in this case. So it's still a big job. At the end of the day, what's happening is the prostate is being disconnected from the urinary tract and from the rectum and from the nerves and so on, and being joined back together. So that's the same whether you do it with a keyhole robot surgery or an old-fashioned cut. But there are some definite, at least short-term advantages, as we've mentioned, going home quickly, very little blood loss. But the really big thing, the cancer results, the return of contaminants, the return of sexual function, it's not really clear at all if doing it with the robot is any better than a very experienced open surgeon making a cut. And I think that's important. It really comes down to the experience and skill of the surgeon and how many cases he or she has done more than the fact that's been done with a keyhole approach. Okay. Thank you. And just so that the audience knows, I probably misled people at the beginning. So the case study is real. This person really exists. I just wanted to reassure people that we didn't make it up. And now on that note, Declan, I wonder if you'd like to just speak about how you would respond to Peter when you got that referral from Jane. Yes, so Jane, very nicely described sort of three stages that the GP gets involved with. One is in a patient who has not yet got a diagnosis, but has perhaps an abnormal blood test and is concerned about the possibility of prostate cancer. The second was the patient has been diagnosed and is going through treatment. And the third is the recovery and the survivorship phase supporting the patient. So I look at my role in a very similar fashion, actually. I'm a urologist, as you know, and my role at Peter McCallum Cancer Center in Melbourne, which is a very big cancer center, could be split into three similar stages, actually. So in the first stage when I see a patient like Peter, he's been referred in because Jane has done a blood test. It's a bit abnormal. She's repeated it a couple of months later.  And it's been sent in for a discussion about am I at risk, what would we advise should we do further investigations? Well, I spend a good chunk of my time dealing with patients like this and we don't just automatically trigger a biopsy and go straight in there and do a test to see if the patient is cancer. So we take into account multiple factors, including the age of the patient, family history, genetic factors, like is there a BRCA2 mutation, for example, in the family. Yes, the PSA level, the blood test is very important because the behavior of the blood test has been going up over the years and all that. And then we'll often use normal grams and other decision-related tools to ultimately advise the patients of the options. And there are three things. I spend a lot of time doing this. Number one, just carry on keeping an eye on things. If we think the level of suspicion is quite low, it's reasonable just to keep observing the patient. Number two, consider an MRI scan. And I can speak more about that, but using a scan has been a very popular suggestion in the past three or four years as we recognize that MRI scanning can help further define who needs a biopsy and who can be safely observed. And then between then, yes, ultimately doing a biopsy, and that's what we offer if we have a significant degree of suspicion, including, for example, an MRI scan being abnormal. But that will process the whole stage, one thing of, should I have a biopsy? Should I have an MRI scan, et cetera? Should I be worried? It is a complex one. And GTs like Jane spent a lot of time talking through these options with patients. It's not like mammography or paddle cancer screening where there are clear guidelines and decisions about everybody should have a test and then whoever's abnormal should be referred. Profake cancer early detection is somewhat confusing area and GP spend a lot of time working these patients out as do I when they come in the door. The second, stage two as she called it is managing the patient who has a diagnosis. And the first thing I'll say here is that in the last ten years there's been a fundamental change in Australia in the way in which we manage the newly diagnosed thoroughly prostate cancer. So it's confined to the prostate. And rather than just go on and have surgery or radiation treatment, these being the main stage of treatment that we've now recognized is a whole bunch of patients up to 60% of select patients who don't need treatment at all. They have a diagnosis of cancer but they can be reassured and those patients can be monitored rather than be treated. And I'm sure Jane and Samantha would agree that certainly takes out a lot of the potential morbidity, psychological and physical in terms of treatment side effects. So we're big fans of surveillance as a strategy. But then the other patients who we've decided are not safe to observe, their cancer just looks a bit threatening, will be offered treatment with either surgery or radiation therapy in the main.  And then that final setting of survivorship or recovery and for me that also includes recurrence actually or advanced cancer, cancers that are advanced at the get-go, they're already into the bones or whatever, is the other area of interest for me and indeed my team at Peter Mack in Melbourne have a very large amount of research programs in managing patients with advanced prostate cancer. So I think as Jane pointed out, a multi-disciplinary approach is terribly important in each of those three stages of the prostate cancer patient. And my simple message about this is that the GP has the most fundamental role because he or she is sort of the quarterback in this patient journey. They're the trusted person who the GP often knows him and his family for years and years. They're the one who's brought the patient towards the diagnosis of prostate cancer. They're the one who understands the social situation. They're the one who can refer in and out with GP management care plans for psychology and physiotherapy, exercise physiology, etc. And they're the ones that raise the flags then when there are recurrences or severe depression, etc. throughout the journey. And so that's my final message really is that I think that one of the GP in this very complex journey for a patient is essential to act as a quarterback and dip in and out of urology and adult health to try and improve quality of life for these patients. Thanks very much, Declan. And I'm glad you did clarify there that the question of screening and early testing is very complex because there was the registration questions about why aren't we just screening everybody over the age of 45. And that's probably a topic for another complete webinar but you acknowledge that it's a really complex area. And it is something that GP spend a lot of time discussing with their individual patients and it's really a case of shared decision making as I understand it. So thank you very much. And just remembering that it's an MHPN webinar under the mental health treatment plan and the different professions that can be involved in providing focused psychological strategies counseling. Obviously we've got social workers, mental health OTs as well as psychologists and clinical psychologists and mental health nurses may also be in a position where they can provide that counseling too. In this case, Jane has referred Peter to see Samantha, who's a psychologist and I'd like to invite you in Samantha to talk about how you would respond to Peter. Thanks. So initially I guess I want to cover what I think are some of the key ingredients for a mental health professional who's seeing Peter. One is just having a basic knowledge of prostate cancer and the treatment effects associated with having surgery and understanding of what's normal adjustment for individuals for men who've had prostate cancer surgery in dealing with those side effects as well as what's normal for couples and the willingness to work with the couples not just the individual that is not only more effective but is more efficient in my experience. The ability to quickly foster a therapeutic alliance and importantly access to a multidisciplinary team across referral. Okay, so I thought I would briefly cover I guess what is normal adjustment as well as abnormal adjustment. So obviously after any cancer diagnosis a man is going to experience really strong and often really unfamiliar and confusing emotions. However, most men unlike women diagnosed with breast cancer will return to pretty normal levels of psychological functioning and life-scatter section and often despite persistent effects of treatment within weeks of the diagnosis or at least having made that treatment decision. But it's not uncommon for some men to experience distress that increases in the months following diagnosis and understandably that places relationships under great stress. So what are the risk factors for men who don't do so well? Well, younger age at the time of diagnosis and for a prostate cancer diagnosis being aged under 50 is very young. Having persistent urinary and sexual side effects having more traditional masculine identity leaving avoidance as a way of coping and reduced expressions of love and intimacy particularly post-diagnosis. Now, Peter has all of those. So we can see actually just from looking at him that he is at increased risk of perhaps not doing so well. So what I've done here is to visually represent I