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Cutting Edge: Episode 6

Dec 03 | 3:30 PM

Watch the senior interventional cardiologist from HCG Hospital, Dr. Jay Shah give his views on the study published in JAMA online on the 30th of November, 2021 ‘Calcium Does Not Benefit Patients in Cardiac Arrest’. Another article related to the use of PRP, suggests that it can be used for 3D printing of blood plasma to speed up the healing process with minimum fibrosis.

[Music] good evening everyone i'm dr naveeda and on behalf of netflix i welcome you all uh to the sixth consecutive uh episode of cutting edge uh we have with us our host dr mahadev desai a senior consultant physician from amthabad seniors and all and welcome to the sixth consecutive episode of cutting edge this weekend medicine a lot of things have happened and we'll try to bring many interesting stories some of them probably for the first time that you might be listening to so let's get with the story number nine this is about amateur boxing linked to increased risk of brain impairment and early onset of defensia we all know that professional boxers who have been having the boxing as a profession are predisposed to chronic traumatic brain injury and i am sure the those who are of our age might be knowing about the greatest of the great boxer who was known as muhammad ali right he also suffered from parkinson's disease and he died of it and there have been so many instances of alzheimer-like illness and dementia in patients are the persons who have taken boxing as a professor but there have been no studies about the box in related injuries in the amateur people so this is the story that appeared in 29th november in the clinical journal of sports medicine and this is the first of the story where they took look at the long-term effects of the amateur boxing on the brain and they selected 2500 men aged 45 to 59 years from the south wales and they studied for almost 30 years and their results they what they study the every five years they would call them get their physical checkup their cognitive functions uh relent investigations and what they found is really really very very interesting and painstaking they found that the chances of getting alzheimer like impairment of the brain activities are double then the persons were not boxed there is one and second that it linked to the earlier onset of dementia by at least five years so earlier dementia and alzheimer's illness are two times the risk in the than the non-boxers and the study researchers suggested that it is high time that we must suggest to the organizations who are organizing for the amateur boxing that the bouts should be shorter ones and there has to be a mandatory head gear for all the amateur boxers so something related to the boxing as our first story next we want to very interesting story that is about what is the power of protest or power of the strong representations the national comprehensive cancer network which is very powerful organizations in the usa which has the members like the membranes loan catering or anderson institute or mayo clinic they all are the members of these organizations who decide who guide give the guided lines for all different types of cancers and most of the people follow them with respect and so they came out with the suggestions that all prostate cancer patients with low risk disease be managed with either active surveillance radiation therapy or surgery means as per these guidelines which were released in september 2021 the there was equal weightage to active surveillance radiation therapy and surgery but this did not was not acceptable to the neurosurgeons and the euro onco surgeons so they protested vehemently they kept on writing representing to nccn and they thought that active surveillance has to be the first line of suggestions for people who have a low grade prostate cancers and ultimately this is for the first time that nccn reversed their guidelines of course they did not reverse this fully they play with the words and they made certain changes in the words but ultimately they suggested that most men with low risk prostate cancer be offered active surveillance as the lone preferred initial treatment option so instead of all men they made it most men and instead of the only treatment they said prefer initial treatment options the obviously the uranus cheered the reversal so the idea is that if there is a strong professional representation who are convinced about the change that is not acceptable for the patient's management we should stick to our suggestions and represent keep representing to the national bodies this is the story about the general belief that the premature ventricular contractions that we see in the treadmill if the patients are asymptomatic and if there are premature ventricular contractions they are benign this appeared in journal of clinical cardiology on 29 november and here 5486 asymmetric participants the people who had participated in lipid research clinical prevalence study right from 10 centers in north america were selected and all patients lipid levels were done they underwent physical examinations they had treadmill test with bruce protocol and their ecgs were recorded at rest at the end of each stage of exercise then immediately after exercise and then at two minutes four minutes six minutes after exercise and then they were followed up for 20 years again very long follow-up studies and what they found is really very very interesting they decided that the certain categories of premature contractions like the premature ventricular contractions which are more than 10 per minute premature