Side effects of Antipsychotics - MCCQE

Added: 2026-05-25

[00:00:00]Heat. Heat.

[00:00:03][music] [music] >> [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] [music] >> Hallelujah. Hallelujah.

[00:01:44]>> [music] [music] [music] [music] >> Heat. Heat.

[00:02:12][music] [music] [music] >> [music] [music] [music] [music] [music] [music] >> HEY DOCTORS, IT'S TIME. It's time. It's time. I'm excited. You know I told you that tomorrow I have a very important meeting and therefore we cannot make up our usual Sunday meeting and that is why we are meeting now. Thank you for making time please I want to know can you hear me clearly? If you can hear me clearly just type yes yes yes yes in the comment section. I know it's late. I know it's a Saturday night. We usually don't do this, but hey, I have a pack with you. I need to meet you every week and I'm going to do everything possible to meet you. So, please let me know. Can you hear me clearly before we jump in and don't forget to send this link to as many friends as possible. If you've not also subscribed to our YouTube channel, please do so. Let's study for the Canadian board exams, MCQ1, Nakoski, TDM, OT, you know, how to prepare for the interviews, everything together.

[00:04:12]Currently, the numbers are growing. They are growing. They are growing. Please share the link. Share the link. Share the link with as many friends as possible. Let's get in there. Let's study. Let's go ace the MCQ1 exam. I don't want to bore you with so much announcement, so we're going to dive right in. Tonight's class is going to be straightforward, simple, you know, facts only so that we can get the best out of our preparation time. I'm excited as usual to meet you. So, let's get into it. We are still reviewing the free MCCQE exam questions by the Medical Council of Canada. They've provided 55 questions. I think we are currently on 24 or so. It's exciting for me. I'm very glad about it because it's revealing a lot of things that candidates don't focus on. I have a question. How many of us have been have been happy with the sessions we've had and you know how the sessions have really opened your eyes to understand what a medical council requires. How many of us can testify to that? I want to see it in the comment section. How many of us were initially just reading Toronto notes or master the boards which are very good books but did not know how to put things into context and now because of these sessions we are having you go like Dr. Brun I think I'm beginning to appreciate how the medical council wants me to think I want to see it in the comment section you know how have you how has these experiences really helped you in your preparation okay so Dr. Jenn Jess Jessica um says she's she's one person it has really really helped and for me that is what gives me joy so far as you are being helped that's the most important thing right because you know many people read books we read master the boss tentali Toronto notes you know AFMC primer but then many people don't know how the question will be crafted and for me if there is anything I'm very grateful about about these Canadian board exams it is these sample questions that the medical counselors offered you know then it helps you okay so this is how they actually craft the question so now let's jump into the class right away and get things going okay so that is what we are doing today and if you need um do you all have the 55 questions do you all have them if you don't have them as well let me know so that I can send them to you right away because for me. It's very very important. If you don't have them, let me know. I'm sharing the link right now. I'm sharing the link right now. Go to the MCC website and make sure that at least tonight before you sleep, you've solved all those questions. I'm sharing the link to the 55 questions right now.

[00:07:07]Okay? So, if you don't have them, please make sure you do have them. If you don't have them, please make sure you do have them so that you can even go back watch some of the previous videos I've done to ex to understand the concepts as they are taught because what's the point preparing for a board exams when you don't know how the board exams will be set. It doesn't make any sense, right?

[00:07:29]So please, I've sent the link. Okay, so I think Dr. um this doctor said I don't have it.

[00:07:37]Please share it with me. Thank you. So I've sent it in the group and you know every day we have new people joining us who don't know um anything about these free questions. So that's why it is good to ask this question. All right. So let's get into the game then. Let's get into the game.

[00:07:54]Let's start the game right away. So this question is focusing on a particular important topic we need to know. So it says a 36 year old man presents to your clinic after receiving a diagnosis of schizoeffective disorder about 6 months ago.

[00:08:16]At that time he started taking an atypical antiscychotic medication and has gained 15 kilograms. Which one of the following is the best next step?

[00:08:30]Which one of the following is the best next step? A prescribe a high protein low carbohydrate diet. B change to a different atypical antiscychotic medication. Counel the patient to live with this adverse effect and D refer the patient for buriatric surgery. What is your answer? What CS DA doctors? What sayest thou? 36 year old man diagnosed with schizo effective disorder prescribed atypical antiscychotic. He's gained 15 kilograms. What will you do for this patient? Prescribe a high protein diet, low carbohydrate diet, change to a different atypical antiscychotic medication.

[00:09:20]Counsel the patient to leave with the adverse effect and D refer the patient for beriatric surgery. What answer will you go for? Will you go for A? Will you go for B? Will you go for C? Will you go for D? And I see a lot of doctors going for B. They said, Dr. Brun, we going for B for boy. B for boy. And B for boy is the correct answer. B for boy is the correct answer. Right.

[00:09:46]And there's a rale behind it. Why is B for boy the correct answer? Now, this patient has experienced significant weight gain. 15 kilograms in six months.

[00:09:57]My goodness, you are predisposing the patient to so many risk for so many things. Now I have a question. What is the patient in danger of developing with this 15 kilogram weight gain in 6 months? Doctors, please give me at least three diagnosis that you are concerned about that the patient can develop because they've gained 15 kilograms in 6 months. I want to see the answers right away. 15 kgs in 6 months. What are the dangers this patient is um open to? What are the dangers this patient is open to?

[00:10:35]What are the dangers this patient is open to? Please let me know. 15 kg 15 kg 15 kg gain in 6 months. What are the dangers?

[00:10:53]Please. I said three. I want five now.

[00:11:05]I want five. So type two diabetes, hypertension. Okay. Metabolic disorders.

[00:11:11]Well, metabolic disorders is not specific. So if you can, you know, um if you can help me to know what can the patient develop? What can the patient develop? What can the patient develop?

[00:11:21]15 kilograms in 6 months. What complications are you concerned about?

[00:11:27]Okay. Cardiovascular risk. Well, yes, but what what is it? So for me, number one, the patient can develop type two diabetes. The patient can also develop um metabolic syndrome. The patient can also develop even non-alcoholic fatty liver disease. Right? When you go to the cardiovascular system, the patient can develop hypertension.

[00:11:46]The patient can also develop obstructive sleep apnea.

