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Cutting Edge: Episode 5

Nov 26 | 3:30 PM

JAMA on the 23rd of November, 2021 published a study that compares intra-articular PRP injections with saline for patients with mild to moderate OA knee. The study concludes that the use of intra-articular PRP did not result in significant improvement in the symptoms of OA. Joining as an expert for this session, Dr. Antony Paul Chettupuzha, Director, Gastroenterology, Insta Specialty Hospitals, gives his views on the ACG updates for GERD. The top story here is the use of electroconvulsive therapy for the use of mental conditions, extensive evidence now shows that ETC is safe and maybe one of the most valuable and effective treatment options.

[Music] good evening everyone i am dr naveda and on behalf of team netflix i welcome you all to the fifth episode of cutting edge we have with us our host uh dr mahadev desai who's a senior consultant a physician at hcg hospital thank you so much for joining in and over to you sir good evening and welcome you all for the fifth consecutive episode of cutting edge this week in medicine and just before two days we thought that our story number one is going to give you lots of relief that means we start from the back to so story number 10 would give you relief and we were hoping that now that in about a month time we are going to complete if we don't use the word celebrate two years of kovite pandemic and looking at the figures in india we thought that the pandemic is going to be over and even the discussion were the same almost world over that when and how soon the pandemic will be over and that's why we have selected three consecutive stories depicting the different aspects of it pandemic from hope to fear to again resurgence of hope so we begin with the first story that even there was an interview appeared in in medscape on 23rd uh interviewer was dr john waite and the person whom he interviewed was william schaffner he's an authority and he's a professor of preventive and social medicine at vanderbilt in university at nashville and the question that was posed to him what how do we know that the pandemic is over and the first sentence that scheffner used was very important he said that what's important is the language what words you use for all describing all these happy discrepancies about all these episodes and he said that please make sure that when i say pandemic is over does not mean the virus has just taken log stock maryland out of the world it's never going to happen in a forceable future we are going to have this virus for number of years and we have to learn to live with it but we have certain metric metrics and we can decide whether the virus has gone from pandemic proportion to endemic proportion and he said that the one of the important parameter that we use the number of hospitalization number of days and the most important parameter that the pnsm people use is mainly the number of tests and the positivity of the number of tests so if if for number of consecutive days the number of positives are less than five percent you can say that the pandemic has come to an epidemic has come to a stage of endemic and we can have some sigh of relief without losing our guards and what another important point he made was that the vaccination definitely prevent the serious diseases and all efforts will be made to vaccinate as many people as possible for both the dosities or even boosters in their country and also that we must not lose our guards or lower our guards and be on vigilant for any emergence of the new by the strains that may come and almost similar sentiments were echoed when our authority dr t jacob john who is a former professor of iron cnc valor and dr sadhari that can we say that india has the epidemic has converted into endemic and he was very very confident in with numbers he said that yes india is probably the first country which has entered the endemic which is something for us to be proud about for the very simple reason a country of 1.3 billion people and with so many resourceful less areas in that we could achieve to a level that think of the second view which on the peak on may 6th of this year we have 4 lakhs 14 000 cases per day from that the figures came to 50 000 in a matter of one and a half months and in another one two months it came down to less than 20 thousands and for last 15 or 18 odd days the figure has remained less than fifteen thousand the count was here means enough to understand what dr jacobs said was that whenever there is an epidemic which is going on with an increasing number and remains sustained for a longer period we call it an pandemic ongoing but when the number remains on the lower side he did not mention about the number of tests to be done but if you see the number of days uh before yesterday india tested about 11 lakh 50 000 and the positive was 213 of less than 10 000 so the point is our positive rate is less than one percent even if their figures may not match exactly to what we see but definitely it is uh we can say that we are into the endemic area and what is important pertinent what dr jacob also said was that this is because of the hard immunity that we achieved with the virus that for which we have been vaccinated and for which we have been infected now maybe if the new virus comes or new strain comes again large of our populations will be unvaccinated or maybe there are children who are still not vaccinated so more focus would be on the vaccination to the children he also advocated that and government also trying to bring the vaccination to the children very nearby future so this is about our story number 10 but before we