guess my understanding of what's going on because once you've done the assessment I think it's helpful for you but it's also helpful for Peter and Anne if you involve her as well to see what you think is going on to help inform your intervention and engage them in the intervention. So we have Peter who's terrified of cancer and who's not uncommonly fears to have a fairly traditional view of masculinity being strong dealing with the burden of incontinence ongoing incontinence or at least urinary symptoms and persistent erectile dysfunction and his way of coping by trying to distance himself from the mind of the best especially lack of potency is preventing him from learning how to do more effectively with the challenges and importantly undermining his most important source of support and that's the support he gets from Anne so it's not surprising that he's now depressed. Okay so let's go on to what we could do with Peter and with Anne. So you know I if I could engage the couple right up front or at least in a significant number of the sessions. So what I've done here is I flagged what I think are the major issues on this in the next slide and then what intervention I might use to address that issue. I might maybe move straight on to you know the depression. I think Jane has dealt beautifully and also I feel very fortunate to have such a skilled urologist who's such a good communicator. Some of these fears have probably already been addressed that have been contributing to that initial avoidance. So if we look at his depression if it is really severe we might need to look at some individual sessions to address that and or perhaps refer along to a psychiatrist but let's look at reasons why he's depressed. I guess you know let's look at particularly his infidelity and the burden that's placing on the relationship. I think and my experience would be he's probably engaging in telephone sex in an effort to perhaps increase his potency. You know he might have read and he might have been encouraged to use it or lose it as a way of improving his erectile function but he's you know he's not prepared to do that with and at risk of disappointing her and perhaps facing up to his own lack of masculinity so he's trying elsewhere to see if he can he can address that but of course you know that is devastating for Anne and so we do have to address Anne's hurt. We have to help her to understand where Peter is coming from and we have to help Peter to hear Anne's hurt and the reassurance she needs from him that she is a priority in his life. So let's look at the withdrawal from intimacy which has probably led to this situation anyway. So what I often find is that men do try to often protect their partners by not engaging in any physical intimacy even in any physical expressions of love including any sort of form of touch because they're worried where that might lead. That might lead to their wife's expectation that they can have a sexual encounter and then if he has a firm erection he's often worried that she won't be satisfied with that. So let's look at that. Is that underlying his withdrawal from intimacy I suspect it is and let's look at with Anne there talking about what is her expectation will she be devastated if he can't get a firm erection and then let's look at perhaps looking at alternative ways to be intimate. Alright then let's look at communication and support because there's increased conflict in the relationship and each of them is feeling really isolated. I would normally get them to in session practice talking about how they're feeling and you might have to help Peter by summarizing what you think is feeling and then help each of the partners to really hear and convey an understanding help them to schedule regular times to practice that skill as well as perhaps offering them some practical ways that they can support each other that might help to give them a little bit of momentum because they're really isolated at the moment they're adding to each other's burden rather than giving each other support and I would also address perhaps getting into getting unless they've already done this under Jane's encouragement getting them to appropriate rehabilitation because what we find is men will often be quite prepared to listen and maybe experiment with alternative forms of intimacy but having a strong erection is often their first preference so if we can make sure he is accessing some specialist reabilitation strategies that suggest the barriers to doing that making sure he's got access to that support but also addressing any barriers he might have to accessing that continent support referring more to the physiotherapist he might be lucky enough to have access to a specialist prostate cancer nurse as well and an exercise physiologist can often be wonderful because that's a really tangible way of increasing master himself has been at the very least so yes that's I guess my input thanks very much Samantha and we will definitely come back to you and so now we're going to move on to having our panel discussion now I think I would like to bring Jane back in first of all so there's been quite a few questions from the audience around the to do with age so often times when someone's diagnosed with prostate cancer even when you find an elevated PSA over the age of 70 people are maybe advised more likely perhaps to go for the watch and wait scenario or even if a prostate cancer is diagnosed they may elect not to have treatment or maybe advise to do that so I just wonder whether you've had experience Jane of supporting older men who are aware that they might have a prostate cancer are not having treatment and whether that affects their mental health yeah it's a difficult issue I mean the once you're diagnosed with prostate cancer it's unlikely to cause harm or death for many years it's a very long lead time to start causing problems so the ideal time is often in the younger man sort of around 50s 60s but when it comes to the older man in the 70s you have to weigh out the question do you test for prostate cancer number one because is the treatment going to be more harmful than not having any treatment not knowing about it so you have to weigh that up but if he was a very healthy 77 year old man who might live to 93 or 95 or he's re-independent and very robust and reactive well then you have the discussion with him and you may well test and if you do find a cancer then he's probably going to need more life than to have radical treatment for that as opposed to an older man who's very unwell at strokes and life expectancy life expectancy is not that long then if you do detect the cancer then you may not have radical treatment or suggest medicine but you do watch and wait and you treat just so that the symptoms do occur you worry about the symptoms if they pick up they don't try and cure it because it's more likely that person may pass away from something else before the cancer will get them so it's a weighing up thing in the older gentlemen and I'm sure Declan will be able to answer that a bit later but those men who have been on the watch and wait who haven't had the radical treatment they tend to be very accepting of it I find and Jane is it sounds like I mean it's a lot of shared decision making isn't it because it's not really clear kind of answers it always needs to be an individual shared decision with the clinicians and their partner or lovers or whoever exactly yeah I mean it's not no one wants prostate cancer but a lot of prostate cancer will not cause symptoms for a long time but a lot of the treatment for prostate cancer will cause a lot of symptoms sooner than later so you're weighing up those sorts of questions when you're having a discussion with the man and his partner and are there some people that would have radiotherapy but not surgery yeah and well first of all my understanding and Declan may may have some idea but often you don't radiation therapy is not often advisable in the younger patients because the radiation effects can last for many many many many years and can cause problems down the track whereas the older gentlemen might not be a fit surgical candidate but may be very suitable for radiation therapy and so it's often very helpful for a man to have he's been diagnosed with prostate cancer to speak with a urologist and also to speak with a radiation therapist and get the two opinions because they might not be a good candidate for one or the other treatment okay thank you in a minute we'll come back to Declan but I just wanted to go to Samantha with another question related to age I also want to acknowledge that not everyone is heterosexual and so I should think that there are particular issues for same sex attracted men in same sex relationships that it may be even harder for them to raise some of the difficulties they're having in that situation so not you're welcome to comment on that Samantha but the particular question I wanted to ask you also was you mentioned that the psychological distress and adjustment is often harder for men in the younger age group I think you said before 50 so do you have some ideas about why it might be harder for that younger age group I think it's because you know being potent and being sexually active in particular is such a part of their life whereas for men in their 70s they might already be experiencing some level of erectile dysfunction and or sex or penetrative sex might not form such a