[00:11:50]Right? The patient can have osteoarthritis as a result of weight gain. The patient can have chronic back pain as a result of the weight gain. If the patient is um a female pose um but that should be something the patient is already having and then this can make it worse. If the patient is a male the patient can even have decreased testosterone right decreased testosterone they can develop depression as a result of that. So please you have to know the dangers involved or associated with increased weight gain.

[00:12:26]The dangers associated with increased weight gain. So let's continue the class. That was just aside. So the best next step is to change to a different atypical antsychotic medication as some have a lower propensity for causing weight gain. And for me this is very critical when the medical council says this this is very critical right in the rational. So if I were studying and I'm going to give you a strategy around this. If I was studying this is something I would really pay attention to which antisycchotics cause weight gain which antisycchotics do not cause weight gain and even the atypical antsychotics what are the unique features of each of them and in fact today's class is going to focus on those ones right and this approach directly addresses the root cause of the weight gain while maintaining the necessary treatment for schizoffective disorder.

[00:13:15]So this patient has two concerns. The patient came in with schizo effective disorder 6 months ago. You prescribe the medication. The medication has caused the patient to gain weight and we've learned all the risk factors assocated with the weight gain. Now we are also thinking how can we still manage the patient's schizoffective disorder but make sure that that weight gain the patient has developed is sorted. So that is why now you have to look for one at one medication which can treat the schizoffective disorder but does not cause weight gain. That is the essence of this question. That is the essence of this question. Now, what are the why are the rest of the answers wrong? Prescribing a high protein, low carbohydrate diet, while potentially beneficial for weight management. It does not address the medication induced weight gain and may not be sufficient alone. Right? This patient has developed weight gain as a result of a medication.

[00:14:15]So in part as part of your management plan you should be seen addressing that particular medication while you still deal with the patient's schizoeffective disorder management.

[00:14:27]Now counseling the patient to live with this adverse effect is not a viable option as it disregards the patient's health and quality of life. as well as referring the patient for biatric surgery. That's an extreme measure because we don't even know the patient's BMI, you know, and typically it is reserved for cases where other interventions have failed and the patient's weight poses an immediate health risk. But this is somebody who has just seen this change in their weight in 6 months. 15 kg weight gain.

[00:15:02]So your duty is deal with it, switch to a different medication and that is the basis of today's class. And what is the reference? This is the reference the medical council got a question from. And guess where it came from? It came from PubMed again.

[00:15:19]Since the beginning of this review, every question has been coming from here.

[00:15:29]Every question has been coming from PubMed.

[00:15:32]So what is the learning point here?

[00:15:35]Please don't just read textbooks, read articles as well. Don't just read textbooks, read articles as well. Nobody has been telling IMGs these things. I am the one who is telling you because I don't just look at the question. I go behind the question to look at even where the question was sourced from.

[00:15:56]Okay? So if I were you tonight, I'll take my time and just read this particular article. This is where the question was drawn from. So now based on all these things that the medical counselor is providing, what will be my study strategy if you are my student? And this is the same thing I'm telling my students. In fact, on Thursday, we are going to have a a six a five hour class, five to six hour class on ethics alone. And it's going to be strategy, strategy, strategy, strategy. That's it. For me, I believe in strategy. I believe in learning the principles because if you understand the principles, then you can apply the principles no matter how the question is set. Right? So for me, it's all about strategy. And so based on this question, what strategic points should you learn?

[00:16:43]Number one, tonight you must review your antiscychotic pharmacology, the side effects of all your antiscychotics, typical and atypical antisycchotics. You must know the side effects of all of them and you must also know which side effects are unique to specific antiscychotics.

[00:17:04]And then number two, you must learn the management of antiscychotic induced weight gain. What is the stepwise approach to antiscychotic induced weight gain? Number three, you must also learn these principles. If I am prescribing an antiscychotic medication to a patient, what metabolic monitoring protocols am I going to put in place for this patient?

[00:17:36]But you know what? You can only learn and know the metabolic monitoring protocols for patients on antisycchotics if you know which antibiotics cause what. Right? So for example, we just talked about um something very very important and I'm just going to walk you through some of them. The fourth point is this schizoza effective disorder. The question was talking about schizo effective disorder. So you need to understand what's the diagnostic criteria of schizo effective disorder.

[00:18:06]And then you also need to know the diagnostic criteria for other various psychiatric presentations like anxiety, like depression, like obsessive compulsive disorder, like schizophrenia, like this d this time, psychia, all these things. Now doctors, I have a question. This is not part of the class, but I have a question. We just talked about all these complications of atyp um of weight gain and we learned in this question that there are some atypical ants psychotics which can cause weight gain and the strategy for learning this particular topic is that we must also learn how we going to monitor the patient. So my question is this.

[00:18:51]If you have a patient who you are prescribing antiscychotics for, please tell me three investigations, just three, three investigations you will request in a patient who has been prescribed antiscychotics cuz for me this is very important. We learned that some complications can be diabetes, hypertension, fatty liver disease, obstructive sleep apnea, um back pain, osteoarthritis, low testosterone, you know, it can worsen polycover syndrome presentation.

[00:19:27]So my question is this it what what investigations will you request for?

[00:19:32]Okay, so thank you very much. God's favor bright just dropped the first question. The first answer says I am going to monitor CBC. Why? You will realize that some antiscychotics can cause a granuloccytosis.

[00:19:48]So that makes a lot of sense. This doctor also says I'm going to monitor the lipids and HBA1C. Why? Because weight gain goes with hyper lipidmia.

[00:19:57]Weight gain goes with diabetes.

[00:19:58]Beautiful. This doctor says I'm going to do CBC and ECG. Why? Because some antsychotics lead to myioabitis. Some antsychotics lead to a granuloccytosis.

[00:20:09]Beautiful. This doctor says I'm going to ask about history of allergies to medications. Well, doctor, yes, you need to ask that. But I'm ask the question I asked specifically was that you have a patient who has been prescribed antiscychotics, right? And we learned that specific anticycchotics cause specific problems. So what are some of the metabolic screening tests that you do? Some people have said ECG, HBA1C, complete blood count, lipid profile, what else? Liver enzymes. Beautiful, beautiful, beautiful. So for me, this makes a lot of sense, right? And as we go through the various antsychotics, we're going to see what to do now. So let's do a deep dive.

[00:20:56]Why do some atypical antsychotics cause weight gain?

[00:21:02]And you have to understand this from first principles. I understand that the MCCQE is not like the US step one where in the US step one you are writing exams on basic science. But do you know something? From the way the medical council has structured these questions, something is really stepping out to me.

