We're going to take a moment to also thank all our partners for this fantastic event. Our presenting partners, Sony Live, We Live to entertain, associate partners, share it. AI and Big Data partner, MoMagic. Baj and Lanyard partner, timesnownews.com. Action begins here and live webcast partner 24 frames digital. Before we march ahead, a quick look at the partner AVs. Let's have the AV on the screen please. This is where the batting begins. And the batsmen too. Here the fans cross their boundaries. Here the gentleman's game is a little less gentle. Because this is not just a game. This is India Tour of Australia. This November, on Sony Live. Ladies and gentlemen, it's time for our next panel discussion. And let me also inform you all that after this panel discussion, we in fact will be announcing the Twitter contest winner, the first winner. So keep those tweets coming using hashtag screen age. Well, moving on, once again, I'd like to invite Mr. Sanjay Trihan, digital and new media consultant, who in fact will once again be moderating our next panel discussion on brand building on mobile only if it's a reality or a myth. So let's have a round of applause to welcome our session moderator, Mr. Sanjay Trihan. And now I'd like to invite our panelists on the stage as well. May I please invite Chandan Sani, head of digital marketing consumer India with Johnson & Johnson. Jahid Ahmad, head digital marketing and web analytics with HDFC Bank. Mahib Vivedi, head mobile and performance marketing with Flipkart. Shawneel Charles, senior vice president, Times Network. Rujitha Nadkarni, head digital marketing Mahindra tractors. Vinay Singhal, co-founder and CEO, Viti Feed and Rahul Grover, president, sales and operations with Sy Estate Consultants Chamber Private Limited. So we have all of our panelists seated here. Can we have a super post lunch, energetic round of applause. Ladies and gentlemen to welcome all our panelists here. And once again, Mr. Trihan, over to you, sir. I think you've all had a sumptuous lunch. But I guess I have to run my lunch now. We'll begin right away. I think the topic for this post lunch discussion is something which is very close to my heart. Because, you know, we've often talked about India being mobile first now. But really, in my view, mobile first has been reduced to a cliche. Organizations in our country are still figuring about the paradox of mobile. They're trying to sort of situate mobile, you know, in its proper context. Where does the mobile sit within the organization? You know, that itself is a channel. Is it product? Is it marketing? Is it experiences? And then, you know, a smart CMO comes out with this interesting wine learner. Guys, we have to win in mobile. You know, without realizing that ultimately the consumer doesn't care. Consumer cares about the experience. So our focus needs to shift from winning in mobile to winning in experiences. So just as we are moving to a cross-platform world, which is increasingly becoming device-agnostic, we need to look at how our marketing objectives need to be all about creating compelling consumer experiences. This is going to be the core of our discussion in this session. And those of you who have attended my previous session, and hopefully this is the last session I'm doing so you don't get an overload of me today, would know that I would like a specific question to be taken by one or two panelists so that we can cover a wide variety of subjects. So the flow of discussion for this afternoon would be about the challenges the companies are facing in terms of creating and maximizing brand value in the mobility space and how they are playing the catch-up game in the space because mobile as a landscape is constantly evolving and the evaluation metrics are also getting constantly reappraised. So how do you win in this space in terms of key parameters? Is mobile content all about bespoke content creation or can we leverage the content that we already produce and leverage it and adapt it to the space? So these are things that we'll be discussing. So let me begin my first question about mobile first. Is it a cliche or reality and maybe Seanil would you like to take this? Sure. Thanks Sanjay. It's good to be here. So when it comes to mobile first, this was tossed around three or four years back. All of us in the publishing business used to publish on desktop and that was our main source of audience and revenue and then this audience started moving to mobile really quickly. So for a brief one-year period, there was a lot of chatter about mobile first but essentially post that it's become mobile only. We're in the news publishing business. I run a website called timesdownnews.com We're a late entrant in the space. There are many publishers who started before us. So we've evolved in the last 12 months or so and we're seeing 90% of traffic only on mobile. So even for brands who associate with us and who work with us as a publisher to advertise on our platforms, our offering has only become mobile. So you can advertise on our channels on television and then there's just mobile. So what Sonil is essentially saying is that it's not only mobile first, it's getting increasingly mobile only. Interesting. Now that is essentially from a premier video publishers like Times Now, Rujitha, which you deal with marketing of tractors. So share with us your experience about is it also the mobile first space or is it getting there? Is it not getting there? Your opening remarks about how the chapter buying consumer is relating to the space. Sure. Thank you so much. The space has evolved in the last four years. The journey began about four years ago and it is essentially the mobile first space. Primarily people use mobile to consume entertaining content for education purposes. They use mobile primarily for social media. WhatsApp is extremely popular. Not so much of financial transactions get done on mobile, primarily because of the lack of trust in such platforms. But they aspire to, you know, go do online purchases through e-commerce, portal, etc. My friends here would be able to get a better perspective on how people interact from the rural areas on mobile essentially. But yes, it's transforming largely. It's also very challenging because the way forward here is you have to give localized content. So it's more about hyper local marketing. You have to bring in the local experiences in your content. It needs to be more relevant and has to also be in multiple languages. So these are a few pieces which I bring to the table from my understanding of. What has been your reaction, your sort of feedback about the receptivity of your efforts by the farming community? Sure. So what I have observed is people do consume largely content over like the TG, essentially being farmers. The age group between which farmers consume content is typically from 18 to 35. They consume a lot of video content. There has been a huge transformation in terms of lead generation from this community, which used to essentially come from below the line activities and van campaigns, essentially earlier. So the larger proportion of spends was in that area. Over the past four years, it's moved to digital giving equal number of leads or more in this space. That alone shows that people are looking for information on tractors online. People are looking for prices online. They today evaluate compare information from how an X brand is different from the other. So they are making these, they're looking for information constantly, but primarily they use it for entertainment. So this has taken a huge shift from where it was four years ago. They use WhatsApp to transact business as well and share information amongst peers, et cetera. There are larger communities of farmers wherein they share best practices and farming from one area or state of the country with the other farmers in the other state of the country. So that just speaks volumes about how it's transforming essentially in the rural segment and primarily in the agriculture segment. I think somebody would, any broadcaster who would start the mobile version of Krishi Darshan and I don't know whether you guys would be aware of the do Darshan program which was way back there in 80s or 90s called Krishi Darshan, which was perhaps the most boring program ever but very relevant to the rural audiences. I think somebody, there's an opportunity there. Okay, Vinay, let me come to you. As somebody who runs, I don't want to call your product a portal, but somebody who runs an offering in the non-news content space and the fact that 95% of your audience comes from the mobile, what does it tell you and how do you intend to leverage this opportunity? Thank you, Sanjay. Let me start by giving you a reference. I was watching this conference by International Advertising Bureau, IAB, and there was this very renowned speaker who was saying that if you are not thinking in mobile today, you're already dead basically. So there's no hope for you if you're not thinking mobile today. That's how the world has become. Having said that, 95% of mobile audiences are what we have on our 45 million Indians that we have and even fortunately we have global experience, American, UK, Canada, Australia, those audiences as well and it's the same sort of trend that we are seeing in those markets as well. Let me give you a context to the panel topic, which is building mobile first brands or is it possible to build brand-on mobile itself? I think on the client side, on the brand side basically and there are a couple of them here on the stage as well, right? Their mindset is also changing and I'm very happy to see that changing lately. I just had a meeting yesterday in Bangalore with the Patreon Travel. They travel as a segment, as a separate brand for them and it was such a happy meeting for a publisher like me because we sat there and he said, you know what, I'm not looking for leads from this. I want to do a mobile first campaign and I want to do it because I want to be there when they are going to consume content. I want to be relevant to them as a brand and I think mobile is the platform where I want to build that brand, right? Having said that, as you said, there are those smart CMOs who are still coming out in the room and saying that let's be mobile first now and as I said for me, according to me at least and not just me but international speakers are saying that now if you are not thinking mobile, you are probably dead already. You missed the bus completely. I think one of the key challenges about building brands in the mobile space is to change the attitude of some of our CMOs because they still tend to see things in a non-convergent ecosystem and now we are looking at an ecosystem which is all about solutions and not just about a specific medium. So mobile needs to be leveraged to create experiences which could be straddling many worlds. So just using mobile for performance of a brand will be only looking at one part of the equation. Let me turn this question to Mahit now who's been using mobile in a big way to acquire and to fulfill audiences in the e-commerce space. What has been your experience? So I think for Flipkart today the majority of the transactions in GMV comes from mobile obviously like any other e-commerce has seen. For us I think the key objective is how do we reach out to more people and today if you just divide India into tier 1 and tier 2 cities a lot of transactions today and audiences. We reach in tier 2. The campaigns are strategically rotated on tier 2 and I'll just take an example of Big Billion Day. We had around I think 47 superstars doing campaigns this time and the proportion of inventory which was split between tier 1 and tier 2 the traction of tier 2 has been increasing and I think