fundamental part of their sex life with their partners but also men who are homosexual are more at risk in my understanding as a literature of experiencing distress particularly if they're not in a committed relationship and so you know that has to be taken into account I know there is a specialist prostate cancer support group for gay men as well and taking that into account is one of the issues they face okay that's I wasn't aware of that and I think that's great to hear that there is that support so I think we'll be coming back to Declan in a minute but I might go back to Jane so Jane some questions have come in about recovery time so Samantha's told us that a lot of men will psychologically adjust and be kind of settled and well again within a few months of the diagnosis what about things like returning to work you know how long is the recovery if someone does have to have a radical prostatectomy whether it's open or robotic what sort of time frame are we looking at? I think it's around the six weeks to a few months stage depending on how they recover the continents most men are well conned by a year and a rectile function recovery depends on what the premorbid rectile function is like if the man was having very good rectile function before surgery and there was a nerve sparing operation so the nerves weren't going to be cut through at the time of the surgery then there's good chance that the man's rectile function will recover it will be different, sex life will be different for him after surgery the penis is shorter and orgasm is dry so it's a different sex life but it's possible but if a man before surgery is having some rectile difficulties for whatever reason and then you upset the whole rectile function with the surgery he may take a long time to recover a rectile function if ever he may not recover it the important thing about the penile rehabilitation is the discussion is that it's the man to start a tablet-like viagra or one of those PD fly inhibitors before surgery just to maintain erections have the surgery once the catheter's out go back on the medication to keep the blood flowing into the penis to maintain that erectile ability even if it's not for sex just purely to have erections to get the blood in there so that when there's erections it's possible but if this is not looked after and erections aren't happening for a long time fibrosis can occur and erectile function may never recurve because of that Thank you for that and I mean because you're a GP so you're dealing with people who have all different kinds of cancer do you think that are the effects of prostate cancer significantly different from other kinds of cancer? I think prostate cancer is significant because it does affect the erectile function of the continents and often these men have got no symptoms they're feeling well they may never have had any other illnesses or problems in the past then someone tells them they've got cancer they don't feel like they have it they're told they have it and then they go through the surgery and the hospital and then it really is a very important part of being a man it's A, getting erections B, having sex and also the continent side so it really does psychologically have greater effect I believe compared to other cancers Okay, thank you and Samantha just coming back to you I mean the other person that's really prominent in this case study is Peter's partner and I guess I might ask you the same question so partners who are having to support their men through different kinds of cancer have you noticed that prostate cancer also has a particular challenge of its own? For partners yeah we often find that partners experience as much as not more distress than the man initially and then over time their distress about the cancer tends to settle down I guess as soon as they know that their partner is not going to die from their cancer and often in the prostate cancer early stage you know they're going to live for a very long time if not forever but often times women's distress will and relationships out of dissatisfaction will increase so the man's distress might start to improve and but the women's distress if there is that relationship dissatisfaction occurring and the man is withdrawing of the way of coping with his impaired potency then often women's relationship to dissatisfaction will increase even though they're not as distressed by the cancer anymore they're often quite aware that the relationship is not what it was and sometimes very upset about that okay and Jane what's your thoughts around the distress for partners with prostate cancer usually there's a lot of support in the partners and they go through the natural worry and anxiety but some consultations I've had where I've had to worry solely about the wife you know the guy's up to cancer he's coping okay but she's distressed she's grieving the man she's lost not lost what her concept of a husband is now he's now a cancer man that's how she sees it they can be quite loss of sex, loss of intimacy I think in these cases there were probably issues in the relationship before it happened but sometimes you spend a lot of time just counselling the partner okay thank you and I guess that's where it's important having the GP in the role of knowing the whole family and certainly the allied health professional and the urologist are probably including partners in the discussions as well now just to remind the audience that please try and keep the discussion to professional many of our topics in MHPN are things where people who are both health professionals and have had their own personal experience just remembering that not everybody has and so we're trying to make this as useful as we can for professionals who don't have special expertise yeah and I think Declan we have you back and I just wanted to ask you we were talking before and we needed your expert advice just around radiotherapy and surgery so I think Jane was saying that perhaps perhaps more often in older people there might be a decision men might choose to have some radiotherapy but not surgery and we were sort of emphasising the importance of in all of these things how it's really shared decisions and I noticed that you know people need to talk to the GP, the urologist maybe the radiation specialist and get a lot of information before making decisions is that been your experience as well that people really need to be informed and to make their own unique decisions yes for sure and I can tell you that one of the most important underlying principles of management of early prostate cancer is to seek the multidisciplinary approach so whether that is reaching out to radiation oncologist surgeons etc or indeed going into a decision tree aids with the supportive GP allied health etc it's very very important that patients feel well supported in the decision they make and prostate cancer is a little bit challenging like that for patients because in the first instance it's not like you've just turned up with an obstructing bowel cancer and you must have surgery there's a very clear path in front of you with early prostate cancer you truly often have complications including surgery, radiation or in some early instances just observation so I think therefore it makes perfect sense to have a multidisciplinary approach and certainly the majority of our patients at Peter McAllen Cancer Centre are second opinions they've been diagnosed elsewhere but even those patients we diagnose ourselves we pretty much insist that they get exposed to a number of people to help them is that also it normalises it doesn't it so if you're just explaining this is our normal practice that we like you to see all these different people then it's just normal that that's what you do so perhaps people that maybe have not been used to kind of you know sharing their stuff with different health professionals and maybe haven't traditionally gone to the doctor very much presumably that helps them to access all those things which they might otherwise be a bit shy about and just getting that Well I think you said very well actually it's quite normal but you know I think some patients feel they're sort of cheating on their specialist if they ask for a second opinion you know and are they last questions like how many of these operations have you done because they've read on a blog or in a support group that you know you should actually ask your specialist what their experience is of surgery or of delivering radiation but these are perfectly reasonable steps to take as you try and reach a decision about your treatment that you feel confident in so multidisciplinary approaches, asking direct questions doing Google searches these are things that people should feel comfortable doing and one of the challenges I suppose we have is that although our listeners tonight are experts all over the country patients often don't really have access to mental health professionals or indeed a regular GP sometimes at Peter Mack we've published a number of online interventions about psychological aspects of prostate cancer over the years including an online intervention called My Road Ahead led by one of our psychologists at the Royal Melbourne Hospital Adi Wuton and she had a very big grant and made it a very nice online intervention which was a journey like a road navigation where patients could dip in and out of specialist nurses psychologists GPs etc to determine if we improved