Cutting Edge: Episode 14

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Cutting Edge: Episode 14

4 Feb, 3:30 PM

[Music] good evening everyone i'm dr niveda and i welcome you all um to the 14th episode of cutting edge um as you all know uh we have with us uh dr madev desai who's a senior consultant physician from amdibar good morning everyone welcome all seniors and friends and this is the 14th episode of cutting edge and thank you very much for being with us for all these episodes and today also we have eight stories and we also know that today is a world cancer day so there is a story for that we also have the leading author as one of the guests for one of the stories so let's begin our journey with something different than the routine and that is about how clean your car is as you think right and this is something interesting that i that caught my eye this is a study carried out by the aston university uh in london and they along with the scrap car comparison uh help isolated different from the different parts of the car the species and then they cultured it and they could find the contaminations as shown in this that the highest contamination was in the boot area of the car and then the driver's seat had the 649 bacteria could be cultured from that then the gear stick then the back seat then the dashboard and the steering film and this has been compared with the different age of the car and the different make of the car and the different usage of the car whether the car is how often is on the road and the steering wheel having less bacteria probably they accounted it that because this study was carried out last year only so probably they knew that people have been using the sanitization very often and that's why probably the steering wheel did not grow many organisms the car boot as we know is probably having the is hosting the highest number of bacteria and the commonest that they found was e coli uh second was the steph aureus and the pseudomonas and it's very very important that we keep this in mind because while driving we also we often open the packet and start eating and some of them is left out in the car and then the bacteria get a good crown to culture so the story essentially wants to say that you don't want your car to be a risk factor on the road as well as to your health so next time when you clean your care make sure that is clean in the real sense of cleaning and it's not only clean but it's also disinfected then we move on to another story that is about the cdc guidelines recently released for the blood donation regarding the in the commitment and this has just come on the 11th of january and it's that cdc clearly states that if you any of these conditions applicable to you better refrain from the blood donations that means if you have an active or suspected covet infection at least do not and your symptoms are not resolved for 10 days do not give the blood for donations if you are asymptomatic but positive again you don't have to donate the blood then if you have received a live attenuated vaccine if you have received a live attend vaccine refrain for blood donation for at least two weeks right and if you are uncertain about which vaccine you have received then also refrain from blood vessels for 14 days and but you can definitely donate your blood if you have a sars antibodies positive antibodies positive but you had no sign symptoms of covalent infections or you never tested positive whether rtpc or rapid antigen was not positive that means you had proline asymptomatic infections any length of time earlier but you had no symptoms and you never tested positive you can go for the blood resistance and cdc says that if you have received the vaccines from the inactivated non replicating or mrna vaccines then you don't have to have a weight period for donations you can straight away donate the blood so this is about the blood donations and in kobe time we went to the next story that is about apixaban versus river oxaban real world data up till now there has been no head-to-head trial for the efficacy and safety of apixaban versus rivaroxaban we know that practically now most of the oral antiguan drugs we have shifted to the near oral anticoagulant drugs whether it's a factor 10 inhibitors or a direct thrombin inhibitors in the form of either apixaban rivaroxaban or maybe the derivation and the vitamin k antagonist like warfarin is practically not used obviously because of its drug drug interactions and drug food interactions so this uh story appear in the andals of internal medicine and it's a basically a retrospective new user code that means all the patients who had received either river examine or apixaban for the first time right and this is the data recovered from the healthcare insurance private companies and it's from 1st january 2015 to 38 june 2020 the participants had were adult with venus thromboembolisms they had actual venous thermometalisms and they have been newly prescribed either a pixar bun or river except one and that was the first head-to-head comparisons and there are two primary endpoints the effective end point is how often is the recurrent venous thrombobolisms composite of either different thrombosis or pulmonary embolism and the second outcome primary outcome is about the safety what is the composite of gastrointestinal bleeding and internal bleeding in either river examine or epic there were total 49 900 close to 50 000 patients who were eligible for having venous thromboembolisms episodes and out of which the eighteen thousand six and eighteen uh in either arm a pizza bun as well as river absorbance they could get it for analysis and they had followed for about hundred two two hundred and five days for a pizza bar in two days and for diwali 105 days the results say that apixaban is clearly superior as far as the for the