move to the next story which is obviously related to the highly mutant virus which has taken the storm of every news channel or newspaper that you see everybody is talking about what is going to happen to us are we going back to the march 20 days 20 20 days or so there is a highly mutant virus which will be named maybe today or tomorrow so any guess what is the virus going to be christian as whether it's a new delta theta beta or nu so what happened in this last few days is again a matter of concern but the same time we can just take the pride in that sense that the medical threatening is moving so fast one may call it a proactive step or little out of its exaggerated steps but that's not the case only before 20 on 20 second the african countries have noticed uh they got the reports of some of their patients who have been infected and they send samples for genomic studies and they uploaded on 22nd of november the whole genome sequence of what they call it be 0.1.1.529 as a new variant and out of the 77 samples they tested all were positive for this b11529 the what is concerning is that this particular variant has more than 30 mutations and majority are in the receptor binding domain what we have studied earlier with the earlier variance also was that whenever there is a varia mutations in the receptor binding domains it is likely to change its infectivity severity and maybe it escapes the immunity from the vaccines so that is why the government was very proactive the cases appeared in botswana south africa and even one of the travelers going to the hong kong so what they did the south african government as i said uploaded the whole genome on 22nd and they insisted and convened a wh of meeting which is being held right now and they are going to decide about how to deal with this particular virus many of the governments have also taken the proactive actions and cancel their flights going to and coming from africa and many other countries we do not know whether it's set to hastily a step or two proactive state or to protective state but definitely this is our best chance to prevent the widespread of this particular variant we do not say that how serious this variant is going to be but what we have learnt in our whole two years experience the same that we have got to contain the virus before it becomes its speed because before it spreads to the whole globe because of the frequent traveling and the rapid spread of virus so this particular variant what is particular about it that it has very high infectivity so transmissibility is definitely proven but so far the scientists over in the africa say that it is not really that severe and we have yet to see about the vaccine efficacy of the vaccines that we have received to this particular new variant so this new variant is a new entrant and it's right now a variant of concern we do not know its overall impact going to be on in the africa or the globe as a whole but something that we have got to keep because this is a virus which as i said they just analyze the sample received between 12 and 20 november and within four or five days everybody is talking about this new virus so this is the speed which the scientists are now working think of the genomic sequence that took so much time and the vaccines developed so something that is good happening as far as this particular aspect of the development is concerned and very importantly the next story is about the vaccine started in canada usa and israel have already started the vaccines but canada is comparatively in another conservative country but they have had the scrutiny of the clinical trials of the children who have been vaccinated as a volunteers and they could find that in the clinical trials more than 90 percent of the children who received the vaccines had no severe carbon infections and the side effects are also minimum what is important is that they use the mrna vaccine in canada while the other countries like chinese countries like china then also uae and cambodian colombia have started the chinese wax into the children the vaccine dose that is used in canada is 10 microgram as against the 30 microgram for adults and canada is the country which has the highest fully vaccinated people over the age of 10 12 years and this almost 85 percent of the eligible people have already been vaccinated and that is why they have also now started the vaccinating the children they use lots of new innovative ideas because to convince children and the parents coming to the vaccine centers they give lot of pictures and they put the unicorns and hockey players and all that around the stations and something that probably will have to also learn our governments when we roll out directions for the children then we move on to the next story that is again something new in the sense that we have been knowing about the latin tuberculosis and we have been testing and even treating also in this specific situations but this is one study which was presented in american heart association scientific assassins in the november session where a gold study the name gold study was presented which is a randomized control study of thousand ugandan children and adolescents who have been diagnosed with echocardiogram the presence of latent traumatic heart disease when the latent dramatic heart disease was diagnosed then they divided the patients into two groups the one group is given the standard penicillin prophylaxis of benzothine penicillin 1.2 mega units every four weeks and followed up for two years with the frequent 2d echocardiogram measurements and another group which has not received the penicillin prophylaxis were also serially followed up and through