we are going in the right way and I think the traction on mobile has to be there. There is I think no other way that you think on a performance side or you think on a branding side. I think both the sides, the first touch point to even millennial today is mobile. If there is a youngster who just passed out from a college he would have enough exposure on the social media to know about what brand is, what is a brand doing about and I think that's all with all means and ways I think this has been proven. The audience may be wondering that why is it that we have straight away jumped into how the brands are leveraging mobile. There is a certain method in my madness. What I intend to establish is that while there are early stirrings of usage of mobile in this part of the world and it is really hopefully going to explode I would ultimately come down to asking the key question and this is for your benefit that is it possible to build a brand only on mobile? Can we look at a world where like the millennials have refused to look at newspapers. I know my daughter who is very well informed, treatingly well informed on every subject just does not read any newspaper and she is still educated herself because she lives in a world where the news comes to her and she doesn't go to the news. So there are ways where this whole pyramid has been inverted. Let me turn my attention to Chanan who has been sitting on my right and wondering whether you know it's going to be her turn. So Johnson & Johnson is a company which I believe is struggling both the worlds of the urban India and the rural India and truly and effectively creating solutions that are meeting unmet needs of women in both parts of the world. I would like Chanan to sort of elaborate on this. Thank you. Thank you Sanjay. So yeah rightfully said I think our consumers are all the way from like you know the most premium consumers that we have for a brand called Neutrogena all the way to the some of the rural parts of the market also that we touch with a brand called Stay Free and I think if you build out the common thread it would be mobile right and I think for me my understanding is and like you say you know I deal with the CMO question is that 100% of people are using internet are using through mobile. I think I'm yet to find somebody who's found internet without mobile right. So I think for us we were very clear that we have to talk to women on both ends of the spectrum and if we have to build that journey on mobile so we use the bottom of the pyramid to basically talk about you know so it's a covert medium also it's a personal medium so it's only mine unlike a TV which I have to share I don't have to share my mobile. So I can you know choose to opt in and opt out much faster so even the struggle for content has to be that much greater so that they don't opt out. So like I was completing the rural end of the segment we are able to sort of sample using mobile we're able to build a brand education story we're able to show them videos that you know sort of built bus submits that they might have and then lead them all the way to actually sampling or sale through partners like Flipkart who are also opening up their you know doors to markets like northeast etc where it's easily you know completion of the full journey from education to sampling. And on the premium end obviously we have a lot of influencers that we work with on the beauty space so those influencers are seen by women who are actively following them then it moves on from there to you know certain communities that we build that we host where they can actually talk to us about their skin problems all the way again back to sale where we are able to give them you know combo offers etc again all of this is not how the offline journey is but we've built it and it's also not the journey on a digital ecosystem but it's a specific mobile journey and you have to think that like I think we started by thinking from that perspective I think this is fascinating in terms of how impactful it can be in terms of changing lives now Jahid, banking industry has been one of the early adopters of the mobile space I remember initially they adapted the email route you know five years back and you still are in fact inundated by various schemes and offers but now they are doing they moved away from the app that they developed a good app now I'm increasingly finding some very very nice responsive designs recently Citibank has got in and I'm a Citibank holder you know account holder so I like the fact that when I need to check in on my app it just does facial recognition in less than a second I'm on no passwords or no OTPs to be filled so share with us your view of your banks strategy to truly leverage the potential of mobile or are you only looking at response generation initially or do you have a larger game plan for this medium Thanks Manju for this question so HDFC bank has won brand Z award for the consecutive fifth time and guess how much have we spend actually in maintaining or spend on media to make our brand it's zero ok so our mod modus operandi to make a brand is completely different the blueprint of our modus operandi is 101 communication which has been happening till date with branch and retail distribution but that's not obviously scalable so what is it that will make this whole thing scalable that is mobile ok so how are we using mobile to build up my brand which is already at the top how can we sustain with it fight the new age mediums which is no more the bank but more of the amazons and the google's of the world which is coming and fighting it out with us so what we do is I somehow love what Aristotle had said that the whole is greater than the sum of its parts ok what are the parts let's look at it in the mobile spectrum ok we have age we have location we have the bounce off journey behavior we have their transactions we have weather apis we have traffic apis now imagine if I can personalize each and every word the image of it the content of it make it relevant to you when you want it right and then show it to you orchestrate my campaign suppress the campaign when you don't need it and then bring it only to you when you need it at that point of time and not only there I have to ensure that you complete the journey in the most seamless way possible ok that is where our agenda is to make it as seamless as possible via mobile only and that's what we envisage to become as the best brands and the most mobile mobile friendly brand ok so personalization is the key and I think that's personalization is complete key yeah Rahul are you leveraging you know the mobile medium or the platform in the real estate industry so let me give you a perspective of how the real estate industry uses or leverages the mobile space obviously you all spoke about mobile only and mobile first where we represent a company which also looks at developers and the consumers who want to transact in real estate so the developers use mobile only just to check the UTR number where they record the funds so essentially that is the only thing they use the mobile for when it comes to the consumer base I think I represent an industry which has been tarnished or has not been very popular with the consumer and it is not essentially a consumer driven industry in that sense it's always been very transactional the developers have missed the bus when it comes to using the mobile space effectively to communicate to the audiences because it's not an instant gratification kind of business as you see you purchase a home today you're going to receive it probably two years, three years in the future which means it's imperative that the developers use this medium to sort of be engaged with the audience and the buyer and the consumer that they're going to be with for the next five or six years having said that the question beckons is whether we can build a brand only on mobile and I'm going to talk specifically about real estate the answer is no I represent an industry which is larger than life if I'm going to show a simple example an elevation of a tower which is 46 floors I don't know what kind of content I'm going to build which can actually show the entire image of a tower on a five inch screen so although I am kicked about the fact that an audience between 18 to 35 consumes content on Instagram, Snapchat, Facebook or whatever else I'm not at all convinced that mobile is a space to build brands only of course a brand is much more than a business it is omnipresent it needs to have association with the customer it needs to be at places which is not only restricted to a seven inch screen or a five inch screen or whatever so I think purely from my perspective and my personal opinion and also about the real estate industry we have not been leveraging the mobile space effectively enough and just to give you an example a 159 character text message that we send out as an organization gets us more responses than creating the best content which means that we're reaching out to a much larger audience we're reaching out to somebody who has a feature phone as opposed to having the latest iPhone XS and that is giving us a much better response so for me mobile today in India is still a lead generation portal or a medium or a platform it is not engaged or it is not reached a point where you can create a brand now that is the kind of provocative statement that I was itching to have I'm glad you said it that mobile in India is essentially a lead generation exercise now let me give you an example of what happened in the United Kingdom recently in the publishing space people who are in the news industry would know that independent as a newspaper was the voice of sanity in UK in the United Kingdom but over time independent saw its circulation dwindling and ultimately reached the rock bottom of just 40,000 paid subscribers now imagine a brand which is more than a 5 decades old in that part of the world what does it do surprise they decided to take a hard decision they decided to kill independent as a brand in print and launched independent as essentially a web and mobile product within a year of its launch it has generated an audience of over a million unique visitors and has turned almost profitable so this is an interesting example of a digital only brand and I'm also aware of the fact that some of the premium broadcasts in India despite the show of bravado with the kind of investments that have got sunk in the business and my question to Shanil is are you looking at ball string I'm not going to ask you to say that are you looking at a mobile only space because that could be counter intuitive at this point of time but are you looking at ball string the times now presence in this space so that you can look at enhancing your reach and reducing your cost you know coming from times this is a problem we grapple with continuously it's been going on for the last couple of years because these are massive legacy players in print and outdoor and huge inventory in magazines and newsprint and multiple languages etc luckily for us here in India and like the independent in the UK which run into trouble quite abruptly is a gradual movement so you know for us we're in a good space because our traditional brands including the brands on broadcast etc are still growing but not as fast as they were maybe five six years ago and we're being able to complement this by new digital platforms it's essentially on mobile so you know a lot of you consume news and you know by the time you pick up the newspaper the next day it actually feels like yesterday's news but there's still a huge amount of people in India who don't mind reading yesterday's news so we are catering to both these segments we're trying to give instant news out to people