efficacy as well as the safety part of it the hazard ratio of a pixar bun we service river examine is 0.77 and for bleeding also the hazard ratio is 0.60 so clearly this first head-to-head comparison says that episode is better than rivarak saban and of course the limitation as for the authors is that it's a short follow-up and rate days follow-up may not give but see main complications as well as the efficacy part definitely can be judged so i for one would say that definitely even choice i would prefer apixaban over ivar examine based on this study of course apixaban is little more cost costly than the river of saban but we have got the availability of epic exam at a lesser cost in at least our part of the country that is in india so that's our story number six then there is another interesting story this is called triglyceride glucose index triglyceride glucose index as a marker of subclinical atherosclerosis triglyceride glucose index as a marker of subclinical atherosclerosis this article appeared in the cardiovascular diabetology january 2022 and this a particular they have taken up 122 patients who for some reasons that is the non-coronary structural heart disease evaluations underwent trans esophageal echocardiogram so what they wanted to study was their basic hypothesis about the triglyceride glucose index how does it fare well with the thoracic outer intima media thickness the intimate intimate thickness of the thoracic outer now thoracic out that can be just only by the trans insulin echocardiogram so trans eco trans esophageal echocardiogram was carried out in 122 patients who were and who underwent this particular procedures that is transvisional echocardiogram for non-coronary structural heart disease may be some valuable disease or some other purpose and they excluded patients having diabetes and patients who already had coronary disease because that basic hypothesis to be tested was that whether triglyceride glucose index is a marker of atherosclerosis if person says only atherosclerosis it doesn't work and they and they studied the correlation of the triglyceride glucose index and the thoracic autointima media thickness the triglyceride glucose index was just a calculation from the blood sample which is collected in the fasting and there is an equation that equation goes as the natural logarithm into fasting blood glucose in milligram into fasting triglycerides into the a milligram percentage divided by two so it's a equation we don't have to worry about that because it's already the available applications and you just enter the values of fasting triglycerides and fasting blood glucose and you get the reading the important thing is that the values they divided the all the results into the persons having the intima media thickness uh having a low intermediate thickness like less than 1.42 equal or less than 1.42 millimeter and those who have higher intimate thickness that is more than 1.42 so obviously the persons with lower a higher intermediate thickness had more atherosclerosis and then they compared with the glyceride glucose index and they found that the triglyceride glucose index was higher in the persons with higher intimate thickness and the cut-off value was 8.69 plus minus 0.59 so persons with the triglyceride index on the higher side definitely are the candidate for the they should be investigated for atherosclerosis that was the outcome of the study and they also studied this with a different logistic regression analysis about the correlation between the age and the triglycerides with the intimate thickness and the conclusion was that this is the first study which shows that an independent relation exists between the triglyceride index and the thoracic outer intima media thickness so if you want to have some taste which is non-invasive which is inexpensive it is just one blood collections of the fasting sample and if it given information like the subclinical atherosclerosis i think it should be included routinely in the screening for the atherosclerosis or asymptomatic atherosclerotic vascular disease so this is something otherwise we'll have to go for the transesophageal echocardiogram or the other carotid ultrasound and the carotid intermediate thickness so triglyceride glucose index is already known in the with the researchers for a long time and they have been using it for other purposes here the first time correlated with the thoracic alternative thickness and we thought that this is something very interesting and we can do it from the next itself so that's about the story number five of course this is a very interesting review article which appeared on yesterday's new england journal of medicine the article is about the pirates of unknown origin we know that pyrex of anunna origin we have been taught in since undergraduate days and in the practice also we see so many patients of p u or f u o as they call it but the first time petersdorf and bison in their study of 100 cases they define the term pyrex of unknown region and they call it a classic puo wherein they describe you as a person having a fever of more than 38.3 degrees centigrade or higher for at least three weeks without a diagnosis and despite one week of hospitalization and protein investigations it was the classical and now we also consider this to be classic po definitions that was in 1961 but uh after 30 years that is in jury constraint in 1991 revised this because during that period we had so many we had the arrival of hiv we have a level of many transplant cases and the post transplant and the many drugs and increased number of hospitalization so this yura can state revise the criteria and they also shorten the investigation period from the three weeks to three in patient days or three opd visits so the classic po remains about the three three weeks duration but the investigations