Yes, I want to share with this experience for some of you. You might be there, I know you are there. The tourist comes the hardest time in life when you feel like you want to go out, when you want to go out, but you cannot access even out because you don't have the requirements, or you don't have what entertizes you to move outside the country, or even go outside the country for your case. And that is, I'm talking about for people that have stayed into the country for a longer period without a QID. Yes, my humble advice would be that it's better you kind of finish up the formality. If it was a company that gave you a freelancer visa, please look for that company, look for that officer of that company. No way that person who gave you a visa is where it's best because after renewal of ID or UQID, it is going to get into a very big problem for you after one year. So it will probably be the best option for you. For people who have stayed into the company, or who have changed in the company, or you've been in hiding for quite a long period of time.


TfNN, The Tiger, Financial News Network, TfNN, Headline News Update. Good morning everyone, this is the 10 AM Thursday, the 17th edition of, let's see it's not the edition of the Tiger Technicians, that's coming up straight off to this 10 news update, Dow's down, S&P's down 50, at 39.08, the Dow is down sharply as well, it is down 288, at 33,269, we've been talking about this for about four or five days, I've been saying, we're in a topping motion right now, at least short term, yesterday we made a confirmed peak F top in the Chapman wave, with a tiny doji candle, and that usually suggests that there's a change in trend possibly happening, I think that's happened at least on the short term, you're looking at the QQQ down sharply, almost four points at 281.56 after peak D, I'll talk about that in my show coming up, we're looking at the IWM, the Russell 2000, down very sharply with a doji candle, probably a peak F, at the 200 period moving average, you're looking at gold down as well, gold is down just 14 points in 1761, being repelled at the 200 period moving average, but only a leg B to the upside, you're looking at the dollar, having a bit of a rally right now, it's up 68 ticks at 106.99, crude oil, we've been talking about crude oil possibly turning around from that peak D top that was made about eight, nine sessions ago, and here we are under the 200 period moving average, this is really important, I think natural gas might even have a little bit of a chance to move higher, let me just get that up right there, it is at 6.35, just 16 cents, but it is trying to change the trend, we're looking at, let me go to the next thing, which is the TLT, the TLT made a strong leg up yesterday, it's pulling back a little bit today, $1.58 down at 9.83, that 100 level is strong resistance, I'll be back in a moment for the Tiger Technicians, there's just a lot to be discussing, and don't forget we start off at nine with Tommy Jr, he has the morning market kickoff and had a great trade, options trade, we'll be back in a moment, and oh do I hear the music, do I hear the music, there it is, we're back for the Tiger Technicians hour and check out my opening call, my daddy needs that, see you in a moment.


Hey guys, I'm Ben from So is it any good? We're here at the Sydney premiere of baby driver Stars are making the way down the red carpet. So, let's see if I can file out my restraining order and approach one of them Has any of Edgar's passion for cinema rubbed off on you are there any classics that introduced you to that you now love? Yes, he sent me a list of his top thousand films. The guy knows films more than anybody So it's pretty incredible. With the action in this film being so well synced up with the music How did you kind of achieve that on set? Was there a particular method you used to sync it up, right? It's not everything sometimes we need to play the music out loud sometimes after be listening to it as headphones Sometimes you use these things called ear weeks where you've got the kind of like the the transistors in the ears So it'd be a bit of everything. This is a really physical role and it's not just the driving You know, there's a lot of stuff outside of the car as well So how much of that did you do yourself on set and we what was your toughest scene? I think you know not toughest But something like that was really fun to film and that was outside of the driving was the one shot in the beginning When he's in the coffee that was a really cool experience and a great shot to film Captain Subaru WRX I did I'm not joking And I kept the jacket and his shirts and his socks and his underwear and his shoes I took everything because I love baby. I'm Ben from so is it any good? And that will that do it for tonight if you want to check out our baby driver review head to our YouTube channel You might go to the film again. I'm gonna hold this mic for me. Mr. Cameraman


So, hello everyone hope you all are doing well. So, today we will be solving exercise 4 of chapter sequence and series. So, till now we have solved the 3 exercise 1, 2 and 3 exercise where we have dealt with sequence problems problems based on AP and GP. So, this exercise mainly consists of mixed problems on the arithmetic progression geometric progressions and harmonic progressions. So, let's begin let's begin with this exercise. So, let's have a look at question number 1. It's saying that A, B, C are in AP and B, C, D are in HP then following options are given and we have to choose the correct one. So, A, B, C are in AP and B, C, D are in HP. So, these two things we are provided with. So, since A, B, C are in AP we can write 2B is equal to A plus C and we can write here C as 2 times BD upon B plus C since B, C, D are in harmonic progressions. So, let's take it as equation 1 this as equation 2. Now, I will be substituting the value of C in the equation 1. So, it will be 2B is equal to A plus C, C in place of C I will write 2BD upon B plus D. Sorry, it will be B plus D here. So, taking LCM it will be AD plus AB plus 2 times BD is equal to 2B. Now cross multiply it we will get 2B square plus 2BD is equal to AD plus AB plus 2BD. Now these 2BD terms will be cancelled out from this equation and we will be left with 2B square is equal to I am taking A common here. So, it will be B plus D. So, 2B square is equal to A into B plus D in place of B plus D we can write 2BD upon C, right. So, 2, 2 will be cancelled out 1B will be cancelled and we will be left with BC is equal to AD. So, AD is equal to BC, option B is correct. So, this will be our answer AD is equal to BC. So, let us move to the next question, question number 2. If ABC are in AB then A by BC, A by C and 2 by D are in. Okay, so, ABC these 3 terms are in AB and we have to say A upon BC comma A upon C comma 2 upon B. Like these terms will lie in AB, GP or HP we have to see. So, since ABC are in AB we can write it as 2B is equal to A plus C. Now, let us check what is asked in the question it is saying A by BC. So, if I divide this equation by BC on both hand sides I will be getting A upon BC term. So, let us try it out. So, 2B upon BC is equal to A upon BC plus C upon BC, right. So, this B will be cancelled out it will be 2 upon C is equal to A upon BC plus this C will be cancelled. 1 upon B. So, if the question was like in place of this 2 by B if the question was like A upon sorry 1 upon B. So, we can easily say that these terms will lie in AP. Because 2 times of middle term is equal to sum of A first term and third term like if second term was in AP then it will be the 2 times of second term will be equal to first term plus third term like what we did here, right. But the question is saying it's 2 by B it's not 1 by B. So, none of these will be answered to this question because none of the answers is matching, right. So, either there is some problem in the question itself like it should be 1 upon B if the if it was in AP but okay let us assume the question is correct. Our answer will be none of these, right. So, let's have a look at the next question question number three. So, if ABC are in AP and ABD are in GP, then A comma A minus B comma D minus C will be in. So, ABC are in AP and ABD. So, ABD is in GP. Now, we have to say A comma A minus B comma D minus C will be in AP, GP or HP. So, from here we get to B is equal to A plus C, okay. Let us assume this as equation 1 and ABD are in GP. So, B square will be equal to AD. Let's take it as equation 2. Now, how should we approach like we will try to have these terms in any of the equation. Then only we can say whether these terms will be in AP, GP or HP, right. So, what I will be doing I will multiply this equation 1 by A. So, what by multiplying A we will have 2 AB is equal to A square plus AC, right. This can be rewritten as A square minus 2 AB is equal to minus of AC. I am able to say like A square minus 2 AB. If I add B square to this side then I will have A minus B whole square, right. So, let's do that. A square minus 2 AB plus B square since B square is not there in our earlier equation. So, I have to add B square on the right hand side also. So, it will be B square minus AC, okay. So, here I am getting A minus B whole square is equal to B square minus AC. B square minus AC and we know B square is equal to AD. So, we will replace this B square by AD. So, this A minus B whole square is equal to AD minus AC. A minus B whole square taking A common from here. It will be A into D minus C. Now, see this A A minus B and D minus C. So, middle term is squared is equal to product of the first and third term. Like this is the property of GP, right. So, A minus B whole square is equal to product of A and A minus C. Sorry, D minus C. So, these three terms are in GP, right. These three terms are in GP. So, option number B is correct. Let's move to the next question, question number 4. If X1 Z are in AP and X2 Z are in GP, then X comma 4 comma Z will be in, okay. So, X comma 1 comma Z, these three terms are in AP and X comma 2 comma Z, these three terms are in GP. Then we have to show like this X comma 4 comma Z will be in either AP, GP or HP. So, from here we can say 2 is equal to X plus 0, right. Let's take it as equation 1 and since X2 and Z are in GP, we can say 2 squared is equal to X into Z or 4 is equal to X into Z. Let's take it as equation 2. Now, we have to comment on X4 and Z, right. X4 and Z, whether it will be AP, GP or HP. So, let's assume this an AP. So, if these three terms were in AP, then 2 times 4 will be equal to X plus Z, right. So, A is equal to X plus Z, but we know X plus Z is equal to 2. So, this