 We will now start recording the webinar. Welcome to our final webinar in this series, which has been focused on the articles published in the Special Issue on Genomics in the March Journal of Nursing Scholarship. All webinars are archived and will be made available on the site at genome.gov, along with speaker slides. Today's topic, a blueprint for genomic nursing science, is presented by, next slide please, Kathy. Myself, Dr. Jean Jenkins, Dr. Kathleen Calzone, Dr. Alexis Bakos, and Dr. Ann Cashin. I will give you a brief synopsis of our information so you know who you're hearing from today. As I mentioned, I am Dr. Jean Jenkins. I'm a clinical advisor at the Genomic Healthcare Branch, Division of Communication Policy and Education at the National Human Genome Research Institute, NIH. I received my degrees from the University of Maryland, Catholic University of America, and a PhD from George Mason University. I've been active in providing leadership in the development and revision of competencies, both at the National Coalition for Healthcare Professional Education and Genetics, or NICHPEG, and building on these efforts that with Dr. Kathy Calzone coordinated the development and consensus of essential nursing competencies and curricular guidelines for genetics and genomics, and have also been instrumental in the G2C2 site and the web-based case scenario site with Dr. Calzone or G3C. Dr. Kathy Calzone is a senior nurse specialist research in the genetics branch of the Center for Cancer Research at the National Cancer Institute. She is credentialed in genetics by the Genetic Nursing Credentialing Commission and is a fellow of the American Academy of Nursing. Dr. Calzone is past president of the International Society of Nurses in Genetics. Dr. Alexis Becos is the acting director of the Division of Nursing within the Bureau of Health Professions at the Health Resource and Service Administration of HRSA. Prior to this appointment at HRSA, Dr. Becos served as chief of the Diversity Training Branch within the Center to Reduce Cancer Health Disparities at the National Cancer Institute. Dr. Becos also served as a program director at the National Institute of Nursing Research NIH, and she has chaired the NIH-wide End-of-Life Scientific Interest Group. She received a BSN and MSN from Catholic University in School of Nursing in Washington, D.C., an MPH with a concentration in epidemiology from George Washington University, and a PhD in Nursing from Johns Hopkins. Dr. Cashin is the acting scientific director of NINR's Division of Intramural Research, and before coming to NIH, Dr. Cashin held the position of professor and chair of the Department of Acute and Chronic Care in the College of Nursing, University of Tennessee Health Science Center, Memphis, Tennessee, where she held a faculty position since 2000. Her previously funded research and clinical interest target genetic, genomic and environmental components associated with outcomes of organ transplantation. And in her most recent NIH-funded study, she combined emerging technologies of microarrays and behavioral questionnaires to investigate gene-environment interactions leading to obesity and recipients of kidney transplantation during the first year after transplant. Welcome to each of these speakers. We are very pleased to have them. They are the co-authors, along with others, on this blueprint for genomic nursing science paper. Next slide, please. Today's webinar includes information about the purpose, the methods to establish, and the focus of the blueprint, as well as consideration of next steps. This blueprint targets research to build the evidence base to inform integration of genomics into nursing practice and regulation. Next slide, please. Funding for this effort was provided by several intramural programs at the National Institutes of Health, including the National Cancer Institute, the National Human Genome Research Institute, and the National Institute of Nursing Research. Next slide, please. So why is this blueprint so important? Well, as many of you are aware, genomic developments are changing healthcare, and because nursing is a fundamental provider of healthcare, genomics is also changing the profession of nursing. Discoveries such as the mapping of the human genome and the illumination of genomic variations associated with health, disease, and management options are now being translated into practice because of a lot of your efforts and work. All aspects of the healthcare continuum are influenced by genomic developments, and as such, the use of genomic information and technology is no longer dependent on referral to genetic specialists, but rather has translated into non-specialty healthcare delivery. Clinical applications begin at the beginning of life and across the entire healthcare continuum and our continuum of life. For example, preconception or prenatal period, newborn screening, risk identification both in adolescents and young adults, screening and diagnosis of disease, disease characterization looking at prognosis and either genetic markers that may indicate what individualized therapy would be best served to be provided to the patient and improve health outcomes. Human management at the end of life incorporates genomic information. For example, in pain control, some individuals respond better because of a genetic contribution to their pain pharmacogenomic dynamics and will respond better to treatment based on their genetic makeup. Even after end of life, individuals may have information that needs to be passed down to the family in regards to why they were at risk for a disease that perhaps ended their life. So as you can see, nurses must be competent in genomics to provide safe, cost-effective and quality healthcare both for today and for tomorrow. Next slide, please. I would like to give you some background information of this Genetic Nursing Competency Initiative or GGNCI. If you'd like to read additional information, there is a publication