[00:21:25]It looks like they've assumed that you must have your basic sciences intact.

[00:21:32]And that is why the MCQ is like the USML step 2 CK, right? So they they assume that you must have your basic sizes intact because this is a typical USMLA step one basis question. Then they've built the step two CK question on top of this. And what do I mean by this? You've got to understand the biochemistry behind this.

[00:22:00]The reason is because antiscychotics block receptors in the brain. That's the first thing you have to understand. And some of these receptors control hunger. [snorts] Now the two big receptors I want you to focus on are the H1 histamine receptor blockage from some atypical antsychotics. And when there's H1 histamine receptor blockage that stimulates appetite directly. So if you have a patient who is taking a medication which blocks H1 histamin receptors it stimulates the patient's appetite and the patient then eats more.

[00:22:40]Then there's another receptor which is the five HT2C serotonin receptors when they are also blocked what happens is that it removes the breaks that are on the patient's appetite. So please remember these two receptors very well.

[00:22:56]You don't need to know it specifically for the MCQE but it helps you to understand the foundational knowledge you need to have right if you are writing the USMLA step one sure you need to know this but for the MCCQE you don't need to really know the names of these receptors but you need to understand what happens if these receptors are blocked one will stimulate the patient's appetite and the other one if it is blocked removes the break on the patient's appetite right So the patient just keeps eating and eating and eating.

[00:23:30]Now two atypical antsychotics I want you to know the tips I need you to know. Closer pin and lanza pin.

[00:23:41]Both closen and lanzapin block both the H1 and 5 H2C receptors.

[00:23:49]And we learned that the H1 will stimulate if you block it, it stimulates hunger and the five H2C if it is blocked it takes away the breaks on the patient's appetite. And so you realize that among the atypical antiscychotics, if you want the two atypical antisycchotics which cause the most weight gain, doctors please I need you to write this in your book. Write this in your book. The two atypical antiscychotics which cause the most weight gain that you need to know for your MCCQE exam which are commonly prescribed in Canada are closen andzapen.

[00:24:35]What they also do these two antsychotics they also directly worsen insulin resistance and they raise triglyceride levels. That is why one doctor said I am going to also monitor the lipid profile of the patient and the worsening of the insulin resistance and raising the retriglycerides they are independent of the weight gain itself and therefore you realize that closenine and oanza pain accelerates cardiovascular disease and diabetes.

[00:25:09]Doctors, I want to put a break here.

[00:25:13]Like the way um the 5H2C receptor blockage puts the removes the break on appetite. Please did you get the point I just made about closing and olanszapin? Did you get that point that I made about it? how it affects triglycerides, how it affects weight and how these two are the most notorious antiscychotic medications. I'm talking about atypical antsychotics which cause weight gain and it associated metabolic risk factors. Please, did you get that?

[00:25:53]I want to make sure. Did you get that?

[00:25:55]Beautiful. Beautiful. So, this doctor says copied. Beautiful. Please write it in your notebook right away. Write it in your notebook. Tonight it's hard facts.

[00:26:06]I'm just giving hard facts you need to know so far as these antsychotics are concerned. All right. Now, there's another there's another set of anticsychotics that I need you to know something unique about and we will take time and break them down.

[00:26:22]Ariprazole and zipidone.

[00:26:26]Ariprazole and zipone. ariprozone and zipone have a low affinity for the H1 N5 HT2C receptors. Guess what? Because of that, these two medications are weight neutral.

[00:26:44]They are weight neutral. So in your questions term if you were switching the patient from closer pain or olansza pen because of the weight gain I would have gone with ariprazole and I've seen that the psychiatrist in Canada love ariprazo they love ariprazo so please note that you know I always say something common things are common things are common doctors Common things are common. Olanza pain closen. Boom. Weight gain. Which medications are weight neutral? Say that if a patient is struggling with their weight, that is what I will prescribe.

[00:27:28]Ariprazole and zipraid.

[00:27:33]Ariprazole and zipraid.

[00:27:37]Okay.

[00:27:39]So doctors, now I give you this table.

[00:27:43]forget about what is on the third column which is the memory trick. I want you to just focus on this particular um table and review this. Review this table.

[00:27:55]Okay. Weight gain risk and the drug.

[00:27:58]Which two medications cause the most weight gain? Closapin oranzapin.

[00:28:06]Which two atypical antsychotics cause the least weight gain? Least least. At least number one, ariprazo number two zipone number three lauracidone.

[00:28:20]Okay, so think about this ariprazole.

[00:28:23]Zepraidone lauracidone they cause the least weight gain. So if you have a patient who is who needs an atypical antsychotics atypical anticotic but the patient is already obese or the patient was tried on a medication like closenine or lanzapin and you need to switch because of weight please go with ariprazo go with zipraidone or go with luracidone now quit and respirone they can cause weight gain but they don't cause weight gain like closer pin and lanza pin. They don't cause weight gain like closer pain and lanza pin. Okay. They don't cause weight gain like closen and lanza pin. So please which medications cause the most weight gain atypical antsychotics closen or lanzapin moderate weight gain quite respirone. Least weight gain ariprazole zippraidone.

[00:29:21]Now beyond the issue of weight there are some unique things you will need to know about specific atypical and psychotics.

[00:29:29]So we're going to pick them one by one.

[00:29:33]We're going to pick them one by one. As I said tonight's class it will be taught in such a way that even if you are sleeping and someone wakes you up you should be able to rattle it. So let's start with closing.

[00:29:44]I know we've talked about weight gain but let's talk about close up. You know the name ends in pin and that reminds me of the pine tree. That is why I put the picture of the pine tree there. What is unique about it and what is it about the pine tree that I need to remember about closeupin?

[00:30:04]Close-up has the highest risk of weight gain among the atypical and psychotics.

[00:30:10]Now why did I put the pine tree there?

[00:30:13]So that it's a memory trick. Remember that close-uping makes appetite climb like a pine tree.

[00:30:20]So in your board exam, remember Dr. Bron was shouting on a Saturday night that close up makes appetite climb like the pine tree.

[00:30:31]Now what are the things which are associated or what are the conditions which are associated with close up?

[00:30:39]Weight gain, we already know that. This lipidmia we already know that hypoglycemia leading to diabetes and type two diabetes risk.

[00:30:48]But remember closing makes appetite climb like a pine tree. That is why it's called closing. Pine closing pine tree.