assumption is wrong, like X comma 4 comma Z can never be in AP. Let's try it out with GP. So, if X comma 4 comma Z is in GP, then 4 square must be equal to XZ or 16 equal to XZ. But we know that XZ is equal to 4 from our equation to from our given conditions. So, this can never, this can never be in GP also. So, only one option is left. Let's assume it has an, let's assume these three terms are in HP, right. So, if these three terms are in HP, then 4 must be equal to 2 times XZ upon X plus Z. So, let's see whether it is satisfying or not. So, 2 into XZ, we know XZ is 4 and X plus Z is 2. So, 2, 2 will be cancelled out, 4 is equal to 4. So, these three terms X, 4 and Z are in HP. Sorry. So, option number C, option C is correct for this question, right. So, we are done with this. Let's move ahead. Question number 5. So, it is saying if A, B, C are in GP, A, B, C are in GP, A comma A minus B comma C minus A comma B minus C are in HP. Then A plus 4B plus C, we have to find the value of A plus 4B plus C. Okay. So, A, B, C, it's given to be in GP. And so, from here we can say B square is equal to AC, right. B square is equal to AC. And the next information is A minus B comma C minus A comma B minus C are in HP. So, if these three terms are in HP. So, a reciprocal of these are must line AP, right. Or we can say, we can proceed directly also. Like C minus A, C minus A must be equal to 2 times A minus B into B minus C upon A minus B plus B minus C, right. So, this minus B plus B will be cancelled out and we will be left with C minus A is equal to 2 times AB minus AC minus B square plus BC. And denominator we will have A minus C, okay. So, let's take a minus sign common from it. So, it will be and I will be cross multiplying. So, it will be C minus A whole square is equal to 2 times AB minus AC minus B square B square is equal to AC, right. So, let me write it AB minus B square can be replaced by AC. So, it will be minus 2 AC plus BC. And since we have taken negative common from this denominator, I have to change the sign also. So, it will become minus AB plus 2 AC and this plus BC will become minus BC, right. So, this will be our final. So, this will be C minus A whole square is equal to 2 times 2 AC minus AB minus BC. So, let's open the square it will be C square plus A square minus 2 AC is equal to 4 times AC minus 2 times AB minus 2 times BC. So, from here we can do one thing I'm able to say this A square term C square term here 2 AB 2 BC. So, let's try to make out like make this equation in terms of A plus B plus C whole square. So, it will be A square plus C square minus 2 AC I'm taking all the terms to the left hand side. It will be then minus 4 AC minus 2 AB minus 2 BC is equal to 0, okay. So, further my approach is to make this equation in terms of A plus B plus C whole square. So, what extra we need here? We need sorry A square plus B square plus C square B square was not here. So, I will be subtracting it minus B square then this will be oh I've done one mistake this will be minus 4 AC this will be plus 2 AB plus 2 BC right. So, minus B square minus 2 AC minus 2 AC and minus 4 AC it will become minus 6 AC minus 6 AC plus 2 AB plus 2 BC for formula we need plus 2 CA also then I have to subtract 2 CA. So, 2 AB 2 BC is already covered now I am adding 2 CA additionally so I am subtracting it and this will be equal to 0. So, it will become A plus B plus C whole square right. So, these three terms this 2 AB 2 BC 2 CA is already covered. So, we are left out with minus B square minus 8 AC this is equal to 0. So, A plus B plus C whole square is equal to B square plus 8 AC right. Now, we know B square is equal to AC since ABC are in GB. So, it will become 9 AC right. So, A plus B plus C whole square sorry I am removing this square I am taking square root. So, this will be removed. So, A plus B plus C will be equal to plus minus 3 under root AC under root AC means what under root AC means B sorry. So, we can replace here only like 8 AC can be replaced with 8 B square ok. So, let me replace it by 9 AC can be written as 9 B square already here also we could have done this thing. So, it will be plus minus 3 B right plus minus 3 B A plus B plus C will be equal to plus minus 3 B. So, when I am taking this plus sign. So, it will be A plus B plus C is equal to 3 B or A plus B plus C is equal to minus 3 B. So, from this equation we will be getting out desired result like A plus 4 B plus C this was asked in the question. So, A plus 4 B plus C will be equal to 0. This is what we need and let this equation be like A minus 2 B plus C is equal to 0. So, either A minus 2 B plus C is equal to 0 or A plus no not both the equations are justified because A plus B plus C is equal to plus minus 3 B. So, when we take minus 3 B it will give A plus 4 B plus C equal to 0 and if we take a plus 3 B it will be A minus 2 B plus C equal to 0. So, 0 is the correct answer for this question. So, option A is correct. Let us move to the next question, question number 6. It is saying that the if the M plus 1th, N plus 1th and R plus 1th term of an EB are in GB and M, N, R are in HP then the value of the ratio of the common difference to the first term of AB. So, M plus 1th term, M plus 1th term of AP and N plus 1th term of AP and R plus 1th term of AP. These three terms of AP are in GB right. So, what will be the M plus 1th term of AP? It will be suppose I am taking A as the first term of the AP and D as the common difference.  Now, these three terms, these three terms are in GB, these three terms are in GB. So, it must satisfy the property of GB that is A plus MD whole square is equal to A plus MD into A plus RD right. Now, what is asked in the question? Then the value of the ratio of the common difference to the first term of the AP. Okay. So, question is asking to find the ratio of D is to A, where D is the common difference of this AP and A is the first term of this AP. So, let's simplify this equation, we will have A square plus N square D square plus two times of A and D is equal to A square plus A RD plus A MD plus M RD square right. So, this A square A square will be cancelled out. This will be left with N square D square plus two A and D is equal to let's take a common from these two terms or AD both. So, let's take AD common from these two terms, we will have M plus R within the bracket. So, AD into M plus R plus M RD square. Okay. So, it will become N square D square plus two A and D is equal to AD. Now, one more information is given in the question M in R in HP, right. We have not utilized this information yet. So, if M in R in HP, so we can write in as two M R upon M plus R right from here we will get M plus R is equal to two M R upon N. So, we will use this information. So, M plus R can be written as two M R upon N. And this will remain same M R B square right. So, what it will become from, from the right hand side, we can take again M R common, right. So, if we take M R common again, we will have two AD upon N plus D square. It will be M R into taking LCM it will be two AD plus N D square. And in left hand side, we will, we are having N square D square plus two AD. Okay. So, from here also we can take N common. So, I'm seeing a, what do you say? If we take N common from this, I'm seeing one common term on both hand sides. So, if we take N common here, it will be N D square plus two AD, right. So, let's bring this thing to the left hand side. We will have N into N D square plus two AD minus M R to AD plus N D. N D square upon N is equal to zero. So, from this we can take N D square plus two AD common. So, N D square plus two AD. If we take common from both these terms, we will be left with N minus M R upon N. So, N D square plus two AD into this thing will be equal to zero. So, from here we can say either N D square plus two AD is equal to zero or we can say N minus M R upon N is equal to zero. So, from here N is equal to M R upon N or N square is equal to M R. But N M R was in HP as per the question, right. N M R on N M R for M N R in HP. So, since this thing is there M N R in HP since M N R in HP so N square can never be equal to M R. If this M N R would have been in GP then only this thing would have been valid, right. So, this thing is rejected N square is equal to M R. From here we get N D square is equal to minus two AD. So, one D will be cancelled from both sides. We will have P upon A is equal to minus two upon N. So, this was asked in the question the ratio of the common difference to the first term. So, it will be minus two upon N. So, let's check whether this is there in option or not D by eight minus two by N. Yes, this option A is correct for this question. Option A is correct. So, let's take the next question, question number seven. It is saying that if ABC are in AP and A square B square C square are in HP then three options are given. We have to say which one is correct. So, ABC are in AP, ABC are in AP, A square B square and C square are in HP. So, from here we can say two B is equal to A plus C. Let's take it as equation one. And from here we can say since A square B square C square are in HP we can say B square is equal to two times A square C square upon A square plus C square. This is our equation number two. So, substitute the value of B here. So, it will be A plus C upon two whole squared is equal to two times A square C square upon A square plus C square. So, let's simplify it. It will be A square plus C square plus two AC upon four is equal to two A square C square upon A square plus C square. So, here also A square plus C square is there and here also A square plus C square is there. So, for sake of convenience let's take A square plus C square is equal to X. I am taking A square plus X is C square is X. So, it will become X plus two AC into X is equal to eight A square C square. So, it will become X square plus two AC X minus eight A square C square is equal to zero. So, it's a quadratic in X. So, we can split this middle term as four minus two four minus two eight. Okay. So, it can be rewritten as X square plus four AC X minus two AC X minus eight A square C square is equal to zero. What is this? It will be A square C square eight. So, minus eight A square C square is equal to zero. I have split this middle term. Now, take X common from first two terms it will be X plus four AC take minus two AC common here. It will be X plus four AC is equal to zero. So, X plus four AC into X minus two AC is equal to zero. So, from here we can say either X plus four AC is equal to zero or X minus two AC is equal to zero. Now, what was X? X was A square plus C square. So, A square plus C square plus four AC is equal to zero or A square plus C square minus two AC is equal to zero. From here we can see A minus C whole square is equal to zero. So, A minus C is equal to zero or we can say A is equal to C. You can say A is equal to C, but ABC was in AP as per the question. ABC are in AP, right? So, since ABC are in AP, so two B is equal to A plus C and A is equal to C. So, two B is equal to two C. So, B will be equal to C. So, from here we can say A is equal to B is equal to C, right? And from here, this was also one of the option, no? Either X plus four AC will be zero or X minus two AC will be zero. From here we get A is equal to B is equal to C. From here we can say A square plus C square minus two AC means plus two AC plus two AC from right hand side it will be minus two AC. So, A plus C square is equal to minus two AC. But nothing, this sort of nothing we are saying in the option. So, we are having only A is equal to B is equal to C in the option. So, yeah, A is equal to B is equal to C. So, this option is correct for this question. So, we are done with this question. Let's take the another one, question number eight. So, it is saying if ABC are in HP. ABC are in HP.  