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Cutting Edge: Episode 7

Dec 10 | 3:30 PM

Here we are with another interesting episode of Cutting edge and we have a few amazing experts joining for adding incredible value to a few interesting stories. Dr. Himanshu Mehta, a Consultant Ophthalmologist at Vision Eye Center, gives his take on the study that linked cataract surgery to a lower risk of dementia, citing examples from the cases he has treated. The ApoB/Apo-A1 ratio is a strong early marker for adverse CV outcomes, watch Dr. Kamal Sharma, an Interventional Cardiologist with SAL Hospital, give his point of view on this study. Lastly, Dr. Desai discusses the increasing evidence for a booster dose in COVID-19, as covered by various studies.

[Music] good evening everyone and uh welcome once again to the seventh episode of cutting edge i'm dr naveda and on behalf of team netflix i welcome you all uh as you all know uh our host our speaker for tonight is dr mahadev desai a senior consultant physician from amdapad hi good evening everyone yeah so the first story is the title is sildenafil users are 69 percent less likely to develop alzheimer's disease that is from the cleveland clinic researchers now the birth sin cylinder itself takes us back to the history we know selena filmed when it was introduced it was introduced for the indication of anti-hypertensive and as an anti-internal medicine but during the course of the therapy there was a one side effect which brought to the notice of the companies and company changed the indications and they applied for the repurposing of the drugs and now practically nobody uses as in the hypertensive but it's used for its main use in the erectile dysfunction sildenafil is also used in the treatment of primary pulmonary hypertension so the issue is appeared in the nature aging in the 6th of december where the researchers have analyzed 7.23 million individuals using this drug for the one or the other purpose as a part of pharmacophilological analysis pharmacoepidemiological analysis for the 7.23 million prescriptions that were used and which has came for the insurance claims and what struck to them was when the sildenafil was used by the people for one of the other indications their chances of developing alzheimer's disease was reduced by 69 percent so that was after six years of follow-up so it's a something totally a new thing just because it's a retrospective analysis of the prescription of this drug it's not something that is to be prescribed for the indications of reducing the alzheimer's disease but it brings to the point of now we have got so many big data which runs in millions and trillions of the drug usages that we can come out with this kind of repurposing of the drugs you have to keep in mind that this is just a correlation that is found by this analysis and it is not a recommendation it is not a proven thing and we need randomized control trials to prove that selena fill use is likely to reduce the alzheimer's disease but something that definitely may change the use of sildenafil of course we have to know that whenever we use drugs like sildenafil there are many things that we have to rule out patients should not be on drugs like nitrates that is very very important otherwise there are a chance of severe hypotension and even death so the point is that because of the big data now we may have many such drugs to be used for the other purposes so kovid has given us the term repurposing and we have started repurposing many trucks and maybe this is the beginning of repurposing of many other drugs selena film may be the future for reducing alzheimer's disease story number seven up till now we remain under the impression that if the patient has compensated cirrhosis earlier many years and probably nothing is going to happen but this particular article caught our eyes that disappeared in the medscape on 6th of december here they studied the 35 361 patients with cirrhosis proven cirrhosis and the mean age of the patient cohorts was 59.5 years and they divided the patients in the patients having cirrhosis with comorbid conditions and cirrhosis without comorbid conditions and what they found was that 25 percent of the patients had comorbidities co-orbitals like cardiovascular disease diabetes hypertension chronic kidney disease and so many and so forth so the common estrogen cbd was the commonest comorbidity which was present in almost 45 percent of the patients 35 000 patients of cirrhosis with a mean age of 59.5 years having 25 percent having comorbidities what are the reasons the results were surprising to the researchers themselves they said that they never expected the patient with compensatory cirrhosis have chance to have a higher hazard ratio of death what was found that the risk of death increases by the number of comorbidities if the patient has compensated cirrhosis and one comorbidity the chances of death risk of death increases by 2.5 times but if there are two comorbidities it will jump to 3.27 and if the there are three comorbidities if the patient of compensated cirrhosis has three comorbidities his son's hazard ratio for death is 4.52 percent so the conclusion was the persons with three comorbidities and a composited cirrhosis as is as bad as persons use uncompensated cirrhosis just like something we say that diabetes and diabetes is as good as one micro infarctions in the past so here the comorbidities are tied to the worse outcomes and especially when they analyze deeply they could found that the patients who had cirrhosis with comorbidities like cardiovascular disease or chronic kidney disease they are the worst outcome and both individually cbd is bad secret is bad but combined together their worst outcome oh and what they found what the survival benefits with the composited cirrhosis and three comorbidities is same as decomposite patient without comorbidities so it's a time that next time when we see a patient of an incidental report of chronic liver disease on a sonography we should