from 2011 that Dr. Calzone and I contributed to in the annual review of nursing research. Next slide, please. In 2004, the National Human Genome Research Institute and the National Cancer Institute collaborated to establish the U.S. Genetic Genomic Nursing Competency Initiative. And as you can see from this timeline, which is also taken from that 2011 paper, a lot of this work began all the way back in 1995. But what I wanted to highlight for you along this extensive timeline is the meeting that was held in 2006. So if you look at the arrow on the timeline, this indicates a meeting that was held in an attempt to address these competency gaps that were identified within the nursing profession. GGNCI convened a meeting of key stakeholders to establish a Genetic and Genomic Nursing Competency Strategic Implementation Plan. Recommendations from this meeting included coordinating strategic plan activities around three priority areas, practicing nurses, academics, and regulation and quality control. The recommendations also identified the need for an infrastructure to coordinate strategic plan activities. Next slide, please. One of the outcomes of this GGNCI effort was the identification of the need for what would be competency indicators that were essential for all genetic and genomic nursing. We worked with a group, an advisory group, to define the essential genetics and genomic competencies for all nurses, regardless of level of academic preparation, practice setting, or specialty. And to date, these competencies have been endorsed by 15 nursing organizations. The second edition incorporated outcome indicators in response to academic faculty that were requesting specific areas of knowledge and clinical performance indicators that would be of value to teach in the curriculum and academic settings. Additionally, since then, as indicated in the next slide, there have been essential genetic and genomic competencies for nurses with graduate degrees developed. And these also define essential genetic and genomic competencies for all graduate nurses, regardless of level of academic preparation, practice setting, or specialty. And they, too, were established by a process of consensus. Another goal of the GGNCI was to determine the gaps in the evidence. Now that we had competency identified, what was the evidence of genomic nursing science and chart the path towards filling the gaps through a nursing science blueprint? To achieve this, a genomic nursing state of the science advisory panel was established. Next slide, please. The significance of moving forward with the Genomic Nursing Science Initiative was to be able to provide the evidence specific to outcomes of genomically competent nursing practice and the impact on the public health, because this is extremely limited as far as we were aware, if not entirely absent. So we wanted to be able to document whether or not our perception of that gap was accurate. The paucity of outcome data was also thought to be hindering efforts to incorporate genomics into curricular, licensure, academic, and healthcare organization accreditation. And just a side note, no one healthcare discipline is at the forefront in the assessment of this evidence. And that was also recognized through our work with interdisciplinary colleagues, realizing that evidence was something that all of us were wanting to have, but was not yet available. Nurses are one of the primary health professions on the leading edge in the integration of genomics. And therefore, the outcomes of this initiative can be used as a model to advance similar efforts to establish a research outcome agenda across other healthcare disciplines. Next slide, please. So let me give you a little background of the Genomic Nursing State of the Science Initiative. Next slide. The aims identified were to establish a blueprint for genomic nursing science that can be used to focus research efforts to fulfill identified evidence gaps and therefore provide an established blueprint through the analysis of the evidence, expert evaluation of the current state of the science, and public comment. Next slide, please. And now I will turn this speaking opportunity over to Dr. Calzone. So the next thing we're going to talk about is the methods to achieve these aims to actually establish the blueprint. And so the very first step, as Jeanne already mentioned, was that we did convene a panel that we titled the State of the Science Advisory Panel. We also did evidence reviews. We had meetings both by webinar, similar to what we're having today, but with our State of the Science Advisory Panel in attendance, as well as in-person meetings, followed by public comment. So let me walk through this for you so that you have an understanding. The two coordinators of the panel were both Dr. Jenkins and myself, as well as 14 invited members. And members were selected based on their expertise in genomics or their expertise in nursing research, expertise in nursing workforce issues, people who had expertise in system change, health services measurement, and evidence-based synthesis. By no means did we have people who fulfilled all of these criteria. So our invited members fulfilled one or more of these specific kinds of expertise. We also had invited members that were representative of the practice environment and the academic environment, underrepresented populations, interdisciplinary groups, and a variety of federal agencies, including HRSA, and multiple institutes within the National Institute of Health, including the National Institute of Nursing Research in particular. This is the list of the panel members, and you have the top four people of our panel members represented speaking to you today, and then the remainder of the members are listed here for your information. And this is a picture of the initial in-person meeting of our advisory panel, and does not have the entire complement included, but gives you a flavor of the spectrum of people who were present at our