We have to say whether these three terms are in A, B, HP or GB. That we have to identify. And the given information is ABC are in HP, right? So, since ABC are in HP we can say B is equal to two times AC upon A plus C. Okay, so how to approach this question?  So, we have to proceed like we have to check separately, like let's assume these three terms are in AP. If these three terms are in AP, then two times middle term that will be two B upon C plus A must be equal to A upon B plus C plus C upon A plus B, right? So, from here we will get B B plus C into A plus B. So, it will become A square plus AB plus BC plus C square is equal to two B upon C plus A. Now, I think it will be B squared from here, B cube. Like, we can, anyhow we can see, we can so if we can so like B is equal to two AC upon A plus C, then we can say that these terms are in AP. But from here I am not able to like simplify this. Anyway, it will be simplified in terms of B, but it will be a difficult one. So, let's hold this and let's check whether these things are in GP or not. So, if these three terms would have been GP, then B upon C plus A whole square must be equal to A upon B plus C into C upon A plus B, right? So, it will be B square upon C plus A square is equal to AC upon A plus B into B plus C. From here also I am not able to like get whether this will result in having the value of B or not. So, let's check with HP also. So, if these three terms were in HP, then B plus C upon A and C plus A upon B and A plus B upon C, these three terms must be in AP, right? So, applying the property of AP here, two times C plus A upon B must be equal to B plus C upon A plus A plus B upon C, right? So, it will be equal to let's take LCM and solve it. So, it will be BC plus C square plus A square plus AB, right? And this is equal to two times C plus A upon B, right? And we have not utilized this information that B is equal to two AC upon A plus C. So, here we can use like this A plus C thing. From here we know A plus C is equal to two AC upon B. So, we will utilize here. So, two upon B into A plus C. A plus C can be written as two AC upon B, right? And this will be equal to BC A square plus C square plus, let's take B common here. So, B common, after taking B common, we will be left with A plus C, right? Upon AC. So, let me go down what, let this thing be in terms of A plus C only. I think that will be more useful to us. Two upon B or two upon B and A plus C, right? Or let me check what it results in A square plus C square plus, no, I am doing something wrong, I think. So, this will be two upon B, C plus A can be written as like ABC varying HP, no? So, this will be B is equal to two times AC upon A plus C, right? Whether we are getting any fruitful here, A square plus C square plus B into A plus C upon AC, right? So, C plus A, two upon B. So, this will be B squared. B is equal to, okay, what like, let me erase it first. Anyhow, we have to prove like B is equal to two AC upon A plus C, right? If we can do that, then we can say like these three terms are in HP. So, let's erase this also. So, we can write it as what was here?  So, two upon B into A plus C is equal to AC means this will become BC plus C squared plus A squared plus A squared plus AB, right? So, let's check the value of B, what will be the value of B from here? So, it will be or two by B is equal into A, sorry, two by B can be written as two by B, we can write two by B as A squared plus C squared plus, take B common from here, it will be A plus C upon AC into A plus C, right? So, it will be A squared plus C squared plus B. Now, A plus C, we can write it as two AC upon B, right? And this is equal to, this is equal to AC into A plus C. A plus C can be again written as two AC upon B, but for A plus C, okay? So, this B, this B will be cancelled out, this will be A plus C whole squared in the numerator, right? So, A plus C whole squared upon AC into A plus C. So, this one term will be cancelled, only in numerator, only A plus C will be left out. So, this will be equal to two upon B, or we can write as B is equal to two times AC upon A plus C. So, hence, like, we arrived the value of B, assuming that these three terms were in, assuming that these three terms were in HP, right? This was justified since we got the value of B as two AC upon A plus C. So, these three terms are in HP basically. These three terms are in HP, right? So, there is no alternative. We have to, like, go one by one only. We have to say whether these three terms are in AP or in GP or in HP. So, finally, we got that these three terms are in HP. So, let's move ahead to the next question, question number nine. Question number nine is saying that if X plus Y by two comma Y comma Y plus Z by two are in HP, then XYZ are in.  Then we have to identify XYZ will be in AP, GP or HP. So, since these three terms are in HP, we can say that Y is equal to two times X plus Y upon two into Y plus Z upon two upon X plus Y upon two plus Y plus Z upon two, right? So, we can rewrite as this two, these two will be cancelled out. So, it will be XY plus XZ plus Y squared plus YZ upon this two X plus Y plus Y plus Z and this is equal to Y. So, this one by two, this two will be cancelled.  So, cross multiplying after cross multiplying, we will have XY plus two Y squared plus YZ is equal to XY plus XZ plus Y squared plus YZ. So, this XY, this XY, this YZ, this YZ will be cancelled. So, two Y squared is equal to XZ plus Y squared or Y squared is equal to XZ. So, this XYZ are in GP. So, we can say XYZ are in GP. Since Y squared is equal to XZ. So, option B is correct for this question. So, one more question is left in this exercise. Question number 10. So, if A plus B upon A minus AB comma B comma B plus C upon 1 minus BC are in AP, then A comma 1 by B comma C are in, okay. So, it is saying A plus B upon 1 minus AB comma B comma B plus C upon 1 minus BC are in AP, right. So, two times of B will be equal to A plus B upon 1 minus AB plus B plus C upon 1 minus BC. So, simplifying this, we will have 1 minus AB into 1 minus BC in the denominator. And in numerator, we will have A minus AB C plus B minus B square C plus B plus, sorry, this will be B minus AB square. Plus C minus ABC, this is equal to 2B, right. So, this will be 2B into M cross multiplied. So, 1 minus BC minus AB plus AB square C is equal to what is written there, 1A plus 2B. So, this term I have taken, BB is taken, plus C, this is also taken, minus 2ABC, this is done, this is done, minus 2ABC minus B square C, right. So, open this bracket, it will be 2B minus 2B square C minus 2AB square plus 2AB cube C is equal to A plus 2B plus C minus 2AB C minus B square C, right. So, this 2B, this 2B will be cancelled out and this will be 2AB cube C is equal to what we are having in right hand side, A plus C minus 2AB C minus B square C, this will be plus 2B square C. And this will be plus 2AB square plus 2AB square. So, this minus B square C plus 2B square C, this will become plus B square C. So, I am erasing this minus term plus B square C plus 2AB square, ok. Now, I will take this 2AB C to this hand side, so to the left hand side. So, 2AB cube C plus 2AB C will be equal to A plus C plus B square C plus 2AB square, right. So, taking 2AB C common from here, we will have B square plus 1 is equal to A plus C plus, if we take B square common from here, we will have C plus, whether I have done something wrong, 2AB square minus AB square, ok, ok. I have left this term or what, minus 2AB C, ok, it is there, minus B square C and one more term will come here, no, minus B square C and minus AB square, right. So, minus AB square will also come here. So, minus AB square. So, it will become, if we take 2A is minus AB square. So, 2AB square minus AB square will be AB square. So, these two will be omitted actually. So, these two will be omitted. So, it will be AB square. So, B square I am taking common. So, it will be having what will be left out C plus A, right. So, 2AB C into B square plus 1 is equal to, again I am taking A plus C common here. So, it will have, we will be left with 1 plus B square, right. So, this 1 plus B square term, we can cancel it out. So, we will be left with 2AB C is equal to A plus C. So, what was question? What was the question asked? So, A comma 1 by B comma C, right. A comma, A comma 1 by B comma C. So, if these three terms were in HP. So, 1 by B must be equal to 2 times AC upon A plus V, right. Suppose, we will taken this in HP. So, from here if we divided by AC, we will have 2AB C upon AC is equal to A plus C upon AC. So, it will be 2B is equal to 1, sorry, 1 upon C plus 1 upon A. Or from here we can say directly that this AC AC will be cancelled out 2B is equal to 2B is equal to A plus C upon AC, right. So, this or B is equal to we can say A plus C upon 2AC. Same we are getting from here also B is equal to A plus C upon AC. So, these three terms A comma 1 by B comma C will be in HP, right. I am omitting this. So, this is all. So, let me mark the correct option. A comma 1 by B comma C should be in HP. This should be in HP. So, option C is correct. So, we are done with this exercise. Hope it is clear to all. We got stuck in some questions, but nothing we can do right now, like this is the nature of the question itself. We have to see whether this the ASP terms are in AP, GP or HP. So, this is all for today. So, we will be coming back once again with the next exercise, exercise number 5. So, till then, okay. Till then, goodbye and good night to all. Thank you.