were either three days inpatient or three oped visits and there are of course he also classified into different kinds of peo one is a classic what peter stuff said but the other pu are also included now as a pu that is the nosocomial po in nosogomalpi again whether the patient a contact infection in icu or non-icu setting that is nosocomolpo there are different causes for that we know that that immunodeficient horse can be either the patient is an hiv patient or he is on immunosuppressant or he has undergone renal transplantations or maybe he has hematosis hemotropic stem cell transplant so these are the immunodeficient host and patients who had history of frequent traveling they also had a different category of the po itself so these are the different ways we can see the patience of po right but interestingly that because of the climate change uh it has been observed that in the population data that our body temperature is also reducing that's something we learned only by this paper that currently the normal range of temperature is 36.3 to 36.7 as again 37 that we have been taught and every decade the body temperature is going down by 0.03 to 0.5 degree centigrade now what else we have learnt from this particular article review article is that not every time fever is harmful we also knew from our days when we were students we were told that in good old days when there was no antibiotic for syphilis people used to induce malaria to get high grade fever because as again also mentioned in this particular that bacteria are what they call it mesophile that means the basal bacteria grow at a body temperature around 35 degree so the fever high grade fever would be opposing the proliferation of the bacteria that means the high grade fever might itself inhibit the growth of bacteria so every time fewer need not be a bad thing and we did not just try to lower down the fever unless the tachycardia resulting out of fever is dangerous to the patient the patient has ccaf for patients other conditions and elderly maybe he cannot withstand the tachycardia arising out of fewer then we have to bring down the fever otherwise people need not be brought down in fact their fever as the article suggests that because of the fever there is generation of hepatic ion sequestering compounds that will not allow the iron to go into the circulation so that the microbial organisms which require iron for the replication is cut off and also that the fever induces the heats of heat sensitive stock proteins right so heat sensitive soft proteins are activated right the horse defenses and in fact enhances the t cell response so point is that fever may be protective rather than harmful all the times and there is one study mentioned in this particular article that a persons who are in critically ill in icu with a temperature up to 39.5 degree had no adverse effect of the fever but there is a caveat that by external warming of the raising the artificial fever will not help right so this is only when there is an endogenous fever then only this applies then the article goes on to discuss about the causes of puo that of course we know that the cause of pu differs not only from country to country but city to city and even hospital to hospitals we'll see different series of the articles or the papers where the causes of is po differ right in their series but in 2021 one study from india and turkey have again suggested in spite of all this that infection is the predominant cause of po in as much as 40 percent while the autoimmune and inflammatory conditions are responsible only one part of the cases as against that the paper same time papers coming from japan greece and south korea have the equal proportion or greater frequency of autoimmune and inflammatic conditions so we need to keep this in mind when we investigate the patient of you where he belongs to geographically where he is coming from or which area which hospital urban rural all that matters and the important thing in this article is assistance is that that we know from our practice that the po requires a detailed history not only of the the patient's symptoms of the other systems but also history like the dietary history whether he takes the milk whether it's like a raw milk whether he takes he has the pet animals and whether he has traveled recently plus any medicines he has been taking we know that drug is one of the important cause of fever and we always keep that in mind and when it comes to examination we have to have a detailed examinations including the joints scheme and so many things and the investigation that we should be minimum be looking for again differs from set setup to set up and institutions but basic investigations for a patient of you should be complete blood count esro crp metabolic panel blood culture two sets are definitely when you are considering puo as per our definitions and pseudological tests for hiv two dimensional echocardiogram mainly to roll out the vector endocarditis then ct scan for the chest abdomen pelvis if there are any findings or suggestions from the sonography or such investigations and we should also discontinue any new or potentially offending medications that might have been started and that could be one of the cause likes you know that some of the drugs like the penicillin group of drugs or cephalosporin group of drugs or the phenytoin they all can cause the fever and the additional test that has suggested from this article but we may do it in our setup much earlier like we will always look out and rule out the tuberculosis in our setup first before we go for the other detail test or even ct scan right and if there is any suggestion we can go for the full collagen profile including the rheumatoid factor by the immunofluorescence method and a test again for immunofluorescence or the tsh and see a serological