be looking for the comorbidity conditions and we should treat them so that they do not go into the more risk of death so that is the story number seven another very interesting story that this is a story which appeared on the 7th of december and this was done by the swedish national ageing and care in consolman kung solman appears a new name but those who know her who watch regularly watch the nobel prize ceremonies right they know that this is a city which is in stockholm and in there is a beautiful stockholm university banquet hall where the nobel prize discipline ceremonies are taking place year after year so in this particular study the researchers were fascinated to find out whether the resting heart rate has any risk of dementia and they selected 2147 patients who are more than 60 years and they studied them for a median age of median duration of 11.4 years persons were followed up for 11.4 years and at the time of recruitment they did not have any dementia and once they kept on following what they found was that out of two and four seven persons 289 patients develop dementia and what they found was that they divided all the patients into three categories those who had a heart rate more than 80 or more than 80 per minutes those who had a heart rate between 17 79 beats per minute and those who have heart rate between 60 and 69 per minute and what they found that the resting heart rate more than 80 bits per minute had a 55 percent increase risk of developing dementia compared to the group who had a resting heart rate of 60 to 69 beats per minute so what they found out that the resting heart rate risk of dementia is independent of the risk of cardiovascular disease or other risk factors so maybe we should be looking for a risk factor which can easily be assessed and they did not just take the pulse rate they did the trial ecg every time they see the patients and it was standardized and this association as i said was not underlying cbd or the other cardiovascular complications like atrial fibrillation or heart failure they have confounded all these parameters and they come to the conclusion that independently also the resting heart rate more than 80 carries the risk of dementia and what they found out that this could be because of the probability underlying increase sympathetic activity and they also postulated that maybe the drugs like beta blockers or evaporating may be of use in future to people who have got resting heart rate above 80 per minute to reduce the risk of dementia as well as other complications we move on to a very interesting story for which you also have an expert opinion and that is about the new leadless pacemaker promising in safety and efficacy we know traditionally we know the trace makers space makers are having a transvenous approach and we implant them whether it's temporary or permanent by trust venus as trans venous root so this is a particular study that appeared in midscape on third of december and here the leadless two-phase study which was carried out across the 43 centers in usa canada and europe and a particular type of lead-less pacemaker that is called the aware lp was used in 200 patients requiring ventricular demand pacing it was used as a single chamber pacemaker and the we know the conventional complications of the transvenous pacemaking we know that it can lead to infections mainly plus there can be pericardial diffusion myocardial injury increase in the trophy all those things so what they wanted to know with how safe and how efficacy is the leadless pacemaker and what they found was very reassuring that almost 98 percent of time there was a success rate in implanting and also it did not require repositioning and from safety point of view there was uh absence of complications in 96 percent of the patients the only limitations probably of the study was that this is only a single chamber pacing at present and that particular kind of indication at present is hardly in 10 to 15 percent of the patients but the research is on the way and manufacture themselves are trying to get the multi chamber placements by the liquids leadless space speaking technology we asked dr kamal sharma no he is a senior cardiologist intervention cardiologist at sal hospital and also a visiting faculty at the un mata institute of cardiology and let's see what dr kamal sarah has to say about the police led leadless pacemakers hi so as we know now the leadless peacemakers in the second generation are trying to overcome their disadvantages of the first generation that is these devices in the first generation were having short life were more likely to get dislodged or even end up with perforation or complications like implant but now with the devices that are more compact uh more likely to be having a longer half-life i think we are headed for a generation where we'll have pacemakers completely lead less in the sense there will be no scar no wires only a small generator with compact battery which is percutaneously implanted into the rv effects and it will start pacing people are now actually companies are working on dual chamber space maker in a needless fashion and probably i'm sure crt etc would also become lead less in a decade or so so that's fantastic technology that's how it's coming up maybe a decade or so there'll be no scars left when you implant the pacemaker that was really very reassuring and we know that the technology is going to make our life easier and probably much better for the patients and they will be more patient friendly and very safe for the as not only for the pacemaker but maybe and one day we'll have aicd as well as sic the crtn all would be possible with a without a lead okay since we have finished the first half of the story we'll just run a poll um so this time we have a different kind of poll for you all um we would like to hear from y'all what y'all would like to watch on netflix next um so you have four options that will be seen on your screen uh if y'all don't like any of them if y'all don't want to hear