Welcome and thanks for coming. I actually, um, I'm delighted to actually go first because then I can like pay attention to all the rest of the, um, speakers and I really enjoy this day and we, we try to make this program fresh every year so you'll see that our agenda and our curriculum changes hopefully with the times. In fact, in fact, you know, we want it to be like a fresh curriculum because really what we want it to do is like inform you to help you with the things that are, you know, coming available with information during the year because as a busy clinician, I know what it's like to like keep up with the literature and like, you know, get into a more in-depth thing when you're so busy. And so if you have comments or what things, topics that you think that we haven't covered, please feel free to email us and let us know because we want to make it the most user-adapted conference that you can spend your Saturday on even in December, which is a really busy time of the year. Okay, so that kind of speech leads to why I picked this topic for the day, which is menopause and manopause. And I know it's a silly kind of a title and I did it on purpose, but here's the reason. I've seen a rash of male patients in the clinic and I see a lot of clinic patients, both men and women, because although I'm the woman's expert, so, so. The women are bringing their husbands and their boyfriends and their fathers and men pick women too, so. But I've seen a rash of male patients who've been put on testosterone who had a lot of complications. I had patients of mine that had gone to see, you know, these low T clinics and put on testosterone. And otherwise you would have been like, no way you can't take the testosterone. I had one seminal patient where he had literally occluded his iliac veins both all the way down to the popliteals on testosterone. Okay, so I thought to myself, oh my gosh, why is no one covering this thing? And then in fact, there was a big New York Times op-ed in 2014 where there had been a study that was released and somebody, a doctor or a urologist had written this beautiful op-ed piece about low T and over treatment. And I thought, oh my gosh, you know, maybe the whole story about women and heart disease is replaying itself in the male world because of a lot of pharmaceutical sponsored stuff. So what we're going to do today is we're going to briefly review the data for women and talk about the data for men because, as I said, I think it's a story that's perpetuating itself. And we haven't done women and heart disease for hormones in a while and there's been like some new developments from some big players in the field. Okay, so that's what we have. So I was going to start out with, for women and heart disease, we're actually doing really well, okay? You can see that the trends for both men and women since really 2000, the statistics for mortality have dropped like a real rock, okay? And I love this slide because it shows that it's working whatever we're doing for prevention and for better treatment of people with vascular disease. It's working well in both men and women. And yes, we may be putting ourselves out of business by reducing the event rates and reducing the death rates and the bypass rates and the stent rates and hopefully the transplant requirements. But we will never reduce the number of transplants we do because there are so many more patients that need a transplant that can get them. So Deborah Myers, you're safe for the future in your job. Okay, the rest of us have some difficulties. So risk factors have changed, but the truth is that yes, biological risk factors, hypertension, tobacco use and family history haven't really changed that much, right? Metabolic risk factors, baseline haven't changed, but how we take care of those metabolic risk factors have changed dramatically. And I would submit to you that one of the main reasons that we have this decline in mortality over the last 16 years is because more people take cholesterol drugs, okay? We have the same level of patients that have hypertension, probably even more as people become more obese. There's more diabetes. There's more insulin resistance. There's more sedentary activity, and yet the disease rates of death have gone down dramatically. Most likely because we're better twofold, better able to prevent disease by the good care that we're providing to our patients. And half of the benefit is also from what we do in buildings like this where we take better care of the patients once they become ill. So the techniques and the streamline approach to how we care for people have improved outcomes. So statin use is up dramatically since 2000. You can see that age over 65, it's gone to nearly 40% in females, about a third. And even in that age group, 45 to 65, that middle age group rates are increased really from very low rates in 2000 to widely accepted, 13 to 16%. People think that if you look at risk factors by obesity, if you look at how people live near the poverty level, the obesity statistics, this is actually interesting, is that people that are below the poverty level are not getting any bigger. They don't have any excess money to get any more bad food. Actually, the obesity rates are increasing at one to two times the poverty level because then there's a little bit extra money. And then people adopt that, you know, kind of really bad American diet in that age group. And so those obesity levels have increased. So what about menopause? So menopause really, honestly, women are at low risk for heart disease before menopause.  Have they had early menopause? As a way of measuring what their innate cardiac risk is for, you know, how quickly do you need to assess the patients? What about menopause increases the risk? So we know that menopause or menopausal women have a two to four fold elevated risk of heart disease. And menopause interacts with all the other risk factors for heart disease. It increases the weight, makes women a little bit more sedentary. It raises the blood pressure. It raises the glucose and LDL cholesterol levels increase. HDL levels tend to reduce a little bit over this period. And so all these things elevate a woman's risk for developing heart disease.  And that may be the reason why women develop heart disease full fold 10 years after men. Okay. So if you look at that ASCVD score, risk calculator score, and I'm going to ask how many people out there are using the risk calculator scores? It's catching on. It's a little cumbersome when you see the patient because you don't always have the laboratory when you see the patient. I find that to be one of the stumbling blocks. So what I tend to do if I've seen the patients before is we will calculate what their ASCVD score is based on this year's weight, and this year's age, this year's, you know, blood pressure, you know, and then use last year's cholesterol. But I will say, okay, this is the nuance of working in the field, is that you don't know what to do about the lipids when they're at that perimenopausal period because the lipids really are changing. If a woman is, you know, five or 10 years from menopause, their lipids, if they're not on drugs, their lipids are pretty stable after menopause. And I find that the, that's maybe a good paper. The ASCVD scores don't really change that much, but it's something I think that it's a little cumbersome. I find it effective, and I think that the patients like the information about is that you're just not like Willie Millen just deciding, you know, without any data. They can look it up themselves, and I sometimes give them, you know, the website, and I sometimes actually print out if the printer is working that's connected to my computer in the office. I print out what their ASCVD score is so that they can take it home, and I encourage them to play with the score. Like, you know, if your blood pressure were better, it would be better. If your LDL were lower, you would have a lower score. So I find that helpful. Okay, so let's go to women in heart disease and look at hormone trials. So I lived through this error, and I worked at the Brigham where Joanne Manson was a researcher for the Women's Health Initiative. And I was around the people that were studying this. And so during my fellowship in formative years, I mean, we really thought hormones were really good for you. And here's the reason why. All the observational studies looking at women pre-hormone and after-hormone or comparing hormone use that hormones, when given to women in the post-menopausal period, had a lower relative risk of heart disease. So these studies, you can see the blue dots are for estrogen replacement therapy and the yellow dots are for hormone or estrogen plus progesterone therapy, showed, you know, a pretty substantial effect on outcome for heart disease. The caveat, and this is what you have to understand, is when you look at these natural, I mean, observational studies, women that take or are willing or eager to take hormones, take hormones when they go through menopause, right? Because there's no reason to take, the main reason that you'd want to take hormones is if you have symptoms of menopause. So if you're far out from menopause, you've probably survived and you're not having that much symptoms long-term. So these studies are of women that started hormone when they went through menopause, right? It probably be age of 50, 51, 52, which is the average median age for menopause in our society. So the observational studies are different than the treatment trials for hormones. The thought was, why are hormones good for you? And one of the biological mechanisms is that estrogen encourages LDL to come down. Okay? It brings up the triglycerides. It raises the HDL a little bit, but the thought was that by reducing LDL cholesterol, it was having some beneficial effect in the vasculature. So the nurses' health study, many nurses here participated, actually my nurse, MC, is still in the nurses' health study, which I think is so cute, was a primary prevention study of coronary disease. They looked at healthy postmenopausal women, and it had a huge number, 28,000 nurses, which were kind of eager to participate in the study because the nurses' health study followed the very famous physician's health study by a few years, which came out with some very important findings and changes in the management of primary prevention. It's the study for which we demonstrated that aspirin was beneficial for heart patient or for primary prevention of heart disease in U.S. and British physicians after the age of 65. But in the nurses' health study, they looked at, it was a non-randomized survey questionnaire that was mailed out. They looked at current users of hormone and compared them to never-users, and they found that there was, in fact, a 40% reduction in coronary or arterovascular risk compared to the non-users, and a 50% reduction in all-cost mortality. They found that there was a loss of benefit after five years when the hormones were stopped and that those that had a natural menopause benefited more than those who had a surgical menopause. So here's the data. When they looked at it, that 28,000, and they looked at them over a longer period of time where they enrolled more nurses. So in the end, they had 70,000 nurses, and there was. This is actually an important study because it shows that if, I love the study because it's going to show something important that's going to be helpful when we look at the male data. We're going to look at stroke and heart disease deaths and compared to never-users, and this is dose-dependent risk, is that over a primary dose of 0.625, there was certainly an increased risk of stroke. There was a protective, thought to be a protective effort by the hormones to prevent heart disease. And this led the way to the HRS trial, which was a secondary prevention trial. Now, I was involved in clinical trials in this period, and really what they did in this trial was they took like a treatment trial for heart disease, much like they would have done for cholesterol drug treatment. So you take a population that you think is at risk that's older because really what is, if you're going to fund a study, you want to have the smallest number of people followed by the smallest amount of time because it costs less money, right? So they ran these trials for secondary prevention for hormone, much like they ran the