ventricular contractions who are originating from different foci as can be seen from the different complexes on an ecg or premature ventricular contractions which are more than two in a row or what we call it in salvos or if there is a salt or a bigger run of entire tachycardia or the ever dangerous are on t premature internal contractions meaning thereby the r of a premature complex fall on the t of the previous sinus beat these are the high grade premature ventricular contractions and those who had this kind of premature ventricular contractions of high grade even they were followed up what they found was that there were 15 percents of the day due to any cause of these participants out of which 37 percents were cardiovascular in nature all whether it's during exercise after exercise or in both time of exercise there were definite experiences of pvcs 1.8 percent during exercise 2.4 during recovery and 0.8 percent during all what they found out by various combinations that those persons who had got high grade premature ventricular contractions after exercise during the rest period where having a high cardiovascular mortality the hazard ratio of 1.82 which is very high and the p values were 0.006 so this is definitely something eye opener really we do not see more not much importance to the premature integral contractions in the recovery period and this particular article opens up our eyes we also happen to ask our cardiologist friend dr jaisha who is a consultant cardiologist and having a group of the cardiologists and practicing in their cardiologists and intervention cardiologists and let's hear from him what he has to say about this particular study test or the stresses which is going to give you infrequent or maybe a multi-frequent vpcs while during exercise but whenever you are finding out that the patient is having during recovery high grade vpcs then there is an area of concern because it increases cardiovascular mortality independent of the underlying cardiovascular risk factors now which are the patients those who are developing more such type of vpcs there are those who are having underlying hypertension diabetes elderly population underlying coronary artery disease they are naturally more prone to develop high grade vpcs now how can you identify that these patients are having hydrate vpcs so by definition hydrate vpcs are frequent means more than 10 per minute they are repetitive they are multifocal sometimes very deadly in form of rnp phenomenon or ventricular tachycardia and all these conditions they are independent of the underlying cardiovascular risk factor and that is the reason it requires to be remembered now uh you will be amazed to find out that there is a mechanism behind this also even though it is a hypothesis but those uh patients who are doing an exercise we all know that sympathetic nervous system is going to get activated but during recovery period after exercise ideally parasympathetic activity also should come in play so whenever there is an insufficient vehicle reaction the chances of development of ventricular premature contractions are very high and that is what is being published in general of american college of cardiology that is jack on 29th of november so i would consider this story as a very important story to be remembered and by this we can definitely give a proper treatment and approach to all our patients thank you very much for inviting me thank you so much thank you dr joy that was interesting we never knew that the parasympathetic system or the vehicle reactivation is very important to counteract the sympathetic overactivity that follows the treadmill and i think we next time we have to be very careful while doing the treadmill test and we have to show sure that there are no vpcs or we have to follow those patients who have pvcs during the recovery period we move on to another interesting talk about the prostate cancers here in the uk this is for the first time that they have used artificial artificial intelligence as the ai pathology software and this came in the bbc news yesterday and they first time used the artificial pathologist for software reading the biopsies and they also have their regular pathologies who had confirmed the prostate cancers and the when it was put to ai pathology software all 105 patients biopsies were correctly diagnosed so we know that artificial intelligence has come a long way in the medical field and it is fear that many of our colleagues in certain areas like radiology dermatology or pathology might lose their job if the ai becomes more powerful what is important as for this study is that it's not only the speed with which the it is diagnosed but it's accuracy they said that it is reading it has so much of details input in it that truly the accuracy is far more than the human eyes that can look at it the biopsy can read the every aspect of the every corner and any number of cells for any number of biopsies so this is something that we are looking upon in the time to come about the use of artificial intelligence with the biopsies or with radiology or with dermatology so let's have a short break and get your ideas about the stories that you like the most so there are four stories that we covered after now and there are four options uh so you all can select your favorite story so far and submit your word and it just helps us know if you're doing a good job by getting the right stories to you okay so uh the highest number of votes has gone to uh the post exercise pvc uh article thank you uh for that result i think in retrospect with that that these stories would have come little lower down in the order we accept your