This document provides an overview of key concepts in medical statistics, including probability, sample size, effect size, odds and odds ratios, risk and risk ratios, standard deviation, confidence intervals, interpreting clinical trials, number needed to treat (NNT), and types of trials. It defines these terms and provides examples to illustrate how to use statistical measures intelligently to evaluate clinical research studies.
These annotated slides will help you interpret an OR or RR in clinical terms. Please download these slides and view them in PowerPoint so you can view the annotations describing each slide.
These annotated slides will help you interpret an OR or RR in clinical terms. Please download these slides and view them in PowerPoint so you can view the annotations describing each slide.
A non technical overview of sample size calculation and why it is necessary with some brief examples of how to approach the problem and why it is useful to actually think of these calculations.
The ppt is a short description about how to ascertain the validity, ie; sensitivity and specificity of a screening test as well as their predictive powers. you can also find the technique to ascertain the best possible screening test through the help of an ROC curve...
A non technical overview of sample size calculation and why it is necessary with some brief examples of how to approach the problem and why it is useful to actually think of these calculations.
The ppt is a short description about how to ascertain the validity, ie; sensitivity and specificity of a screening test as well as their predictive powers. you can also find the technique to ascertain the best possible screening test through the help of an ROC curve...
Study of the distribution and determinants of
health-related states or events in specified populations and the application of this study to control health problems.
John M. Last, Dictionary of Epidemiology
In order to understand medical statistics, you have to learn the very basic concepts as mean, median, and standard deviation. interpretation and understanding of clinical study results depends mainly on statistical background.
Wellens syndrome. Wellens syndrome (also referred to as LAD coronary T-wave syndrome) refers to an ECG pattern specific for critical stenosis of the proximal left anterior descending artery. The anomalies described occur in patients with recent anginal chest pain, and do not have chest pain when the ECG is recorded.
Congenital defects can put a strain on the heart, causing it to work harder. To stop your heart from getting weaker with this extra work, your doctor may try to treat you with medications. They are aimed at easing the burden on the heart muscle. You need to control your blood pressure if you have any type of heart problem.
Changing your lifestyle can help control and manage high blood pressure. Your health care provider may recommend that you make lifestyle changes including:
Eating a heart-healthy diet with less salt
Getting regular physical activity
Maintaining a healthy weight or losing weight
Limiting alcohol
Not smoking
Getting 7 to 9 hours of sleep daily
CRISPR technologies have progressed by leaps and bounds over the past decade, not only having a transformative effect on
biomedical research but also yielding new therapies that are poised to enter the clinic. In this review, I give an overview of (i)
the various CRISPR DNA-editing technologies, including standard nuclease gene editing, base editing, prime editing, and epigenome editing, (ii) their impact on cardiovascular basic science research, including animal models, human pluripotent stem
cell models, and functional screens, and (iii) emerging therapeutic applications for patients with cardiovascular diseases, focusing on the examples of Hypercholesterolemia, transthyretin amyloidosis, and Duchenne muscular dystrophy.
A post-splenectomy patient suffers from frequent infections due to capsulated bacteria like Streptococcus
pneumoniae, Hemophilus influenzae, and Neisseria meningitidis despite vaccination because of a lack of
memory B lymphocytes. Pacemaker implantation after splenectomy is less common. Our patient underwent
splenectomy for splenic rupture after a road traffic accident. He developed a complete heart block after
seven years, during which a dual-chamber pacemaker was implanted. However, he was operated on seven
times to treat the complication related to that pacemaker over a period of one year because of various
reasons, which have been shared in this case report. The clinical translation of this interesting observation
is that, though the pacemaker implantation procedure is a well-established procedure, the procedural
outcome is influenced by patient factors like the absence of a spleen, procedural factors like septic measures,
and device factors like the reuse of an already-used pacemaker or leads.
Transcatheter closure of patent ductus arteriosus (PDA) is feasible in low-birth-weight infants. A female baby was born prematurely with a birth weight of 924 g. She had a PDA measuring 3.7 mm. She was dependent on positive pressure ventilation for congestive heart failure in addition to the heart failure medications. She could not be discharged from the hospital even after 79 days of birth, and even though her weight reached 1.9 kg in the neonatal intensive care unit. We attempted to plug the PDA using an Amplatzer Piccolo Occluder, but the device failed to anchor. Then, the PDA was plugged using a 4-6 Amplatzer Duct Occluder using a 6-Fr sheath which was challenging.
