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Cutting Edge: Episode 1

Oct 22 | 3:30 PM

In this launch episode of cutting edge, Dr. Mahadev Desai discusses the USPSTF's new guideline, which states that aspirin should not be used for people above the age of 60 who have primary CVD. Another intriguing story for this episode is one that looks into a study that uncovers the difference between human and chimp brains. According to the study, the answers can be found in 'junk DNA.' In just eight months, India has vaccinated one billion people against COVID-19, an incredible achievement for such a vast country. Join us live to take a sneak peak into a few top stories of the medical world.

[Music] so good evening dear friends um i'm i'm very happy to see everyone here and today is indeed a very special moment in the journey of netflix as cutting edge is the first show that we premiered today going forward we'd like to bring many more shows so as most of you who've been following netflix are aware we've done individual sessions so far and we've done sessions in clubs uh but but this will be the first regularly repeating show so every friday nine o'clock we will be here with the top 10 stories of the week the the idea for cutting it started uh since we we've been thinking for some time that you have general news channels and general news shows you have business news shows you have sports segments within news shows but there's nothing really which is dedicated to medicine and which is surprising because medicine is probably the largest most dynamic field of profession across professions is there's so much which happens uh every week in medicine hundreds of trial outcomes hundreds of publications and the only possible answer as to why there isn't a new show in medicine is that the producers don't think it's a it's a sizable market because everybody caters to the mass audience when you do sports and entertainment and general news for us at matlix medicine is our business so we we have uh conceptualized this show and uh we really hope that we can substitute a lot of the effort that doctors would have to put in uh in order to keep pace with the rapidly evolving science uh while we were putting together the stories for today it was a very interesting experience we could we could find 20 30 really exciting stories and then we come down to 10. uh this is the beginning and we really look forward to your feedback all sorts of feedback uh stories uh did we did we miss any really important stories and we would love to hear from you and make sure that we are tracking them from next time and uh if you think it's too fast it's too slow uh it's not engaging enough all all feedback is welcome so please write to support the rate metrics dot app and your feedback will help us make this better just a a small note on the structure of the show so we have dr martial desai he's a senior practicing physician and a very well known academician with us to host this show he's graciously accepted to host this show alongside his really busy practice and we couldn't think of a better host for this show because the variety of content we will be discussing every week will span uh across specialities and um it really helps to have somebody from internal medicine uh to anchor this and give their perspective wherever possible wherever we have a very detailed story uh like today we have something on copied on diabetes we will try and get expert opinions uh and share those clips with you along with the story so that's the host we'll run down from rank 10 to rank one uh and hopefully that will keep the suspense and the anticipation going as we go along um and there will be some fun polls along the way uh there will be a quiz at the end the quiz is not really to grill anybody's capacity to memorize but really it's just another way to [Music] reinforce the three key takeaways that we think are there from the session today so it's just a way to put the takeaways in a question format and just to make things interesting we'll be uh giving uh some fun token prizes to the first three people who answer the quiz so when the question pops up on your screen uh just write the answer in the comment box and the first correct answer our team will get in touch with you i don't think there is anything else i need to add but but nivedita and lakshay will be here to help manage the show and i think i'll hand it over to dr madison with this uh welcome everyone once again and uh if you like it then please spread the word thank you dr madhu decides yes good ending thank you rohan and welcome to each and everyone who has spent their valuable time for this first day for so and we really look forward to your constructive comments criticisms for soul and we have planned this so in such a way that we cover good number of stories that is the 10 in the first last week that has appeared which are relevant to the practicing physicians either in the form of some new knowledge or some new practice changing guidelines or new molecules that is added and as everyone is rightly said we'll be seeking the opinion from the experts who are real experts in their field for that particular story so to begin with we'll start with the story number one so our story starts with the story number 10 that is about the everybody knows about the breakthrough transplant scientists have attached a big kidney to a human but before that why we need to run this story because we know that in india we have got as on first of october one lakh six thousand seven and thirty nine persons waiting uh men women children included all for the various organs and every day we lose 17 percent for want of the organ and every nine minutes one person is added to the list of waiting list of the organs so in that context this story and another story from india are very very relevant and important and that should drive us for not only the organ donations and encouragement to the patients who are brain dead and some of the pledge that we can help in getting the donations at the right time