who are on their mobiles and who want to stay continuously updated but then the parent company and the broadcasting unit are catering to a lot of the audiences which are still consuming digital media so we're at a cusp right now I know mobile is important I know more people are moving there and it worries us at times but so we are trying to bolster our you know our traditional businesses with the whole host of mobile offerings Maheep the question is the question where is the money in mobile that I think is already getting answered at least from your perspective would you share or would you be able to share actually the intention of Flipkart to spend more monies on mobile with a view to garner more revenues so I am saying that since the customer has already moved on to this platform and the response is now visible and calibrated are the marketing dollars shifting in that kind of proportion to this medium well at a overall level if you ask me I think ATL will still be you know on a higher side however if you talk specifically on digital and if I just talk on performance I think we continue to invest you know and acquire new users month on month it has never stopped right we are close to I think you know 200 million installs today just on place to Android but what happens essentially is you need to you know keep the traffic coming on right there will be users who would you know come to you stay with you and also you know uninstall the app right app specifically I think you know we are investing heavily and we will continue to invest however there is a lot of you know intentions in terms of how do you get new set of customers after you know almost e-com shoppers are already there on your platform right so I think that is one of the challenges that we face but I think on mobile specific investments in terms of branding as well as in terms of performance I think we are very focused of you know keep doing it because there is a direct value proportion specifically I would say that in tier two cities the focus will still be on because we see a lot of potential there I think it touched an important point about not just customer acquisition but customer retention and you did talk about building engagement we have seen that you know mobile as a medium is being driven essentially tactically these days and no long term community building efforts barring some smart FMCG brand like Leavers for instance is actually doing a good job in terms of building community based engagement on the space. Vinay you are 95% of your audience comes from mobile you are not sitting in the mainstream you know cities of India language is where the next growth of internet is predicted to come in form so my question to you is do you see a marriage between languages and mobile happening and how do you see the space exploding? I think mobile and language are hand in hand stories in India they are the whole language space became relevant because of mobile because on desktop language was never so big because we were limited to the 30 to 50 million premium audience in India which usually speaks English which is in the metros and that's about it but then first mobile happened and then of course geo happened and then all of a sudden this huge audience of almost half a billion now in India on internet which carries this supercomputer in the pocket every day and they don't know what to do with it frankly the only thing that they don't know is to consume content and not to be disrespectful to the audience but I was sitting with a Bollywood director luckily a couple of days ago and he was telling me a story of the 90s when they were making very serious movies and this is a very famous director they then three of them gathered and they said this is not working out how do you make something mass and then they used one term they said we need to dump it down so when you create mass you have to basically dump it down the same way in content also this whole half a billion audience is in language they don't understand English of course English is not natural to them there is no common language which is why regional has become so huge and the content also that they are consuming is non serious in nature which was another reason that when we were building our brand we took a stance that news is not where we want to be one because of the nature of the beast and because of the whole thing and also the larger audience is coming online frankly not to consume news but to literally kill their boredom they have a lot of time on their hand and because as Chen was also saying that the device is so personal it's always there with you another reference I'm sure you all must have seen Alan that famous interview where he smocked the weed and all that stuff he said something about mobiles mobiles are extension of our bodies today and this whole typing that we do on mobile through which we communicate to mobile is basically is a medium of exchange of information between the mobile and our body and very soon that medium is going to change what I mean is voice is one example of that but very soon we are going to be actually connected connected to this we probably will have our skin will become the screen and so on and so forth imagine the world where we will stop talking about mobile before before we know it and it's all going to be so digital is going to be the word that is going to carry forward not mobile and language and it's going to be very personal so language is also for me language is a subset of personalization so how well you can be relevant to the audience if you start to solve that question language becomes an answer to that question automatically that if you want to talk to that customer that customer or that consumer or that user does not understand English so you have to speak their language and this is also not about just the language language like the English and that it's also about the tonality the way you use it you have to speak in their terminology itself I think you talked about tonality and aside some of the people in the audience who may not know about the lullantop must visit lullantop to see how they are leveraging Hindi and how they are getting the tenor and tonality of Hindi so right to look at a captioning audience in the tier 2, tier 3 towns of the middle India so do visit lullantop absolutely fascinating product which is coming from because you said lullantop I have an example I have a reference to add to that we just signed up this guy his name is Charles Biharilal he's an Australian he's living in India for the last 25 years he speaks amazing Bhospuri so we signed him to do a show with us on the Hindi property we'll be building a talk show with him where Charles Biharilal hosts guests and we'll be talking about topics relevant to the northern part of India the Hindi speaking belt basically so that's how local you have to get when you get there absolutely this space is revolving and it's full of exciting possibilities now I would like to focus a little bit on some of the key challenges the current marketers are facing in terms of we've painted a pretty interesting picture in terms of the possibilities and how mobile is getting increasing acceptance but from your perspective what are the key challenges that you face are you facing any challenges at all yeah lots of them first we are a legacy bank right so language we love to do language but then language only the creative is language he comes in the call center is talking in English there is a fractured approach over there right second the mindset has to change of the organization people have to wait that a brand over a mobile will take time there's a difference between impact property and building up a brand so if I have to create an impact advertisement I can just paint the red paint the city blue but if I have to slowly you know be a part of the customer's journey from the exploratory phase see he's not getting up in the morning to buy a financial product he's getting in getting up in the morning to fulfill one of his dreams financial product is just an aid to fulfill his dreams right so how can I be a part of his journey when he's trying to explore what dream he has to fulfill right so that takes time so the mindset has to wait that you know via language via content it will take time but it will slowly and steadily build up the brand third is the whole creative set you know people talk about mobile day in day out but people fail they still make a creative which is vertical and not portrait they still make creatives which is desktop first and then we will say ok abisco responsive one other okay so I think these are the challenges that we face continuously where people talk about it but the whole mindset the DNA has to change throughout be it the customer's point of view be it the organization's point of view where each and everybody with the brand team be it the CFO be it the CMO they all have to be patient and they all have to come in a very collaborative way to understand that mobile will succeed the languages will succeed but yes we have to give it time to succeed yeah please so I think also once you do that entire you know end on your side of the thing the mobile itself changes so the technology itself is going so you're going to go and get the right creative for an Instagram or for like a Snapchat and then they'll open a vertical video because technology itself will change and more phones are coming into the market and you know they keep experimenting with their own technology so I think one of the bigger challenges is also how are you going to always catch up with this first medium which is personal and you can't do that without having enough resources and to have enough resources on mobile you need to have enough metrics or results that have proved the worth of those resources in the first place so I think that's a bigger challenge because again from a thinking perspective it has to be thought mobile first one of the challenges that I can probably bring to the panel is the call to action I mean once you sort of have a mobile campaign that's running for any product or any campaign that you're running we as Indians I may be wrong but we like to talk we like to speak we need to voice our opinion we need to talk to a human at the other end so when it's a call to action which essentially is a chat board or an artificial intelligence tool that's communicating with you there is no personalized field to that whole engagement so even though you are on your mobile you've been chatting with your friends on WhatsApp where you have a connect and hence you can establish that relationship the mobile restricts you from getting into that actual engagement or a personalized communication which is an effective call to action to finally get into a transaction I mean all of us here having said whatever we've said we essentially want to make money and do business on mobile but unless there is an effective call to action tool which personalizes the experience and the engagement with the consumer whatever brand, product, service that you're selling is not effective enough to communicate your query your question to the audience or to answer their queries I think it's going to be ineffective to sort of build that bridge between the consumer and the brand Would you like to respond? Yeah, so I'm just on a chatbot right I think if you've observed Facebook has has an allowed chatbot notification to each user and now today let's say a brand I'll just take an example of an example I was with BigBasket earlier now let's say two person is speaking on a chat and you have allowed a chatbot to listen to your conversation in between a bot will come in between and he can actually suggest groceries to you right if you start talking to a chatbot depending