Accidental misplacement of the limb lead electrodes is a common cause of ECG abnormality and may simulate pathology such as ectopic atrial rhythm, chamber enlargement or myocardial ischaemia and infarction
A Case of Device Closure of an Eccentric Atrial Septal Defect Using a Large D...Ramachandra Barik
Device closure of an eccentric atrial septal defect can be challenging and needs technical modifications to avoid unnecessary complications. Here, we present a case of a 45-year-old woman who underwent device closure of an eccentric defect with a large device. The patient developed pericardial effusion and left-sided pleural effusion due to injury to the junction of right atrium and superior vena cava because of the malalignment of the delivery sheath and left atrial disc before the device was pulled across the eccentric defect despite releasing the left atrial disc in the left atrium in place of the left pulmonary vein. These two serious complications were managed conservatively with close monitoring of the case during and after the procedure.
Trio of Rheumatic Mitral Stenosis, Right Posterior Septal Accessory Pathway a...Ramachandra Barik
A 57-year-old male presented with recurrent palpitations. He was diagnosed with rheumatic mitral stenosis, right posterior septal accessory pathway and atrial flutter. An electrophysiological study after percutaneous balloon mitral valvotomy showed that the palpitations were due to atrial flutter with right bundle branch aberrancy. The right posterior septal pathway was a bystander because it had a higher refractory period than the atrioventricular node.
Percutaneous balloon dilatation, first described by
Andreas Gruentzig in 1979, was initially performed
without the use of guidewires.1 The prototype
balloon catheter was developed as a double lumen
catheter (one lumen for pressure monitoring or
distal perfusion, the other lumen for balloon inflation/deflation) with a short fixed and atraumatic
guidewire at the tip. Indeed, initially the technique
involved advancing a rather rigid balloon catheter
freely without much torque control into a coronary
artery. Bends, tortuosities, angulations, bifurcations,
and eccentric lesions could hardly, if at all, be negotiated, resulting in a rather frustrating low procedural success rate whenever the initial limited
indications (proximal, short, concentric, noncalcified) were negated.2 Luck was almost as
important as expertise, not only for the operator,
but also for the patient. It is to the merit of
Simpson who, in 1982, introduced the novelty of
advancing the balloon catheter over a removable
guidewire, which had first been advanced in the
target vessel.3 This major technical improvement
resulted overnight in a notable increase in the procedural success rate. Guidewires have since evolved
into very sophisticated devices.
Optical coherence tomography-guided algorithm for percutaneous coronary intervention. Vessel diameter should be assessed using the external elastic lamina (EEL)-EEL diameter at the reference segments, and rounded down to select interventional devices (balloons, stents). If the EEL cannot be identified, luminal measures are used and rounded up to 0.5 mm larger for selection of the devices. Optical coherence tomography (OCT)-guided optimisation strategies post stent implantation per EEL-based diameter measurement and per lumen-based diameter measurement are shown. For instance, if the distal EEL-EEL diameter measures 3.2 mm×3.1 mm (i.e., the mean EEL-based diameter is 3.15 mm), this number is rounded down to the next available stent size and post-dilation balloon to be used at the distal segment. Thus, a 3.0 mm stent and non-compliant balloon diameter is selected. If the proximal EEL cannot be visualised, the mean lumen diameter should be used for device sizing. For instance, if the mean proximal lumen diameter measures 3.4 mm, this number is rounded up to the next available balloon diameter (within up to 0.5 mm larger) for post-dilation. MLA: minimal lumen area; MSA: minimal stent area;NC: non-compliant
Brugada syndrome (BrS) is an inherited cardiac disorder,
characterised by a typical ECG pattern and an increased
risk of arrhythmias and sudden cardiac death (SCD).
BrS is a challenging entity, in regard to diagnosis as
well as arrhythmia risk prediction and management.
Nowadays, asymptomatic patients represent the majority
of newly diagnosed patients with BrS, and its incidence
is expected to rise due to (genetic) family screening.
Progress in our understanding of the genetic and
molecular pathophysiology is limited by the absence
of a true gold standard, with consensus on its clinical
definition changing over time. Nevertheless, novel
insights continue to arise from detailed and in-depth
studies, including the complex genetic and molecular
basis. This includes the increasingly recognised
relevance of an underlying structural substrate. Risk
stratification in patients with BrS remains challenging,
particularly in those who are asymptomatic, but recent
studies have demonstrated the potential usefulness
of risk scores to identify patients at high risk of
arrhythmia and SCD. Development and validation of
a model that incorporates clinical and genetic factors,
comorbidities, age and gender, and environmental
aspects may facilitate improved prediction of disease
expressivity and arrhythmia/SCD risk, and potentially
guide patient management and therapy. This review
provides an update of the diagnosis, pathophysiology
and management of BrS, and discusses its future
perspectives.