so this was a story from the new york city where a big kidney has been transplanted into a human without triggering immediate rejection the peak kidney at the peak kidney has been genetically modified in such a way that there is no immediate rejections and the person was a brain-dead person and he family agreed to an experiment that was very very important and essential and they knew that she is not going to survive but they were ready for this operation and the transplant peak tissues are not new to the cardiothoracic surgeons we have been using the porcine valves for the complex valueless surgeries but donation of a kidney was absolutely for the first time and the person who did this what dr montague and himself was a heart transplant patients and they what they could find that the persons who received the kidney and of course the kidneys were kept outside and the blood vessels the kidney were attached with the blood vessels with of the persons and they could see that the kidney function just like a normal and the renal functions also normalize and for three days till the reports came everything was fine so that is about the big kidney and that heralds the new era of organs because we need a lot of organs and we don't have enough organs to save our patients who need them badly and we know that the time is very very important for most of the people who are terminally ill and institutional disease which is one of the commonest organ required in india almost 80 percent of the urban donations waiting list comprised of kidney so that's about the first story the second part of the first story is the in belongs to india in a private hospital in delhi uh liver transplant re-transplant of the liver which was transplanted in one person's the original liver belong to a 44 year lady then that was transplant to a 54 year gentleman and unfortunately the person died within a matter of seven days because of the interactional bleed incidentally the first person whose liver was transparent also had died of the interaction bleeding and then the question of whether to use this uh in a person's reuse of the transplanted liver was very much in the mind of the surgeons but they tried with 21 prospective owners of the blood match but only one of them in spite of complete counseling agreed for the reuse of the transplant and that is how the re-transplant of the transplanted liver was done the essence relatives have been counseled that there could be a problem of bleeding has occurred in the previous two occasions but they agreed to take the chance and so far the writing is goes uh there has been no untoward effect and they already saw to it that the liver functions were normal in the transplanted kidney and we have to wait eagerly for this but it's a new beginning again that we can use a re-transplant because so many of the patients who have been transplanted different organs they died of some other cause and their transplanted organs may be good enough to be transplanted to the other person so that's about our first story number 10 then come to story number nine for a long time and we got so many apps and experience with the topic oh we produce these bronchogenic carcinoma or copd or cancer all these things then it doesn't work it it doesn't work but here what they found contrary to these expectations that the persons what they do was they take the samples of around six seven hundred percent and they'll run the almost seven questionnaires and these questions were anything from what is their idea about the obesity or financial constraints or their social stigma and obesity and death and illnesses all these five important parameters were being questioned through almost seven grading and contrary to their expectations they could find that if a particular message is given in the form of a death related illnesses which can be prevented by exercise or any illness can be prevented by exercise then that has the best exception compared to the obesity or other such parameters for the finance involvement so the point is that whoever develops the health fitness apps or if we have to suggest our patients about the exercise we have to bring it about the benefits as far as the prevention of death or the disability that's very very important people have tried with the obesity that this is a canadian study and when they put the questions like that one in four persons in canada is obese or that the persons who are physically negative die of the illness all these type of questions were put and they could find that it is the death and the illness related campaign or the motivational messages that work the best for the exercise so that's what we should also be doing it on our patients who ask for the benefits of exercise right then comes the story number eight this is a very very important story for the field of diabetology and field of obesity there is a new molecule called terzapetide dissipator is a novel molecule which works on the incretins we know that incretins are the hormones which there are two types of increasing hormones one is called gip and another is called glp1 gip stands for the glucose dependent insulinotropic polypeptides and glv1 stands for glucagon like peptides both these hormones work at the level of the stomach as well as the pancreas they stimulate the pancreatic insulin secretions they also work on the increase of the gastric and delay the gastric emptying time and thereby lose the weight so the precipitate is the molecule which works on both glp one as well as the gip and it was titrated with three different doses of five milligram 10 milligram 50 milligrams of cream injections once a week versus the long acting insulin which is called the insulin large or both the parameters of the ovaries [Music] as far as the fba one reduction is con we started with the dual uh grid so the point is that pizza peptide subcutaneously as against insulin safety profile less and reactions but we need to know how good it is from our experts so we have already contacted dr bansi sabo he is the president of