their surprise a good surprise that the children who received penicillin prophylaxis had slow progression of the rheumatic activity and this is for the first time it is documented that penicillin profile axis should be tried even in the people who are having electron traumatic heart disease of course this is going to require a lot of infrastructure facilities of echocardiogram in the remote place but as of now we can say that certain populations like those who are staying in the overcrowding areas or repeated upper respective infections or those who have malnourishment they should be screened for at least the latent traumatic heart disease and should be offered penicillin prophylaxis next we move on to another story which is about the finding of non-alcoholic fatty liver disease and alcohol associated liver disease amongst the year this was present in the liver meeting uh in the last week and there were 1319 patients persons who have participated out which 100 volunteered that they have used excessive alcohol while one two one nine patients had mild to no alcohol consumptions and this is the first time that this use fibroscan to designate as nfld over and above the liver enzymes obviously the patients with an obvious alcoholic or any other liver disease or enzymes more than 500 were excluded from the study and what they found was that the people with excessive drinking have been said more than 52 persons had alcohol related diseases liver diseases and out of them 87 percent had no or mild fibrosis and 12.3 percent motivated to severe fibrosis and the significant eld predictors were male sex higher bmi high alt and hb1c what they found which is surprising is the people who had minimum or no alcohol consumption a 40 percent had nfld and out of which almost two thirds had mild fibrosis and 31 percent the important part is that almost one third of the people have wanted to severe fibrosis no symptoms and the alcohol consumption is very on the lower side and people who had the elevated alt ast albumin platelets low and the hp1c on the higher side and higher bmi were the people who are having an nafld we now know that even in our countries in practice we know that the alcoholic cirrhosis or cirrhosis because of the hepatitis b and c are becoming less and less and we see more number of patients with chronic liver disease because of the nf fld because of either the diabetes obesity or hyper dyslipidemia so something that we should be looking at much younger age so that we can modify their metabolic risk and prevent or delay the fibrosis that is the very idea of bringing the story that we should catch them young and try to convince them about the metabolic effects of liver liver is going to be the main organ for research for most of the metabolic studies and even diabetes so we take a break and ask you yeah what are the favorite stories so far for you yeah yes so i'll start the poll and you'll have the five stories that we just went over um y'all can scroll there are five stories um please let us know what was your favorite story up to now okay so we have a maximum votes going for is the pandemic or the the 10th article that we started the uh session with right another interesting story a good news for all of us that the indian regulator also approved empaglifozen for heart failure with reduced ejection fraction ampaglyphosin is one of the sglt2 inhibitor which has already been approved in by usfda in this year august only for the heart failure indications indian regulator has also now approved so we can use the ampaglyphosin for the heart failure with reduced ejection fraction it has already been approved for diabetes diabetes limited cardiovascular diseases but for heart failure with or without diabetes that's very very important that we can use this particular drug even without patients having diabetes but only heart failure because what is found that with the use of empire glyphosate there is a significant relative risk reduction of the cardiovascular death or hospitalization for heart fueler by as much as 25 percent so previous indication or approval of diabetes with heart failure diabetes with coronary disease or previous established cardiovascular disease on top of it there is a new indication or new approval for the empagly foreseen and i'm sure the other sclt-2 are also in the class are going to follow for this dipaglyphosis is also approved for the heart failure with reduced ejection fracture in diabetics another story that is up till now we have been treating hypertension mainly in elderly people for preventing the stroke seve stroke but now this particular journal that is general epilepsy november 20 21 carried out one good article where the participants were taken off from the cohorts of remingham framingham health studies and almost about 3000 participants were selected and they were followed up and what they found that those who had hypertension had they were followed off a long period and what they found was that the hypertension itself becomes a risk factor for the late onset epilepsy whenever there is a late onset epilepsy we think of the slow small vessel disease we think of some sol but remember hypertension is something a modifiable risk factors for the persons who are over the age of 65 and what they found out that even if the patient's or blood pressure is controlled if you exclude that and if only the patients were higher blood pressure then the risk of later onset epilepsy is almost 2.5 percent so what important point we take from this study is that we should control blood pressure in all illegal people not only to prevent the seven stroke but also to prevent the late onset epilepsy move on to another