on your query that you have built it at the back end it can actually lead to a transaction and if you just read their various blogs how you know brands are actually leveraging that I would say it was not very successful for us in terms of transaction but at least if for any new guy who actually doesn't know about about a brand at least you are going and telling them hey there is something you know or there is something which is available for you as a solution On the bot's part because I think with the HGFC bank we have developed on the most successful bots and going to the transactional space also we've also got I think one of the first banks to come with on Alexa as well as Google Assistant till the time your backend is fixed no AI no NLP can help you our backend has to be fixed because your offers have to be streamlined because AI and NLP is just a tool to read it properly and then kind of learn over it over a period of time so that's very important great so we talked about I'm coming to you on a specific question because so we've talked about challenges which would include the task orientation the lack of mobile specific creatives in terms of communication you will look at challenges of building engagement now one of the key challenges is the custom content which is bespoke content for mobile and since your core audience is the farming community and they would be more conversant with the various vernacular languages are you seeing some movement in your company towards custom content creation for them yes absolutely in fact we've already started the journey sorry we've already started the journey a while ago all my websites are responsive and are in 9 languages all the content that we create for social media has to go in several languages which is being 9 languages to get to different states the next step we're looking at is actually getting into the hyper local content piece of it wherein a person will get localized content which he can comprehend and relate to from his relevant state and from the relevant geography that he comes from so this is where we're getting at and it's a fairly complicated and complex task to achieve the other challenge that we need to really cater to is the comprehension levels of these audiences with the changing speed of changes that happen in digital for them to catch up and try to understand how to use certain applications is a huge challenge it's like a new everyday learning for them this also dissuades them from engaging a lot more with applications the other bit is it has to be supplemented with on-ground experiences so this sort of completes the entire journey absolutely we've already overshot our time but before I come to the audience I think one of the key things for us as students of the space is to appreciate that no specific medium is actually going to call the shots in fact Satya Nadella has already talked about the age of the super platform and this is going to be a converged space where you're looking at multiple platforms coming together and depending on the consumer proclivity or the consumer movement or consumer preference these platforms are going to coalesce and will create a seamless experience so any company which is looking at essentially pivoting to generating compelling consumer experiences moving from winning in mobile to moving to winning in experiences will actually leverage the space with this I would like now to invite the audience to shoot their questions please identify yourself and also ask your question to a specific panelist if you have any queries and if there are no questions then we can give you some time Hi I'm working in Vodafone idea so a lot of you said about brands being built on mobile so essentially from a smartphone you're talking about except Mr. Rahul who said that he's still dependent on the SMS as a medium for his communication so what about the non-smartphone users how have you thought about building your brand to them because in India still we are a very big market for the 2G phones and the feature phones how are you thinking about building your business to those customers they're still far away from being a complete 4G base how do we go about that I think great question on feature phones out of 500 million we still have only 200 million less than 200 million smartphones there is 60% of audience still on feature phones who would like to take this question Vinay, try an address I may not have the right answer to this but the way we look at it see businesses are built on the future not on the past feature phone whatever may be the reality that there may be a few million feature phone users out there but they are not going to be in couple of years or a few years and I'll give you an example from my house my father used to be a feature phone guy forever in his life and last year he switched to a smartphone one thing you can take his phone away from him now it's not possible because he is now he is hooked to facebook to whatsapp and he is connected with his community and it's my father and mother both actually and you know probably I don't know both of them chat to each other on whatsapp or not but point being it's not possible to take that away and that conversion is happening really really fast so you don't build your business for something that is going out it's not an incoming technology it's not an incoming technology I think for some of us where part of our top line still comes from there we can't take that view but I think for feature phones there are a lot of there are a host of things we can do so there are caller tunes that are still in place there are prepaid cards where you know you can add on a service to a particular prepaid card where you can also offer a discount to them if they were to have a particular call to action so you have to think again out of the box because it's a very very niche population so how you think niche premium you have to think super niche feature and how much of radio they are listening on their phone how much of you know so for benadryl for example we push caller tunes we push ringtones literally ringtones to mass populations so I think the more as long as you are still able to reach them three times a day the feature phone also allows you to do that you should be able to try and use the mechanics of that phone may be one last question before we close yep hi my name is rajgupal I am from kroma this question is for mahe from flipkart what percentage of your revenues come from mobile so there was a stock of you guys being only mobile so is that thought still persists or you guys given up that thought so almost 90% is mobile and that would include mobile app and mweb essentially so is it a thought of being only on mobile is that thought still persists or you given up that thought I didn't get you can you please repeat I mean there was this thought and there was a talk saying that you guys will only be on mobile so I think earlier there was a strategy where I think also adopted and flipkart also was one of them but I think you can't take desktop away from people in India right I think even I am a heavy mobile user but whenever I am at work or you know anybody who is at a workplace essentially in metros or if you go back even in tier 2 cities where there are still desktops available right I think that 7-8% or a 10% is still a higher gmv to you today apart from a mobile app and I think that's a decision which has been taken by a company where we figured out that you know until we still get traction on web I think let's keep it just to add on to this also people are using mobile to explore but it's a lot of huge segment of people when it's coming to transactions they still depend on desktops I will just add right and I think I think great insight so I was with bigbasket earlier and our gmv or let's say a basket value on desktop is still heavier than the mobile right what bigbasket essentially does today is if you go on a app there's a smartbasket right whenever you keep buying they keep adding the products and it is right I think on a second tile today what essentially does is when you remember that you want to let's say buy only I think sugar or potato or any of the vegetables you will just buy it online because you are on the go you are in hurry you will just buy checkout and go the smartbasket actually reminds you that you know you need to probably order something more right and I think that is like one of the examples which which tells me that ecom can be you know one of the players which is heavy on mobile but I think desktop will still play a very very vital role great with this we call it a wrap and audience thank you for your patience and panelists it's been a fascinating conversation thanks for your insights thanks very much indeed to all of our panelists I'm going to request you all to please remain on the stage and may I please request our session moderator Mr. Sanjay Trehan to please present the mementos to all of our speakers as well we're going to request our speakers to please remain on the stage for a group photograph as well meanwhile ladies and gentlemen we're also going to march ahead with our next session so I'm going to request all of you to please be seated also keep those tweets coming because now we're going to be announcing our first winner of the Twitter contest in just couple of seconds so keep those tweets coming using hashtag screen age


Here I'm going to show you 20 different soccer moves that you can use and most importantly practice Now if you don't have a teammate to practice with you can use a cone or just imagine that there's someone there What's most important is that you're doing these exercises with speed So as soon as I get the ball whether it's in practice or in a game I want to take off. I want to go out the defender quickly and not give him a chance to get set up Okay, after you make the move Try to accelerate because too many players make one move and they don't get away quickly enough And they end up having to beat the same player over and over again So after you make you one quick move accelerate into space and get past the defender


Accrued expense is an example of an accrual adjusting entry. It occurs when expense is incurred before cash is paid. Let's learn how to accrue salary expense. Assume Morrissey band members earn $10,000 per week. December 31st is on a Wednesday. Let's figure out how much salary needs to be accrued, and then how to record the adjusting entry. If the band members make $10,000 per week, let's divide that by five to get a daily amount of $2,000. Next, December 31st is a Wednesday. So that means we need to accrue three days of salary for a total of $6,000. When we record an adjusting entry to accrue expense, we always debit an expense account and credit a liability. In this example, we debit salary's expense and credit salary's payable for $6,000.


Well, I've got the solution here. There's elements that we can put inside of that word to teach it where to break. And there's two different strategies here and let's dig in. So reproduce. There's our non breaking words. Well, let's add a break in here. We know the break element. It's going to give us a line break. But what about the word break element? Let's add two right where we want the word to break and look at this. So now it breaks along that word only when it needs it, which is really cool. There's another one though, which is the shy HTML entity and we add that one in when the word breaks, it will create hyphens in between so that we can kind of inform users that the word has been broken here. Let's check that out on a nice bigger view. There's our solution and all of that with just a little bit of HTML. I love it so much. I'll see you next on the GUI challenge snippets. Take it easy y'all.