anything that's okay you don't have to submit the award uh but you all can scroll through and uh you can see the options that are available and um team netflix will try and arrange for those sessions as soon as possible the sessions that get the most uh words okay so we have interpretation of renal functions getting the highest uh votes so we'll keep that in mind uh going to our uh second poll uh so it's again the same question it's just next four or topic options that we have y'all can scroll on the screen and uh let us know which one you all like or you all would like to hear uh watch on netflix y'all can give us your options here y'all can also put in if y'all know any faculty who you all think would be really good for that topic y'all can put that in the comments section as well uh so in this list we have pcod the modern epidemic thank you and um going for the third uh poll so these are the next four set of topics uh same thing let us know what you all would like to hear on netflix next um you can also tell us if you all have any other topic that you had in mind that we haven't covered do put it in the comment section and we'll get to it thank you and this is how to publish a study or article in a journal okay we will work on all these and not only the topics that i've got the most words but all of them will grade them and we'll start them together thank you so much okay so this is another very interesting story and i'm sure you are going to love it and put it into practice from today or if not today tomorrow morning itself that we know that we use exercise mainly for the purpose of the cardiac rehabilitation and also for the stamina and some them for the weight reductions but this particular story appear in the nature.com on the 6th of december where the researchers have come out with the conclusion that running for 10 minutes improves thinking and thought process and it's also a pleasure activity and we know that we have got different types of exercise whether it is paddling walking or jogging or running and here 26 healthy japanese participants who are all right-handed dominant were studied why this finded nuts was important because they wanted to study the dominant hemisphere activity while doing the activities so what they did was that all the participants in random fashion either they went for the 10 minute running on a treadmill or they had a resting session right and all participants were definitely first cleared that they did not have any complications or not suffering from any disease or not under any medications and they were all healthy and willing to go for the test and they were tested by the elaborate taste for the executive function as well as the woof and there are tests available the neurologist and psychoanalysts use this test very often so both the test how they perform was done for the at the time of running or after resting and for executive functions and mode testing they did they did different types of activities like they would just show the play cards of different letters right uh there are different colors of the letters but color is red and it is written in green or color is yellow and it's written in black something like that and see they see the response and they see how fast a person responds when is running in the running sessions or when he's at the rest right so this is how they perform the test and moore also was whether they were energetic happy light shed all these kind of moods cars were there so it's a very elaborate i cannot describe here in a detail but it was done with the professionals who have been regularly doing this kind of analysis and what they found was very interesting and also simultaneously they use neuroimaging and they measure by the functional near infrared spectroscopy they measured the activity in the prefrontal cortex on the left side because they were all right-handed so they measured the activity and they also showed that the oxyhemoglobin cows in the pre-fertile context was very innovative erotic at the time of running was increased at the time of running so for the first time they could show that running significantly increased the arousal as well as the pressure levels compared to the control and what they hypothesized was that because of the running there is a potential for mood and executive function with broad prefrontal activations what they thought and postulated that role it is not only the running but when we run we use entire body including from all the neural neurons are activated right from the foot to the cortex and really there is some connections which releases neuroadrenergics eurotology copper energy so there is a feel good factors there is an increase heightened arousal and they all leak to the shortening of the reflexes and really we should start running at least provided we are physically fit and we have of course just like any other exercise we always say that make sure that you are not having any contraindication to exercise and if not it's better that we start certain things we start practicing and see ourselves whether it works for us or not then very interesting and at the first time when i read it i thought that well this is not possible because what was the title is the cataract surgery linked to lower dementia risk i thought that harvest contract related to the dementia but and this appeared in jama and what they did was the researchers took 300 participants who were diagnosed to cataract but they did not go for surgery and parallel they also have patients of glaucoma as a part of control who also did not have dementia at the time of involvement so they have two cohorts one had cataract who did not go for the surgery another had glaucoma and both did not have any dementia and they were analyzed every two years for their cognitive abilities and they followed them up for average of 7.8 years ranging from anything from seven years to 10 years and what they found was that 853 subjects developed dementia and 709 had alzheimer's full-blown alzheimer's disease and