their satisfaction on their prostate cancer journey compared to standard treatment and yes we published this data in European Urology and more recently in Psycho Oncology showing that those patients who access the online intervention had better outcomes, better quality of life so I think that's very important we just don't have enough resource around the country to make these things physically available to people but we must make efforts to have interventions online or decision aids online to help patients access their support I'm glad you, I think you read my mind Declan because I was just thinking about people in rural and remote areas that the multidisciplinary team at the Peter Mac sounds like where we'd all want to go Australia's an enormous country and it's great to hear that some of those resources are available online. Samantha have you had any experience with rural and remote clients and also supporting rural and remote professionals? Certainly I've had experience delivering telephone and Skype interventions to people in rural and remote areas including telephones for interventions and I found that they work equally as effectively delivering them over the telephone the good thing that's recently come in terms of the better access, the mental health care plan is now available to use over the telephone for people in certain rural and remote areas who couldn't have obtained that rebate a couple of months ago because they had to see a psychologist face to face so that's a way of increasing access for men and their partners particularly in rural and remote areas who are significantly distressed or anxious. This is another, I mean it's probably Declan and Jane as well but I'm going to ask you, you know a lot of health professionals, counselling professionals, mental health clinicians who had personal or family experiences of cancer so how do we you know understand the experiences of the person and their partner how can we empathise with people having something as confronting as cancer? I think most people have had some exposure to someone who's been diagnosed with a life threat and illness and so often you can connect with how that felt or how you thought that person might have felt and or if you haven't with a life threatening illness then any trauma because it really is the adjustment to a cancer diagnosis is like the adjustment to any trauma whether that be anything exposed to a hold up or in a car accident there's often that sort of sequelae and you know feeling really distressed often unlike you're going crazy to start with and as psychologists or mental health professionals who are sort of intervening with someone really close to a diagnosis often just normalising but you know that's you know that's actually quite normal to experience those symptoms can be incredibly powerful as an intervention because it's often their anxiety about being anxious or feeling that they're not coping that's a big contributor to their distress. Okay thanks Amanda Jane I just wanted to come back to you with a couple of questions people in the audience are wondering why GPs don't do a rectal examination to prostate as much as we used to so used to be kind of an expected thing that as you got older as a man that was one of the preventive activities in general practice was that your GP would do a rectal exam to check your prostate and that's not done so much anymore do you know why that is? Well I think over years there have been lots of different guidelines from lots of different areas of advice as to how to screen for prostate cancer when I started as always did the PSA and the rectal examination then for a while there was a concern about the amount of over diagnosis of prostate cancer and you have a treatment and more harm than benefits so our College of General Practitioners suggested don't even screen, don't even counsel them and don't advise against testing for prostate cancer and that wasn't in line with other colleges and especially guidelines so it's evolved with time so GPs were doing them and then we weren't doing it but what we had to hold on is to do it if a man requested to be tested or counseled somebody if he asked about it so in 2017 all the colleges got together and produced a set of guidelines and they were giving up that same message and the bottom line was in the primary practices to do the PSA test and not to do a rectal examination I think possibly I'm not really sure why we're told not to do it but I know some GPs still do it but the guidelines in primary care not to do the rectal examination but to refer at a lower level of the PSA test so that and then when they were referred on to urologists that's when the rectal examination would be done so it's still quite controversial, a lot of GPs still do it but the guidelines are suggesting not to I'm really relieved to hear that the colleges all got together and came up with the same guidelines because it sounds as though the profession was confused themselves which must have made it very confusing for the patient so Declan I'd like to come back to you on that so just do you have any comments around prostate examination, I presume that is probably part of your practice Yes it is unfortunately trying to reach a consensus on a recently confusing and contentious issue like this means that you have to dilute things down and not everyone agrees so I don't agree with that recommendation it was quite controversial actually when it came out that we shouldn't offer that and at the moment I'm just revising some text for cancer council Australia on a care pathway they're just proposing and we refer in the cancer council guidelines to this quite straight up recommendation not to do a rectal examination and I think it does that value I don't think it's essential I think if a man says look I'm interested enough to come and have a chat with you about my early prostate cancer risk my brother has just been diagnosed or I've just realized three of my uncles died but however I'm not having one of those rectal exams that's okay that's fine in fact data from the screening studies in Europe showed that there was still value in just having a PSA test I just think there's added value in having a rectal examination as well in my own career I was picking fingers up bottoms to examine prostate so I've diagnosed three rectal cancers for example and I think just as a physician approach to someone in terms of pelvic health it's hard enough to get a bloke in the door of your practice in their 50s and 60s and I think I do routinely offer it and I think it's a reasonable recommendation okay and I've got another question for you regarding I mean it's maybe hard to give a figure but people are sort of wondering what proportion of people would go back to having a sex life that they're content with so Sam's already told us that it's going to be different but what proportion of men in your practice do you think end up having a sexual life after prostatectomy that is satisfying to them and their sexual partners yeah so the first way you phrase that Mary was what proportion of men go back to having a normal sex life and that's not percent quite simply because the impact of treatment for prostate cancer on prostate function is very profound if you have a prostatectomy for example you no longer ejaculate so that's a fundamental big change from normality so we explained that to patients and for example having more children is an issue these are usually older men typically in their 60s but you never know you know I've been caught short on that once before when the 30 year younger wife comes in the door and they say yes no we're definitely having six more children but that's an issue so men don't ejaculate but our holy grail if you like for sexual recovery what we would love to be able to achieve is rigidity and orgasm and going on from that you think okay that means satisfaction let me tell you that achieving rigidity and orgasm rigidity for penetration is extremely difficult and the minority of men in my experience undergoing this type of surgery will be able to achieve rigidity penetration in the five years after prostatectomy so this is the most important part of counseling patients for surgery in my view we have to be very honest and say we expect you're going to have a good cancer outcome we expect you'll have a very good confidence outcome however we expect there will be a profound impact on your ability to have what you may regard as normal sex no ejaculation and also rigidity may be very very difficult to achieve and if we set reasonable expectations for our patients in that regard the further question about satisfaction in sexual activity is the meaning of it it's quite different if you say to a couple that Peter is very unlikely to be able to achieve rigidity for penetrative sex etc and won't be ejaculating and that's already important that they understand that because not all patients have that explanation and have that expectation and then if we work very hard with our patients with the support of our allied health professionals which in my practice includes an intimacy consultant who is a specialist in orgasm and pleasure with strategies around that not just penetrative restoration then patients can be satisfied if their expectation is no rigidity and they achieve some rigidity or they achieve a renavigation of their sexual lives and there's less rigidity in penetration but perhaps more focus on