She created history by winning the women's world championship at the age of 16 and she's won it four times since. She's fearless on the board and off it. Women are inspired by her chess, men fear to play her. I'm very honoured to have with us four times women's world champion. Who you fan? Hi, Tanya. Hi, you fan. Welcome back to Gibraltar. You really like it here? Yeah, of course. I mean, it's one of the best open tournaments I've played and this is my third time to be here. The first time was in 2012 where my result was kind of fantastic. I have to admit that actually that tournament was one of my best tournaments until this moment. Best women players are playing here, but for recent years even there are so many top players from the world are coming here. For example, this time I heard that the average rating from top 10 players is like 2,750 or something. It's incredible. That's amazing for an open tournament. Also today I saw a website like 78 or 76 grandmasters are playing here. So I got surprised to see that Open could attract all players from the world to come here to this very beautiful rock place. Absolutely. And you find out you travel a lot with your mother. In fact, she's here with you this time as well. Yeah. Tell us a little bit about that relationship and how much it... Has there ever been any pressure or is it just full support? Of course, it's full of support. My mom accompanied me since very young age because I went to another province to learn chess when I was like seven years old. So that's why at that moment my mom decided to kind of not give up but temporarily pause her job to accompany me and sooner or later we got used to this. And currently my mom accompanied me mainly not because of... to take care of my daily life but from psychological point of view we both got used to this traveling tournament together. It's very important to have, okay, it could be best friends or it could be relatives or the people you really, really enjoy to spend time with them. And I could say like that my mom really helped me a lot for this series of chess achievements. Right. And now you're one of the big stars from China and China is a powerhouse in chess. So what is the secret behind your country's success? Yeah, actually for a woman's chess actually China has a brilliant resource even before I came to the chess world. And recent years the open team, the man's chess actually improved a lot. China are well-known by teamwork. Yes. Especially where the men are helping women to improve their chess results but currently it's different because our boys, our guys, they also played quite well so they also need to focus on their chess. So now that's why I said the situation changed probably there could be a small group or even by individual but just like people, especially the young people are encouraged by the previous results so they wanted to devote themselves to the chess world. I'm always very glad to do some promotion not only in China but all around the world especially for women's chess but in China also. I could feel like when the top players are playing Simon giving a lecture or things like that or even giving a speech to share their experience the young children always really get inspired and wanted to say, oh, mama, dad, I really want to learn chess. It also reminds me one of my early experience where I was one of the participants to play as Simon with a top Grandmaster and after that game I remember I got some advantage and then the Grandmaster offered me a draw and I agreed, very happy and later I thought, oh, maybe I could also be a very good chess player so after that experience I think I was trying more harder on chess. You were motivated. Yeah, yeah, yeah, like from my own experience I realized how motivated it could be. And you found if you had to give one advice to the upcoming girls who are taking up the sport professionally who are at that level where they decided that they want to play chess as a career, what would be your advice to them? Hard to say, I mean as a professional chess player of course I would say something like you should have full concentration and inspiration for chess, you should truly love it but your inner peace is not because of, you know, your parents told you to learn or they told you it could be a good profession for your future career but you should truly love it. But on the other hand I could also suggest that while you're learning chess you shouldn't give up like studying or other daily life from a very young age until you could make the decision for your own life because currently I see a lot of young kids where the parents wanted them to own inner chess trying to be a top player at a young age. It's good, I mean from one side but on the other side you also lack something of the life that for that kind of age you could experience so I suggest that you should just keep chess as one of your interests until you could make up your mind that what kind of role do you want to experience in the future? Right, now Yuvan you took a very big decision when you opted out of the Grand Prix in many ways you were okay with letting go of your world championship title without playing for it because you strongly stand against the knockout system and you've been very vocal and passionate about it you stand for what you believe in but it must have been a very tough decision to make Yeah, actually to see backwards that was a very tough decision but when I made it it's like naturally I had this idea I want to set up my mind for this not thinking that it's really a critical moment because I was under this circle more than six years since I won the first World Champion and I played all the different formats so I could say that I have experienced that what kind of format is the most fair tournament to select a best player for both men and women so that's why I think in case to improve women's chess we need to suffer a moment that there will be somebody to stand out to say their point of view to express that what could be the way that chess could improve in that sense and of course this is critical you know why because now it's kind of I need to even put myself more harder in case to be more comfortable in the open section because the previous time probably I could say okay I might enjoy my performance in women's chess I could kind of keep the title for many years it's things like this but now I mean I automatically like give up that chance which means you need to like perform better in open section in case to stand there and that's very interesting what you said and I think that is one of the big reasons why people draw so many parallels between you and Judith Polger because in many ways by being by far the strongest women chess player you are letting go of that in many ways to even focus to be able to play in the top level open section I believe most of the female players are more or less inspired by her experience or at least she is one of the model for the young generation I have to admit that although I think our case is not something exactly the same because Judith quit women's chess at her very young age even she didn't play any of the world championship circle but for my case it's different because for me I think at least you should kind of showing your performance in women's section then that could be your next step so I just wanted to make my own road and you have often said that you are that chess is a big part of your life but it's not your life yeah but to be someone of your level one would think that it requires 100% devotion so how did you I mean how do you balance that out and how is that even possible to be at this level when chess is just a part of your life well I think that's my something came from nature when I was born because I feel that I'm kind of person who doesn't think that there will only be one thing in your life you should focus on trying to be the best on the other hand I want to enjoy life from different spikes trying to make myself step to the new directions trying to experience more and trying to explore my potentials in different areas so chess is a part of my life and it contributes me until this moment so I really appreciate it but I also hope that to learn from this experience I could make more for this world not only contributes the chess for the next generation but in general so what is it that would really make you satisfied with your career in the game well that's actually a good question when I said answer I mean I don't really have an answer for that because normally I don't make an ultimate goal in any aspects of the life because I thought that once you achieve that you might get confused by where you want to go in the future so that's why I thought instead of that I should make a small goal step by step like progressively improve in that case you will have the hope for the life at any moment so that's why I guess for chess it's the same that's very nice so what you're saying is to make smaller goals and in the process of doing those smaller goals achieve the bigger picture in life yeah probably when you really achieve something after after decades and when you look back you realize ah actually that could be my ultimate goal let's say for chess or for other career yeah I think that makes more sense in case to motivate yourself of course probably because my personality is that I need something to motivate myself I mean if you're from different personality probably you could just make one goal and step by step how to say continuously to achieve that but for me probably I'm another type of person right no well we wish you all the best with your step by step goals and yes all the best for this tournament as well thank you for talking to us thanks my pleasure


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Brexit is depressing. Have Bankbetcher stage a coup. Why different versions of Brexit exiting with WTO or seems more true to the vote than any other option? Yeah, Brexit is depressing. But look, I predicted this. I warned you that they would mess it up. Brexit was always, was always problematic. Because why are you Brexiting? What is the goal? What is the purpose? Is there agreement about the goal? Is there agreement about the purpose? So the real question is, what's, what was the purpose of Brexit? And clearly there's no agreement about that. Now, if the purpose of Brexit was to establish a fantastic free market economy and establish free trade on this island called England and to get rid of the regulations, the controls, the limitations of the European Union, but to focus on freedom on the British Isle, then that is, that would have been fantastic. And if they'd been agreement on that, then they probably would have just gone with a hard Brexit immediately after Brexiting, lower tariffs to zero, eliminated regulation and told the European Union to go to hell. If they wanted to trade with the Britain, they would reduce tariffs as well. If not, they're not. And then gone to the world and said, here we are, we'll open a business, let's deal. But that's not what happened, right? That's not what happened. You had a referendum, a non-binding referendum, one that the government took seriously and decided to act on. The referendum, people voted in the referendum for a variety of different reasons. It was Lee Brexit, but it wasn't clear why. So some people voted because they didn't want immigrants. And you might think it's it, Muslim immigrants, but speaking to people there, most of people didn't want Polish immigrants because they didn't want competition for their jobs. So a lot of people voted because they didn't want immigrants. Some people voted because they wanted something called sovereignty. You know, this is like, you ever see Braveheart, the movie Braveheart? I mean, the things about that movie I like a lot. I think it's a clever movie in many respects, but the thing about it that I hate, and one of them is that people think it's a pro-freedom movie, but the movie has nothing to do with freedom, nothing. When Mel Gibson yells freedom and they all rally around in freedom, what are they talking about? It's not the freedom I mean, I don't know about you guys, but I mean, which is freedom from coercion, the ability to live free of coercion, the absence of coercion. No, to them, freedom means we want a Scottish king, not an English king. We want to be ruled by somebody who is Scottish, not English, as if there's a difference. We want to be ruled by somebody who has, I don't know, 77% of our genetic makeup instead of 80, instead of 53.  We want to be ruled by a local king, not a king far away. That's our freedom. That has nothing to do with freedom. That's about independence from a crown by establishing your own crown. So what's the validity of that? Crown is a crown is a crown. Authoritarianism is authoritarianism is authoritarianism is authoritarianism. Lack of freedom is lack of freedom is lack of freedom. Why doesn't matter if it's imposed by your own kind or by somebody from 200 miles away in England, Evil England drives me crazy, right? So Brexit is about sovereignty. We want to be ruled by people in London, ruled by people in Brussels. But if you mean ruled, if they're going to do the same things to you, or maybe even worse, who knows, then what is the value of it? So I mean, I was mildly for Brexit, only in that it gave Britain the opportunity to become better. It gave Britain the opportunity to do the right thing. Because I think the European Union is a mess, is a disaster, is moving in the wrong direction, and is ultimately going to take down all of Europe, right? So you want to leave, you want to leave to have the opportunity to become more free than the European Union. But that's not what's going to happen. And I said this one past. I said I'm for it if they do the right thing. And the probability of they were doing the right thing is very close to zero, because the people who voted for it were not voting for anything coherent, for not one policy. If they were voting for freedom and some kind of freedom manifesto, and part of that freedom manifesto included, included, leaving the European Union, but only as part of a bigger commitment to true freedom, that's economic freedom, then yeah, great, I'd be rallying for Brexit, but it wasn't. Potentially, it's quite the opposite.