particular meeting. So the evidence reviews, we took two approaches to this. And the first was a systematic evidence review, and then the second was actually looking at the report mechanism for NINR and other nursing-specific research. I'll go back and just comment that our systematic evidence review was really focused on practice-based evidence, and so that particular evidence review was somewhat limited in that it focused on whether or not there was evidence that nurses who were competent in genetics and genomics made a difference in health outcomes, whereas the report mechanism looking for active research was really focused more on what nurses were doing in research that incorporated genetic and genomic concepts and sciences. So we had two webinars, as I mentioned. The first webinar was really to get people sort of understanding what the purpose of this initiative was, who were the other panel members that they'd be working with as they pursued this initiative to overview what exactly we were going to try to achieve as an outcome of this particular effort and the strategies that we were going to use to achieve that outcome, and then what work had already been done today. As I think Jeannie mentioned, way back at our strategic implementation planning meeting in 2006 was when this idea presented itself, and we continued to hold meetings and planning and seek funding for this, and so there was quite a bit of work that had been done, including some of the evidence reviews by the time we actually convened our panel to actually begin work. The second webinar was to actually hear from key stakeholders. So in addition to our panel members, we felt we needed to have some perspective from key stakeholders that extended beyond the panel itself. And those included people from the nursing leadership, the consumer perspective, and the medical perspective. And by medical, I mean the physician perspective of all of this kind of evidence and research work. We did review in the second webinar findings from the systematic evidence review and provided people with the actual written overview of that review. And if you go to the JNS manuscript, you can access that systematic evidence review as supplemental material in its final form. And then we had a long discussion with the panel in regards to what additional preparatory materials they felt that they would need before they convened in person to actually do the bulk of the work associated with this effort. Our first in-person meeting was held in June of last year. And there were six key things that we really discussed. The first was sort of models for establishing the research agenda and overview of the actual evidence gaps, the scope of the research that would be needed to be addressed to cover the evidence gaps, to identify within that scope of research what would be the key priorities and then address specific research directions and funding considerations. After that particular, after that particular meeting and the draft of the research agenda, we sent the research agenda out for a public comment period. And that public comment period was in that intervening period between the June 8th meeting and our second in-person meeting on September 20th. That particular meeting, which was actually sponsored by the National Institute of Nursing Research, we had an opportunity to have a keynote address by Dr. Grady, who's the director of NINR. And we spent the bulk of the meeting really reviewing the details of the public conference, making revisions to the blueprint itself based on those public comments, planning for the manuscript associated with the outcome of all of this work and then the preliminary discussions of next steps because just having the blueprint is not sufficient and we really need to then think about how to move that forward. If you are interested in seeing the public comments which people had the opportunity to either comment in-person and say who they were, they could have very long comments or short comments or they could put up their comments and submit them anonymously. Those are all still available for viewing and you're welcome to go to the genome.gov website listed here and this will be on the slides that you can access to actually see the comments that people submitted, all of which we thought were very thoughtful and very helpful in strengthening the blueprint to move it forward. So what does the blueprint actually begin to look like? Basically there were a number of things that the advisory panel concluded and the first was that the focus of the research needed to produce clinically relevant evidence that was along the translation signs continue on and that we needed to use multiple methodologies, multiple measurements but build on existing work. Most importantly was to frame the blueprint so that it aligned with the National Institute of Nursing Research strategic plan areas and then we made some major sort of concept definitions and the panel agreed that the client should be consistent with the definition that is in all of the competency documents that Dr. Jenkins already reviewed with you which is the broadest possible definition. So the client constitutes persons, families, communities and or populations. The other thing was that there should be two major research areas, focus on the client and focus on the context in which healthcare is delivered and that there were some cross cutting themes that went across all of the blueprint recommendations. So the focus on the context versus the client is actually important because this is one area of research where we need to really focus on capacity building. We have to have increased capacity for nursing scientists, nursing faculty, for students as well and perhaps most importantly the practicing nurse regardless of what their role is or their clinical specialty or their level of academic preparation. And there are a lot of environmental influences in the context all of which plays a role in all of the science that