they also studied the persons who had undergone surgery in between the time and how many of them are the ones who did not fall in the dementia group and those who did not have the surgery how many of them go into surgery and they found that the 45 percent said cataract surgery during the study period which amounted to 138 to individuals and subjects who underwent cataract surgery had nearly 30 percent lower risk of developing dementia from any cause compared to those who did not go for it so if the person is advised cataract surgery and then he undergoes the surgery sooner the better that is what the outcome of the studies and they said that the lower is prostituted for at least a decade after the surgery so if you go for the surgery you not defer dementia by more than a decade and they also said that the cataract surgery was also associated with lower risk of alzheimer's disease dementia specifically and the hypothesis was that cataracts specifically block the blue light we know that blue light is in the picture uh now in news again and again that the blue light affects our sleep because it affects the melatonin pigmentations blue light also has many problems with the younger youngsters who have insomnia and sleepless night and aggression and everything so here really the hypothesis is that the after removing the cataract the blue lights are again appreciated and it will lead to the reactivation of the neural cells and prevent the dementia so we could not think of a better person than our very own dr himanshu mehta who is a very renowned ophthalmologist having a vision eye center of his own also attached to the hospitals and he is one of our regular contributors he himself hosts so many souls and he is a ophthalmic surgeon for excellence and com the correspondent rx let us hear from him what he has to say about the cataract surgery and risk of dementia that surgery and dementia a very important thing which has been very underutilized in the society in fact the largest cause of fractures depression and dementia in elderly above the age of 60 is actually a cataract there's a good old saying in india it's not satyagan they don't want to be dependent elders parents don't want to be dependent on children and because they can't see they fumble they walk slowly they fall down they have fractures they are depressed and which is why all cataracts i have recommend to do them as early as possible don't wait and don't allow it to become mature or right because the vision starts diminishing gradually and there is a huge amount of problem in quality of life the vision suffers the confidence level suffers recently last week two patients i can tell you were fractures they fell down because i didn't see in dark area and they take it as as normal with the age that this can happen with age little realizing that there was a big cataract and because of the cataract they missed out on the stone down below on the pavement and they fell down at a hip fracture i have a classical case of a doctor a surgeon whose father was an is officer and an ex-principal commissioner of mumbai he was depressed in a room for two years not looking or not walking out of the street and after we did his scat track which is a brown black cat he changed so much within 15 days it started traveling across the country this is what we have learned from very big individuals some very intellectuals because the highest form of sensory input in the body is the eyes eighty percent is visual input not touch feel sensation and if that is deprived they get into a lot of depression and dementia friends so i would recommend surely those days when you used to wait for cataract surgery and cataract to grow is over don't let them suffer if not today tomorrow they will have to do it so there is nothing like waiting left and the sooner the better because today's modern revolutionary femto laser cataract surgery with a multifocal lens implant is a game changer it's a great game changer for the society and for people and all those people who have been operated unanimously have agreed that this changed their quality of life phenomenally their confidence is bad they can move around they can play card they can walk they can watch television do not wait get the surgery done as early as possible is the bottom line carry on message thank you thank you dr himanshu yeah that was very very interesting and very reassuring as i said we have our own doubts when we started the story that this is really the case but as doctor mata has rightly said that truly vision is one of the most important input right sensor input compared to other inputs and the persons who are suffering from gradual loss of vision are definitely going to have more feeling of depression chances of fall and their world they go into more depression so something that is a big learning and now the technique is also such that we can operate the persons where the cataract has just become without loss of any of the efficacies right another very very interesting story and what is going to change the way we look at the lipid profiles uh conventionally when we ask for the lipid profile we go for the total cholesterol triglycerides high density lipoproteins low density lipoproteins vldl and the ratios but this particular study which appeared in the public library of science uh is an open source right in the 1st of december and here this study was the swedish story of apolipopulating related mortality risk and it's a huge data the study sample was one leg 37 thousands it was the retrospective study and it was the period of almost 17.8 years and the sample was one leg 37 thousands what they studied was the ratio of apob apo a and whether it's a marker of early cardiovascular disease adverse outcomes we know that mass is a very common term for the physicians and cardiologists major adverse cardiac events is called mace and the common maze are the non-photomicroinfox and the stroke and the cardiovascular mortality and as we know that we also study lipid profile like apobian