cholesterol drug treatment trials. They took a population of women that were older, that had already gone through menopause and had been off hormone for at least a decade. So they took a riskier population of women, and they randomized them to estrogen or progesterone, or with progesterone in two groups. So there was HRS1 and HRS2, but long story, they had an average age of 67, so it was older women, and they looked at a four-year follow-up, and then the HRS2 trial was like a registry after the HRS1 where they followed women even longer for 6.8 years, and they had hard end points. They looked at CV death and MI, and here's what they showed. They showed really that the hormones really didn't make that much of a difference, but there was a little bit of an excess risk in that first four years for more women in the group that got the hormones, had more heart attacks and more deaths, and the study was stopped early, because it was clearly not going to show benefit. And even followed long-term, which was a beautiful thing that they did, because a lot of people would have said, well, maybe you didn't treat them long enough. So they enrolled and kept following the patients, half of them for another 2.8 years, and still no benefit. So this really was a wake-up call, and I remember it was like 2002. It changed how we practiced. So if you looked at the data for venous thromboembolism, or PE in the HRS trial, clearly there was excess risk of venous thromboembolism. Excess risk in the first year, the second year, the third year, the fourth year. All the years, excess venous thrombus, venovascular disease. So clearly a risk factor for DVT and PE. So then that led to the Women's Health Initiative, the WHOI, which was the first primary prevention randomized trial. But again, so this becomes a little bit more complicated, again they enrolled women at average age 63. So why did they wait? Okay, so the other rule about clinical trials is you want to run the trial as economically conservatively as you can, but you also don't want patients dropping out of your trial early because of side effects. So what they didn't want is people that were seriously symptomatic from vasomotor symptoms that got randomized to placebo to drop out of the trial and cross over to your active treatment. And they also didn't want women to bleed. So they started the trial in older post-menopausal women, average age 63, again, 10 years after the menopause. So nothing like the natural observational trials where women were started in the 50s. Does that make sense? Different kind of populations. So this was actually quite important actually as a trial. It was funded obviously by the NIH and was well done trial. They ran two concurrent trials. So they basically ran a trial for women that had a uterus and they ran a trial for those that had a hysterectomy. So the women and those two groups were not exactly the same. So they can't be co-mingled. The women that had the hysterectomy tended to be more underserved and more minorities. In this group, they got unopposed estrogen and they enrolled almost 11,000 women. This trials was stopped on time. It's almost seven years. Those that had a uterus, a bigger cohort, almost 17,000 were a lower risk group. Remember, they didn't have the ASCVD score. But if you look at the risk pool, that pool of patients was lower. This group got both estrogen and progestin in order to protect the uterus from uterine cancers, risk of the unopposed estrogen. And this study was stopped early because of risk greater than the benefit. The average age in this trial was 63. The primary outcome was non-fatal MI, heart disease death, safety outcomes were breast cancer. And then they did this thing called a global index looking at how many fractures did you have, how many colon cancers. And they were trying to figure out, overall, was this kind of treatment beneficial to the woman?  Maybe she died less of heart disease. And here's what the results showed. So in the patients who got estrogen and progestin, the heart disease risk was elevated by 29%. So you can see that here. The stroke rate was elevated by 41%. The venous thromboembolic disease risk was twofold. And this has actually been a very stable number for all treatment trials for women and heart disease. Total CVD was 22%. Fractures were actually down because estrogen improved the bone health and decreased fracture rate. Cancer was basically null. Death rate was null, but the global index was in the wrong favor of the hormones. And the trial was stopped and all the press was like, hormones are not indicated for primary prevention. They're not indicated in secondary prevention after hers. And there's some excess risk to take an estrogen and progesterone for women that have an intact uterus. When it's prescribed in your 60s. That's really what the outcome data shows. If we look at the annualized heart disease risk by year, the risk was the highest in the first year for a woman that's been without hormone and then you give her hormone. And then the risk kind of was basically undulating and followed the placebo group pretty well. If you look at what is the excess event rate per event in this study, estrogen and progesterone, there were seven additional heart disease events. There were eight extra strokes. There were eight pulmonary embolized. There were eight invasive breast cancers. There were six less colorectal cancers. There were five less hip fractures. So the global index was, you know, not in favor of the woman by 19 excess events. And because of this data, it really halted the practice of women receiving hormones.  I mean, there was a lot of like turbulence in the medical field during this period. If you looked at more in depth at the data, how women responded to hormone therapy was really, and what the risk group was like, really had a lot to do with how many years past menopause were they when they received the hormones. So for women within that 10 years of menopause, even with estrogen and progesterone in this study, and I know it's a subgroup analysis, and I'm leery of saying anything about that, but in that group, they appeared to be safer from hormone exposure than women who were over 10 years after menopause. So clearly, you would never treat some woman 10 years post menopause with hormones, but I would make the observation to you, we wouldn't treat that woman with hormones really anyway, because really the predominant reason to treat a woman is for symptoms, and symptoms occur early and they abate over time. So it kind of nullifies why we really treat a woman, but at this time in the period of, you know, medical knowledge, we really thought estrogen or progesterone would be beneficial long term for a woman, and we clearly demonstrated, especially in older women, and for those post 10 years after menopause, hormone treatment is actually adversely affecting their health. But it took, you saw how big the numbers were in the trial, it took thousands of women in a trial followed for four years before that data became obvious. Okay? I'm making the case for the men. Okay, so if you looked at the women only arm, actually it was much better, which suggests that the progestin added to the estrogen added a lot of the risk. So overall heart disease risk was null in women that had no uterus with treatment with just estrogen alone. But still you see this excess risk of stroke with estrogen alone, excess risk of PE. In this case there was an excess risk of, oh, venous thrombolymbolism, and overall hip fractures and overall fractures were down. If you look at it again, timing of when you give the hormone to the women without a uterus, then you see this gradient of risk by age and by time from onset from menopause. Not as robust as the one, the graph with the estrogen plus progesterone, but still an adverse risk as women grow older. And if you look at the number of events, you can see them and this is just for inclusion in your syllabus. It just shows you across the board elevated risk in women. Again, markedly changed by their timing from menopause. Again, I'm making the big case about hormones in all the trials showed an elevated risk of stroke. If estrogen alone, estrogen plus progestin, and I think the takeaway message is that hormones for women are not good long, long term for the prevention or for the elevation of your health. Certainly there's excess risk from all the data that we've seen, even the observational trials and from primary and secondary prevention randomized control data that shows that yes, indeed hormones increase your risk of stroke and your risk of venous thromboembolic disease. And because of those things, I warn women every time I see them at the risk of the hormone and you have to look at the risk-benefit ratio. Certainly this data is helpful in reassuring that for women that are going through menopause that have the most symptoms, taking hormones early may be safe. And here's some more data about the stroke risk. And so basically, I think we've summarized the WHOI in saying that there's elevated risk of breast cancer for those that received the progestin compound. There was definitely an increased risk of heart disease, particularly in the first year. There's elevated risk of stroke and the global risk was increased. For those that take estrogen only, it may be safer than those that take estrogen and progesterone, but still there's an increased risk of stroke and certainly no long-term benefit in these women. So basically, hormones are contraindicated in women with established disease for sure. Hormones should not be initiated for primary heart disease prevention. This is no statin drug and estrogen increases clearly the risk of stroke and venous thrombosis and hormones should be considered early after menopause for the relief of vasomotor symptoms. And honestly, the rule kind of in the community is hormones should be taken at the smallest dose amount of time and then encourage other kind of lifestyle modifications to help with that. Now, this brings up one important point about the timing hypothesis. So I know that people in the field thought that and you can tell, I kind of share that feeling that maybe those trials weren't really the treatment, randomized trials weren't really and didn't really capture what we really do in the real world by treating women with hormones when they go through menopause. The problem now is that we have two major treatment trials of women that showed harm, right? Which means that nobody's really going to be too eager to fund a trial of women for treatment effect of hormones even if you wanted to try it in people that are going through menopause. Does that make sense? An earlier treatment trial might have given us a different outcome and the timing hypothesis kind of addresses this. The question is whether estrogen when given to a woman as she go through menopause someone that has not withdrawn from estrogen may actually slow the development of atherosclerosis by improving lipids and endothelial function and the question is, can you prevent that? And so there's this whole thought that the observational and the clinical trials were disparate populations where the clinical trials were in older women the observational trials were in younger women menopausal symptoms were excluded in the treatment trial but those were the people that were included in the observational trials and then the timing since menopause obviously is much shorter in a treatment trial of women and then the whole question about the treatment of people post menopausal with symptoms and the observational trials they got estrogen for I mean I still see patients that just like refuse to come off their estrogen and they may be like close to 80 and you're like really I'm really not thinking it's benefiting you anymore and they're very hesitant to change their dose for those that have done well they don't want to come off they think it's the fountain of view in this whole question about obesity so if you look at those relative risks again you can see that in young women that get hormone, either estrogen or progesterone if they get it young and stay on it they did well but there may be some bias in these groups that those young healthy people that were really interested in their well-being were healthier enough to be exercising some intrinsic bias in these observational studies these were healthier vainer eager beaver women