The Human Developmental Cell Atlas (HDCA) initiative, which is part of the Human Cell Atlas, aims to create a comprehensive reference map of cells during development. This will be critical to understanding normal organogenesis, the effect of mutations, environmental factors and infectious agents on human development, congenital and childhood disorders, and the cellular basis of ageing, cancer and regenerative medicine. Here we outline the HDCA initiative and the challenges of mapping and modelling human development using state-of-the-art technologies to create a reference atlas across gestation. Similar to the Human Genome Project, the HDCA will integrate the output from a growing community of scientists who are mapping human development into a unified atlas. We describe the early milestones that have been achieved and the use of human stem-cell-derived cultures, organoids and animal models to inform the HDCA, especially for prenatal tissues that are hard to acquire. Finally, we provide a roadmap towards a complete atlas of human development.
The treatment of patients with advanced acute heart failure is still challenging.
Intra-aortic balloon pump (IABP) has widely been used in the management of
patients with cardiogenic shock. However, according to international guidelines, its
routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated
that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian
Association of Hospital Cardiologists, reviews the available data derived from clinical
studies. It also provides practical recommendations for the optimal use of IABP in
the treatment of cardiogenic shock and advanced acute heart failure.
Left ventricular false tendons (LVFTs) are fibromuscular
structures, connecting the left ventricular
free wall or papillary muscle and the ventricular
septum.
There is some discussion about safety issues during
intense exercise in athletes with LVFTs, as these
bands have been associated with ventricular arrhythmias
and abnormal cardiac remodelling. However,
presence of LVFTs appears to be much more common
than previously noted as imaging techniques
have improved and the association between LVFTs
and abnormal remodelling could very well be explained
by better visibility in a dilated left ventricular
lumen.
Although LVFTsmay result in electrocardiographic abnormalities
and could form a substrate for ventricular
arrhythmias, it should be considered as a normal
anatomic variant. Persons with LVFTs do not appear
to have increased risk for ventricular arrhythmias or
sudden cardiac death.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
2. KEYWORDS
• PROBABILITY: (P)
• SAMPLE SIZE
• EFFECT SIZE
• ODDS AND ODDS RATIO
• RISK AND RISK RATIO
• STANDARD DEVIATION
• HOW TO USE SD INTELLIGENTLY
• CONFIDENCE INTERVAL
• HOW TO INTERPRET A CLINICAL TRIAL
• CALCULATE NNT
• TYPES OF TRIAL
3. PROBABILITY
• Probability is an indicator of how much of the data can happen just by chance. p value of less
than (<) 0.5 p <0.5 = 5/10 = ½ indicates that there is 50% chance that the result may be
happening just because of a chance
• p = 0.05 = 5/100 = 1/20
• To be statistically significant look for a p value of at least less than 0.05
• p <0.05 Statistically significant
• p <0.01 Highly significant
• p <0.001 Very highly significant
• Always look at the sample size /confidence interval (CI) before giving a judgment on p value
alone
4. SAMPLE & EFFECT SIZE
• The value of p is inversely proportional to effect size and sample size
• This means if we are testing the effects of a new blood pressure medicine is reducing
blood pressure by 20 mm Hg, but was tested in only 100 patients, the p value may be
significant but the sample size is too small to be significant. In similar lines, a drug
reducing blood pressure by merely 1 mm Hg may return a significant p value, when
tested in 1 million populations but the effect size is too small to be worthwhile
statistically
• To avoid statistical error, today the statistician calculates the minimum sample
size that would be required to show a difference of results depending on the
prevalence of the event rate in the natural course of the disease in the population
being studied
5. ODDS
• The term Odds means a disease or effect happening versus not happening
• Supposing that 10 out of 100 patients of acute myocardial infarction would die, the
odds are 10 will die and 90 will live. So, the Odds are 10/90 = 0.11 (Happens/Not
Happen) Now a medical paper says that there is a new drug ABC shows benefit in
reducing death rate of myocardial infarction. On being treated with the new drug, only
2 out of 100 acute myocardial infarction cases died. This means 2 dies and 98 live. So
Odds for this new treatment are 2/98 = 0.02
6. ODD RATIO