verdict and we'll be careful next time and may move on to the another interesting uh publications that is about the nice guidelines you know nestle installed clinical excellence again the uk based organizations which are known for their strict and very simple easy to follow guidelines and on 23rd of november they come out with the guidelines for the depression after 12 years and this is very very important they come out with the guidelines where they said that in depression patients we must emphasize on the sad decision making between the patient and the health practice now that means up till now probably the patience say was minimum and it was mainly the clinicians who decide about the type of treatment the patient should receive but nice guidelines suggest categorically that we have to see what kind of depression the patient is having and if there is a mild depressants then out of the four options that the patients have for the mild depression management that is cognitive behavior therapy exercise counseling or psychotherapy so as a practitioner we should put forward all the four options with pros and cons of each and every option and let the patient decide about the mild depression and as you can see that in these four options there is no treat drugs as a treatment for the mild depression as far as the guidelines are concerned but for more severe depressions anti-depressant and other options need to be discussed with this kind of guidelines so currently those with mild depression are offered anti-depressant as a high intensity cycle intervention such as cbt so this is what the guidelines suggest that probably we should be have more kind of participatory medicine management really we should also in our setup follow up with involving patients at every stage of decision making particularly when there are two options which are pulls apart or where there are the cost or the risk is involved it's heightened that we involve patients and the relatives for the decision making then yeah this is the talk of the town and truly it's then everywhere including all electronics and print media that we have also joined the omicron club we can say that we have reported yesterday only reported two cases from karnataka one was one is a 66 year uh foreigner who came from the south africa came here at positive and went back and second one is a very interesting part is one of our colleague who is an anesthetist practicing in bengaluru or tcx here but he had no travel history of anywhere outside the karnataka so it's really very interesting to know how probably the health authorities that explain that probably he had been exposed to one of the patients who yet to be diagnosed the good part is that both the sufferers are having mild symptoms and there are no signs of any complications in either of them the government has become very proactive and has traced the primary as well as the secondary context of both the persons have been tested means those who are likely to have come in contact with them the people who were in the air planes along with them as well as the persons who is working in the hospital and the government authorities have said or us that we have to be cautious but do not panic at this time and we must follow the appropriate behavior and the government's tagline was that it is concerning but not alarming what is important as a aftermath of this omicron likely wave is that the government in the evening at the main organizing or the expert bodies which are called the indian sars kovi genomic sequencing consortium known as insac they have suggested that it is worthwhile considering the booster dose for all those who are above the age of 40. this is the latest in the news that all those who are above the age of 40 should be considered and amongst them those who are the highest should be given the booster doors so maybe the government will accept in a short time and we might see the suggestions of booster dose for or as one of the aftermath for this omicron and maybe that we have to be on lookout the initial results of the omicron variant is that it is definitely highly infectious the reason is that there are more than 30 variants right the mutations out of the maximum are in this pipe protein which is known to cause the change in the its infectivity as well as maybe an escape from the vaccine immunization so that remains to be seen right now it is too early to say most of the people believe that the end of the december would be very very this year this month is very crucial and will get to know the exact seriousness of this omicron variant right in the time to come but till then we have got to be on toes and we just cannot be complacent and we as health professional also should follow and insist for the covet-appropriate behavior this is another cardiology story and we'll have our expert's opinion on the same that we know that time and again in spite of not being recommended as one of the treatment calcium has been given in cardiac arrest patients whether it is in hospital or out of hospital cardiac arrest and this story published in the jama on 30th november that this is a double-blind randomized control studies of 397 patients who had out of hospital cardiac arrest at the central denmark region in this year and what the participants were divided into those who received the calcium and those who received the saline and 197 patients received the calcium chloride up to two intravenous dosages or intraosseous diseases when ivy lying was not possible in the emergency intraosseous doses is of 5 millimolar calcium chloride was given and the other cell was saline was given in the next 200 people the