toys, games, lubricants etc pleasure and quality of life may still be achievable. So my key message there is it's very different afterwards and we have to set very realistic expectations for our patients so that they're not ultimately very dissatisfied because their expectations have been reached. Thanks for that. Look it's great to be able to have the nuts and bolts details of these sort of questions because there's often conversations that are hard to have. Samantha I'm just going to come back to you now so I will ask you to give us your final key messages because as always we're running out we're having a great discussion and time is coming to an end but I just wondered if you've got any particular tips that what strategies have you found are effective with men so we mentioned mindfulness at the beginning that doesn't fit all men by any means. What are the things that tend to affect men in your experience? Okay in my experience it's normalising his experience so it doesn't feel like a freak and that he's somehow different to other men and because men don't often speak to other men they often don't know that so normalising it and validating and particularly working with the couple to help them to understand how each of them is feeling and why they are reacting the way they are reacting to clear up those misunderstandings and then enhancing or getting that communication working getting that back on board and exploring different ways of being close and connected that don't involve necessarily a firm erection and working with each other to explore what that would look like is very powerful. Thanks Tam and is there any other things that you just wanted to leave the audience with as we wrap up this evening? I guess you know most men and their partners do well after a diagnosis despite ongoing difficulties with potency so you know it doesn't mean you're not going to cope just because you've had a diagnosis but it isn't a duty path to travel and you do need to work on particularly the relationship to ensure that you're supporting each other through this rather than working alone and potentially then increasing each other's distress. Thanks so much Sam and I'd like to now invite Jane back in just to give us any final comments that you'd like to have and I just wanted to observe whether it's GPs, urologists allied health counsellors psychologists that we should be able to talk about sexual functions, sexual behaviour sexual practices it's going to help our patients feel more comfortable so the urologist is talking about things like lubricant and toys and there's lots of couples in Australia that wouldn't normally have those conversations so I guess I'm just observing it's great to have the example of practitioners who can just comfortably have those conversations so you can comment on that but also if there's some final things that you'd like to say Well on that note and with all the other allied health your resources and your local referral network is so important to know who you're referring to I mean Declan mentioned the intimacy counsellor I have certainly referred to her and she's fantastic and so it's always lovely to know it's in the skills of the allied health people you refer to it is a multi-disciplinary team requirement the goal of the GP is to hang in there with Peter go along the journey with him and coordinate his care and try and maintain hope and as good as quality of life as possible for him Thanks Jane and Declan I'd like to invite you back in to give us your final comments thanks Yes Mary because you made a very fair point about the discussion around toys and lubricants is something that not all patients are comfortable with but part of my real role is making people feel comfortable talking about this so the average age of my patients is 61 or there about so there's couples in their early 60s sitting in front of me and I have to address straight up front before we discuss treatment do you mind me asking do you still enjoy reasonable erections of the penis a little bit about what you two enjoy together in many instances this is a conversation that's never happened between a couple but it's very important it's cathartic because it's a big change for the couple and certainly the man afterwards and then we've set the goalpost we're going to be talking about this on a Monday morning in my office and then when we come back afterwards and I talk about the role of an intimacy specialist the way I say it is she likes to see you as a couple for one hour pleasure, intimacy etc in other words it's away from rigidity and penetration which men and surgeons that was kind of obsessed with we think we want to get the erections back but in actual fact what couples wanted to get the pleasure back and get the quality of life and I can tell you in final that the amount of patients in their 60s who come back to me and say that consultation was fantastic I wish we met her in her 40s you know when we could have done with a bit of a boost etc so I think re-focusing re-navigation away from rigidity and penetration which is very very difficult I'm afraid to say after this on to pleasure or orgasm without rigidity and penetration it's a very important evolution of my view on that part of survivorship I was actually just thinking the same thing I was imagining there would be lots of couples who'd come back and say I wish we'd done that 20 or 30 years ago that's great to hear so thank you all so much for a really interesting discussion and thanks to our audience tonight so we're just about at the end of our evening so I'd like to just make sure that everyone completes the feedback survey before you log out so there'll be a feedback survey tab that you can just log on we really do want your feedback and we listen to it and if there is any other topics that you think you would like covered you're really welcome to ask for that in the resources and I know Declan mentioned the resources from Penny McCallum and other things that the panellists have recommended are in the resources box the webinar will be available to view again or to recommend for other people online as are all the MHPN webinars in the library certificates of attendance will be issued within four weeks based on your registration and your login and you will also be sent a link to the online resources so we also would like to invite you to continue attending MHPN webinars you will get sent notifications and we also support the engagement and ongoing maintenance of professional practitioner networks where clinicians from different disciplines meet around specific topics or local areas to share tips and resources, build local referral pathways and engage in CPD activities together some of those networks are online many of them are local so to learn more about joining your local practitioner network contact the MHPN or go to the new section of the website and you could also put your interest in the exit survey and before I close I'd also like to acknowledge the consumers and carers who've lived with mental illness in the past and know to continue to live with mental illness in the present and also on this occasion given that our topic is prostate cancer to acknowledge the men and women whose lives have been affected by prostate cancer. So thank you everyone for your participation this evening and we look forward to seeing you again in the future. Good night


Self-directedness is a personality trait of self-determination, that is, the ability to regulate and adapt behavior to the demands of a situation in order to achieve personally chosen goals and values. It is one of the character dimensions in Claudinger's temperament and character inventory TCI. Claudinger has described it as willpower defined as a metaphorical abstract concept to describe the extent to which a person identifies the imaginal self as an integrated, purposeful whole individual, rather than a disorganized set of reactive impulses. Claudinger's research has found that low self-directedness is a major common feature of personality disorders generally. Self-directedness is conceptually related to locus of control. That is, low self-directedness is associated with external locus of control, whereas high self-directedness is associated with internal locus of control. In the five-factor model of personality, self-directedness has a strong inverse association with neuroticism and a strong positive association with conscientiousness.


Crop monitoring is essential for precision agriculture, as it allows growers to accurately estimate the vitality of their crops and predict yields. This study used a combination of high resolution imagery captured from a small unmanned aerial vehicle, UAV, along with plant height data collected from a crop surface model, CSM, to estimate both fresh and dry biomass on a summer barley test site. The results showed a strong correlation between the plant height data and the actual biomass, with an R2 value of 0.92. Additionally, five models were developed to estimate biomass between different nitrogen treatments, with the best performing model achieving an R2 value of 0.71. This method could be useful for farmers who are not professionally trained, allowing them to easily assess the health of their crops and make informed decisions about fertilizer applications. This article was authored by Julian Bindig, Andreas Bolton, Simon Benertz, and others. We are article.tv, links in the description below.