This study found that most online patient education materials for the medical treatment of glaucoma are written at a level too difficult for the general population and failed to meet accountability standards. This article was authored by Edward Lee and Lois Crabtree.


Good morning. I'd like to thank Stephanie Coulter for the invitation to speak with you today on the treatment risk paradox in blood pressure management. And I'm coming to you from New Hyde Park in New York on Long Island. I'm sorry I can't be with you in person but it's a pleasure to be speaking with you. So I'd like to start by talking about the current hypertension guidelines which came out in 2017. These guidelines created a lot of attention because they really changed our definition of hypertension as we defined it prior to 2017. And you can see here in this slide that prior to 2017, we defined normal blood pressure as 120 over 80. That hasn't changed since 2017. That is still the definition of normal blood pressure. And for individuals with normal blood pressure, we just encourage optimal lifestyle habits. Before 2017, starting with the 2014 guidelines, we defined blood pressures of 120 to 139 for systolic or 80 to 89 millimeters of mercury for diastolic as pre-hypertension, not unlike what we say with hemoglobin A1C when we define pre-diabetes. This was considered a warning, not true hypertension but a warning of the potential for developing hypertension. Then we had these two stages of hypertension, stage one for blood pressures 140 to 159 over 90 to 99, and stage two hypertension which was defined as blood pressures consistently above 160 or diastolics consistently above 180, above 100. So in 2017 these definitions got considerably stricter. So blood pressures between 120 to 129 were considered elevated blood pressure. And if systolic blood pressures ranged 130 to 139, or diastolic blood pressure ranged 80 to 89, this is now considered stage one hypertension. Blood pressures that in the past were considered normal. Stage two hypertension now is considered 140 for systolic or 90 or greater. In prior guidelines, this would have been the definition of hypertension. Now it's the definition of stage two hypertension. With elevated blood pressure or stage one hypertension, we recommend non pharmacologic interventions, and also considering therapy with blood pressure lowering medications. We certainly recommend antihypertensive treatment for stage two hypertension. However, when we're in these elevated or stage one hypertension range, we will often consider underlying conditions. So we might ask our patients if they have cardiovascular disease, diabetes, chronic kidney disease, or we may go to our ASCVD calculator and calculate a 10 year risk score. If the score comes out less than 10% or there are no concurring conditions, we may consider lifestyle modifications aiming possibly for a goal of less than 130 over 80. However, if any of these conditions exist, or there's a CVD risk greater than 10%, we will recommend treatment of blood pressure to a goal of less than 130 over 80. So how did we get to these newer stricter guidelines? Well, I've outlined here several studies that kind of paved the way to this. There are several studies that were done in elderly population. The SHEP trial, the Cysteur trial, and I might also add there was also a CysteChina study as well, and the Hyvet trial. We'll talk about the African-American study of kidney disease and hypertension, which looked at a population of individuals with high blood pressure and underlying kidney disease. And then two more recent trials, the Accord Action to Control Cardiovascular Risk Disease and Diabetes trial, and the Sprint Cystallic Blood Pressure Intervention trial. So let's first look at the studies in elderly populations. The SHEP trial, which was very well known by many people in the 1980s, recruited 4,736 patients, a large trial, they were at least 60 years of age. Blood pressure is ranging 160 to 219 millimeters of mercury for systolic. Diastolics were below 90 millimeters of mercury, so this was mostly a population of systolic hypertensive individuals. The active treated arm was treated to blood pressures averaging 143 over 68 versus the placebo group at 155 over 72. And the results of this trial showed a 36% reduction in stroke, 32% reduction in cardiovascular events, 27% reduction in non-fatal MI or coronary death, significant findings, and a 13% reduction in all-cause mortality, which is significant. Interestingly enough, in this study, they also found fewer adverse events in the treatment group compared to the placebo group. So adverse events was not so much an issue in treating blood pressure to a level of about 140 over 70 in this population. The SIST year, systolic hypertension in Europe trial, also a large trial, 4,695 patients at least 60 years of age, systolic blood pressures again ranging 160 to 219, diastolics below 95, randomized to treatment versus placebo, the treatment arm being focused on calcium channel blockers, the dihydropyridines, and the treated goal was to 151 over 80, the placebo averaged about 161 over 86. And given this difference in treatment, they also found significant reduction of events, 42% reduction in strokes, 26% reduction in cardiac events, 31% reduction in overall cardiovascular events. The last study in the elderly that I'm going to talk about is the HIVET study or hypertension in the very elderly trial. This study looked at 3,845 patients at least 80 years old, with systolic blood pressures that were at or above 160 millimeters of mercury, again randomized to treatment, in this case with pyrindipril and ACE inhibitor plus or minus endapamide, the diuretic versus placebo. And in this group, with a follow up period of up to five years, the treated group achieved blood pressures averaging 145 over 77 millimeters of mercury, and the placebo group 159 over 84 millimeters of mercury. And with this treatment difference, it was found that there was a 30% reduction in strokes, 39% reduction in stroke death, and a 64% reduction in the development of heart failure. Overall, a 21% reduction in all cause mortality and a 23% reduction in cardiovascular death. And again, in this study in the very elderly, it was found that there were fewer serious adverse events in the treatment group compared to the placebo group. So the conclusions from these trials seem to suggest that treatment to a goal of about 150 millimeters of mercury or less has benefit in terms of prevention of stroke, heart failure, cardiovascular events. So let's now look at the population with kidney disease. The African American study of kidney disease and hypertension looked at 1094 African American individuals. They were non diabetic hypertensives with chronic kidney disease baseline GFRs range between 20 to 65 milliliters per minute per 1.73 meters squared. The main composite outcome of this trial was the effect on kidney function, which included the time of declining GFR how much GFR changed over time or decreased over time. The development of end stage renal disease or progression to hemodialysis, and also death. And in this group, there were two blood pressure goals. There was a usual blood pressure goal and an aggressive or low blood pressure goal these were based on mean arterial pressure. So the usual goal was for a mean arterial pressure 102 to 107 millimeters of mercury, which is around the blood pressure of about 140 over 90. The more aggressive treatment goal treated to a mean arterial pressure of less than 93 millimeters of mercury or really treating down to 125 over 75 millimeters mercury on average. What's interesting in this trial to get to these goals, often required multiple agents, the agents that were used in this trial were dihydropyridine calcium channel blocker that's amlodipine, the endotensin converting enzyme inhibitor Ramapril and the beta blocker metoprolol. And you can see over the follow up time. Again, what's really striking for a trial such as this was that they were able to achieve their treatment goals and you can see that the aggressive treatment goal was achieved with an average of about 128 over 78 versus the usual treatment goal which averaged to about 141 over 85 millimeters of mercury. And what we see in terms of outcomes, overall events plotted on the y axis, a couple of interesting things. What appeared in kidney disease was that patients who were given the ACE inhibitor Ramapril did better than other groups. So you can see the Ramapril event curve, over here, fared better than either the metoprolol or amlodipine curves, which are rather close over here so no significant differences between Ramapril, between metoprolol and amlodipine, but significant improvement with the use of Ramapril. Another interesting finding in the ASC study was looking at patients based on the underlying presence of proteinuria. And in this plot here, we look at standard treatment, which is the dotted lines versus intensive control and plotting over time, looking at the cumulative presence of primary events in this study, the progression of decline of GFR progression to end stage renal disease and death. And we see that in patients who had significant proteinuria greater than 300 milligrams a day. There was a significant improvement in the intensive control group compared to the standard control group. This difference was present, but not at all to the same extent in patients that had no significant proteinuria, less than 300 milligrams per day. So that was an interesting finding. But again, in a highly risk group of hypertensives who have kidney disease, who have proteinuria, we see here that the aggressive therapy and use of ACE inhibitors had benefit, significant benefit. So let's move on to a trial that actually included diabetics. That's the Accord trial. And in this study, 10,251 subjects with high risk, hypertension, type 2 diabetes, stratified by intensive versus standard glycemic control were looked at. And in this study, there were 4,733 who were also randomly assigned to blood