that were keeping their body weight down and less diabetes and making themselves healthier in other ways which could help to explain some of these findings the WHI took those primary prevention women that were randomized to hormone and when the study was halted they got money and they went out and calcium scores on over a thousand patients that were enrolled in the clinical trial which I think is a really a very fine test and I think some of you I've given a lecture here about calcium scoring looking for plaque as a marker of who has coronary disease so you might expect if somebody were to have more events later they'd have more of a calcium score when they're younger so they went back and they didn't have a lot of money they wanted to look at that early group of women age 50 to 59 who went through menopause recently and were randomized to WHI and were studied on the hormones for 7.4 years and they obtained calcium scores 1.3 years after the WHI initially stopped the mean age at the time of the calcium score was almost 65 and why calcium score is a marker of how much plaque you have and it's an inflammatory kind of marker that you can get that's actually very stable between measurements so it's like there's not a lot of error in the measurement it's like the calcium goes into a plaque and it sparkles so it sparkles under the X-ray so you can count the sparkles and it's a marker a pretty validated marker of elevated cardiac risk it's a pretty cheap test in the community it costs about $150 most insurance won't pay but it's I love it it helps me a lot and so you know who has plaque and in this study the women that got the estrogens alone actually had lower plaque mean scores and also had a significant p-value oops had lower plaque numbers so with some thought that this timing of when you give the hormone would maybe affect a surrogate marker for outcome and most I'm going to skip this one because this kind of goes again this shows that there's this aged variant variable on a gradient of risk in older versus younger women and it really remains unanswered quite honestly because I think people are going to find it problematic to run a trial of the right magnitude to answer the question but there is intrinsic data like mice models that estrogen itself inhibits progression of established lesions in the vascular and I'll say to look at I'm going to go to this one important case the elite trial because it was a New England journal article two years ago where they actually was earlier in this year where they took 600 post-menopausal women with no coronary disease and they treated them this is mainly in California so those people are kind of healthier they looked at two groups women that had been through menopause within six years and women who were over ten years from menopause and they looked at their treatment outcomes after being on hormone therapy and they used both hormones with uterus without uterus estrogen plus progesterone or estrogen alone and they looked at crotted entomal thickness and they did demonstrate that plaque growth was slower in the estrogen treated group taking hormones within six years after menopause compared to the group that had been ten years so I think that it's very clear that if you've been past menopause very clearly there's excess risk for women that are I think that the corollary would maybe be for women that are at ASCVD score higher that hormones would not be a good idea for those women even for prevention of vasomotor symptoms and so I kind of restrict the treatment or the counseling of women to treatment with hormones to those that are asymptomatic without heart disease who've been through symptomatic through menopause within the last six years really because after that you kind of already gone through it and then to restrict the hormones to that group that's in the low risk category because there are women out there that are suffering with vasomotor symptoms and honestly the best treatment really is hormone and if they're at low risk for heart disease I'm really kind of okay with letting them take it but again you don't know how long you need it until you withdraw the hormone and see how your symptoms are so I strongly advocate for taking the low dose that settles down your symptoms for the shortest amount of time and then to wean the dose off okay so what about menopause okay so there's this robust commercial advertisement to men about taking testosterone and I mean we are seeing young men I mean like one of my fellows last night told me see I'm the girl heart doctor so I have a different experience in my clinic than the male heart doctors that one of my colleagues is seeing men that are like all on taking the testosterone and makes me very worried knowing what I know about women and heart disease and hormone replacement therapy what we are increasing or are we increasing the risk in our male counterparts who may be at higher risk of disease anyway at similar age just because they're men right so what about menopause is it real I mean is it a manufactured disease to elevate the treatment of men to spend more money on testosterone products is it real is it worthy is it valuable is it safe and the answer is we don't have much information so I'm going to go through the data because there's going to be more data coming out so I'm preparing you for your reading of the literature in the next few years because people are interested in this more now than they have been so what are the symptoms of menopause well men will tell you they have low libido they're fatigued they're depressed they may have loss of muscle mass they may have more fat deposition and the signs of male menopause may be this loss of body hair low real androgen deficiency will cause low bone mineral density it'll cause gynecomastia it'll reduce the size of the testes reduce muscle strength and unfortunately it increases your fat mass so what's the relationship between age and hormones and men well guess what men when they're young make a lot of testosterone huge numbers look at the numbers 900 nanograms per deciliter it's a huge number and we all know men in their 20s act much differently than men in their 70s and I have a college student it's kind of scary to see this okay so it declines over time and this has been well demonstrated in multiple trials which came out in 2008 shows the relationship between age and hormone but it also shows the relationship between testosterone free testosterone and LH and sex hormone binding globulin so you get an idea what's the cause of why the testosterone declines in the male as he ages so with age there's definitely a component to end organ testicular production failure okay because the LH goes up okay obvious right so it has to be that the end organ has stopped producing very much like the end organ ovary and the woman stops producing hormone clearly it's not like the woman where it stops almost 100% by the age of 55 and a woman clearly in men they produce hormone much longer such that men can reproduce with children I can make some funny comments I'm gonna restrict my comments about men having babies in their 70s you know they can still have produce children and heirs but seriously after age 70 testicular production of testosterone declines so age is important in this decline in testosterone but the most important factor that makes testosterone decline is obesity okay and so they look at the same hormone levels testosterone free testosterone LH and sex hormone binding globulin and they broke it down by BMI so BMI less than 25 is pretty normal in America well no no I shouldn't say normal it should be normal it's not common right so BMI 25 to 29 which is really kind of normalish but it's called overweight and those over 30 are called obese although that is skewed by our population as well and they looked at the testosterone levels the LH levels the free and the sex hormone binding globulin and you can see that as the BMI's increase there's no real step up in the luteinizing hormone level which means that it's not just an end organ effect it's not that obesity suppressing the testes from making testosterone it's because obesity interferes with the hypothalamus pituitary axis to make hormones so it's interfering on top of age as men grow older they grow fatter you see how this rolls in together and it makes their testosterone levels drop even more so in fact it turns out that obesity has a much greater effect on male production of testosterone much much more than age in that if a man goes from a BMI on average from a BMI of 25 or less to over 25 he drops his testosterone concentration equivalent to 15 years of life okay so one could make the argument that if you want to have robust testosterone levels you need to stay skinny okay and that would help you the most so how do we make the diagnosis what's the real diagnosis of androgen deficiency you have to have symptoms of you know manopause and a subnormal testosterone level collected in the morning between 8 and 10 am why because testosterone has a diurnal variation and it's standardized at the highest level in the morning it's lowest at night and treatment is strongly discouraged for because if you don't need it if you don't really have really low testosterone levels because this is the funny part of the story if you treat a man with testosterone you're going to turn off his hypothalamus to pituitary to test his axis so that you're going to suppress his innate ability to make testosterone right so you're going to turn off his ability to make it and testosterone exogenously shrinks the testee size and makes less you're going to make that man less manly by giving him hormone and you're going to make him an addict to the hormone that you've given him which isn't good okay I should have been a lawyer okay so what are the contraindications you can't take it if you have known prostate cancer or breast cancer obviously so you have to check the PSA and make sure it's less than four but in men that are at high risk of prostate cancer like African American men or men with first degree relatives with prostate cancer you don't want to give the hormone to any man with the PSA over three it turns out that testosterone treatment makes BPH symptoms much worse and a BPH scale for BPH and a BPH scale of over 19 is going to do really poorly with testosterone it causes erythrocytosis so you don't want to give it to a man with a hematocrit over 50 because hormones increase your risk of venous thromboembolism right and thick blood increases that risk as well okay you shouldn't give it to a man that has untreated sleep apnea which is going to highly be prevalent in your population of these overweight older men because it makes sleep apnea worse you shouldn't give it to untreated heart failure people with known heart disease or people with the prior history of DVT PE okay that makes sense because it causes erythrocytosis sleep apnea there's a warning about DVT heart disease and these warnings have come out in the last two years okay so have we taken the diagnosis of adult onset hypogonadism and made it a disorder or are we just letting these advertisers have a robust marketing strategy and make you feel like you have a disease which in fact you just got older and got fat so what about the prescriptions for testosterone well guess what we're talking about like a serious billion dollar baby okay it's now administered in five forms patches gels injections over three million prescriptions since 2012 for androgel alone testosterone boosting cells are like off the chart I've got young men coming in asking for testosterone and so like I was like somebody I beg Dr. Willerson to do in his itinerary for the like the male and he was like I don't know if we want to get into that testosterone stuff and I was like you do you really do because it's a problem so I decided I tackle it so I'm brave I went for it so there's a warning from 2003 where the National Institute of Aging noted that there was scant evidence to support the idea of male menopause caused by transmission testosterone especially in men as they reach their 30s this rapidly growing use of testosterone by men seeking to fend off the effects of aging had outpaced the scientific evidence and so guess what some scientific studies have come a meta-analysis a meta-analysis of 27 small small remember how many people were in the women treatment or observational trials