In the future, we will try and hold this event like once every two months and if anybody who wants to step up and be co-organiser can just contact me okay because it will be good to have more eyes and ears and hands and brain okay so i will go on to the next topic okay so this topic is Http2 and express it was actually inspired by a Http2 topic that was presented by the PHP user group about two months ago yeah so i have to give them some credit no actually we give them credit for this okay so what are the features of Http2 the most important is that is backward compatible with Http1 so basically the same methods that are that are used like get put post all this and the status codes it's all the same so the next one that's important is actually the multiplex streams so currently Http1 every request you do it's a it's one connection you have to establish get the data and close so if like you have many pictures to pull for the web page you basically open and close open and close many many times so for Http2 you just open one time every request using that one connection uh to to get all the data okay the next thing is is header compression so the the headers is all is compressed uh there's this server push but they are still still figure out what to use it for some people say that the sum of the css not important to load they'll push it out later the other one is binary protocol so the responses for Http2 is um no more text so if you want to use the curl and you see it's a bit harder to see what you are getting back then the request priorities this another one where you can prioritize the request uh this is an obscure feature which uh also actually it's just they're not sure how good it will be in the real world okay so due to multiplexing and handling of multi request handling multiple request is cheap in Http2 because you have only one dns lookup one connection one slow start then you don't need to shut the domains um so a lot of trouble can be taken out you don't need to catenate your js files or your css files you can just yeah serve as many i mean a few files um all these things are inlining and spriting is no longer needed um and you don't really need to batch your methods for the restful api calls so it's your restful call you need to do one call which calls another five or ten calls you can just go ahead and use http2 without needing to write something to batch or the the api calls so yeah this the benefits so what's the downs the other thing is um major browsers uh actually it's not a benefit but major browsers require http s for http2 that is a firefox chrome and i think a microsoft h the other benefit is with a header compression and a binary protocol you have a smaller network footprint the drawbacks is the binary protocol is harder to debug the response and it requires because of the http s you require a certificate so for development you can use self-sinsert but production i think you need to get you can get a free ones ah from less encrypt yeah they are free ones okay so the yeah i mentioned really the most support i accept safari and opera mini i can see it from this website cannotuse.com and then you just search for http2 they'll tell you which one can use which one cannot use okay so on the server side those using php or patchy you just need to use this a mod http2 nginx from version 1.9.5 plus onwards our iis is version 10 on windows 10 or server 2016 so yeah you can start playing around with http2 if you have all this the other these are quite new this h2o i do take note of this there's quite a bit of write up on this because this one is purely built for i think they focus on http2 this h2o server yeah so yeah aperture nginx h2o so the references that i took for this uh this uh this talk was from from from all these sources API card regarding how http2 uh what you can expect for restful api services for http2 okay so um before i go to the demo there's one side that uh i like to show i think it's on akamai so there's a http2 demo oh yeah you can't see it yet because i need to do this okay so this is the http1 loading this http2 so you see this one loading lots of small little files they have lots of requests and using many many connections whereas this one has one connection and then they do many requests in a one connection and you can see uh this uh the load time is much faster don't have to up and tear down so do take note of this this one was shown during the php meetup okay so now going to the demo um for those of you who are using note js it's very straightforward uh basically you do an npm install express and then after that you do a npm install spdy not http2 because http2 to this module will not work on the current express which is version 4 hanya apabila version 5 ini akan bekerja jadi selepas itu untuk menghasilkan ssl cert okay jadi biar saya masuk ke dalam jadi ini adalah ini adalah file projek yang sudah ssl cert ini ini adalah kode yang berjalan ini sangat mudah dan mudah anda perlukan file system fs untuk sebenarnya membaca certifikasi untuk menghubungi sebagai pilihan dan kemudian menghargai aplikasi jadi ini adalah aplikasi yang sangat mudah saya akan mulakan dengan http2 dulu dan apa yang berlaku adalah okey apabila anda menggunakan aplikasi maaf bukan http2 ini adalah ini adalah http ya http jadi apabila anda menggunakan aplikasi saya akan membuat pilihan f5 yang ini saya perlu mulakan okey maaf saya memilih okey jadi selepas memilih yang ini anda akan melihat protokol adalah http1 jadi saya akan mengubah untuk ini adalah bagaimana anda menggunakan apabila anda menggunakan http2 atau http1 apabila anda menggunakan aplikasi atau apa-apa saja yang anda menggunakan jadi sekarang saya akan mengubah untuk http2 bagaimana anda tidak membunuh diri okey jadi untuk http2 saya akan melakukan f5 okey dan apa yang berlaku adalah di sini anda melihat protokol ini h2 saya rasa beberapa anda tidak dapat melihat tapi itu hanya pilihan h2 di sini untuk mengindikkan http2 jadi ini adalah bagaimana anda mengubah untuk apabila http1 atau 2 anda dapat menggunakan aplikasi jadi mereka akan beritahu anda apa yang berlaku jadi saya rasa dengan ini saya datang ke atas dari atas dan jadi pada masa ini adalah pembukaan ada sesiapa yang akan ingin membuat penerbangan yang anda mencari atau mencari kerja atau jika tidak, kita hanya boleh berada di luar dan hanya mempunyai sesuatu penerbangan sebelum bergerak sesiapa-siapa yang beritahu sesuatu


Still in reverse, the state's command of the LSDC has destroyed seven illegal refineries dump sites. It has also arrested nine suspected oil thieves. Four motorcycles were among the items seized from the suspects. The state's commandant of the LSDC, Aliyu Baturi disclosed these while parading some of the suspects at the commandant's coaches in the Port Harcourt River to the capital. It was represented by the command public relations officer assistant commandant Michael Oguntrashi. At about 17, 15 hours of 11th January 2022, seven illegal refineries were sighted and destroyed at Rumec Bay in the Emoha Luka government area of the state. Nine suspects were arrested. Four are the crime scene. Seventy-five cell of him bags filled with suspected illegally refined AGO, popular known as diesel, was also arrested and conveyed here, which you are seeing here from the crime scene. Oguntrashi, a federal express that the command has intensified strategies to rid the state of illegal refineries in order to reduce the impact of suit on the state and its environs. The destruction of these illegal products, it's not as if we are banning them. What they do is from booking.  We don't ban them. It is the banning that actually causes or contributes to the suit. We also have our internal mechanisms whereby we send our men out to scan for information and also to do what we call checking on some of these trucks when they are passing so as to ensure that any truck that is passing, if at all you succeed in getting this particular illegal product in your trucks, getting it to the target market has become a problem because you are going to meet our intelligence officers and an anti-vandal team who are there to check to know if the product you are carrying is actually adulterated or not. I believe this fight against them, stopping them from doing this cooking consistently is gradually stopping the issue or reducing the impact of the suit in the state.


This year, whistleblowers also voted for one special category winner, the journalist who's work in case most exemplifies the importance of a free press. We're honoured to have Jeremy Corbyn here to present this board. Thank you. Thank you very much. Just to say I've just come from Atalante, the Latin American annual conference which we held at the Hamilton House, the National Education Union place. And there were colleagues there from Ecuador who were genuinely very supportive of Julian Assange. And we expressed our support for Julian that conference which is overwhelmingly well received by everybody there. And indeed his cause is supported by a number of very important leaders across Latin America. Particularly President Lopez Obrador in Mexico, Lula in Brazil and others. They're all making the case to the US to stop the appeal so that Julian Assange can be freed. And so our campaign goes on everywhere we can raise it. And I'm very proud to present this award, Gavin McFudden Award 2022. Special category, the journalist whose work most exemplifies the importance of a free press. Julian Assange. Sadly Julian cannot be here to receive it but we had a wonderful event in Strasbourg this week where we had a very long session of speeches and music and presentations about Julian Assange. And the high point of the evening was when Julian came on the phone to the meeting. He didn't say anything, he was just on the phone. And so he heard our applause. And so as I present this to Craig, very grateful to Craig for receiving it on his behalf. Can we just have a thunderous round of applause so Julian can hear it. Even behind those stony walls of Belmarsh. Craig.