rssdi india and is also very well known figure in the field of diabetes and metabolic diseases so we would like dr bansi sabu to have his comments dear friends i am dr bansi sabu a hybridologist based i am going to talk about the newer molecule which is in clinical research we have now data phase 3 data which is published which is talking about the transapatite which is a dual antagonist compared with glycine insulin as we know now with recent data of american diabetic association guideline also talking that the glp one analog should be considered as a first injectable therapy rather before starting these patients on basal insulin the glycine is a basal insulin which works primarily to control the fasting plasma glucose while glp1 or glp based therapy decreases post meal glucose level primarily because they suppress the appetite and there is a primary pathophysiological problem of type 2 diabetes they have obesity and their major reason for developing diabetes is their food habit it's high carbohydrate intake which is responsible for them to develop diabetes these molecules glp based therapy are also having cv benefit and that's the reason now they are also choice of therapy is a first line anti-diabetic agents after met four million patients with heart disease along with sglt2 inhibitor the problem of these newer molecules are costly and injectable and that is the reason many of our indian patients are not willing to take it on regular basis but this data shows they improve a1c even better than insulin and they are the one which decrease the body weight and decrease hypoglycemia also so the future lies with these newer molecules glp1 or the dual antagonist which will be available to us maybe in another two or three years to treat our type 2 diabetic patients thank you thank you very much so the interesting part is that the weight reduction with the 15 milligram highest those has been as high as 11 kg that is too substantial and the hb1c drops also 2.3 compared to 1.4 with the clutching so it's a very impressive data only thing that remains to be seen is the how expensive it is going to be to the end users and how good are the long term results but the initial results are definitely very good and the argument is that it has a the gip which has so far been the neglected hormone as far as the management of these glp1 analogues are concerned a this reset point works better over the gip than the glp one and gl gip has definitely effect on the stomach more than the glp one and that is how this scores over the glp one as well as the clutching that's the theory behind it move on to the next story that is the story number seven here the story is about the tuberculosis we know when the covey 19 pandemic started that how it spreads initially we thought that it was a droplet infections and also spread by the formides and then the scientists came out with the theory that former it's not really matter much it's mainly the droplets but the aerosol spread is also expected and has been proven in some of the states and that is why it remains for a longer time as an aerosol so the tuberculosis uh is also a big threat compared to the kovic is just now the two years old pandemic but the tuberculosis has been killing the patients year after year for a long time and most of the tuberculosis bacilli are emitted at least when the person is just routinely talking or exhaling as against the cough if a person just breathe he breathes almost around 22 000 in a day and when he cups his cups around 500 times a day so if you compare the coughing versus breathing or exhaling it can you can say that ninety percent of time the bacilli are emitted at the time of routine conversations or exhalations while the coughing will contribute to the seven percent of the tuberculosis basically the point here is covered or no covet the mask the right mask is very very important here to stay because of not only the covet but many infections including the tuberculosis and as it is an aerosol spray so the all the clothes places whether it's a prison or theater or a mall where the chances of the tuberculosis spread is very much and that is the reason that we have kept the stories that even if the covert is under control but we need to be very watchful about the other diseases which are spread by the aerosols and one is being tuberculosis the another being influenza like illnesses and the h1n1 influenza so it's very important to keep the mask and our all guards on we may call it a kovid appropriate behavior but all in all the mask is here to stay the story number six is about a tremendous we all perceive especially most of the doctors feel that the tremor is a very safe and potent analysis in drugs there is no doubt about the potency part of it but the safety point of v is highlighted in this particular medscape new article before three days and it's mentioned that tremoro is one of the most commonly prescribed drugs among the orthopedic surgeons and tremendous has a very high risk of mortality and cardiovascular events compared to codeine we know that codeine we usually prescribe only in the cancer related or such kind of chronic severe pain but tremodo has been prescribed right left and center and particularly in elderly patients when we are worried about using the nsaids we more often go to prescribe the time at all but tramadol because of its metabolism and interference many of the commonly prescribed drugs it causes many many drug drug interactions and the side effects and what has been found out that there is no significant difference in the risk of false delirium constipation or dependence on the sleep disorder between two but the seven mortality is clearly more with the tri model and mainly because of its effect and mainly the drug drug interactions with the other molecules that are commonly probe described and in fact in practice also we see and we know that the terminal is not easily tolerable drugs patients of persistent nausea and that is why we usually start with a very small dose of half tablets of 32.5 milligram