apple frequently as an extended lipid profile we know that apobian apple are the lipid transporter proteins right and they are not affected by the diet on the previous day or the different kind of drugs the patient might be missing so maybe after going through the paper i also feel that probably apobie and apple are worth much stronger and star stout markers and predictable markers for the adverse outcomes and what they found was that the out of one like 37 hundred uh participants there were 22 473 major adverse cardiac events and when they analyzed the lipid transporter proteins they found that it was apope apo e1 and the ratio of apob to foi1 were very very important markers for these outcomes the increased apob apoy1 ratio is the strongest marker for the major adverse major adverse cardiac events and its sub components that means individually above b or apoa levels are also important at all ages so probably the apple b apoy ratio already had two decays ahead of the time that they were could have predicted the adverse outcomes that was what the serial measurements of apobian apostate and maybe we should include apob apoa ratio as the routine uh screening for the lipid profile for the early detection of atherogenic dyslipidemia we know that apob practically is a lipid transporter for ldl and apple a for hdl we asked again dr kamal sharma who is our the cardiologist who is attached to sal hospital as well as uranus hospitals or his comments and the opinion about the the use of this lipid transporter proteins let's hear from dr kamal sharma the ligands for the transport and also the associated with the hdl and led respectively so though ldl hdl ratio is often used primarily as the reverse and approach uh transport mechanism as the atherogenic and etherogenic lipid profiles but it's now believed that the apple b ratio may be a better predictor than ldl hdl ratio and that's why a lot of studies are now focusing uh on the extended lipid profile which encompasses looking also at the airport ratios apart from the ldn hdl so it's a extended lip profiles are here to stay a lot of times you may have something more than that which is called as lipo little a which is lipoprotein smaller which is extremely prevalent in our what you mean to say that lpa lp literally or small little dense lipoprotein which is the most atherogenic of the lipoproteins right the apob is the ligand for that so even if the lipid profile shows a normal lipid profile including the ldl if you have not done lpa or small little lpa or apob probably would miss the persons who is having a high risk of developing atherogenic cardiovascular diseases we want our next story now this is our story number one which itself is divided into four different scientific papers to clip to what we say is the talk of the town right now do we need booster dosages uh is there a real efficacy of the vaccine against the omicron that is the new variant that is in the news and the first study was the one which appeared before a day that was in new england of medicine here the study was from israel here what is studied uh was the what is the pfizer vaccine was studied and what they found was that over a period of six months right of the persons who have received the pfizer vaccines what happened to their antibodies levels they tested for the anti-spike igg that is for the evidence of the the infections by the sars cov2 and the neutralizing antibodies that is for the evidence of the efficacy and what they did was they studied this particular series in the persons who are the medical ones health care care ones and out of 4 868 participants the 3 88 were included because they were the ones who could giving the samples every month and after the vaccinations and what they found was that the igg antibodies decrease at a consistent rate while the neutralizing antibodies level decrease rapidly as i said earlier neutralizing antibodies are the one which are the protective antibodies while igg antibodies just suggest that either patient has received and received their vaccines or were infected so after three months there was a rapid declining of the levels of the neutralizing antibodies and human response was reduced especially in the men and the persons above the age of 65 years or older and among the persons were immunosuppressed six months after the second dose so this was the very reasons that the countries like usa started giving the booster vaccines after five months of the second dose that is six months after the first house so this was first paper the second was the same kind of the pfizer vaccine efficacy in qatar and again appeared in new england journal of medicine to estimate the effectiveness of the vaccine against any type of sarcoid infections and against severe critical or fatal case of covenant infection they studied the all the participants who had received the vaccines from january 1 to january september 5 and the results were that vaccine efficacy was in the first two weeks after the first dose there was negligible efficacy as we know that it takes two weeks for some response to mount then third week after the first dose 36 percent of the persons had the protective efficacy levels and after first month after the second dose nearly 77.5 percent had the effective antibody levels but this effectiveness started reducing after fourth month to reach approximately only 20 percent between five through seven months after the second dose so efficacy which has gone up to 80 percent after the second dose has declined to almost 20 percent in between the fifth and the seven months but the good part was that the protection against hospitalizations and death persisted for a wrong so robust level even six months after the second dose that could be one of the reasons that even though the new omicron virus has probably been having if effect on the evasion of the immunity the serious infections are still not reported even after two weeks of it being detected the third very interesting is the first time that they found out