Hi, this video will walk you through how to search in Nursing Reference Center Plus. To get started, let's enter the search terms cardiac stress test and the search bar at the top of the page, then click search. This will pull up a results page where you can scroll through the results to see if anything looks relevant by looking at the titles. Let's check out the first result, patient education, preparing the patient for a nuclear stress test by clicking the title. Here you can read the material by either clicking the PDF full text option on the left or reading the HTML full text in the browser. As you scroll through the material you'll notice it provides a comprehensive overview of what a cardiac stress test is and how to prepare your patients for such a test. It even links that to materials such as the checklist. You can also hone in on more relevant results by using the refine results tab on the left side of the results page. Refining results by material types is one of Nursing Reference Center Plus's most helpful tools. Nursing Reference Center Plus provides information both for you as a medical professional and also information you can provide to your patients. For example, let's say you want to know how to conduct a specific aspect of a cardiac stress test. You can click the check box next to skills to narrow your results to training materials. Back on the results page, let's look at the drug monograph material type. Nairing to this type allows us to view information about specific drugs used in a cardiac stress test. Click the title of the source to learn the drugs, uses, dosage, warnings, and more. Another useful material types are the patient handouts. These materials are items you can print and give to patients to educate them about procedures and tests. For example, this cardiac stress test handout tells patients the reasons for the test, what to expect, complications, and when to call a doctor. Let's go back to the main search page. Another way you can search within Nursing Reference Center Plus is by searching for a specific drug using the drugs tab above the main search bar. Let's search for a tenonol. On the results page, let's look at the titles for a result that seems most relevant and click the title of the source that meets our needs. This tenonol drug monograph gives you a comprehensive look at the drug. You can use the table of contents to go to a specific section or scroll through the chapter to get an in-depth understanding of the drug. You can also look at the related information box on the left-hand side of the screen to find other relevant information. If you need more help, you can always ask a librarian.


Now so far we've talked about a number of different trees That we've kind of seen in our our videos. So we have our traditional binary search tree This is effectively what allows us to kind of operate in some kind of confined manner where a node can either have one child or two children and And you know or no children But we worked off the principle that anything that was to the right was greater anything to the left was less than And we expanded on that we started to look into a few different trees We actually took that same idea of well Oh, this I can only have zero one or two children and then we expanded it to something like a two Three tree and the entire premise behind this is now Maybe we can have we can have a node with two keys and Three children Now a two three key is just a very very specific implementation of what we would call a be tree Be tree a balanced tree, but that's not the only type of tree that we talked about We also introduced something like an AVL tree and the entire premise behind the AVL tree was that it was Self-balancing by using the balance factor by using the balance factor It would do multiple rotations To set itself back into some particular order and then we also introduced this idea of splay trees Which moved Moved to the root now one of the issues that we have with every one of these is We get hung up a little bit on how we interact with it when I insert and remove in a two three tree I'm stuck with the idea that I have to split and I have to do fusions and transfers when I do AVLs I have to do rotations and if I that rotation didn't work then I do a double rotation and with splays Well, I do that same thing, but I just don't do a balance with it So one of the things that we want to introduce is a different kind of tree that looks To try and resolve those problems and we like to call that something known as the red and just because I Want to black tree So this red black tree it does follow a few rules That we do have to kind of maintain as long as we maintain these rules We can actually keep a very balanced tree. So the first rule is root is Black and now this seems a little interesting what you see we have these two colors here And what we're looking at is that my tree is now going to have nodes that are either red or black So when I say root must be black, we're saying that that root node has to have the color black to it the next one is all Leaf nodes are also black Now we you're trying to say to yourself well, when do it when do we start getting a red node in this place? well, ha ha ha how conveniently all children of Red nodes are black and Finally we have something known as a black depth We must maintain this and the entire premise behind this is that What we're looking at is for from any node from any node all children must have the same number of black nodes The entire premise here nodes is again if I'm looking at any Node say for example, I'm at the root of my tree from all Potential paths that are leading from this node. They must all calculate out to the same number of black nodes So let's actually kind of take a look at one And if you kind of take a look and you look at this for a moment You will see that yes. Ah, the root is black and Huh? Leaf nodes aren't black. You know, they're here here here so one of the things that's interesting about a Red black tree is where we're sort of doing a little bit of a disservice right now the idea is if We were to implement this if you know we were to spend time with each one of these each one of these is Some kind of node which means that this node has a left child and a right child The reason why this is important is because if I look at five if I look at 20 if I look at 40 65 80 90 They all still technically have some child It's just empty right now And so what we would do in our kind of to maintain the rules of a red black tree is We would also kind of visualize that all of our Nodes If they can have a child it is a black null child So just to kind of finish up here. You see that I'm Putting in the final touches of these null children and Done So if we follow that premise again that all of my nodes must have children And if they don't have children those are null children we classify those null children as black that second property works as well Then you see if all the children of a red node are black. Well, here's a red child or here's a red node Here's a red node. Here's four red nodes the children What do you know are black the children are black and if we're looking at these these bottom ones that have Null children since we classify a null node as being black We would say that this does in fact still work in our position Now finally we were talking about that idea of black death Black depth there we are The idea is from any node. Let's say just arbitrarily we pick 15 From any node all the possible paths from that node are going to equal Or have the same number of black nodes in them. So how many paths can 15 take it can go down the route. I'm going to Do a little bit of an eraser. I'm going to get rid of just this so we can see it You know that that's true Let's see. We'll take it and we'll We'll shrink it down There we go Yeah So that works so like I was saying I Have 15. Well, what are my paths?  I can go down to 25 Down to 20 down to its left child down to 25 down to 20 down to its right child Down to 25 down to 40 down to its left and then again for its right For every single one of those paths that I just identified I would count the number of black nodes that I see so in case that first one I see five that's one and then again this null is still classified as black So we'd see that this has a depth of two We check it for its second path and we see that five one black node black null node two Then when we get to 25 well 25, that's a black node. So we count it We don't count 20 because it's you know not a Black node, but it's leaf node is so what do you know this one happens to have two And as you can already guess so does this one so does this one and so does this one You could do this for every single node if I did it for five It has a black depth of all possible paths one-on-one if I did it with 50 I did it with 85 every single one of my nodes would work perfectly