interesting story this is something that probably has become more popularized by the people who advocate them this is about the platelet-rich plasma injections for knee joint osteoarthritis we know that osteoarthritis has become very very common and so many people do not want to undergo knee replacement for obvious reasons and that is why the alternative therapy or therapies with different types of intra-articular injections or even oral tablets are being used by practitioners so in jama this three days back the story appeared which is called a restore study here 288 patients with mild to moderate knee osteoarthritis were taken and they are divided into two groups the one group was given three weekly injections of platelet plasma and another three groups were just given the normal saline and they were followed up serially for 12 months and they were also followed off with the mra scan and what why it is important that literature plasma is being used even in india made by many of the practitioners and what conclusions are that the intra-articular injection of platelet-rich plasma compared to the injection of saline is no better and is as good as placebo and there is hardly any difference in the outcome even after 12 months of the analysis of the x-rays and the mri in the joint structure hasn't made much difference so the outcome is that the platelet-rich plasma is interactive injections is not effective in mild to moderate that is we service any placebo therapy we asked our orthopedic friend colleague and a very senior orthopedic surgeon dr jyotindra pandit from ahmedabad who has been the professor head of the department and the head of the institute of the paraplegia institute and been in the practice for a long time he is into the trauma as well as the joint replacement surgery let us say what he has to say about the intra-articular injection of platelet-rich plasma in oa uh in osteoarthritis have been used extensively as local injections but in my opinion this is also a placebo and does not have any clear cut evidence over other placebos in curing the condition it make you temporarily believe that the condition of australia which is a disease of cartilage remains as it is and the use of regular exercise and other anti-inflammatory medicines is equally effective thank you so much as you say from the expert's mouth that this is no better than a placebo and at least when the patients ask us it may not be the area of our expertise when the patients ask us about this statement we should say that something that really not proven and stay away from it gastroesophageal reflux diseases become a very common diagnosis anybody coming with the pain in the epigestum or heterosternal or regards and we immediately get a diagnosis of gerd without waiting for the final diagnosis and may start the proton from inhibitors or h2 blockers or antacids but this particular week the guidelines have come in it's a very detailed exhaustive guidelines which has included the pharmacological therapy lifestyle surgical and endoscopic management very detailed guideline all that we want to say the highlights of these points are that what is important is that whenever you clinically diagnose grd even before diagnosing you can give an empirical treatment of eight weeks of ppi only the protein from inhibitors should whenever should be given should be given before at least 30 to 60 60 minutes before meal for a better effect and it should be given for no more than eight weeks after eight weeks if there is poor response or no response then it is better that you subject that patient to endoscopy and for diagnosis of gerd barium swallow is no longer recommended it's better that you go into it and see the actual effects of gard and another important point that's taken that is mentioned here that weight loss should be given an importance something that definitely helps the symptoms of grd second part the patient should be advised to finish their meal two to three hours before the pet time and they must strictly avoid tobacco automated products and another interesting point probably at least i was not in practicing this particular in my practice was that we must tell patients that they have to find out the trigger foods the foods that trigger their symptoms of heartburn or regard must be avoided and another important take away from this was that please do not give ppi we know ppi have many side effects whether it's a b12 deficiency or mechanism deficiency or the effect on the osteoporosis or effect on the kidney in the form of acute interstitial nephritis there are so many side effects associated with ppi and many many drug drug interactions so it's better that we give proton pump inhibitors the proton pump inhibitors can be given a standard dose somebody is asking for those so standard dose remains the 40 milligram of pentoprazole or 40 milligram of rabbiprazole or sme brussels we can up to 40 to 60 milligram so we interviewed or we asked our expert panel who incidentally talked about uh gerd last week only last friday he talked none other than dr anthony paul from cochi is a renowned gastroenterologist and let's see what he has to say about these new guidelines [Music] the last meal and your sleep to avoid smoking avoid trigger foods these are the new recommendations or updated uh recommendations rest medical management were more or less similar to the old guideline except that here there is no root for backlog in jet similarly properties cannot be used there is no display here overall the guideline is very good but i think it will be helpful for day-to-day practice thank you right so dr anthony paul stressed that we should not be using prokinetic just