markers for hepatitis virus also need to be looked for because hepatitis b hepatitis could be the cause of puo if you have not look for it maybe we miss it and conditions where tick bone infections are very common the test of pcr as well as the synological test are available for the same so is for endemic mycoses like we can go for beta glycan or those tests then lastly they say that the test that is required to be done for the which are expensive but if no cause of pu is found we may go for the pet scan and you may need to go for the biopsies whether it's a biopsy of a temporal artery or a lymph node or a mass right and always the article ends with the caution that if there is a factitious fever right keep that in mind if all our investigations are normal patient is otherwise healthy patient is not losing weight and repeated tests like cbc asr crp are coming normal maybe we keep in mind that there could be something uh fishy about it and we keep practicing fever in mind and see the patients in more detail and evaluates for his psychiatric background also yes yes we started practicing in the era of 1978-79 right and can you imagine the era where there was no sonography there was no city scan no mri the present generation will not even believe this that you cut it in an era where these strategies are not available so i remember two distinct things in my unit when i was resident the patient of pirate i think that the po is probably a misnomer it is direction of not known origin not unknown it is not known to us the cause is always there but in this era we have started knowing causes of so many other things like autoimmune disorder infected endocarditis because of 2d echo because of ct scan and mre also we have certain causes of so many other causes there are two distinct that i remember in almost all cases of pyruvates of unknown region it was a practice in our unit and so many other medical needs to give trial of akt because we knew that there could be some hidden tuberculosis somewhere in the body and that could be responsible for this kind of a low grade temperature which is not responding and if the patient had very high temperature and we were not able to make out what is the cause that victim was past somewhere in the body was nowhere in the body the past below the diaphragm so we used to ask the surgeon to tap and put a needle below the diaphragm to see if there is any any abscess or not or there the over the last period of 40 years the number of cases of pyrex are fun the causes which i have seen are mostly malignancies then i have seen hematogenous period of tuberculosis i mean the malaria tuberculosis i have seen once coming up on seventh or eighth chase x-ray and then you can see the malaria tuberculosis infective of course once again is a very common cause and then of course the collagen disorders and autoimmune disorders the practice of po has changed a lot because of the availability of antibiotics and so many other investigative facilities which have these days so agreed i agree because nowadays we do not consider when we were students the spectrum of collagen disease was coming in the pu because we did not have the investigations one of the important bacterial cause that we often don't go for it because we don't look for his brucellosis time and again if you go for it probably will get it you know the one which resembles malignancy was sarcoidosis right yeah psychology looks like a typhoid or tuberculosis better first get group cell losses because if you empirically treat with tuberculosis the treatment for brucellosis and tuberculosis is reformation so then unnecessary you have to do it for six months and otherwise you don't need it for brucellosis six months of frequency see especially patients are from yesterday yeah and see we have we had patients who had uh i remember one patient who was from the just inquired about the poultry and he had sacroiliitis and it turned out to be brucellosis it would have been on academy if you not ask about his profession he was about working in the veterinary department and you could get that he had pro cellulosis and he was fine then read by few are also these lists yeah yeah see doctor come lesson mentioned about recusal diseases we do see recursive diseases now and even but generally see that is what exactly that we have got now test for the tick bone diseases also scrub drivers also we have to keep in mind now because unless we have to look for search for in the examination about the uh typical scar that we see in case of these scrub typhus right and that is like a one cigarette burst that is what they say ash car so that s car if you look for and if you get that history probably it's a very because doxycycline is priority right but we have to think of it and get the investment for these crop diapers we have got the antibody type test available physiological test available for scruff divers also that's true yes if you're in area like surah leptospirosis is one thing we need to think about yes very very true generally they would not come as a pu but even an active female illness we have to think uh leptospirosis that's good yeah right thank you so much talked about the occupational health disease definitely we have to keep in mind then we always inquire about the occupation for the same as i said i give the example of cautionary disease even as we as medical persons are all exposed to some of the infections by the patients so we have to keep in mind so we move on to the next story that is about a new drug that is called pharisee map it's a new drug which has been approved for the diabetic macular edema as well as neovascular age-related macular degeneration that is for the ophthalmologist up till now the ophthalmologist had been using mainly the vascular endothelial growth factor antagonist drugs like all different