[00:30:59]Okay. Now the mechanism h me memory is that it blocks both the H1 and the 5HT2C maximally and it increases appetite and sedation. So please remember close up in pine tree grows fast.

[00:31:19]Right? So appetite goes up, weight gain goes up. What are the risks involved?

[00:31:26]Weight gain, dysipidemia, hypoglycemia, type 2 diabetes.

[00:31:33]Which receptors does it block? H1 uh receptor and five HTT2C.

[00:31:40]It blocks it maximally. What is the unique thing about it? Closeup increases appetite and also increases sedation.

[00:31:49]Please doctors please if you got it just type close-upin. Just type close up so that I know that we are sealing the class on closeupin. If you got it just type close up for me. Type close up.

[00:32:03]Close up. Close up. Close up. Tonight we need to understand some things. Cold.

[00:32:09]Cold, cold, cold, cold. I'm not going to joke with them. Cold, cold, cold. Close up can also lead to certain unique things.

[00:32:19]A granuloscytosis, myioarditis, seizures, and constipation.

[00:32:29]So just type close-upin. If all that we've said about close-upin makes sense to you, it makes appetite climb like the pine tree. Close up pine. pine right leads to hypoglycemia, metabolic syndrome, hypertlycemia.

[00:32:45]It can lead to sedation and other things which a patient with closer pain, you should watch out for a granuloccytosis.

[00:32:53]So this is the patient that you want to check their complete blood count.

[00:32:57]Myioarditis, this is the patient that if the patient complains of chest pain, you want to get your ECG, you want to get your troponine levels. Seizures. So if I have a patient who already has seizure disorder, I will not prescribe close-upin for the patient and it can lead to constipation as well.

[00:33:17]Hello doctors, please I need to to to know that you are following me. I need to know you are following me. So please are we all good on closeup pain? Are we all good on close-up pain because I'm going to the next medication. Are we all good on closeup pain? So if the question asks you for the antsychotic with the greatest metabolic risk burden, please think about close-up. Think about close zapping. Think about closeup.

[00:33:46]Okay, close up. Think about that. Now let's go to the next one. Olan Zappen.

[00:33:54]Lanzanapen.

[00:34:10]Okay.

[00:34:14]Olanzapen.

[00:34:16]Soapen. Think about lard.

[00:34:19]Lad is like the the fat in pig. And I know you know um as a multicultural country we have brothers and sisters who don't eat pork.

[00:34:31]In fact I myself don't eat pork you know. Um but just for teaching purposes that's why I brought this. So I hope no one is offended by it. Right lad right just to so that you can understand it.

[00:34:42]It's that fat which lines pork. Okay. That fat which lines pork.

[00:34:50]So olanzapin always remember lad lad the fat which lines pork.

[00:34:57]So what will eating fat do to a patient?

[00:35:01]It can increase weight gain as well.

[00:35:04]Right? And olanzapin is as notorious in causing weight gain as close.

[00:35:12]So just remember olan zapin lad olad ulad ulan zapin it's at lad right and it is strongly associated with increased appetite it's also strongly associated with sedation insulin resistance and this lipidmia so its side effect profile is very similar to close upapping right its side effect profile is very sim similar to close-upin So, we've talked about closing.

[00:35:45]We've talked about pin. Now, let's go to quayappen.

[00:35:51]Quit pin. Look, look at the way quit pin is spelled. Quiet appin. Quit pin. Why am I saying that? And why did I put the emoji of the the the patient with the hand on the mouth? There's something unique I want you to learn about it. Why did I put it there?

[00:36:10]Quitapping we learned causes moderate weight gain. And the memory trick about quiet is that quitin makes the patients quiet, sleepy and ity. So they eat a lot, they feel sleepy, [snorts] right? And then they are also quiet.

[00:36:33]That is why I put quiten quiet and eating.

[00:36:39]Okay. So, quitin is a very sedating medication because it has strong histamine H1 blockage and you realize that when it comes to weight gain, the weight gain of quitin is not as severe as that of closenolon.

[00:36:58]But the unique things you need to know for your exam are quit can lead to autostatic hypotension. So if you prescribe quitin for a patient what will you monitor? I have a question doctors autoatic hypotension. If you prescribe quitin for a patient what will you monitor when the patient comes into your clinic to visit you? What will you monitor?

[00:37:27]What will you monitor?

[00:37:31]What will you monitor if beautiful beautiful so doctors before you jump to ECG do the blood pressure before you jump to ECG do the blood pressure right so quit can lead to autostatic hypotension so what will I do I will check the blood pressure when the patient comes to me it can also lead to sedation and it can also lead to metabolic changes But remember that the metabolic changes are not as severe as the metabolic changes that closen and lanzapin will will cause. So for me remember quarapin will cause the patient to be quiet the patient to be sleepy and the patient to eat a lot right doctors.

[00:38:19]So please are we all on the same page with quitin?

[00:38:24]Okay. So with quitin think about the sleepy antiscychotic and remember that if you have a patient who is sleeping a lot and the patient is not exercising that can also lead to weight gain but the weight gain of quitin is not as bad as that of oanszapin and closen.

[00:38:48]So please remember remember remember these things doctors please is it making sense so far I I don't want to overwhelm anybody. So if you are sleeping tonight and I want to see the comment in the comment section or else then I'll have to go back right. If I should quiz you on Olanza pin and closing doctors please can you answer questions on them? I want to know pin closing. Can you answer questions on them?

[00:39:16]Can you answer questions on pin and close pin? Okay good. Now can you also answer questions on quay pin the unique things about quit pin can you answer questions on them beautiful okay if that is the case now let's move on to the next stage resperidon resperidon resperidon resperidon rises prolactin moderate weight. It rises prolactin.

[00:39:53]Resperidone rise. It rises prolactin. It causes increased prolactin levels. So I have a question. If you have a patient on respirone and the patient comes to your clinic, what question will you ask the patient? You have a patient with who is taking resperidone and the patient comes to your office. What question will you ask? In fact, I'm really enjoying today's class. Eh because of you know the unique things about each of these medications you have a patient on resperidone and the patient comes to you beautiful so the doctor is saying because of the issue of prolactin I'll ask about galactoia beautiful any breast description another another doctor said someone is also saying aminora yeah that because of the effect on prolactin right but galactoria gynecomastia the patient a male and if it patients a female immora as well respirone rises rises doctors please I hope you are enjoying the connections we are building right like close up pain pine resperidone rise quarin quiet and sleepy right okay okay good good okay so let's continue let's continue so resperon can cause weight gain but it weight gain is the weight gain profile is similar to quitapen it weight gain is not as bad as oans pen and closen okay good so what are the unique issues about respirone it causes moderate weight gain and the unique thing you need to remember is the prolactin elev ele elevation that's why I said it rises prolactin So it can cause galactoia, it can lead to aminora, it can lead to sexual dysfunction and in males it can lead to gynecomastia.