pressure control and intensive versus standard blood pressure control approach. And in this study, the intensive treatment goal was to less than 120 millimeters of mercury versus the standard treatment of less than 140 millimeters of mercury, with the outcomes being non fatal MI non fatal stroke and overall cardiovascular death. And then a very well done study in which over periods of time the intensive treatment goals were met very well, as were the standard goals. And again, just like with the ask study, you can see that it often took two to three medications to achieve blood pressure control. So one thing the ask study, the Accord and as you'll see in the sprint study showed us is that if you want to achieve strict blood pressure goal. You're going to need two to three anti hypertensive medications to get to that goal. The Accord study, when looking at primary outcome showed a 1.87% per year outcome in the intensive therapy group, which was really not significantly different than the event rate in the standard therapy group 2.09% per year with a hazard ratio of 0.88. This did not achieve any statistical significance. So it was quite a surprise that in the diabetic population. It did not demonstrated that intensive therapy led to significant improvement in primary outcomes. However, when they looked at predefined or pre specified secondary outcomes, which included any stroke or non fatal stroke. In those situations, they did see improvement in terms of lower stroke rates in the intensive therapy group versus the standard therapy group. And given these event rates, the number needed to treat to prevent one stroke over five years was about 92. So the Accord trial actually had some impact on our guidelines, particularly the ones that came out of Europe, as you'll see, and did not show findings that were subsequently shown in in the sprint trial which will get to the implications of the Accord trial are summarized here. The serious adverse events that were attributed to the antihypertensive treatment occurred in 77 out of 2362 participants in the intensive therapy group that's about 3.3%. And only 30 out of 2371 participants in the standard therapy group. So we did see more adverse events in the intensive therapy group. We saw that there were really about twice as many adverse events in the intensive therapy group. These were treatable treatable events metabolic hypotensive events they were not permanent they didn't result in death. So you have to balance that with the fact that there were half the number of strokes, which is usually a more permanent event. And that is something that is food for thought for those of us clinicians who are making decisions on how aggressive to treat our patients with hypertension. The failure of the Accord trial to show superiority in terms of the primary outcome led to the European guidelines to recommend more conservative goals for diabetic populations and we'll see that shortly. Let's now move on to the sprint, the systolic blood pressure intervention trial. In the sprint trial participants were high risk with more than with one or more of the following situations, clinical or subclinical cardiovascular disease, framing cardiovascular risk of 15% or more evidence of chronic kidney disease, older age, and in this case patients with a history of stroke or diabetes were excluded. So this is a unique kind of population so we often refer to them as the sprint population may not be extractable to all populations, but certainly a high risk hypertensive group. So this is an examining intensive treatment with a goal to less than 120 versus standard treatment to 140 millimeters of mercury in these patients similar to what was done with the Accord trial. And again, we see that over period of years that the ability to get the intensive treatment individuals to goal was quite good. Again, it required generally several antihypertensive medications, but they were able to achieve this goal as was achieved with the standard treatment group. And what was shown in terms of primary outcomes, the cumulative hazard ratios plotted here is that there was a 25% reduction in the composite primary outcome for those who got intensive treatment that primary outcome being cardiovascular mortality, non fatal MI stroke, and heart failure. So definitely a significant improvement with the intensive therapy group. What was also shown was that given that 20 cent, the 27% reduction in all cause mortality was that the number the number needed to treat to prevent one death was 90. The number needed to treat to prevent one primary cardiovascular outcome as defined by this trial was 61. So this does give impetus to being more aggressive in terms of achieving stricter blood pressure goals. There were fewer primary outcomes in intensively treated individuals ages 75 or greater. This group of individuals highlighted here, and these individuals experienced significantly fewer primary outcomes and significantly less all cause mortality when they were treated to a goal of 120. So again, showing that this high risk group, the elderly group that up until now we've been less aggressive in terms of blood pressure lowering seem to have benefit. In terms of significant or severe adverse events. There were no significant differences in all cause. Severe adverse events by treatment group. However, the intensive group did have higher rates of hypotension, more syncope and more elevations of seum creatinine evidence of acute kidney injury. So not to be taken likely. So here we summarize the impact of these trials on both the AHA ACC guidelines versus the European guidelines, and you can see some of treatment goals outlined here. For example, office clinic blood pressure, according to the American guidelines are recommending treatment for systolic blood pressures greater than or equal to 130 for systolic greater than or equal to 80. So as we discussed because of the Accord trial that that that goal is a little bit less intense, particularly in diabetic populations where it's 140 and 90 here. So a little bit of controversy remaining in terms of how different groups approach the aggressiveness of treatment. Again, these are the guidelines as of 2017 influenced by the trials we just discussed. Again, we define elevated blood pressure now as systolic 120 to 129 stage one hypertension 130 to 139 for systolic 80 to 89 for diastolic and stage two hypertension greater than 140 or greater than 90. So with stage one or stage two hypertension, we always recommend non pharmacologic interventions but we would also consider starting anti hypertensive medication. When when doing so we're going to consider underlying comorbidities cardiovascular disease diabetes, the presence of kidney disease, and also the pooled risk. Cardiovascular risk, which the guidelines use a cut off of about 10%, and if you have one of these comorbidities, you're going to aim for a treatment goal of less than 130 over 80. If you don't have these comorbidities, you might still consider a treatment goal of less than 130 over 80. So notice how the current guidelines introduced the concept of cardiovascular risk into the decision making of how aggressive to be with blood pressure. This is again new, since all the previous guidelines. Given this more aggressiveness, it has an impact on how we define hypertension. So if we compare the prevalence of hypertension, we would say based on 2014 guidelines, the prevalence is about 32%, but now based on the stricter definition of hypertension. In 2017, the prevalence of hypertension is about 45%. We're going to recommend treatment now to about 36% of people versus 2014 where we would recommend it to about 30% of individuals. The potential events cardiovascular events prevented based on the 2017 guidelines is 610,000 versus 270,000 in 2000 in 2014. The potential total deaths prevented based on 2017 guidelines is 334,000 versus 177,000 in the 2014 guidelines. However, nothing is free. The 2017 guidelines might lead to an increase of hypotensive events upwards of 62,000 per year or acute kidney injury by upwards of 79,000 per year. In a study by Adam Bress in 2017, he projected that with aggressive blood pressure control to a treatment goal of 120, we can avert approximately 107,500 deaths annually in the United States. But with an incremental increase in serious adverse events upwards of 56,000 hypotension episodes upwards of 34,400 episodes of syncope electrolyte disorders which typically hypokalemia hyponatremia hypomagnesemia in upwards of 43,400 and acute kidney injury in upwards of 88,700. So we clinicians are faced with a dilemma. While there are significant reduction in cardiovascular events and death from intensive treatment, it comes with a price and the price are these adverse events. And so that brings us to the definition and the title of my talk which is the treatment risk paradox in blood pressure management. In other words, the reluctance to aggressively lower blood pressure in those at most risk due to the potential for adverse events. Thus patients at higher risk and with the greatest potential to gain from treatment receive less intensive treatment than patients at lower risk and there's the paradox in cardiology we've seen this before this is not the first time. We saw this with using anti coagulation for atrial fibrillation. And so we know there was the development of the Chad's VASC score and as a result of that, we started to be more aggressive in anti coagulating older people. We've seen this in lipid management as well. So this paradox tells us that we need methods that integrate both individualized risk with routine clinical care so that we can better address how we're going to overcome this paradox. We need to be alerting clinicians to each patient's potential benefits from treatment. And this may enable a more patient centered, more evidence based, more efficient care with the overall safer, better outcomes. So hypertension goals. Where are we now? Well, based on what we've learned so far we know that intensive lowering of blood pressure