kinds of lucentries and avastin and the one which they have used in this particular study is called efflipercept effluent that was the drug they have used it this study appeared in the landsat on 24th of january and this is a reporting of the two randomized double mass phase three non-inferiority trials the trial called yosemite and rhino trials and here 1891 patients having a vision loss due to the central involving diabetic molecular edema this particular trial was for diabetic macular edema and they were randomly assigned to two different rosaries of pharisee map and one those of the vascular endocrine gore factor antagonist that is epilepsy so one cohort received the intravitreal ferrism of six milligram every eight weeks the another group received the ferris map six milligram on a personalized treatment interval that means the the treating doctor as was at liberty to change depending on the optical coherence chromography that is oct results they put all of the patient with oct and if they feel that the patient has not deteriorated it's better they may extend the period of the second dose and this study was every eight weeks the patients were followed up up to week hundred and the primary endpoint was what is the mean change in the best corrected visual acuity at one year that was the primary change and they found that the efficacy durability and safety of intra vital ferrocement was definitely much better than the other class of drugs that is the vgf antagonist drugs and there was a clear-cut improvement with this even when the the duration between the ferris injections were extended up to 16 weeks so we have to call the patients less frequently and it also reduces the cost if when it is available here so the reason why pharisee web is better than the vascular analytical goal factor in antagonist is that this particular drug is also vgf antagonist but it also works on another mechanisms that is it's an angiopoietin to blocking trucks ngo bottom two makes the drug weaker so if you block that probably there is not leakage so that is the advantage of this ferry semap and that is why fd has approved only last week this drug for both the indications of diabetic macular edema and neovascular age-related macular degenerations and definitely we will be looking for this drug because we now know that our diabetic patients uh also and we do come across the age-related macular degenerations so very often and we refer to our ophthalmologist calling and we have got one more drug in our armamentarism then very interesting story as we began with that this is today 4th february is the world cancer day and this year's world cancer day theme is that close the care gap let us close the care gap that means we know that our patients are coming from different status different populations and there's a clear-cut gap between the availability for the drugs as well as for the preventions and one of the cancers which can be treated and with a good survival is the breast cancer and up till now we know that for breast cancer diagnosis we rely mainly on the mammography and when there is a nodule something we go for the biopsy but mammography recently has been proved to have not good outcome for the mortality benefit of the ca breast so this particular study which appeared in the nature communication journal on the 1st of february they have done an interesting novel way of looking for the breast cancers we know that the basic molecule of our genetic material is dna and dna is composed of four base units but if there is methylation that is an addition of one methyl group it changes the dna profile and this is called the epigenetic shift so epigenetic mechanisms are being used for the diagnosis of ca breast before it just comes to the surface so in this particular study they have used the pap smear which is normally used for the cervical cancer only after the pap smear the cervical cancer detection has improved and the mortality is also reduced more than 50 percent as per this this paper so the researchers have identified this particular epigenetic that is called the dna methylation they call it dna dna me right changes in the normal breast issues around the person's having some beginning of the breast cancer growth so this particular study at look for the dna me from the 329 women with the primary breast cancers with the poor prognosis from the 14 european countries so patients who already had the bad kind of the worst kind of prognostic see a breast what was the dna me in the pap smear that is what they studied and they also had the match control of persons who did not have the cancers and their pap smear was studied for dnme and they established a one particular kind of risk ratification index they call it wid bc that is women's risk identification or breast cancer and they validated it not only they did the dna for the breast cancers from the pap smear right that they prepared a liquid cytology uh material from the paper smear and they went for this dna me but they also did it for 240 cervical samples from the women with ovarian cancers and 217 samples from the endometrial cancer so one per smear can as per this paper diagnose ca cervix say endometrium c ca ovary and cf brace so that is what something really breakthrough when it is validated in large numbers so dna is a signature for the w that is the women's identification risk identification breast cancers and maybe in the future we'll get similar kind of tests which can diagnose early and then the very theme of this today's world cancer day would be justified that we can say that close the care gap if we can diagnose early if we start treatment early definitely we can go for the better survival for the cancer patients and now we come to our top story of the day and that is about the yoga for vasovagal saw syn cup we know that this appeared on the 