Dedicated on back today with another video shout out you for tuning in if you are not subscribed do me a favor and Smash the scrubber why you gonna smash the scrubber because it's the best gig to channel on YouTube and even close on this channel We do the most and guess what they're gonna see me pull up and it goes now in today's video We got another one. We got another new amp for you guys in this video I'm gonna do order and I'm gonna show you guys how to sign up now the app is called Skip card come up below and let me know if you heard a skip part before it's my first time really doing one But come up alone and let me know how it is in your area, but we're about to go ahead and get busy I'm glad you guys are with me now the pickup place is 7-eleven We're gonna 7-eleven and from where we're at right now to the pickup location to the drop-off location to the customer It's 4.2 miles and we receive a payment of 1062 get this money. It's what we're about to do Let's go and just like that. We are here at 7-eleven Don't forget to thank God for our blessings. We're about to get this money when you stress it It's the pickup location. It's um, oh What a picker right here. How you doing sir? I have a pickup for Natalia Natalia the last zero zero three seven That's it. All right. Thank you. You have a good one. Let's go And just like that we are here at the drop-off location with those who have me on keep on skating and being great So, I'm not the joint open right here. Oh, nope Hey This is maybe her. Thanks, uh, that's how you I'm this my first time doing it. So I have no idea what I'm supposed to do. I guess I'm supposed to yes, yeah Make sure I can give it to any strangers I guess so I mean, maybe that or age wise. I don't know 12 seconds later. It's taken 3,000 years Sometimes people are lucky it goes bad like really quick But I've had issues with like for some people just take a photo of the stuff Got that. Now. I'm good to go. Thank you very much. Never a great day Now as you guys just saw I kind of tweaked a little bit I kind of tweaked a little bit on my first order But we learned and earned and if you hate it ain't your concern it now The reason why we had to get the id is because I think it has cigarettes in there Previously I didn't know that I thought it was a coffee and a donut But maybe it was coffee and cigarettes or something like that because I did need to get her id So we can get that cheese and get busy now What do I think about skip cards to me? Honestly that joint was super sweet All you do is walk in there tell them the order number They give you stuff and you take it right down to the customer house And the customer house was literally one mile away and we made 1062 for that. So I think it was super sweet now What I kind of don't like with skip card is you actually have to go to a specific area in order to get orders So on the map it's like a map and it's like green circles So you have to go in the green circle in order to get an order Also, just so you guys know sometimes you would not be able to accept an order if you're more than 16 Minutes away from the green area from like the hot spot if you're more than 16 minutes away from the hot spot It's not going to allow you to get the order So you're going to have to drive in some more so you can get the order so you can go out there and get in order But other than that, I like it a lot, baby. I think it was super easy I think it was super sweet and the payout was very decent The payout was actually one dollar and 62 cent from uh from the delivery and then there was nine dollars from the customer Not out of tip off the rip so it's a little flip the game is over Now another thing that's great about skip card is they have a lot of promotions all the time, baby All the time you can go out there and get on the grind They have some like maybe you do 30 orders you get an extra 75 dollars Plus it's an extra like three or four dollars on top of the order already anyway So you can get paid pull up a little excavation You can make a lot of money fast Especially if you're in a bigger city one of the things that I don't like I wish it was kind of close to us because we had to go to chicago to actually do this order So we can go out there and get an order But if you are close to a big city you might want to Sign up because I think it's a great after half You don't have to do no shopping you don't have to do nothing You just walk in and get it in and get them different ends Now these are the requirements you must have these requirements done or else You will not be able to get in skip card Number one, you must be at least 21 years of age Number two, you must have a reliable vehicle. Number three You must have a smartphone with at least these versions of software iPhone ios software nine or newer And android 7.0 or newer those are the different types of software you have to have I don't know about that, but I'm sure that if you have a phone You probably get it to get in so you get them different ends Number four, you must have a valid us driver's license and auto insurance Number five a thorough background check is required Number six, you must be able to lift at least 50 pounds and last but not least number seven You must have a valid social security number Now that we've done the skip card order, you know what I feel about it We're actually going to go sign up right now. All you're going to do is go to google type in skip card There you go right there. Uh skip card right there. Then you're going to hit driver sign up. We hit that Hopefully this internet ain't tweaking right now slide down. Okay. We're going to go down type in your first name Jerome Last name Adams email address romeshousereviews At gmail.com You want to put your phone around one two three four five six seven eight nine ten? We are here to win and get these dividends State illinois from what it looks like as you guys can see it look like they have all 50 states select Select a metro i'm going to go The closest thing to me is chicago.  I'm going to oh sadan motorcycle suv or pickup. I'm going to go with sadan I'm going to add snow white to this joint next Do you have a valid us driver license? Absolutely next Are you over the age of 21? yes Now after you hit continue They're going to send you a code to your email g14 classified code what you're going to do is go in your email Copy and paste it you're going to go to the next step the next step Is going to be you filling out all your personal information your name your birthday your social security number Your phone number and stuff like that and then your address and everything and we're going to go to the next step So we can get this ground after you have completed your personal information They are going to send you a thing called a fcr a consumer report disclosure So pretty much what this is is this saying that you are authorizing them to run a background check on You and it's going to go through a third party and not them So that's how you got to do that and then you're going to hit you read it and you verify it make sure you really verify it though After that they're going to send you a thing called state law notices and disclosures background investigations If you live in these states make sure you read everything you need every this whole thing baby if you live in new york minnesota oklahoma Or washington state you make sure you read this because you guys have special instructions about your states I don't know what it is but make sure you read everything if you do not You're going to say you acknowledge this and you're going to move on to the next phase Then the next thing is going to be a summary of your rights under the fair credit reporting act So they have to report your credit fairly, baby So that you got to sign that and then you got to go down click a more couple things and go on to the next step Next is going to be acknowledgement and authorization for a consumer report This is telling them that you are authorizing them to run a background check on you If you do not click this they're not going to run a background check and you will not be able to get in skip car So you're going to scroll down acknowledge that you know everything and then you're going to type your name out That's going to that's going to be the same thing as you sign. It's like electronic signature. So jerome adams junior Next step now after you complete that they are going to do a background check This background check can take up to three to five business days for them to clear you for the skip car app Now i'm going to answer a question that I always get on every single app We ever do when do you get paid when you get paid when you get i'm gonna tell you right now, baby I got you no trip so With the skip car app their payment cycles run weekly Normally it begins at 4 a.m. On monday and ends on 4 a.m. The following monday But i got some great information for you guys. Guess what? With the skip car app you can get your payment the next day, but but the It's a but to it They're going to take one percent or one dollar and ninety nine cent One percent of the payment or one dollar and ninety nine cent whichever one is greater So if you want your instant payout you go ahead and click pay now And you are going to get paid and just like that. It is in the video I hope you guys enjoy the content comment below and let me know if you enjoy the videos when I do the Order and help you guys sign up for these different apps comment below and let me know so you go out there and scroll I'm trying to get this though. Do not forget make sure you smash that subscribe button The goal is a hundred thousand subscribers by december 31st 2023 and I need your help so we can get busy so we can get this cheese and get these jeans because we need that plaque baby So it's up to y'all to help us ball and don't stall I hope you guys enjoyed this video Make sure you lock in tomorrow because going back down because we ain't playing around the 2023 is big bad Excuse me. We'll keep on giving a reason. I see you guys on next time We grew we grew before you already know the ddk and i'm on my way