first dose of calcium was given after adrenaline injections and out of this 391 including the final analysis 193 in the calcium group and 198 in the saline group and the results suggested that the spontaneous circulation recoveries a return of the spontaneous circulations occurring 19 percent of the patients with calcium group as against 27 percent of the saline group so the relative risk rates are 0.72 or the p value is 0.09 that means it's definitely not something that is favorable and at 30 days 5.2 percent of the patients in the calcium group and 9.1 percent in the saline group were alive as such we know that out of hospital cardiac arrest very few people survive so those who have survived definitely the values are definitely good but the point is whether it's a calcium that has made the difference no in fact calcium did not improve the sustained return of spontaneous circulations and there was a suggestion towards the worst outcome so it's not only it is not helpful it might harm and that is what we wanted our expert cardiologist to us and again we requested dr jaisha to give his opinion and let's listen to him about calcium in cardiac arrest first of all i would like to congratulate team netflix especially motherfaces or for the phenomenal success or this live streaming of 10 best stories in the last one so when i heard about this story that the calcium does not benefit in patient with cardiac arrest i was surprised because i knew that calcium is an ionotropic agent it has got a pressure effect it has got a memory stabilizing effect and that is the reason we were using very commonly in our cardiac respiration but this trial which was being published in jama online on 30th of november it has proven that in modern day practice and trial which has been done and it has already been published it has shown that the cardiac arrest patient out of hospital cardiac arrest they do not have any beneficial effects by injectable calcium but sometimes in some of the condition it might become harmful as well and why is it so because it produces mitochondrial calcium overload or cytosolic calcium overload which can ultimately lead to oxidative stress and apoptosis which is responsible for worsening of cardiac contractility there are only three conditions in which the inhospital cardiac arrest patients by giving injectable calciums are going to get benefited and they are the condition called hyperkalemia hypocalcemia and those patients who are having calcium blocker overdose these are the three condition in which definitely the role of calcium or injectable calcium has already been established and it should ideally be used but the calcium as a nutshell which was being used very frequently does not benefit in patients of out hospital cardiac arrest thank you very much for inviting me thank you dr j it was really very very useful and very succinct points that you made that we should use calcium in the cardiac arrest patients only if they have hypocalcemia hyperkalemia or it's because of the calcium channel or overdosages that was really great and we move on to our next story which is very very interesting one of the new things that really this is a new oral factor eight inhibitor name mill vaccine new oral factor eight inhibitor we know about the factor 10 inhibitors right that we use then they out like all the exhaust whether it's a rivaroxaban or a pixaband right but this is a new melvaxian is a new oral factor eight inhibitor versus enoxaparin or the post-operative venous thromboembolisms this appeared in the yesterday's new england journal of medicine and they released the trial which is called the exomatic tkr trial where all 1242 patients who underwent the plan total knee replacement right were divided into two groups of one received the enoxaparin subcutaneously and the other group uh we had seven different types of the dosages of melvaxian when this is a phase two trial so we need to have those uh efficacy as the safety also need to be studied so what is milwaukee uh or factor eight we know that there is an intrinsic and extrinsic crossfield for the uh thrombosis or thrombin generations and the uh from fibrinogen to fibrin we know that is the activation of the factor eight leaders to activated factor eight factor eleven which works on the factor nine activates the factor nine a then factor 10 to 10 a and which works on the prothrombin and which converts fibrosis to fibrin then fibrin polymer to monomer 2 timer and polymers and that becomes a good clot and then when the job is over there is a system of fibrinolysis so factor 11 has not been studied that extensively earlier but it may so happen that the people who are born with the factor 11 deficiency they were curiously found to have no venous thrombus embolisms or they were devoid of that risk of fin venous thromboembolisms and that is how the researchers got the idea and 11 factor 11 deficiency is also known as hemophilia c and what they found out was that factor 11 is more important in the consolidation of the thrombin or for stronger attachment of the thrombin but it has no role in the bleeding the hemostasis part is not important and that is how they studied as i said earlier there were seven different kinds of dosages the twice daily dose of milvaxian 25 milligram 50 milligram 18 milligram 200 milligram and three different doses of one city like 20 milli 25 milligram 50 milligram and 200 milligram against the 40 milligram circuit in single dose they were all given for 10 days and patients were followed up closely or any kind of the symptomatic venous thromboembolisms they also under they underwent the venous vinography to see whether