20th of january uh this last month and it appeared in the medscape and the best part and for something for which you would be proud about that this story appeared right the lead author is dr haigry rao he is the senior cardiologist from working at this kim's hospital hyderabad his special interest in the electrophysiology and he is with us today for sharing his uh opinion ideas and how he went for all these studies so would welcome him i'll just give the brief part of how what was done by dr rao and his team welcome dr rao thank you very much for accepting our invitation the last minute and be alive live here on this stage and we'll i'll just go through what was done in this study and then stage is all yours right so we know that resource syncope the commonest cause of syncope is a neurogenic mediated reservable syncope and it could be because of some kind of reflex stimulations whether the patient had been studying for a long time was hungry or is in the stress and the this study dr raven team has selected 113 patients who are diagnosed with recurrent vasovagal syncope and they were given the standard treatment and maintaining the hydration is one of the important treatment avoiding long-standing uh postures all were done and then they selected 61 patients who were additionally trained for practicing a particular kind of asana called tadasana is a palm tree so that kind of posture uh is what is being taught to these patients all these patients of 61 patients were recurrent vasovagal and they had to do this for 15 minutes twice a day and they had the follow-up was 20 months and they could see that with tadas with edison they also went for the breathing coordinations and they could see that because of the applications of tadasana their symcopy as well as near syncope episodes were drastically reduced and i think we'll just run the video for the tadasana and then we go further means palm tree keep your feet two inches apart interlock the fingers and turn the wrist outwards inhale raise the arms up and bring them in line with the shoulders raise the heels off the floor and balance on the toes stay in this position for 10 to 15 seconds this asana brings stability in the body helps to clear up congestion of the spinal nerves corrects faulty posture exhale bring the heels down release the interlock of the fingers and bring the arms down parallel to the trunk and come back to a standing posture thank you yeah thank you dr rav is a senior cardiologist at kim's hospital hyderabad he has an interest in the electrophysiology and would like to hear from him about his study as well as how he ventured upon this particular study and what is his experience by going for the studies and follow up for 20 months sir thank you thank you sir and so thank you for this opportunity to be able to talk to you uh this vasovegal syncope or a neurocardiogenic copy is a commonest syncope if you look at hundred patients about 60 70 percent of the syncopies are vasovegal these are typically seen when a person gets up from sleep and goes to the bathroom and he falls down there or a student a young student stands in the assembly of his school and falls down or somebody who is sitting for a long time in these days of work from home and suddenly stands up and falls down any of these things some of them actually they i have seen people on pillion riding of a scooter for a long time falling down so these are all race vehicles in copy now what the challenge is two things that i found in the last 10 years or 15 years of my practice in cardiology the first is the diagnosis itself most of them undergo extensive investigations of the brain ct scans eegs and all that but which are actually they don't turn out to be anything and the patient is still very uh you know psychologically depressed that uh including his family that he's got a sym copy or a loss of consciousness for which there is no diagnosis and he doesn't know when it will occur again so this is the first thing that i found over the period of time the second part of the uh challenge was the treatment itself now in the historically all over the world uh last 20 years there have been so many papers on medications and so many things unfortunately none of them have found to be useful in the treatment of esophageal consistently um they've been even miradry in beta blockers fluorocartisone everything has been tried sir uh you know central in ssris you know all these things none of them they've done extensive research pacemakers are very rarely used and what was found was actually the little bit i studied was the little bit that was found to be useful or the physical manures the tilt training the you know fluids excessive fluid take taking syncope avoidance you know the hand grip exercises these are the only things i found in literature which are a little effective so at this point there was a lot of work on yoga and cardiovascular disease being helping in arrhythmias and other things so then uh there is also yoga and vasovagal syncope also there were a lot of there are one or two papers but then that required extensive yoga one hour of yoga with seven or eight or even 10 or 15 asanas and when many of them which cannot be done by many people actually on an everyday basis and much less by patients some of them are obese patients also so i realized that this is a particular asana which actually is the one which makes the real contribution to reductions in copy and we accidentally we did it for four or five patients and it was a very uh you know uh gratifying thing one lady was actually bedridden not able to move from bed because she went every time she got up she was unconscious so we tried on this and then uh thought that we should do a proper study we publish it so then we went on for 50 60 patients in each arm in the conventional we used all the things that we