[00:41:59]Gynecomastia gynecomastia okay so this doctor says what beautiful explanation y [laughter] doctors look let's make Q1 nak oski tdm preparation simplica it should be simple it should not be anything complex it should be simple and that is why we do this in med cognto beautiful explanation beautiful doctors we thank you that you've appreciated what we do so tricks to notes about respironone.

[00:42:30]The weight gain is usually less than that of olanzapin and closen.

[00:42:36]But the weight gain in respiron is more than that of ariprazo zipraidone and rasidone.

[00:42:44]Okay, that's something you need to know.

[00:42:47]Okay, good. So the memory trick if the question combines an antiscychotic use with aminora or galactoia think about respir okay so you may have the question which talks about weight gain and aminora okay go with respirone weight severe weight gain in a short period with this lipidmia think about close up in right weight gain some weight gain and the patient is very sleepy and the patient's blood pressure is dropping please doctors what atypical and psychotic will you think about some weight gain but the patient's blood pressure is dropping some weight gain but the patient's blood pressure is dropping what will you choose some weight gain but the patient's blood pressure is dropping when the patient stands the patient feels dizzy.

[00:43:50]Feels dizzy.

[00:43:52]Beautiful. So the doctor says I'll go with quit tapping. So you see antisycchotics are not difficult and I I just did a poll and I'll be putting out the results of the poll very soon because um I asked the candidates next month we are going to do another marathon session free for metcognito students, right?

[00:44:15]what area do you want us to deal with?

[00:44:17]And some people are saying Dr. Bon we want you to go through psychiatry but the the the the the the vote is still going on and if you want to partake in the vote I want to plead with you just click on this link and join our Facebook channel.

[00:44:37]Okay, if you're not part of our Facebook channel yet, just join our Facebook channel. Just join the Medco Facebook channel or you can send me your WhatsApp on plus 1368915649 plus 1368915649 plus 3068915649 I'll respond myself and he say Dr. Everybody, I want you to add me to the WhatsApp channel, you know. Good. Oh, what is this doctor saying? Let me see.

[00:45:05]He says, I was very afraid of anticychotic questions because I find them very difficult, but your session is helping. So nice of you, doctor. Yes doctors, these things, this is what we do in the marathon sessions, right?

[00:45:18]These are the things we do in the marathon sessions so that you'll be able to appreciate exactly what we are dealing with. There's no need to be afraid. Q1 is not a difficult exam. If you should learn the right way, you should make it simple. So let's continue. Let's continue. Okay. So antsychotic with aminora, antsychotic with gynecomastia, antsychotic with galacto. Think about respirator.

[00:45:42]Beautiful. Now let's go to ariprazole.

[00:45:46]Ar prazol. Ar prazo. Remember, think about a repeat. Ripped. Somebody who is ripped. So people go to the gym. Let me go and let me show you this. They go to the gym.

[00:46:00]They lift weights, right? People go and go to the gym. These are the baby weights my my daughters use.

[00:46:06]They they they lift weights. So think about ariprazle as the antsychotic which makes you get ripped. You are ripped, right? You are ripped on the fat. And so that's why this guy looks so ripped.

[00:46:17]Look at him. He has the sixpacks.

[00:46:20]He has six packs. Why?

[00:46:22]because ariprazole is ripping him of the fat because we learned that ariprazole zipidone lauracidone do not cause a lot of weight gain right so that's what I used to remember ariprazo will keep you ripped right so ariprazo causes low weight gain risk there's low weight gain risk because the patient is ripped right so just think about it when you see a reprozle think about the patient who goes to the gym and the patient Arupo patients don't look like those who are onapp or closing right they are ripped so think about it that Dr. Bon brought some weight to show. Okay. All right.

[00:47:03]All right. So, let's continue that. I repeat, Brazil unique mechanism. They cause partial dopamine D2.

[00:47:13]Um they they are partial dopamine D2 agonists and they are less likely to cause weight gain. They are less likely to cause prolactin elevation and they are less likely to cause sedation. And that is why you see the psychiatrist like it in patients with schizophrenia, schizoffective disorder, psychosis. If they have to um prescribe something, they can go for this. But what is the unique thing about ariprazo? It can cause athesia.

[00:47:46]Athesia.

[00:47:48]Athesia. Doctors remember these unique things about the various medications.

[00:47:54]acthesia.

[00:47:58]So sometimes ariprazole is used when patients develop hyper prolactinmia from other antiscychotics. Okay. So for me the exam pearl is this a more metabolically friendly antiscychotic is I repeatzle I repeatzle I repeatzle doctors please is it making sense? Is it making a lot of sense? Is it making a lot of sense? Ariprazo. Then we go to zraidon.

[00:48:26]Zraidon.

[00:48:29]Zepra. You know the way you have a zip in your dress, right? In your shirt or in your sweater or in your jacket.

[00:48:37]Zipraidone zips up the weight. It zips up the weight. So now we are looking at all the medications which cause decrease weight gain or they don't cause a lot of weight gain as atypical ants psychotis.

[00:48:51]We've left ariprazo now we looking at zraidone but we learned that ariprazo even though it does not cause a lot of weight gain it can lead to athesia so that is something I'll always remember right zippraidone.

[00:49:06]So zepraidone zips up the weight. So that's one to zipping up. It's like I always tell my daughters zip your mouth. You know if you zip your mouth that means you don't see anything. So if you have something which is zipping the weight that means it does not allow the weight to go out of control. It has low weight gain risk and it has because of that it has minimal metabolic effect compared to closenine pain and quit pain. But the unique thing about zepraided is QT prolongation.

[00:49:39]QT prolongation.

[00:49:41]And another thing about zprocidone is that you need to take zipone with food for proper absorption. So I have a question for you doctors. Since zipidone causes QT prolongation, what investigation will you request before you prescribe zraidone?