of tremor so next time we prescribe tremor as a safe drug we have to be very watchful and we must make sure of see the list of the patients who have been receiving the other drugs especially when the patients are swinging drugs like ondensetron or the patients receiving the drugs like linus only you've got to be very careful and there have been instances of serotonin syndrome along with the tomatoes or prescribed with the drugs like ondensetron or the whenever the patient becomes restless get started fever agitations tachycardia rigidity think of this kind of serotonin-like syndromes when we prescribe tremendous so tramadol is not all that safe that is pursued that was the very idea of putting this story and just come in the midst so feel free to put whatever story you all think was your favorite up to now uh i'll just run this quick call uh so there are five stories that we covered up till now and there are five options so scroll or to see all the options and then you can put in your votes so i think this will give us a nice feedback so now we come to very important molecule which made headlines as if uh malnutrition is something new drug which is the practically a cure as people pursue for the fight against kovite 19. monno piravir is an another antiviral drug where the company mark has investigated the drug and they have studied and released the interim analysis of their phase 2 trials and based on that they applied for the emerging use emergency use authorization to the authorities and what the studies have shown that it reduces the hospitalization as well as the death by 50 percent which is very very tall claim and it belongs to a drug which is called mutagenic ribonucleotism what it does it the drug goes into the genetic material of the virus and it introduces errors and thereby prevents the replications and eventually death of the viruses that is how it works it's a oral molecule and it can be given on an opid basis what the companies have suggested is that should be used in the mild to moderate cases of the cov19 infections and in the earlier part it's a five-day course so the hope and the hype is very good we need to see that whether it's going to stand the test of the time we had many drugs like the fevi piravi ram desure and many other drugs also we have tried in the last and a half years we talked to our another experts the dr sarsa is a very well known critical specialist and internist and we the persons in the netflix have already enjoyed his very classical lecture on the clinical parameters of how to deal with monsoon illness febrile illnesses so we wanted dr sarsa to give his honest and opinion about this particular molecule whether malnupara is going to be a hype or hope for the covenant netflix has asked me to give my two cells on my pyramid as we know one location is uh newly assigned to kovite 19 by the manufacturers and it is probably going to receive an emergency authorization in the usa soon first let me start with comparing favi pyramid with small nuclear and therefore uh why i am skeptical about non-operable fabric japanese molecule uh initially created to fight influenza monopoly american molecule again initially created to fight influenza in that sense both have been repurposed fabulous was brought with great enthusiasm in india and it has fizzled out because we have seen through experience and through data that it does not do much malnutrition has very little data so far to support it both drugs have a similar mechanism action through inhibition of the polymerase enzyme in the virus and therefore they're not very different from each other so i do feel that monopoly may suffer the same fate both are five day drugs both are overall drugs both need to be given early in the disease with monopoly will be as expensive as it is seven hundred dollars for a five-day course and with smaller having uh to be given for five days which means we waste time before we decide about the monotony antibodies administration i do think monopoly will not have a great place in the in the treatment of women i hope i am wrong and any new addition to the argumentation against covet you're absolutely welcome if effective thank you thank you thank you very much sir your opinion definitely matters because you have been treating on the forefront the patients in the maharashtra with all different kinds of complications of the so and we agree with you in that sense that that we have to wait for the overall results and a drug which is expensive and it takes away the five important days where we can see the patients this question was also kept to the company in the press conference and what they came out with the answer was that the mild to moderate cases are differently defined in india as well as this and that is why probably all the doubts and the suspicions but time will say whether malnu piraville is going to change the face or the treatment of kovite 19 we are eagerly awaiting but the company even if he gets the eua permissions it will not come before at least two years in indian market that's what the report suggests so we have to wait for malnutrition coming into the indian market but as of now the opinion is divided amongst the key opinion leaders the abouts is uh whether it's a heap hype or hope let's wait for that and move on to the next uh this is a story number four which story is called the broken heart syndrome which is up in the last 15 years and there are greater incidents almost almost 10 times in the women than the counterpart and what is broken heart syndrome is an acute onset stress cardiomyopathy also known as tacotsubo cardiomyopathy which physicians know for a long time and the kovid scenario has led to many of the people knowing and countering such kind of acute cardiomyopathy but to others it may not be known that it's a one kind of the stress hormones induced and it suggests the brain heart connections that is what the researchers say that we know that the brain heart is connected and because of this the acute stress of any type of emotional disturbances