the effect of vaccine in the adolescence we know that vaccines in adolescence have yet not started in india but it has already started in the other countries and this is the first paper where the evaluation of modern vaccine in almost 2 000 1200 adolescents were compared with persons who had not received the vaccinations or who had received the placebo and what they found was that safe safety wise these vaccines are same as the efficacy same as that in the adults with very few minor side effects and the efficacy is also same as in the adults or young adults so the reastoring part is that even in adolescence there were fear that the mrna vaccine might produce more immune reactions and the very young and the adolescents might have more complications but so far in the trial of this number of participants nothing of that thing has happened and the vaccine is as safe as in the adult counterparts and the last now is the booster dose effects now we already have now the results coming out for the efficacy of the booster dose because in usa the this particular study also appeared in the nejm day before yesterday and here the efficacy of pfizer vaccines the mrna vaccines were studied in eight lake forty thous forty three thousand two hundred eight participants who are more than the fifty years of age right and who had received ninety percent received the booster dose during the 54-day trial it was a two-month trial so out of this 90 percent had received the booster dose out of 8 lakhs 40 000 and what they studied was what was the death due to covet in people who received the booster dose and the people who did not receive the booster doors and the results analyzed suggested that 65 persons participants who had received the booster dose died while 137 participants who did not have the booster dose died and ninety percent lower mortality due to covet 19 in the persons who received at least five months after the second rose then the who did not receive the second loss and vaccine induced protections appear to vein rapidly that is what has been suggested now so after the second dose but protection against hospitalization and death persist all these papers suggest that for its time has come when you have to think of the booster dose just because that probably the new variant are appearing because the vaccines are the efficacy of vaccines or the neutralizing antibodies are fading and maybe the booster dose will give one more rise in the protective efficacy of neutralizing antibodies and that will bode off this pandemic into endemic so this is what we feel that booster dose is the hot topic and that is why we selected as our number one story and we hope you like all our stories and we go to the quiz section so people who join the new we have a lot of repeat uh doctors who've joined in but for the doctors who come in for the first time we have three questions uh based on the stories that we've heard so far uh so every question uh y'all can put in the correct answers in the comment section and the first person to get the right answer uh someone from team netflix will get in touch with you to give a prize and we'll announce the three winners at the end of the third question uh so the first question uh you'll just have it on your screens now yeah yeah before that we want to hear from you the stories that we want to run and whatever stories that you feel that our other audience members and the viewers would like to learn and enjoy we want you to come to us right so the first story is first quiz is which disease is less likely to occur in silence users is it parkinsonism it's alzheimer's disease is it gulen body syndrome or it's a multiple sclerosis so i am yet to see a wrong answer so all right the next comes the which commodity contributes to higher mortality in cirrhosis what we mean is the compensated cirrhosis which co-morbidity is likely to result into higher mortality is it bronchiologist is it acute kidney disease is it cardiovascular disease or muscular dystrophy so again most of the viewers have given the right answers that is cardiovascular disease and the last of the quiz is which is the new early predictive marker of adverse cardiovascular outcome is it ldl sdl ratio is it triglycerides hdl ratio is it cholesterol hdl ratio or it's an apob fo 1 ratio right again most of the viewers are right we are so happy to know that at least uh you have received oh and listen to us intently and uh taken the message correctly that these are the few things that even if you start practicing from day one whether it's an uh screening with apple bfoa or whether it's running for 10 minutes or all such good and we prepare ourselves for the boosters because we are the ones who received the second dose immediately after the first days in the span of only 28 days and earlier studies have shown that those who have received the second rules within the four weeks the efficacy of the vaccines are the levels of the antibodies have come down uh drastically so let's wait for the results then over to you thank you sir uh the team just figured out who the three are because you're trying not to repeat the same uh winners as the last time also uh cutting edge uh episode seven will be available to view uh in the replay section uh by sunday and the other um sessions that have taken place will also be available in the replay tab itself i think we've got our winners so the first question we have dr kiran kumar for the second question we have dr and um for the third question we have dr i'm sorry if i mispronounced it but um someone from team netflix will get in touch with you all and we'll dispatch the gifts uh the prices right away um thank you so much for coming in on a friday evening and we'll see you again next time on next friday uh till then uh good night uh happy weekend and like uh sir likes to say uh let's maintain a covert appropriate protocol and so we get over this pandemic real fast thank you everyone for coming in and good night

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