[00:50:02]unique things. Unique things you need to know these simple simple it's not it's not because you can sit down and just read read and go psychotics psychotics but if you take your time and break it down beautiful yeah so someone says I'm going to request ECG and that's the correct thing ECG and remember that if you are prescribing zraidone you are prescribing it with food you are prescribing zroidone with food okay so zraidone is weight friendly But always watch out for QT interval.

[00:50:36]So I'll be very careful to prescribe zraidone in a patient who is also taking something like acetroycin or in a patient who is taking something like um effluinolone right because zraidone can affect a cutie and we also know that and so if you have a patient whose is already prolonged please exam trick don't give zepraidone this This is how you prepare for the exam. Simple stuff, right? Okay.

[00:51:10]So, I know zraidone weight gain. Um um zraidone is weight gain.

[00:51:19]And then which other medication goes with you'll be asking yourself which other medication goes with athesia?

[00:51:26]Agatsia.

[00:51:28]Okay. So, which medication goes with acesthesia? Then you go like okay I remember it's right. So unique unique unique unique unique unique things. And then lauracidone luracone it's also lean rasidon lauracidone while ariprazole is ripping and zypraidone is zipping luracidone is leaning. It makes the person lean. It doesn't cause a lot of weight gain right. Low weight gain risk.

[00:51:59]And the memory trick is that luracidone will keep the patients lean. It also has good metabolic profile but it must also be taken with food at least 350 calories for absorption. You don't need to remember that 350. You just remember that it is good that you take it with food. It is often used in bipolar depression and schizophrenia and it has no risk of sedation and weight gain than quitin and doctor. So the exam pearl is this.

[00:52:35]Luracidone is a great lean antiscychotic to remember. But always remember that you need to take it with food.

[00:52:43]Luracidone. Lean acidone. Luracidone.

[00:52:47]Lean acidone. It is a good antiquotic which will keep you slim and good and you you are okay. But remember that you need to make sure that the patient is taken with with food. So let's get our color coding going. Closapin and lanzapin will make you your your weight climbed. Quitin and resperidone they sit in the middle so far as weight gain is concerned. Ariprazo, zipracidone and luracidone keep it lighter. It keeps the weight lighter. Doctors please I have a question now.

[00:53:26]With all that we've done, are you now confident that you can solve some questions?

[00:53:32]Are you now confident that you can now attempt some questions? Please, I want to know. Are you confident that you can now attempt some questions? We've gone through you know the likes of Oanzapin Cloapin and then we went through quarapin and resperidon and then we've gone through luracidone ariprazole and um zepraidone so now that we've done all this are you sure that you can solve some questions good so for today that is why I didn't lead today's class with questions first right I wanted to establish the principles then based on the principles we can go into some questions. But before we get into the questions, I want to remind you if you love the explanations we did and you want to have similar deep explanations on ethics at least five to six hours where we're going to cover everything from CMPA doing right and for the metcognito students you have a replay in your portal so far as your access is concerned but if you're not a metcognito student you can have access to the replay for at least one month. And remember after that class on ethics, you're also going to get mock exams which will quiz you on each of these ethical principles.

[00:54:55]So doctors, for me, it's very simple.

[00:55:00]It's one of three things.

[00:55:02]I will encourage you to go for the six months metcognito program so that you can have access to all the monthly deep dive sessions with me for free. Okay? Or you can even decide to register for just one month. Just one month. One month you get access to everything in Medco including our question bank, our mock exams. You can attend all the live lessons we will do and you can even review all the lessons we've done if you can review everything in one month. You have access to all the notes as well for just $450.

[00:55:41]Or you go like Dr. Bon, my exam is June 1st, so I don't have time to go for one month, but I want to attend this ethics class. That's fine, doctors. For just $100, just $100, you get access to the ethics class. You get access to replay of it for one month. You get access to all the mock exams under ethics as well.

[00:56:04]It is I'm I'm usually this class is conducted for only met cognto students but a lot of people reached out. So doctors please let me know if you are interested in just one month. I will send you the link and you can do the registration right now as we speak.

[00:56:22]Okay? I'm sending you the link right now. you can do the registration before we start solving the questions. So I'm sending you the registration for the one month so that you can get access to everything in metcognito for one month and then if somebody also says Dr. Bony I just want it for I just want the ethics class and everything which comes with it. Okay, that's fine. It's only $100 and doctors, you know, to spend time with me for one five hours for $100.

[00:56:52]It's it's it's it's it's a giveaway. But I'm like, you know what?

[00:56:57]I want you to commit yourself. I will suggest that go for the 6 months. Okay?

[00:57:04]And for the 6 months, you have various options.

[00:57:07]You have various options.

[00:57:09]You have an option to become a meditative student for 6 months. onetime payment of $2,199.

[00:57:16]Or if you want to pay it monthly, it's only $420 every month. Okay? Or you can do just one month payment, $450 to get everything in metal, including that ethics class for free. Or if you want just one one time ethics class with us, so you can get replay for one month, that is also fine. That's just $100.

[00:57:39]Okay? And after the class, I'm sure we can you can I will stay up and answer all your questions. So if you want to reach out to me, plus 1368915649 plus 1 3068915649.

[00:57:52]I think there are two questions here.

[00:57:54]Let me answer them and then we'll go into the questions right away. So someone says, "Doctor, my exam is in October. So can you do ethics class of 5 hours in the end of September?" Doctor, we are doing it now. the replay of that class will be in your portal till so so far as your met cognto student right but because every month we deal with a problem the candidates want so next month we'll deal with something different okay I'm not going back to this ethics class in September because in September the students may say Dr. we want you to deal with pediatric emergency medicine or we want you to deal with public health and bioatistics or we want you to deal with screening something I don't know the candidates themselves decide and currently there's a poll going on where candidates are deciding on what they want us to teach next month some are saying psychiatry some are saying emergency medicine so I'll take time analyze it and then I'll make the results known to you that when we threw the challenge you said you want us to do this next month all the topics that we do the marathon sessions we do with me it is the candidates who decide don't forget that we already have a timet which is running which is running right every Sunday evening and every Thursday evening so tomorrow evening you have a class but these are special classes we do once every month with me okay and these are things that you tell me Dr. this is my weakness and we deal with it. Okay. So if you want this ethics it will be recorded. It will be in your portal. Remember if you're not a metcognito student you'll get access for one month. If you're met cognto student you get access so far as you are in the med cognto program. Okay good. Someone was saying I was looking to take your ethics class at the end of September.