they were thousands and thousands before we got the right answer so what I'm suggesting to you that if this kind of risk is coming out in men in these small trials what's it going to look like in a big randomized trial which is why the industry is not going to support a trial to show that their drug is harmful you get it so it's going to take like the NIH maybe somebody in Europe to perform a trial so there have been 27 trials nearly 3,000 older men there were 180 cardiovascular risk and guess what testosterone had an odds ratio for increasing risk of 1.54 which really is just a 54% increase which isn't that great but they had a lot of healthier people because in this when they looked at a retrospective cohort of 56,000 men relative risk for MI was 1.36 in the three months after starting testosterone so it's little bit like the estrogen story where the added risk was really at the beginning of the treatment because it makes the blood a little bit stickier and if you already have plaques and you make your blood sticky you might be more likely to form a thrombus the risk was 2.2 fold higher in men when given testosterone the age of 65 compared to men less than 65 it was still 2 ok so that's an absolute risk of 6.25 or 10 cases per 1,000 patient years and pre-treatment serum testosterone weren't even included in this because most of these men didn't have their serum testosterone check they just decided they needed testosterone does that make sense they just went for it they just went for it so there is actually some studies looking at retrospective data in men here's the first one, 8,700 with low serum testosterone less than 300 which is low they were subsequently prescribed testosterone and they had a composite higher risk of all cause mortality MI and stroke compared to men that never saw testosterone hazard ratio 1.29 and these men were mostly older and 80% of these men had coronary disease the authors of the study wanted to reflect that it was just a small absolute risk of heart disease only 1.3% overall which I would submit to you is actually a generous risk ok remember in cardiology trials an absolute risk of 1% changed which you know the TPA dose we use for decades ok so 1% can be a lot of people if you're giving it to a lot of people out there so the testosterone trials this is important because this is new data there was they know that this is going to be a big problem for the public and they know it's going to cost a lot of money to answer the question so the urologists got together and they decided that instead of funding some huge amount of 20,000 30,000 men on testosterone they'd look to see first whether the testosterone treatment made any beneficial effect to mood, libido muscle mass and oh by the way we'll look at some heart disease risks because if we prove that it's not really making you feel better nobody's really going to want to take it anyway I think that's kind of reasonable that's what came out in the New England Journal and there was an editorial this year these are called the testosterone trials it's like a series of 7 double-blind randomized trials at 12 sites but there's 3 main trials one's a sexual function trial, one's a physical function trial and one's a vitality trial they were received these patients received testosterone gel or placebo for one year they were all older than 65 they all had serum testosterone levels lower than 275 on two episodes so they followed the rules it took forever to enroll only 1.5% of those that were reviewed because it was so hard to find men that made these criteria which is testosterone levels on two occasions lower than 275 with all the symptoms they excluded prostate cancer high risk cardiac patients why'd they do that because they don't want to have people dying in their trial so they excluded high risk cardiac patients because they're worried they excluded severe depression and what did they find it increased sexual activity sexual desire and erectile function but no difference between the groups on physical function or a 6 minute walk no benefit of vitality and their rates of adverse events were basically the same between group so in conclusion for women menopause increases your cardiac risk it increases your risk of DVTPE it clearly increases your risk of stroke it increases CBD risk in patients with established disease and it increases CBD risk in women over 60 over 10 years past menopause it is safe in women with low clinical risk it should be given only to symptomatic menopausal women in the smallest dose for the shortest possible time and what do we know about menopause and androgen deficiency is that testosterone levels decrease with age and more importantly they decrease with obesity androgen deficiency treatment with testosterone probably increases the risk of DVTPE probably increases the risk of heart disease and clearly increases the risk of prostate cancer may have some beneficial effects on sexual function but the jury is out on physical function and overall vitality so I'm going to leave it there and let you think about it I think that the questions aren't fully resolved like I personally I'm 50 I'm worried about it and I think there may be a role that hormone plays for women as they go through menopause that may actually may actually be preventative I'm holding out hope it may be true in men but I'm actually very cautious about given people treatment for which there's unknown benefit and clearly unclear previously ill defined risks especially to men that are at risk so in my population they're at risk and those are the guys that have the most erectile dysfunction because they have heart disease so one of my colleagues he really needs to like not suggest that the testosterone is going to make these guys healthier because it may be making more heart disease so I'm going to leave you all with that perfect


Welcome back to another beautiful day in Red Dead Redemption 7. Ah, hi. This is part 5 of my Breath of the Wild on Master Mode playthrough. It's like a 1 month and then 2 month and then 4 month in between each of these parts, so if you're somehow following along, I hope you're enjoying them. I said on the last one if we hit 20,000 likes, I'd do it again. Y'all have been screaming at me the last month or so, telling me that it's at 22,000 likes. So we're long overdue. If this one hits 20,000 likes, I'd do a part 6. Also, I actually went back and watched the very first episode. Apparently, I forgot I said at the start of the episode, this. Should I just keep Link naked? Smash like on this video right now. 20,000 to 25,000 likes and I'll keep Link naked for the entire playthrough. Um, I really don't want to do it because I'll be defenseless and cold, but I did say that I would and that video blitzed that goal, so I gotta make it naked. You know what? If this video can hit 25,000 likes, I get to redress Link the way I want, but as a trade-off, I have to do the entire next episode only walking backwards in master mode. I think I'd rather just be naked. So we left off in this town, Kakarot Village. It is now our responsibility as the savior of Hyrule to go to these four divine beasts and rescue each one. If I remember correctly, the one closest was a water elephant one, but I kind of want to go on like a road trip adventure. So how about we do things completely backwards and upside down and pick the one furthest away? It might actually take this entire episode to even get to this divine beast, knowing me playing on this mode, but it'll be an adventure. It'll be a road trip. We can go on together. Okay, look at ya! This is something you lay about, just doing nothing. I'm working right now. I'm in the middle of filming my breath. I'm filming my breath at the one! Nobody cares! Hey, you heard about Skillshare though? Oh, the online learning community where thousands come together to take the next step in their creative journey with thousands of inspiring classes, including but in no way limited to illustration, design, photography, video editing, and much more. You know, a simple yes would have been fine. Oh, oh yeah, sorry. Um, yeah, I've heard of it. Right. Well, you know in the past how I've taken guitar lessons, Japanese, and my personal favorite, Geordi's classes on Adobe After Effects, where I easily learned how to build scenes and create cool finger fire animations. And there was another class you took as well. What was it called? Oh yeah, the complete guide to eyebrow makeup. No, I didn't. I don't even know what you're referring to. Yes, you did. I remember you saying you hated how your eyebrows kind of gave up halfway across your face and you wanted to fill them out more. Anyway, my point is, there's always something new to learn on Skillshare. Whether you're looking to discover a brand new skill, perfect an existing one, or just crush some free time. Plus, Skillshare is super affordable. Yearly subscription costs less than $10 a month. And for a very limited time, Skillshare is offering you, my viewers, a free trial membership of Skillshare Premium. Just click the link in the description. I don't know what you're worried about. I think you have really nice eyebrows. Really?  And so our Trappered Adventurer heads out on his quest. A lengthy road trip across the land. What carols will he face along the way? What challenges will he overcome?  No, Blueby's fine. Look at him. You get to start the adventure with me today. I'm going to take great care of you. There is no way anything bad is happening to you today, okay?  You ain't going nowhere. Don't hit my foot! No need to waste that arrow. What kind of greeting is that?  All right, whatever. Let's do it. Let's knock out this shrine real quick so that I have a spot I can teleport to if I get stuck. You know what's actually kind of creepy? I'm just kind of goofing and gaffing for the video along with the music, but I actually felt really at peace then while I was doing that. Like I was actually meditating. If I get stressed out at any point during this playthrough, I'm oming my way to calm mind. Ah, great. Oh, no. We got this. Round one. I might die. Okay, I gotta do it a couple more times though. Oh my god. Oh, one, two, three, four, four. There we go. There we go. There we go. There we go. You don't really even have to count. It's just when he, when he blasts. Round three. Yeah, no, easy, easy, easy, easy. See, this game, it's going to be okay. As long as I can master parrying, it's going to be okay. As long as every enemy gives me that wind up where I can time it, and they do it on a strict schedule, it's going to be okay. Actually, this might work. Go, go, go, go, go, shield.  Ah, just, just, just keep moving. Just keep moving. You got to really get down there. Otherwise it doesn't work. I'm talking like the diaphragm, not your throat, not your gut, from the freaking diaphragm. If you can get that oom out of your diaphragm, that's inner peace. Your inner peace is right here. I've learnt today, I'm a guru now. Oh no, I'm going to block him off here. Float link, float. Oh, easy. I swear that one right there is like the easiest shrine. And it took me a good 10 minutes to get through. What is that guy over there doing? Is that a damsel in distress? Oh my gosh, it's a damsel in distress. Possibly a male. I'm not going to assume. I'm coming. Bluebee, we have work to do. Your hero is here, milady. Just knock him into the water. Just knock him into the water. Knock him into the water. There he go. Oh, oh, oh. There he go. You all right now, milady? Milady. Oh, look who's here.  A little help next time, maybe. You'd be, you're, are you, are you kidding me? Yeah, yeah. I could end the play through right here right now. Just run straight into the castle and take down Ganon with my master torch. It'd be pretty easy. You know, I, I skilled Zelda player like myself to just run in there with my, my, my, uh, Twiggin' Berries and just take down the old Ganon. But I feel like you guys want more of a play through than that. So purely for your sakes. I'm going to keep on going. Don't, no, no, no, no. Bazinga. Oh, he's so fast. I can't get away.  