lowers rates of cardiovascular mortality and morbidity in the general hypertensive population, including the very elderly. However, this may not apply to all populations, an example being the diabetic population as we saw with the Accord study. We know that intensive lowering of blood pressure increases rates of potential serious adverse events. So one potential strategy to help guide us from intensive treatment at an acceptable level of risk would be able to stratify populations by their risk of cardiovascular events. So this stratification might identify a particular group of patients who would benefit the most from intensive treatment, but with an acceptable level of risk for adverse events. A history of this, I think a good example would be lipid management, as well as blood pressure treatment. So prior to 2013 prescribers aimed for specific LDL goals, LDL of 160 LDL of 130 LDL less than 100 or aggressive LDL management to 70. The 2013 ACC and AHA guidelines changed this focus, not so much to the actual LDL goal, but more toward the intensity of statin therapy based on an ASCVD risk. So it was recommended to use moderate statin therapy if the 10-year ASCVD risk was greater than 5% and consider an intensive statin therapy if the risk was greater than 7.5%. And this is without quoting a specific number goal for LDL cholesterol. The 2018 adaptation of lipid guidelines tried to incorporate both risk and LDL cholesterol goal into the intensity of treatment. You know, this is to take into account how clinicians think about treatment, making it a little bit easier for us to kind of discuss goals with our patients. So cardiovascular disease risk calculators are easily accessible. These are two examples of them. The one on the right is I took from my health system at Northwell. It's built into the electronic record. You plug in the patient's age, gender, ethnicity, total cholesterol, HDL cholesterol, systolic blood pressure, and then questions of whether or not the patient is under treatment for hypertension, whether they're diabetic and whether they smoke. And after plugging that in, you get a calculated 10-year risk score, and often they'll also give you a comparative risk score to an individual with optimized risk factors. And based on this, we can get some clinical information on our patient. And if we look at a plot like this, we've seen this with lipids, and now we're seeing it with blood pressure control as well, that as we aggressively lower blood pressure, we see less cardiovascular events. But a factor that we have to take into account is the patient's underlying risk of cardiovascular disease. So we see here in a patient with a low ASCVD score, there is some degree of benefit with aggressive blood pressure lowering. But that benefit seems to be significantly more when the underlying cardiovascular disease risk is 16 to 21% or greater than 21%. As you can see, the steepness of these changes as we lower systolic blood pressure compared to patients who have lower cardiovascular disease risk. So the impact of cardiovascular risk on the relative benefit versus harm of intensive treatment of blood pressure was addressed by trials that were based on the sprint population. Back in 2018 or 2017, the New England Journal opened up the sprint database to allow investigators to ask questions about this population. And so I was fortunate enough to participate in a group that was headed by Dr. Robert Phillips, who many of you know down in Texas, as well as the individuals quoted at the bottom here, including myself, did an analysis where we stratified subjects from the spin trial into quartiles based on their 10 year cardiovascular risk. We applied a statistical approach to these patients. It was a Cox proportional hazards model to examine the associations of treatment with primary outcome events, and with serious adverse events. It was a complex process. Statistically, in this study, we use the multiplicative Poisson regression, which is a predictive model developed to determine a benefit to harm ratio as a function of cardiovascular risk. And so you can see here that if you look at these quartiles of risk, the first quartile being the lowest risk and the fourth quartile being the highest risk, and look at participants experiencing primary outcomes based on the sprint trial. You can see that there is an increase of events in both standard treatment in red and an intensive treatment individuals in green, that they all increase as you get into these higher cardiovascular risk quartiles. You can see that there's a bigger spread over here than there is over here, which means that there is a big, bigger difference in protection from primary outcomes in the intensive treatment group who are in this higher risk cardiovascular risk. If we add to that plot a significant adverse events, which we see here, we see here that there's not a dramatic difference between serious adverse events in the standard group which is red versus the intensive treated group in green throughout the quartiles. However, the difference between the two actually turns out to be less in the higher risk group. So when you combine the improved benefit with the with the low difference of serious adverse events, you get this blue curve here, the benefit to harm ratio, where we see in this area here, a significant benefit over harm versus this group here, where we see perhaps more harm than good. And so in the third and fourth quartile of cardiovascular risk, we see improved benefit to harm as risk increases. And so in our trial, we were able to divide patients based on risk with a dividing line here at about 18.2% cardiovascular risk. And those who had ASCVD risks less than 18.2% had a benefit to harm ratio that showed that treating aggressively did not necessarily have more improvement than harm. But if you looked at patients who had an ASCVD risk of greater than 18 to 18.2%, they had greater benefit than harm with intensive therapy. A nice clear division here where you use the ratio of benefit to harm ratio of one as your divider. And you see here, these groups are less than one, and these groups here are greater than one. So the implications of this are quite significant. Because if you remember the guidelines from 2017 told you to look at a 10 year risk of 10%. And that to consider more aggressive treatment at that 10% threshold. Whereas in the analysis of the sprint trial that we did shifted that up to a threshold of about 18.2%. So those with less than 18.2% would fare better with the usual treatment goal of 140. And then those with cardiovascular risk more than 18.2% would do better with more aggressive blood pressure management. And this is significant because upwards of 10 million Americans have 10 year risk between 10 and 18.2%. So our analysis of risk has an impact on approximately 10 million individuals. It was controversial when this data came out. But what is comforting to know is that in March of this year, 2021, Adam Bress and his group did another, did a sub analysis of the spin trial, and they used a different statistical approach than the one that Dr. Phillips and his group used. But having used their approach, they showed similar finding. They showed that that in higher quartile risk groups, if you compared standards therapy in this case a solid line versus intensive therapy which is a dashed line that the cumulative incidence of cardiovascular events dropped considerably in the higher risk quartile groups compared to the lower quartile groups. They also showed increased adverse events as you went into higher risk groups. But again, that difference as you got into the higher risk groups became less striking between the intensive and less intensive treatment groups so that the overall benefit, the overall benefit compared to harm was significant in these higher risk groups. So this is a little summary from Bress's group showing again that in higher risk patients, there was a higher tendency to have adverse events, just as in the low risk groups, low probability of having intense events, but as you got to higher risk cardiovascular event groups, aggressive therapy, the benefit you got for reducing cardiovascular events outweighed the harm from adverse events. So putting all this together, how do we treat our patients? How do we address this? Well, we see that organizations including the American College of Cardiology, the American Heart Association, the American College of Physicians, and the American Academy of Family Physicians are moving towards incorporating cardiovascular risk stratification in patients for the treatment of hypertension, as we are already doing for treating lipid disorders. If large increases of serious adverse events such as acute kidney injury, hypotension, syncope and falls are clinically important as relatively small reductions in heart failure or cardiovascular mortality, then one may not aggressively treat patients with lower overall cardiovascular risk. But when we are dealing with our high risk patients, we are learning that we may have to change our practice to meet these goals and intervene early on the potential adverse events. So if you have an older patient that you want to aggressively treat blood pressure, you may have to see them more frequently in the office to assess for orthostatic hypotension. You may want to arrange for telemedicine visits to review medications, to review self-obtained hemodynamics as more and more people are purchasing blood pressure machines and measuring blood pressure at home. And we know that these self-obtained readings are accurate. You may need to obtain more frequent laboratory assessments for hypokalemia, hypomagnesemia, elevations of serum creatinine. And again, as we change our approach to these patients, we may have to consider the rapidly changing healthcare payment and delivery model in this country as we see. So with that, I'm going to end my talk and I want to thank you for your attention to this. And again, I really enjoyed participating in this conference with you. Thank you very much.