can bring about an attack in a matter of few days and usually it is the middle age women to the elder women who have come to a particular tipping point when these kind of acute stress induce cardiac events occur and most of the women have the symptoms of breathlessness or chest pain and it mimics like an acute marker infarction but the ecg would not swear changes of infections even the parameters or the blood parameters may not so the classical infarctions and these studies have come out we just wanted it because of the data that it is more common in the women and they analyze a retrospective analysis of almost one leg 35 000 cases and were collected over a period of 2006 2017 and majority were women and the women in the 50 to 70 years are of greater risk so broken heart syndrome the name appears catchy and tucker syndrome takotsubo cardiomyopathy is the name for this kind of myopathy we do come across in the clinical practice but we wanted to know about the tachor super cardiomyopathy irrespective whether it's in the this setting or mainly in the kovit setting we could not think of persons other than our cardiologist friend dr kamal sharma who already had three papers on the takatsubo cardiomyopathy so we talked to dr kamal sarma and here is what he has to say about records of cardiomyopathy so broken heart syndrome is this name for taco super is a disorder which cardamom triggered by either emotional or physical stress in patients undergoing surgery but offline is being found very profoundly in patients with post code this may be triggered directly by the virus virus itself or it may be triggered by the stress you know initiated by the disease itself in terms of the physical disorder or also by the emotional stress that the disease may entail we have our own two three papers on this disorder you can search on google and you can find the details of the same but otherwise has got a good prognosis the broken heart syndrome as it is called as is associated with acute element dysfunctional ballooning it's the apex which stops contracting because of the differentiated innervations of the same and this is a transient ideology if you can manage the acute stress most of these patients do well however these differences are there with regards to covet where the incidence of bad prognosis was documented more to be associated with associated broken heart as compared to the others for more details you can go through the publication and papers that we have thank you very much take care bye thank you dr kamal it was really very very informative inside about the court's book cardamom apathy many of you might have heard the name for the first time it's very very important to keep in mind any persons and especially the women who come with the history of chest pain government and ecg may not accurate market informations the best way to diagnose is to go for the bedside 2d echo and that will keep up as dr carmichael said the apical ballooning and good part is the treatment is there and the it's a very it's transient illness and it has a very good prognosis as long as it is not related to the ovate so it's very very important that uh we keep in mind that kosovo cardiomethi as one of the differential diagnose any person presenting which is in the brahman then we go to our story number three this is a story about the draft recommendation it's not a final recommendations for the guidelines and you know that this u.s task force is an independent body and it is independent of the us government and they come out regularly with the suggestions and the recommendations and this particular recommendation came out only two days back that the aspirin is no longer recommended as for the draft recommendations and this recommendation is open to the general public for the comments till 8th of november so the new recommendations suggest that the experience should not be prescribed left right and center at least especially in persons over the age of 60 years because there are more chances of harm than benefit with aspirin in this age group however a person's between the age group of 40 and 59 years should be evaluated for their asvd risk course that is the atherosclerosis cardiovascular disease risk score if it is more than 10 percent in the day for the 10 years then there is a small net benefit of course we have to keep looking for the aspirin related side effects and yearly checking for the hemoglobin and any of the bleeding diathesis and persons who do not have any increased risk of bleeding may be given but it becomes a very very individualized decisions and the final recommendations wait but the point is experiencing no longer a drug for the primary prevention i must emphasize that for secondary prevention aspirin is definitely proven beyond doubt and there is no question of not giving it any persons who had cardiac event or undergone procedures has to be given aspirin or profitable depending on the situations and the type of the stand that might have been used and at times we use dual antiplatelet drugs but as far as the primary prevention is concerned aspirin is no longer a universal prescription for the persons especially over the age of 60 years so that is story number three now we come to a very interesting story about what makes us human right so we know that our clauses if you go by the violation parameters then evolutionary we are just our closest uh relatives are the chimpanzees and we separated from chimpanzees before five million years and up till now we have been thinking all the while and we have been taught that it is the two persons of the dna which forms the genetic material the proteins of the two persons of dna which forms the genetic material are the ones we decide about everything but this study was done in the sweden and the corroborators have studied the chimpanzees as well as human beings not directly into the patients but they have cultivated the stem cells from the humans as well as the chimpanzees and they could see that there are the dnas which were up to now overlooked