[00:59:42]Sorry doctor. No we are not doing it at the end of September. We just doing it this time and the class will be available if you are coming in in September. [clears throat] So that should be fine. Okay. Good. All right.

[00:59:53]So now let's jump in and solve some questions based on everything we've learned.

[01:00:01]So the first question is this.

[01:00:04]A 45year-old man with schizopffective disorder has been stable on Oanza pin for 2 years. His physical exam shows a BMI of 38. His hbaw1c 7.2%.

[01:00:15]Triglycerides is 4.5. His psychiatrist wants to switch to a weight neutral antiscychotic. Which of the following would be the most appropriate switch?

[01:00:26]This one should be easy. You should be able to close your eyes because we've already done it. A quitin B. Close up.

[01:00:32]C. Ariprazo. D resperadone. E. Clomrom.

[01:00:39]What's the correct answer? This one. Do it quickly because we've already gone through it. We've gone through it. We've gone through it. We've gone through it.

[01:00:46]You know what the answer is. You know what the answer is. You see now look at the way the doctors are answering the questions with a lot of courage. I repeat everybody's getting it right.

[01:00:55]Everybody is getting it right. Why?

[01:00:56]Because you've been taught right.

[01:00:59]Doctors look I always say these concepts they are not difficult. The only thing is who is teaching you? Who is guiding you? Who is leading you to the promised land right? And that is why metro is here. So ariprazo we learned is the has the lowest metabolic risk among the atypical antsychotics and they did a meta analysis of 59 studies which showed switching to ariprazole resulted in a mean weight loss of 5.52 kilograms with improvements in the patients fasting glucose and triglycerides.

[01:01:30]We learned that qualar pain and respirone they cause moderate weight gain. Closer pain and lanza pain cause moderate to high metabolic risk.

[01:01:39]Resperadone moderate risk. Clomroin is a first generation antiscychotic with severe metabolic side effects. So we'll go with ariprazola.

[01:01:51]Next question. You have a 22 year old woman with first episode of psychosis needs to start an antsychotic. She has a family history of type 2 diabetes and a BMI of 31. She's very concerned about weight gain. She also has a history of long QT syndrome. Which antiscychotic is the best choice? Haha. You know, we threw in a wrench. Woohoo. You know, you you have the question. You think we are going to just deal with weight. Now, we've thrown in the issue of QTC. So, you are going to avoid medications which affects the weight and you're also going to avoid that unique antsychotic which affects the QT. So are you going to go with zraidone, ariprazole, olansza pen, quay pen or closen?

[01:02:42]What answer will you go with?

[01:02:45]What answer will you go with in the first place from what we learned? Which antisycchotic affects QT QTC? Which antisycchotic affects QTC?

[01:02:56]Which antiscychotic affects QTC? Please someone should tell me which antsychotic will affect QTC the patient's QTC which antsychotic will affect the QTC. So let's reason through it because if we know the antsychotic which will affect the QTC okay if we know the antiquotic which will affect the QTC then we will want to avoid it and then we'll also want to avoid antiquotics which cause increased weight gain.

[01:03:26]So what's the best choice?

[01:03:29]What's the best choice?

[01:03:32]And the best choice would be ariprazo.

[01:03:35]So the answer is B because the patient has a history of long QTC. So you want to avoid zippracidone which causes which will affect the QTC and you also want to avoid olanszapin and closing which cause so much weight gain and you also want to avoid quitin which causes some weight gain but a reprazil will not affect QTC and a reprazil will not increase the weight. Doctors are you getting the whole thing? The answer is B not A. The answer is B not A. So please, if you chose A, I'm sorry. The answer is B. Why is it B? Let's think through it again.

[01:04:16]This patient is concerned about two things. Number one, weight gain. Number two, the patient has QT issues. So you don't want to prescribe a medication which will affect the patient's QTC. So among the atypical antsychotics, which medication affects the QTC? It is zipone. So I'm not going to give zipone.

[01:04:34]So A is canled. Now the patient is also concerned about weight gain. So I asked myself the rest of the answers B, C, D, and E. Do they all affect weight?

[01:04:45]Does close-upin affect weight? Yes.

[01:04:48]Closapin causes mad weight increase.

[01:04:52]Quitapen. Yes, but it is moderate. Not as bad as close-up. Olanza pen, yes.

[01:04:57]Similar to closen therefore I'm going to avoid olanszapen, quitapen, and closen on the basis of the weight. and I'm going to avoid zipidon on the basis of the QTC. So the obvious answer is B.

[01:05:11]Doctors, you can solve QE questions like you're doing mathematics.

[01:05:16]I eliminate this. I eliminate this. You know, so the the medical council throws a wrench. I dodge this one. I dodge that one. I dodge that one. And then beautiful. Now the correct answer smiling at you. Okay, good. Let's go on to the next one. So the question test two things. When I was printing explanation, I put the question is testing you two things. Zraidone will be weight neutral but is contraindicated in long QTC and ariprazole is weight neutral and has minimal QT prolongation and closen quit and they carry significant metabolic risk and poor choices given her diabetes risk factors. So the obvious answer will be arr.

[01:06:02]Beautiful.

[01:06:04]Next question.

[01:06:06]Next question. A 30-year-old man on the respirone for schizophrenia develops gynecomastia and galactoia. His prolactin level is 85 and a normal is less than 20. His psychotic symptoms are well controlled. What is the best next step?

[01:06:26]Haha. A 30-year-old man on resperidon for schizophrenia develops gynecomastia and galactoia. His prolactin level is 85 nanog per male. The normal is less than 20. His psychotic symptoms are well controlled. What is the best next step?

[01:06:47]A add brooccin. B switch to ar prazo. C add kabolin.

[01:06:56]D reduce resperidone dose by 50%. And E switch to olanza pain. What's the correct answer? What's the correct answer?

[01:07:07]What is the correct answer?

[01:07:11]Someone says switch to ariprazo. A lot of doctors are going with BB and the correct answer is B. The correct answer is B. Resperadone causes prolactin elevation. Switching to ariprazo which is a partial D2 agonist with lower prolactin will lower prolactin because it stimulates rather than blocks D2 receptors in the tubo infendibular pathway. Right? Adding a dopamine agonist which is A and C is not first line and it introduces unnecessary drug interactions and reducing the dose may worsen the psychosis and remember that olanzapin has moderate prolactin effects and significant metabolic risk that is why you are going with ariprazo okay let's go to another question so you have a 25-year-old old woman who was started on Rip Brazil for schizophrenia.