is recommended and that includes health disparities, cost, some policy implications and the public education and that we need to have this evidence to guide practice. So at this point I will turn this over for this discussion on the focus on the context versus the client with this beginning part of focus on the context being delivered by Dr. Bezos. So thank you. So as Kathy said, we will now focus on the context in which healthcare is delivered. And this first contextual category is technology development which involves incorporating new technologies, applications and the policy guidelines to support the applications as well as ethical considerations of technological development. Technology development also encompasses genomic bioinformatics as well as translation, dissemination and implementation of information. The use of genomic information and technology is no longer dependent on referral to a genetic specialist but has transitioned into non-specialty healthcare delivery. We need to be cognizant of the use of technology in information delivery, provider performance improvement, as well as resources that support genomic research such as best practices and nursing outcomes. Next slide, please. Informatics support systems and environmental influences are additional contextual categories to consider. Nurses should be poised to become the point of care, decision support for clients, help facilitate cross-generational sharing of genomic data and assist in the management analysis and interpretation of genomic information. Nursing should help broker common formats for Davis storage and use to facilitate research processes and outcomes as well as standardized terminology and taxonomy. Environmental influences can have an important impact on the progress needed to be made. The development of evidence-based guidelines, economic factors such as nursing's impact on cost effectiveness, regulatory gaps or variability across states, as well as the impact of the Affordable Care Act's coverage of preventive services such as breast cancer, genetic testing and counseling for women at high risk are all examples of environmental influences. Next slide, please. As the largest and most trusted healthcare profession, nurses must be competent in genomics to provide safe, cost-effective quality healthcare. We know that a broad segment of nurses and nursing faculty have limited genomic competency. Consequently, we need to train future nursing scientists and nursing faculty as well as educate advanced practice nurses and research nurse coordinators in genomics. As part of the capacity building, we must promote innovative use of biopositories and advance the use of bioethics to support this growth. The full spectrum of the nursing workforce from nursing leadership to those entering pre-licensure programs must be trained in genomics to support genomic translation, research and practice. Next slide. Finally, there are broader influences that cut across almost all of the research topic areas within this rubric of contextual. And we need to look at health disparities and its impact on ultimately achieving health equity as well as factors such as the disproportionate occurrence of disease in the population and genomic misinformation that sometimes occurs among ethnic minority communities is important to consider. Regarding cost, it is important to address the strategic imperative of measuring the impact of competencies on cost, quality and outcomes of care. Also, we know that research shouldn't form policy and that policy becomes the context of science so that it's quite an iterative process. And finally, it's important that we focus on improving the overall health literacy of the public and specifically their genomic literacy as well. I would like to now turn the presentation over to Dr. Anne Cashin who will discuss research focus on the client. Thank you. We will divide the research focus on the client into two categories primarily. One is called health promotion and disease prevention. The second category is named advancing the quality of life. I'll go through the specific nursing research categories specific to those topics at this time. So when we're looking at genetics, we usually, many of nurses actually do start looking at risk assessment. A lot of nurses want to be able to predict who will actually be at risk for certain diseases or certain conditions or disorders. So risk assessment is an important element of nursing research. And we can be looking at that in terms of a biologic probability which is looking at actual pathways that are involved or mechanisms that are involved. You hear many people speaking to say about biomarkers but the specific things or proteins that would actually indicate someone's at risk. So those are involved in risk assessment. We also look at comprehensive screening opportunities that we could use in order to determine groups of populations who would be at risk. Components of risk assessment can also include family history. The person general family history website has been used by many nurse educators to help nursing students become familiar with the effect family history could have on their own genetic history or their single outcome. And we can also look at risk specific top-tier decision-making. Again, that can be seen as becoming increasingly focused on decision-making and gaining a lot of focus on the national level. And nurses have been concerned about how individuals make decisions regarding genetic testing for many years. We may have been some of the cars to really start doing research in that area. So another category under health promotion as a big provision is communication. Again, we come back to risk communication and that's in front of what you leave with the patient about what do they want to know about and what the family should know in terms of genetics of the actual patient. And one concept is becoming increasingly discussed area as we move into whole genome sequencing and our ability to actually