like that unless there is an indication for prokinetic and the baclofen which is also used by many should we avoid it and you can go through the talk of dr anthony paul which is available on our replay on our platform of netflix so that we can get more detailed informations about gerd now we go on to our story number one which is picked up for because we have so many other ideas about the use of electroconvulsive therapy we have probably all of us have ideas about the electro conversion therapy and the very senior patients were subjected to ect right when we are have our psychiatric term in the under the youth but this time in the frontiers in psychology we have this story about the 157th patients who underwent electroconsulting therapy for 3100 sessions over a period of three years they were followed up and what is important and reassuring is that this particular therapy which has been there for a long time has very good safety profile and compared to what we have been thinking that probably gives damage permanent damage to the brain and it's an inhuman and it should not be done because you have got many good anti depression therapy or antipsychotic therapy and only about two percent of the people had severe or treatment resistant depression and currently they are treating with ect and what has been found out that the ect may be one of the most valuable and effective option for the severe and treatment resistant mental conditions such as schizophrenia depressants and there have been thankfully no permanent impairment from the treatment and only three sessions out of more than three thousand sessions caused potentially life-threatening events but they were all managed medically uh without any residual effects now we have invited dr himanshu desai he is our psychiatrist very senior psychiatrist and a very close friend again we want him to give his expert opinion about the electroconvulsive therapy and electroconsole therapy is placed this time and how often they use it and how safe it is and we service the newer anti or the old antipsychotic drugs and antidepressant drugs what is the place of ect these days dr himanshu welcome to our show and we are very happy to have you with us and let's be enlightened by your expert opinion uh thank you sir good evening good evening basically your city is one of the yet one of the major treatment modality in our country because in our country you see it is one of the cheap therapy in compared to long-term medications and ect is again one of the fastest acting antidepressants one of the fastest tactic antidepressants because because that database will take it is two to four weeks to be effective acidity works very nicely even after three to four sessions patients shows remarkable improvement those patients were suicidal we prefer in suicidal patients because very it is very much required in such conditions in acute psychotic in acute mania also ect works very nicely when patient is not responding to routine antidepressant medications we use ect as one of the supportive treatment wherever patients are not responding well to the pluto therapy recently we have started using ect as a maintenance therapy when patients are relapsing very frequently so we give them ecd as a maintenance therapy maybe once in a in a month also so usually we give five to six session obviously but is it very poorly shown in a movies and everywhere in a media so ect is is really stigma it's very difficult for us to convince people regarding ect because it is very much stigmatized thing so i request all of you that ecd is one of the fast one of the safest thing only complications may be maybe because of anesthesia competitions otherwise you see the person has no complications sometimes there is a reversible memory disturbance occur because of ect but it's a hundred percent reversible you know in a fifteen days to one month it's it's a reversible memory disturbance how safe is it is in pregnancy it is very much safe in pregnancy because many times we hesitate to give other medications in pregnancy but it is one of the safe in pregnancy it is safe in old age population also it is safe in all these populations where there are other complications of medicine occurs but it is safe in old age it is safe in pregnancy also right we know that the antipsychotic and anti-depressant medicine especially in the elderly people many drug drug interactions and many side effects and even the history of the complaints of falls sustaining fractures and all are too common so what is the acceptance of ect at the professional levels means how often you live we are using very oftenly uh very frequently in depressive patients when patient is not responding to medications we use them in in many patients because any antibiotic drug will it will take at least two to four weeks of the time and during though that time it is very difficult to control such patients while ect will give fastest fast effect so in many patients in acute mania you see it is one of the very good mainstay we are giving a city very frequently in india a city is very frequently in periphery of of the country ecd is used very frequently now in us also people have started using more and more ect but it is very badly stigmatized therapy so people are scared yet but one of the main thing is that yet the exact mechanism action is not known but that's that's one of the things but that's that's true for all anti-depressant and for all antipsychotics also science is working on on this area like anti-diabetes i like how diabetes occurs again it's like like all all depression how it occurs it is not low right don't you think that there are so many areas in medicine which have