there is asymptomatic evidence of venous thromboembolisms they also look for whether there is any bleeding minor major breeding complications and they found that there is a definite dose response relationship with twice daily mill vaccines which is very low what they decided looking at the cohort of the patients that they had they expected 30 percent of the patients to get vte venous thromboembolisms so had there been 30 persons it is at par but because this code got only 12 of the patients developed vte they said it is significantly better relations to the any other treatment that is currently suggested for venous thermal embolisms and when it comes to bleeding or complications the complications were practically four percent in both the arms the any dose of the mildaxion or the enoxaparin but the significant bleeding that is called the bleeding may be interacting bleeding or bleeding that requires the blood transfusions uh this kind of bleedings were not there in either of the cases one person bleeding occurred in the middle action group and two percent of the enochs are carrying looks up and group but they were all surgical side building and none of them required the blood transmissions so the outcome of this is that we probably are waiting for the larger studies and the milvexian is a new oral factor 11 inhibitor which is in the horizon for taking for the post-operative venous thermo-organisms a very important molecule maybe on the horizons and we should be on looking for it the reason is the safety profile as far as the bleeding is concerned and the efficacy as far as the prevention of the venous thrombus embolism is concerned then we move toward the last that is the best of our studies stories from our side if you remember the last week the second last story was about the platelet-rich plasma not having effect in the intra articular injections when it compared for the osteoarthritis so we should not go under the impression that all prv preparations are all plp are negative this is one which is definitely encouraging and giving us a very good hope of the use of platelet-rich plasma we know that literature is plasma is a very natural source of the growth factors there are host of growth factors in it whether it is angiogram cofactor like the egf vascular endothelial gold factor or fibrous growth factor or platelet derived growth factor pdgf all different kinds of growth factors are there in the platelet-rich plasma this study appear in the advanced functional materials and this was carried out at the royal college of surgeons of ireland which is a very prestigious institute and the head is in dublin and there they studied they created a 3d dye they created a bio ink of the they collected the blood from the patient right initially when they were doing the studies they created the collected blood from the blood bank and they separated the platelet rich plasma that is the buffy coat and they put it in a gelatin methyl acrylate it is called gel mi that is what they give gel me so they put this literally plasma liquid into the gelatin and they made a ink and they put this in a printer and on the scaffold that is the material which is put to be put for the dressing on this this prp activated bio ink was spread and this was used in a single sitting for the wound healing and what they found was that the prp was having its effect of releasing the vascular endoscope growth factor for 14 days and when they studied the gelatine methyl acrylate alone and the gelatin methylate with the bio ink of prp they found that the results with prp are very good and very another interesting part is that though there was neurovascularization and rapid healing there was no fibrosis otherwise we know that whenever there is a big skin ulcers or the wounds the heel by skyros fibrosis was carrying so what is important in this particular story was that the prp activated buying with three breeding technology has definite advantage in not only the early link but it leaves minimum fibrosis something that is definitely the most welcome and we don't have to use the different the regenerating molecules are costly molecules this 3d printing has again like artificial intelligence has come a big way in our medical field and all other fields in fact when i was reading 3d printing i knew that i came to know for the first time that in amsterdam there is a bridge bridge which is formed by the exclusively by the 3d printing facilities so 3d printing is again going to be in use for all medical facilities in the time to come but this particular story we thought is very interesting and will definitely open up and give a relief for it since how to otherwise only option is to go for the skin grafting and the plastic surgery so this is all about our stories for the night and probably will have another polls also after this your poll and the quiz sections over to you thank you sir so we have the next poll that covers the last five stories um uh there are five options they all can scroll around and uh pick the story that was your favorite apple now uh just provide the feedback for us uh to see if we ranked them the way y'all are like them um and in the week if you all do come across any articles news articles that you all feel should come should be read out here please do let us know so we have a tie between uh no use of calcium in cardiac arrest and melvexium for venous thromboembolism okay we will rank them a little better next time onwards uh thank you so much uh for uh participating in the poll uh so get ready for the quiz we have three questions lined up um so you just have to uh write the correct answer the first person to get the