locate specific mutations that may not have been part of the initial research study. And the question is how much of this information does the patient or such as you want to know and what is our responsibility as researchers to give that information? So communication is a large area direct to consumer marketing and testing has also been studied by a nursing researcher. Decision support, again, we talk about in some consent. The match of the values of the preferences with the decisions and that comes in again into discussing whether or not the subject or patient can bother the study much to be told whether it's important information or not. This perception and accuracy is a concern as we talk about clinical utility and personal utility. Personal utility meaning does it actually affect but it actually does the individuals with that information and clinical utility would be whether or not the individual can use that information to make clinical decisions. Next slide please. Thank you. So advancing quality of life, that is divided into family and central management on this particular slide with family, we look at family context and nurses are very interested in that area of research, ethical issues. We have funded many studies in that as well. Health care provider communication with families is another area under central management. Again, we have found when we were developing this loop ramp that it was very difficult to put some of the topic areas only in one specific research category. So you will see that a few of them do cost categories. So under central management, you had the biologic possibility again the clinical utility, personal utility, pharmacogenomics is a booming area of research when we try to decide it's a specific mutation that's more or less likely to respond to medication or therapy, particularly in the cancer or oncology area. And I've already discussed the Susan making and then evidence-based effectiveness of approaches is something that is particularly pertinent to clinical setting at this particular time. Next slide please. On this slide, we look at disease states and also client self-management. In disease states, we recognize that frequently nurses do look at specific kinetics within a disease state whether it's diabetes or obesity or cystic fibrosis. So we are looking at genomic based innovations that can reduce morbidity and mortality in this area. Gene environment interactions are more on the molecular, this is more on the molecular biology level. And as a genetic is certainly becoming more prominent in some of the research that's going on. Pharmacogenomics, I've discussed that, and then evidence-based effectiveness of this treatment and support. Again, oncology is leading the way in this where we're actually seeing a treatment based on specific genotype and following and changing treatment based on the genotype or the tumor or the individual. Under client and self-management, we look at collecting and conveying information that informs self-management. Again, we talked about family history, lifestyle behaviors. Certain genotypes have been associated with specific of our lifestyle. So that may become a bigger factor in the future. Environmental exposure and protection that are occupational areas and the synergy of the client and the provider expectations. And then personal utility which I have discussed and that's basically whether or not it's important to the individual whether genetic like that is. Next slide, please. So our next step, we want to further refine the belief grant and so NINR has been working on an initiative to potentially have a workshop in this future and look at drilling down even more in these particular areas that is being discussed at this time. Infect structure is looking at designing and implementing and evaluating the clinical and educational infrastructure that supports genetic capacity and competency. And that involves some of what Dr. Bezos has discussed earlier is that we need actually educational settings that can teach this information. We need research labs where nurse scientists have access to the technology and equipment in order to do this type of research. And then we also need hospitals and clinical settings that support nurses who are providing this type of clinical management. Measurement is an issue that needs to be addressed in terms of trying to have consistent measures and evaluation of the measures across studies and across clinical settings. So building this capacity is in the forefront right now. Some of you may have been aware of initiatives that are called big data initiatives. These initiatives have been ongoing and some other disciplines outside of healthcare for a number of years, but it is extremely important in healthcare based on the amount of data that we get from our genetic research studies in trying to incorporate that amount of data into our clinical data and then come up with some type of algorithm or modeling that would help us include care of our patients. So big data and data-based infrastructure is very important at this time. And funding is always usually a question and a concern as well. We get agencies such as HOSA who specifically focus on workforce capacity and building that, NINR and all of the NIH, because many of the institutes here at NIH do some nurses, but we provide funding for genetic research and then also foundations are available to fund this type of research, whether it's for Robert Wood Johnson, or professional organizations, whether it's on College of Nursing Society or Sigma Theta Hall. So there are many opportunities for funding, some small and some larger. Next slide, please. So in conclusion, genomics underlies all healthcare and it's fundamental in genetic practice. Nursing research and genomics will help establish the evidence-based needed to facilitate the translation of the genomics into practice to include healthcare. And the Blue Press for Genomic Nursing Science provides the initial platform to