the dns which do not take part into the genetic material this is it forms almost 98 of the dna which does not become the genetic material but what they could see that in the laboratories the chimpanzees stem cells as well as the human stem cells we have differently and they could find out that the genetic pool was not involved in this and they could find out that the long streak of dna which was up till now considers a junk dna or useless dna was the one which was deciding the overall outcome of the development of the brain and the scientists feel that the many of the diseases like schizophrenia could be also explained based on this kind of new it's very very new but it's very important to know that the science of dna science of genetics has become more complicated than this up till now we are looking for the two persons dna now it is all 98 percent of dna that also has to be looked for for many of the abnormalities and we know that brain is the one which is most important that is why they selected brain because it's because of that that the humans are different from the chimpanzees and other or that is why we say that let us look for the junk dna as much as for the two percent of the genetic material that was story number two now we go to the story number one obviously this has become the headlines all over whether you open up the any print or tv media or electronic media or in the scientific we must be very proud indian today because india crossed 1 billion dosages of the vaccines it's a really proud moment for every one of us when the pandemic started we were nowhere we were very late in starting this particular treatment and we know that it's not only the proud moment for the 1 million dosages but what is important is the all 1 billion doses were manufactured in india and we could prove that they are very safe so it's really commendable on the part of the authorities and all the stakeholders which have come unitedly to go the best i would say the news that anybody would expect all that we achieved we started if you remember we started on the 16th of january of this year and by 21st of october that is only in 279 days we have delivered 1 billion processes it's very very proud moment for every one of us and as i said repeatedly that it's that it is an absolutely making india story and that too has proved that is very safe and initially there were a lot of apprehensions and there were many anti-vaxxers but we could eventually see that the vaccine hesitancy is gone and now the government urges that all the remaining persons should also be vaccinated and our next analyze in the 44 crore children who are waiting and so we are waiting everly for the vaccines in the children right now the government priorities to find out those subset of children who should be vaccinated just like in the other countries the specific persons or the children with a specific status or conditions need to be vaccinated first so we must say that we must salute all our scientists researchers and the drug manufacturers and we he has a huge country and we have a lot of logistic also the temperature has to be maintained the drug has to be delivered and also the digital divide that india has we know that india is a country where we have all kinds of people and not that everybody is connected digitally but in spite of that we have come across all the huddle and we overcome all these hurdles and we have proved that we are good and as comes to the number of the fully vaccinated also we are almost about 28 percent of the population which is definitely a big number and we must salute each and every one of them so that's our story number one and i'm sure that everybody is proud with the story and we are girly waiting for the next round of the stories on the next friday so it was indeed a great pleasure to host this and we enjoyed preparing and delivering these stories and i'm sure we'll have lots of comments from you about this what need to be included what need to be prioritized and how we go about for the next affiliate shows so over to neva thank you sir so here goes the poll tell us which story you all like um goes the same there are five stories that we covered in the second half uh there are five options that you see uh just scroll through and you can see all the options and i had i had no doubt that all of y'all are going to like that india across the 1 billion mark story uh the most so we have prepared a quiz on basically the 10 stories that we covered so far we do have this fastest finger first so the um every person who gets the right answer for every question um we will give you a gift a price from our end so you all need to mention uh whether it's option a b c or d in the comments the first person to get the right answer uh is gonna be the winner and we'll announce all the three winners at the end of the third question so here goes the first question so which of the following is the new anti-diabetic yes so we can move to the next so this is um about the kobe drug how does malnu pyravid work in covet 19 correct answer is it's a meteorogenic and the river nuclear site though c is the correct answer and the idea of giving this process to re-emphasize or re-learn something that we already discuss about it new uspsdf guidelines discouraged in this initiation of aspirin for primary cbd prevention in which age group yeah this is the correct answer over 60 years it's out and we already given the reasons that the chances of benefits are less than the bleeding especially the interactional breathing as well as the gr reading so we sign off uh quickly the winners that we had so for the first question we had dr rajat rane for the second question we had dr sahil narangi and nagrangi and for the third question we had dr bhavik kumar johan

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dr. Mahadev Desai

Dr. Mahadev Desai

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dr. Mahadev Desai

Dr. Mahadev Desai

Senior Consultant Physician | Ahmedabad

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