All right, yeah, stay there, stay there, stay there. I guess they have a barrier they can't cross through. Um, you want to move? You want to move? Oh, Bluebee. Oh, Bluebee. Oh, what do you say, pal? We saved the maiden for old times sake. No, we die. I am so sorry. Do you have any recollection as to what happened to you, my friend? It's so fast. Well, maybe Bluebee is just really slow. I just got to keep spinning it. It's fine. I just have to keep dodging it and not get caught up. Oh my gosh. There's another one down there. Okay, I think we, we've shaken maybe. Yeah, we've shaken that one. All right, we're fine. Why is there another one down there?  Master mode straight up turns Breath of the Wild into an Australian house. I don't need you spider freak. Behind the tree, behind the tree, behind the tree. Hit the tree. Oh no. Oh, Bluebee. Bluebee. Bluebee. Bluebee. Bluebee. It can't climb. Surely it can't climb. Oh, it can climb.  Oh, this is cool. This is a real pretty area. I think I should probably try and get down here though. You got this, Bloobs. Turn around. Just right down there. There we go. Good boy. Or girl. We still don't really know. The sky is really pretty in this game. I can't wait for the sequel. I'm excited to see how it looks because this game looks pretty good, but it was. There's no way we're beating that. I kind of want to try though. Oh, I can pick it up. Drop it.  I like that they give you the weapon. Like, here's a sword. Do what you can. That will hit. Good. Good. Good. Good. Good. One more. Get out. Get out. Get out. Baby. Stop healing. Stop healing. He's healing again. I'm doing so bad. Get him. Get him. Get him. He's almost... I'm not even, I'm not even in the diaphragm. Little tree. I know you're going to do it. Oh no. Oh no, I hit the tree. I wish I could do more damage, man. Go, go, go, go, go. Go. Stop pushing the trunk. You absolute mad man. Booty slam. Booty slam. Works for me, buddy. Works for me. You get two more hits him when you do that. Take a phone or something. All right. Just stare at me. Just freaking stare. Why can't I run with it? Run, run, run, run. Oh, I can throw it. Oh, he brings it back in. Oh shoot. Oh shoot. No.  I don't know what I'm doing. Look how healed he is. Look how healed he gets. I have nothing left. I have nothing left. I literally have nothing left. I don't know what to do. I need another weapon though. I feel like I've trapped his eye away from him, but I have nothing to attack with anymore. I wonder if I can grab anything off of him. I guess you just have to keep the eye away from him from a certain amount of time and he just deteriorates? I did it. I'm happy. Can I skyrim this up the mountain or is my horse going to be difficult about it? My horse is going to be difficult about it. Come on, Bluebee. Are you coming, Bluebee? Bluebee. Good job.  I don't know how you figured it out. You're so reliable, buddy. You're so dependable. I definitely haven't killed you twice now. Oh, that's a nice tree. There has to be some kind of secret on that tree, right? Yeah, definitely a secret here. Hey, buddy. You found me. Here's some poop. So we might need to make the rest of this on foot. I don't think Bluebee's going to be able to make it. I'm sorry, Bluebee. I'm sorry. Oh yeah, we've made it. We're good. We're good. We're good. I really wish I could see a stable. Wait, is that a stable right there? I think that is. Oh, it has to be a stable, because there's a guy here. Hello? I am an adventurer from a faraway land. And I didn't realize that y'all have the power of invisibility or instant transport. We're going to be reunited once again. I would like to order one Bluebee, please. And there you go. Thanks for choosing us for all your horsey needs. Also, why are you naked? All right, bud. You see that big flying ominous bird in the distance? That's where we're headed. Am I going to get around this with my horse? I don't want to abandon him again. Don't tell me I've come all this way and I can't make it over there. I can't make it. Maybe if I go up there. Oh my gosh. What? Oh my god. Like, there's no way I can make it. I'm going to fall to my doom. Oh, it's going to be close. It's going to be close. I might. Oh, Bluebee, I'm sorry to love you and leave you, but I think I can make it, bud. We can never be reunited for more than a minute. He's so sad. He's just staring off into the distance. He always leaves me alone cold at night. He's killed me multiple times. See, usually people don't do this one first.  But I do like that. I mean, everyone's adventure is so different, right? I can start where I started and try and get here on nothing. And this is the way I got here, you know? Like I climbed around the side of the mountain. Like other people might have found an actual path. That made sense. Not me. This is how I did it. And I like that it's so different for everyone. Hey, guys. Oh no, wait. Are they bad? Oh, those are bad. Oh, those are very bad. Oh, that's bad too. Oh, that's all bad. This is all bad. Oh, there's another. Bluebee, I keep getting to these stables on foot, calling my horse and then having to do it again immediately. I'm so close. I'm so close. I can, I can taste it. I can sniff it. I can lick it. Oh my gosh. That honestly was one heck of an adventure. We did so much on the way here. I'm really glad I decided to road trip this first one. Oh, I was like, what is happening? I do not look forward to battling the blight on board that thing with four hearts and three weapons. It's not happening. It's just not happening. Hey, look, I'm here. A traveler at this hour. I'd show you around, but now it's not a good time. You could say we're not in a welcoming mood. Well, I came a long way, so you better roll out the red carpet. Talk to the folks in the village to hear all about it. Any other questions? Well, this guy's kind of had it rough. He's had a bad day. I'm going to leave him alone. All right. Well, in the next episode, I'm going to explore this village. I'm hoping that you guys can do the 25,000 likes. So I don't have to be naked anymore. I guess try and take down that giant thing only walking backwards. So don't hit 25,000 likes. Just try and hit 20,000 so we can get another one of these. And just call it there. You don't need to go the extra 5,000. That's fine. I hope you had a good time watching this. I feel like this was one of the better episodes. I had a lot of fun today. So I hope you guys did too. I love you all. Hey, if you haven't subscribed to me yet, I'd appreciate it. We do a lot of fun things here. Stick around. Also, if you want to watch me play games live without all these crazy edits, you can come follow me over on Twitch. We have a stream schedule now, so you'll know when to find me live and what I'll be doing. We play Nintendo Switch every Saturday. What will I play? I don't know. I'm not in the future yet. Just come hang out and follow me there. Have a good time. Oh, legit meditation today is a good day.


When the narcissist gets their karma, when the narcissist brings misery and misfortune upon themselves resulting from their actions Towards the end of the relationship The narcissist showed no consideration for you They showed no care or concern It was all about them It was all about what they could get from you They scapegoated you They used you as that emotional punching bag They took out all of their emotions on you They got angry at you Even though you may not have done anything wrong They had you running on this endless hamster wheel trying to please them Trying to make them happy Trying to make things right But nothing was ever enough for them They could never be satisfied They were never grateful for anything you did for them They never appreciated you They always criticized everything you did for them what acted like it wasn't enough They ran you into the ground and showed no consideration for you Because it was all about them It was all about what they could get from you Regardless of how it affected you By the end of it you felt defeated You felt immoralized and overcome by adversity You ended up in this difficult and unpleasant situation While the narcissist just seemed to ride off into the sunset Many people who go through these situations May begin to lose faith in whatever they once believed in They may question how God could allow this to happen to them And they may wonder why didn't the narcissist get their karma How could they just ride off into the sunset after everything they did to you? How could you be left behind with nothing after everything you invested in them? The truth is this is all a part of your experience in life You didn't come here to live in a perfect world with sunshine and roses There are unpleasant things to deal with too Things that will help you to learn more about the nature of other people Things that will help you to learn more about yourself And there is nothing more valuable than having this awareness You could have all of the money and success in the world But what is it worth if you have no awareness of anything? You had to experience these things so that you could raise your level of consciousness So that you could become more aware So don't think that God isn't on your side God would never put you through something that he knows you cannot deal with You have everything you need to come out of this stronger and more aware You may not see it right now But one day you will feel grateful for this experience Because it has woken you up to the truth Now you know the true nature of people You know what some people are capable of And now you've learned more about yourself The narcissist is already getting their karma How we treat people is a direct reflection Of how we feel about ourselves Their behaviors should reveal to you how they really feel They will act like they're doing great They will act like they're so much happier without you But just look at everything they did to you Look at how they left you Look at how they had no consideration for you Those are not the behaviors of someone who is happy Only someone who hates themselves would engage in those behaviors And when they leave you Nothing changes They may post pictures on social media And act like they're so much happier with someone else But that's still a part of the illusion Remember how happy they pretended to be when they were with you It's all an act And it's only a matter of time until they reveal what they really are They know that no one wants to be around a miserable angry person So they hide it They pretend like they're happy Because if you look back You will realize that's what drew you in That's what attracted you to them You wanted to be around that fun happy person Until you realized that it was all a lie And now they're just doing the same thing with someone else They're fooling them and they're fooling you They are getting their karma Every day is hell for the narcissist That's why they always need a source of supply They can't be alone They always need something To distract themselves from reality They always have to project their shame onto someone else They always need someone to be their emotional tampon Because they're miserable inside And they cannot cope with those feelings When the narcissist leaves you They think they're getting away with everything They think they've won something But that is actually just another part of their karma Because by leaving you without taking accountability They never grow or develop They never learn from their faults and mistakes And they stay the same for the rest of their lives They never progress It doesn't help them in any way It only causes more problems for them down the line Because the only way to progress in life Is by taking accountability It's only then that you are able to make the changes that you need to progress To become better But they will never make the changes that they need to progress Because they're always playing the victim It's always someone else's fault And that is why they stay stuck That is why they stay miserable and dissatisfied For the rest of their lives Their entire life is just a distraction from reality They never really live in They find people, drugs, alcohol Whatever will help them to escape from life But they are not happy They are receiving their karma They are dealing with the consequences of their actions And that is why they are acting this way towards you It's just another distraction from their miserable lives Thank you for watching I hope this video isn't with you Please like, comment, share and subscribe If you would like to donate My PayPal link is in the video description Coaching queries You can email me at coaching.narksurvivor.uk Thank you for watching and I'll talk to you soon