accelerate research and pressing the critical gap. I'll hand this back over to Dr. Jenkins at this time. Thank you. So I now have a lawnmower blown by the window, so you'll hear some background noise, I'm afraid. I will open it up for questions. There was one comment that I wanted to share with a group from Joanna Speos that says, I would add one more category to the genetic and genomic influences across the continuum, and that is transition to adult healthcare. So thank you for that consideration. I know a couple of you said that it was hard to hear at times on the microphone and I'm sorry, we do our best to make sure that the sound is clear, but hopefully it'll come out clear on the archived version and perhaps you can listen to that. This is just the blueprint for Genomic Nursing Science. As you are aware, the Journal of Nursing Scholarship March 213 had the genomic special issue and a reminder that all the articles are open access, including this article that we just presented information about. If you have any questions, please submit them. And Cathy, if you can go to the last slide. Just a reminder that the webinar series can be revisited. They were presented by both nursing and medical expert authors of the manuscripts, and archived video and slides from each webinar are available at this genome.gov website. So I'll open it up for questions. Any comments or questions? And as we wait, I'll open up all the authors from this paper to see if there are any general comments that any of you wish to make. Cathy? I think my only comment about the blueprint is we think it's a very useful tool for anybody in any setting as you're beginning to think about nursing research and incorporating genomics that it can provide a platform for your thinking and provides a way to begin to identify areas where the panel of experts has identified clear gaps in the evidence. So there are lots of opportunities to utilize this if you're thinking in how you can move forward. Alexis, would you like to share any last minute thoughts? Only that I'd like to thank Anne for mentioning looking at the broad array of possible funding opportunities that are within the National Institutes of Health, specifically NINR, but also to please look at the funding opportunities that will be issued probably in the fall of the year, late fall, early winter of the year from the Division of Nursing from HRSA. There will be had in the past funding opportunities that have focused on interprofessional education as well as interprofessional practice. And hopefully we can leave specifically some genomic areas of focus into that. But the bottom line is that those are two funding opportunities that would be perfect for this. And so I hope that those of you who are participating in the webinar will go to the Division of Nursing website or send me an email so that I can put you on the HRSA Division of Nursing listserv and we'll get that information as soon as it is released to the public. But even if you choose not to be part of the HRSA Division of Nursing listserv, I would definitely encourage you to check back in late fall or early winter of the year for those upcoming funding opportunities announcements. Thanks, Alexis. I would like to just add. Go ahead, Ian. Yes, I just wanted to add that nurses have been shown to be excellent interdisciplinary leaders. And so leading a team that is conducting genetic research is definitely within the scope of what nurses are able to do. I have found that to be the case a lot of times because we actually have some foundational knowledge about diseases and general. And then we are usually very good communicators and collaborators. And that can translate into an excellent team member. To do genetic research in the health care setting, you can't be involved in this one discipline because it takes a whole team. You need a morphobiologist. You need a statistician. You need usually access to patients. So it is definitely a team's bias. That's all. Thank you. Thank you. There was a question that I'll put to the team. Are you planning something similar with proteomics and metabolomics? I'm not sure what is meant by that. Hello, this is Alexis. I would think that our planning opportunities that might be issued, I'm sure, would be broad enough that it wouldn't encompass something like proteomics. So I don't think that that will probably be a problem. We can't usually get for, I mean, I think that if you, at least I know in terms of for HRSA, that we will make it broad enough that I think that it should be possible for you to mend an application or a response so that they can see an accident. And I think on behalf of the blueprint discussion, yes, we talked about genomics. But indeed, the other components of DNA, metabolomics, proteomics, any kind of omic would probably be able to be replaced within our recommendations and still need the research in terms of finding out if genomic nursing competency made a difference to patient outcomes using that information and care. I'd also like to read this comment. This blueprint and presentation has given me many ideas from my BSN completion students to pursue and thinking about topics for their research projects. Thanks to all of you for your foresight and hard work. We all need blueprints to guide our work, and this has been well planned and executed. Any other comments from the team or participants? Can you still hear me OK? No, you're fading out there. OK, it's a lost audio connection for a moment. I said, are there any last comments or questions from the team or from the attendees? OK, we will close off the webinar a little early today. We appreciate everyone's close attention to the Journal of Nursing Scholarship series, and we welcome any further comments from you once you have your students or others view the webinars. And if there are any questions that come up, please feel free to email Dr. Kathy Calzone or myself, jeanjenkins at nih.gov. We'd be happy to hear from you. Thank you. Thank you.