been wrongly projected in the movie so all of us collectively should do something some presentation representation or something so that at least people general people just they what they see they start believing and that's their resistance come mainly because of their ideas that they get from such kind of movies very true sir it is very badly depicted uh to to just get there get the sympathy of general population last year also there was one movie had come then then our society had had fought with them very very strongly and they had to change the name of that movie so so we need to collectively we need to work very hard to break the stigma because it's very easy for them to epic anything in a movie then people take it so fast into their mind that it takes long time to remove or wash out this this effect from their mind so we really need to work very hard as a professional i think the name itself was something like mental or something they have mentioned yes yes sir they had used word mental and so so mentally is really very stigmatized word yeah basically we are psyched his name is stigmatized he will not say to anyone that that he is my friend nobody the population is suffering from some or another kind of uh psychiatric illnesses we gave we are treating only tip of the iceberg but the rest of the patient goes to other constituents we ask them to treat them more more frequently then if they have a better knowledge of how to use antidepressant how to use antipsychotic that will reduce half of the problem of the society also right thank you so much dr himansu and we love to have you on a full scale discussion on many of the topics which are of interest to us and that belongs to your domain so thank you so much and yeah with this we come to end of our as i repeat what dr himanshu said specially about the city that it is inexpensive it is easily available it has no side effects it is the fastest acting and it is safe in illegal as well as in the pregnancy so i think there should be more acceptance with such kind of studies when published and with the safety uh with this we complete our ten stories and we help yeah fine so over to you thank you sir um so these i'm running the polls for the second set of five stories that we went through uh again there are five options so please do tell us what your favorite story was and also you all can write to us if you all come across any uh good articles in the week uh please do tell us and we will make it a point of having those as well so yes uh the maximum votes have gone to electroconvulsive therapy for mental conditions we've got 43 percent words uh that's the favorite story and it was ranked number one by us so i think we are doing something right uh coming to uh the segment of the session that is um the quiz section um so i'll just go over the rules for people who joined the new um we have we finished one question already we'll announce the winners together we have two more questions for you uh so the first person to get the right answer uh gets a prize from netflix you can just put in uh whether it's a b c or d and i'll wait for a couple of seconds on this slide and then we can go over to the next slide for the last question of this week so these are questions that we pick up from the stories itself where we feel uh it would make an impact uh and these stories are important uh in the day-to-day practice because i see a lot of answers coming in um let's move on uh to the next uh question this is the third question of the uh session so again the same rules apply uh you can write in your answer either a b c or d and uh the first person to get the right answer uh gets a g or gets a price from netflix someone from netflix will get in touch with you all uh after announcing the winners um to drop the gifts or have the prizes delivered to your place all right moving on uh while the team collates who the winners are for all the three questions something about the quiz that we asked before the new mutant virus that what is the name going to be the name and we have given new delta beta theta or nu nu so probably the who's decided the naming of the virus mutant virus would be named according to greek alphabet and because they don't want to stigmatize any country or the area from which these disease has first appeared and that is the reason that they first was was given alpha that was the california then came the beta uh then the delta from usa and then brazil and all this now rolling royal is going to be the new new so let's say that today that will they are going to decide about it so that's all about our stories so far thank you very much for remaining with us for all this time yeah i'll just quickly announce the names of the winners so for the first question that servers is talking about the winner is dr iris chaudhary uh for the second question we have dr vittel arora and for the third question uh we have dr alvin john we uh team netflix will get in touch with you all pretty soon uh in so that we can send the prizes to you all and thank you so much for coming in on a friday night and we'll meet you all next friday same time 9 00 p.m uh certain meat will be up yeah and we have to maintain the kawaii appropriate behavior to again rate rate because we do not know there cannot be a better vaccine than the mask because of the new variants that is on the horizon let's hope that it doesn't touch the indian soil and we remain in the endemic zone and so thank you goodbye stay safe stay healthy thank you thank you good night everyone

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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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