generally do like for example the hydration the physical maneuvers everything and that also reduced the episodes from 65 uh 165 episodes it reduced to as much as 12. so the conventional thing was working it's not that it's not working but then on top of it we use tadasana that was a real you know game changer because when we use this on top of this we found that syncope was totally gone none of the patients had syncope at all and the few patients had prison coping so they never felt unconscious that was everybody came back and told that now they are not having single and second thing is the medications where all of them start on medications in the tadasana group all of them could be taken taken off the medications which we are using and uh whereas most of them rather i think ten percent of the patients continue to have medications that's all here 74 percent continue to be on medications conversation so this was a great uh gratifying result and this time it was published in jack journal of american college of cardiology ep and this was published in this online version few days back so that was and that was you know taken up by the midscape and that's what you have mentioning in your time so this is a brief story sir right do you suggest that we have to rule out the other causes of before we go for the tadasana because we know that communist is very vehicle but should we be doing a tilt table test for the confirming or is it required before putting the patients or tadasana or how often do you go forward absolutely sir all these patients which i am talking have undergone till table now we beso vehicle we diagnose only if a person has syncope and is still table positive and say the first part of your question is even more important for physician sir the first part of question is syncope although vasovagal is a commonest everybody must undergo two tests one is ecg on his eco the reason is those patients with abnormal echo if they have syncope we must think of sudden cardiac death not a vasovagal and similarly ecg showing a old heart attack or some specific ecgs like brugada hd elevation long qt all these things must definitely be ruled out so we found that instead of going for eeg ct mri and other things most of the patients with syncope the first thing is history sir the most important thing is history so there is nothing to substitute history so sometimes i have even called people across the countries to get a history because a person has seen them only in u.s they came back here so i had to talk to them because the person who falls unconscious will not be able to tell the correct history the person who has seen the person will tell you so history is the first thing an ecg and echo are the second after this if i confirm that there is no structural heart disease then i go for the till test then all of them are tilt positive especially brady most of them her blood pressure drop some of them have heart rate drop but that is very rare those require pacemakers but they are very rare but most of them have either a depression of blood pressure or a depression blood pressure along with depression of heart rate you know a combination so we go like this right i think what you said very very important that syncope has to be we have to extrude other causes like syncope mimic like whether it could be a tia or whether it said some kind of caesar because there the line of the treatment is totally different very nice very good sir i think your paper has done a wonderful for the and will definitely try i just wanted to ask one simple question was this video that we have shown was taken up from the youtube is it the same that or is there some difference in the practice that you perform in your patients approximately same the only thing is i saw that only the toes were raised so what we do is we reach the toes no doubt but second part we raise the ball we rest the weight on the ball of the feet and raise the toes so raise the ball of the feet raise the toes alternately plantar flexion dorsiflexion right so this way 10 to 15 seconds and two times a day they do under raise their hands high and second thing is the breathing is synchronized see the most important thing about yoga is the difference between yoga and exercise is that is synchrony with breathing so as the people raise their hands and raise their toes they take in inhale and when they come down the exhale this synchrony also is extremely important in yoga right see one of the viewers has commented it said video of the international yoga we agree and we accept but we just wanted to show that at least how the tadasana is being performed but as you rightly said it's not only one part of the movement we have to do both on the toes as well as on the heel both we have to make the alternately just correct that part thank you so much sir for it's a great pleasure having you and the bro you are the first person who is the lead author who is on our show and thank you very much for the same and definitely call you again for the other areas of your interest yes please thank you sir and this brings end of our round of stories for the 14th episode thank you everyone for stopping by on a friday evening and we shall meet you next friday same time thank you good night have a good time

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Watch to find out what the two randomized, double masked phase 3 non-inferiority trials had to say about Farcimab being used as a new drug for diabetic macular oedema and nAMD. Nature communication journal on the 1st of February, 2022 published an article on the use of PAP smear for the screening of Ca-Breast and Ca-Endometrium. The author of the study, Dr. Hygriv Rao, himself joins us this episode to talk about his study on the effect of Yoga for vasovagal syncope.

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