right answer for every question uh netflix will get in touch with you for a price so could we have the first question please let's go for the quiz yeah the new oral drug found effective in preventing venous thromboembolism after knee arthroplasty is it an oxaparin is it destiny it is malwaxion or it is endocrine we wait for a couple of seconds on this and then i think uh many of them got the right answer that is milwaksean yeah so we can move on to the next yes which state reported first omicron variant in india obviously it is kerala tamil nadu andhra pradesh or karnataka a lot of them are getting it right you all have pay attention to the session somebody else also suggested this probably the government has come out that there are no missing people from the andhra pradesh so it pushed to the right that uh there is no case of that now what does nccn recommends the most men with low respect prostate cancer be offered as initial treatment options the what we mean is the latest guidelines not the earlier ones is it chemotherapy plus surgery active surveillance radiotherapy or all of the above so this is one of the stories where we said that the nccn has to reverse their earlier guidelines because of the strong protest and objections from the practicing and the bodies and the neurosurgeons lobby so it is the active surveillance is the right answer and we can take up the comments or if anybody wants to come on the stage for any contributions to any of the stories they are most welcome yeah there was one dr sunil mehta has raised his hand can we get him yes sir i'm accepting your request as a very senior physician and very active and had done a lot of work in the kovid pandemic at our hospitals so you'll get an option you'll get a prompt to turn on your audio video so you can turn that on and uh i've already accepted your request so you are already you can come up on now motherboard it was an excellent uh presentation and the first time i attended this well i feel like editing every now and then uh the only comment i want to make about that malignant vpc is what we were talking about yeah yeah then we were studying in md there was a bedside sign which we used to elicit in most of the patients we used to give a gentle uh vehicle massage on the carotid massage i would say that would induce if they induced uh multiple vpcs there are high risk patients and then incidentally their current qt interval was also prolonged so this was a bad side sign which we used to do quite frequently and that was quite effective that way that we could we could predict that this patient is likely to have malignant uh arrhythmia so we beforehand we should uh take care of him and that was the only comment which i wanted to make other things are extremely good uh i think your point is well taken and we'll get the doctor jaisal's opinion also about this is unfortunate not here right now but incidentally since you are here you would like to know your opinion about the first use of malnutrition with the antiviral medicines for the sars kovi i've used in four patients today morning and today afternoon also i have taken their follow-up their fever has gone down within uh 48 hours and they have no side effects so far and they are comfortable oxygen saturation is normal otherwise all other parameters are within normal limits they are comfortable so it's a good sign right only thing is probably you have to use it in the right time for the right window frame are the disease to be started in first 48 hours and at the most 72 hours and not beyond that after that how did you procure how did you procure monopoly yeah it's very expensive yeah it is expensive the patient himself got it from the abroad and in anticipation and incidentally it was useful for himself only great great thank you so much to have you and your opinion dr sunil will also want you to be on the stage some other day with your other uh stories thank you so much thank you bye-bye bye thank you so much um we just have our robin house of this quiz um till they collate the answers so we're trying not to repeat the winners from the previous time so everybody on the session on the talk uh gets the prize from netflix um so yeah we're just trying to work out who the winners are um i think we got the list so for the first question we have dr srishti gopani for the second question it is a dr mustang jindal and for the third question we have dr pankari agarwal uh congratulations everyone uh so we will get in touch with you someone from netflix will get in touch with you shortly and we'll start the process of sending forward the prizes to you all um and thank you so much for coming in today and uh so do you have anything yeah i think again we'll every time we just say that we have to follow the code appropriate behavior and more so at this time point of time when we have omicron threat looming all around right that please follow the code appropriate behavior there can not be a better vaccine than the mask and the avoiding the distancing the crowd and also this suggests everyone that we have to put the mass not just to save from the penalty but also to save ourselves from the virus infections so with that we wish you all a good weekend and a happy and healthy weekend and see you next friday thanks friday same time thank you so much and good night everyone you

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dr. Mahadev Desai

Dr. Mahadev Desai

Senior Consultant Physician | Ahmedabad

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dr. Mahadev Desai

Dr. Mahadev Desai

Senior Consultant Physician | Ahmedabad

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