[01:08:11]After one week, she reports an unbearable urge to move, pacing constantly and inability to sit still.

[01:08:20]Her mental status is otherwise unchanged. What is the most likely diagnosis and best treatment? A tardive diskynesia start valenazin.

[01:08:32]B athesia start Ben's tropin. C athesia start propranol.

[01:08:40]D drug induced parkinsonism start benzropping and e restless leg syndrome start primeipex.

[01:08:52]What's the correct answer?

[01:08:54]So this question is testing you at three levels. Number one, the patient is taking RPA. What is the side effects profile of RPA?

[01:09:08]If you know the side effect profile of Brazil like they've described it, but what is the answer? Is it Parkinsonism?

[01:09:14]Is it tad disynesia? Is it um um athesia? What is it? Okay. Now, if you know what is being described in the question, what is the treatment for that?

[01:09:27]What is the treatment for that? So, some people are saying it's athesia. Okay. So if it's acthesia, are you going to start broncry? No, sorry. Benstropping or you going to start propanol? So this question is now testing you. Do you even know the management principles for athesia?

[01:09:44][laughter] Do you know the management for athesia?

[01:09:46]And the correct answer is C. You're going to start propanol. You're going to start propranol.

[01:09:53]Why? So some people will go for B because they know it's a cathsia. But the answer is B and C. This is acthesia and the most common side effect of RP preso. [snorts] Now the key distinguishing feature is a subjective inner restlessness with an urge to move you know which occurring within days to weeks of starting the drug. The treatment is with beta blockers not anticolinergics.

[01:10:23]Okay. The treatment is beta blockers not anticolinergics.

[01:10:27]and benstroen treats drug induced parkinsonism not acthesia and tardive diskynesia will take months to years to develop not one week. So you see you need to know the side effect profile of typical and atypical antsychotics how they present like how will the patient be presented to you in a board exam the timeline and then the management.

[01:10:59]Okay. So, tab diskynesia takes months to years to develop not one week and restless leg syndrome is worse at rest and at night and it involves the legs specifically. So, doctors that is it.

[01:11:14]Next question.

[01:11:16]A 42year-old woman on closeup pain for 3 weeks presents with fever 38.5° tachicardia chest pain and fatigue. Her absolute neutrfil count is 3,500 which is normal. Troponin is elevated at 0.8 nanog per mill and her CRP is 95 mg per liter. What's the most likely diagnosis?

[01:11:46]A a granuloccytosis, B neolytic malignant syndrome, Closapene induced myocarditis, D pulmonary emolism, and E pneumonia.

[01:12:02]What's the correct answer? What's the correct answer? What's the correct answer, doctors? You see, I got you. I got you. I got you. I got I got you so bad. Those who are going for a I got you so bad. You know we know that closer pain can lead to a granuloccytosis. But if you look at the absolute neutral count the question says the absolute neutral count is normal.

[01:12:31]It is normal. So why are you going for a? The correct answer is C. The patient has closing induced myocarditis. Why?

[01:12:42]The patient has a fever.

[01:12:44]normal absolute neutrfil count. The patient has chest pain. The patient has elevated troponine.

[01:12:52]Therefore, the patient has something going on with the heart. Which of the answers goes with the heart? It is closing induced myocarditis.

[01:13:02]That's the correct answer doctors. The answer is C, not B.

[01:13:08]The answer is C. Closer pain induced myocarditis. When we started the class and I was talking about the unique medications and their concerns, remember I talked about closer pain and this is this is how the classic closing induced myocarditis presents.

[01:13:30]The patient will have fever, the patient will have tachicardia, the patient will have chest pain, the patient will have elevated troponin and the patient will have elevated CRP.

[01:13:42]doctors are you picking up the tricks?

[01:13:45]So you see I always say it is not enough to read a textbook.

[01:13:50]Read a textbook but solve as many questions as possible whether ASQ Bank the for the medical council of Canada and the questions they sell. Please don't go into the exam without buying them. Buy them. Do them right. It helps you. It it shapes your mind so that you can now put things in context. Okay. I've read about psychosis and psychotics but how do I approach it in a board exam?

[01:14:19]So this is closeupin induced nioarditis.

[01:14:23]So doctors it's been a wonderful evening. I've really enjoyed this class antiscychotics atypical antsychotics side effect profile.

[01:14:33]You want to talk to Dr. Brony. This is my phone number. I know it's a Saturday night but I'm here for you.

[01:14:39]It's 10:15, but I'm going to stay up and respond to every phone call which comes through. Doctors, Dr. Bony, I want to take advantage of it and, you know, jump onto the um class you're going to do on ethics. I'm sharing the link. Dr. Bony, I need one month access for everything in mito for just $450. I'm sharing the link. Dr. Bony my exam the way you've taught me I think Dr. Bony I need help Dr. I need to revise badly.

[01:15:14]Okay, I'm sharing the link. 6 months access.

[01:15:19]Someone says, "I love antiscychotics now." [laughter] Look, this doctor says, "I love antiscychotics now." Well done. Good, good, good, good. I love anticycotics as well. Doctors, Dr. Brun, I want everything in met cognitive for 6 months. I'm sharing the link right now.

[01:15:40]I'm sharing the link right now.

[01:15:41]Everything in Medco Cognito for 6 months, I'm sharing the link right now.

[01:15:45]Okay. So, doctors, please reach out right away before we all go to bed. I'm ready to pick your calls. Let's have a conversation. Call me right now if you need help. Dr. Bony, please help me. Dr. Bony, let me cognto hold my hand. Dr. Bony, let me cognito guide me. This is what we are here for. Okay. a granuloccytosis, myioarditis, ariprazo, growing like a pine, lard, all those things. It's also going to be on YouTube for you. Please come back, watch it tonight, review it, share the link with as many friends as possible. Please reach out right now. I prefer WhatsApp plus 1 306891-5649.

[01:16:27]Plus 1 306891-5649.

[01:16:30]Again, plus 1 3068915649.

[01:16:34]Let's get talking. I'm waiting for the first call. I'm waiting for the first call. Doctors, good night. All the best.

[01:16:40]Sleep well. Remember, we are not meeting tomorrow in the afternoon, but you are meeting tomorrow in the evening. It's been a wonderful evening. Good night.

[01:16:49]Bye-bye. Bye-bye. Bye-bye. Bye-bye.

[01:16:56][music] [music] Heat. Heat.

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