• Odds Ratio = control odds/Treatment Odds = 0.11/0.02 = 5.5
• This means treatment with this new drug reduces chance of death by 5.5 times
7. RISK AND RISK RATIO
• Risk is a similar term that means disease or effect out of the entire population. In
the same example of the heart attack above, the risk of death is 10 out of 100
(not 10/90 as in odds) Risk of death in MI 10/100 = 0.10 (Happens/Total) Similarly
risk after being administered ABC has a risk of 2/100 = 0.02
8. RISK RATIO
• Risk ratio = 0.10/0.02 = 5 (very close to odds ratio)
• In most cases, odds ratio and risk ratio is close
• Now consider, unlike the example of myocardial infarction, a disease has a
mortality of 90% (90 out of 100 die). In such a scenario, the odds would be 90/10
(died 10 survived) returning a value of odds of 9, while the risk ratio would be
90/100 = 0.9. So, dichotomy between odds and risk indicate high event rate in
control group and this may corrupt a study
9. STANDARD DEVIATION
• Any physiological parameter will have variation from people to people
• If we take sufficient number of people and plot their values, they tend to follow a
normal or nominal distribution (a Bell-shaped curve)
• The central line in the curve is the mean (akin to arithmetic average)
• As we go farther away from the mean, the degree of deviation (from mean)
increases
• One standard deviation (1 SD) covers 68.2% of data spread from mean. 2SD
covers more, up to 95.4% data and 3 SD covers almost a whooping 99.7% data
10. EXAMPLE OF S.D
• Serum cholesterol in a population of a town of 8,000 people . Most people have a
mean cholesterol of 200 mg (Central Line), while some as low as 100 and as high
as 300. Standard deviation is 25 mg of cholesterol. This means if we look at ± 1
standard deviation the value would range from 175 to 225. One standard
deviation constitutes of 68.2% of the population data in any normal distribution
(5456 people) the entire dark group. If we take two standard deviation it covers
the cholesterol values from 150 to 250 covering 95.4% of the population (7,632
people). The dark and light group. Three standard deviation covers 99.7% of the
population from the cholesterol level of 100–300 (7,976 of 8,000). This means
three standard deviation practically cover entire data set.=The whole shaded area.
11.
12. CONFIDENCE INTERVAL
• Confidence interval = 0.83 (CI 0.88–0.98) The upper value is below 1. So, it is
statistically significant. However, clinical significance of a value is considered only
when it is below 0.85. So, in this case, it is statistically significant, but clinically not
significant
• Confidence interval = 0.78 (CI 0.76–0.97) Here the upper value is below 1, while the
lower one is below 0.85. Hence, it is statistically significant and may be clinically
significant
• Confidence interval = 0.78 (CI 0.57–1.12) Here the value wraps around 1, hence
statistically not significant. However, since the lower value is below 0.85, it may still be
clinically significant. In such cases, a repeat trial is indicated.
• Confidence interval = 0.59 (CI 0.43 – 0.76) In this case, both the upper and lower
values are below 0.85, so it is statistically as well as clinically significant
13.
14. EXAMPLE
• Journal Report New Drug XYZ Reduces Heart Failure Mortality by 20%
• Study with a new drug XYZ’ for heart failure.
• 5/1,000 patients died with standard care at end of 1 year=0.5%
• 4/1,000 patients on XYZ died at end of 1 year=0.4%
• Absolute risk reduction (ARR) – the real thing = 0.5 – 0.4 = 0.1%
• Relative risk reduction (RRR) = 0.1/0.5 = 20%
• The logical next step would be to check for p value, NNT and CI Look for p value
•
15. CONTD……EXAMPLE
• Accept if p < 0.05
• Many noninferiority trials try to show weather the drug or treatment is “not worse”
compared to the present gold standard, but do not ask whether it is better or not. This
means it is checking one end (single tail) of the standard bell curve and not both the
ends (double tails). A single tailed trial needs a higher p value to be significant (at least
p, 0.01)
• Ask for confidence interval, if wraps around unity
• Reject it (e.g. 0.56–1.23 goes to junk)
• Enquire pre-specified endpoints.
16. NNT
• Calculate NNT NNT is number needed to treat to prevent one event (let one
Death) NNT is calculated by dividing 100/APR = 100/0.1 = 1000 So, you need to
treat 1,000 patients to prevent one death
• NNT is significant (acceptable) if more than 50
• Here ,it is 1,000, so not significant.
17. TYPES OF TRIAL
• Observational studies: prevalence of a disease or its complications
• Interventional studies: Randomized and placebo- controlled for guideline
formation
19. CONCLUSION
• A step-by step approach to look for
• ARR
• p value
• NNT
• CI
• Can simply data
20. BIBLIOGRAPHY
1. Harris M, Taylor G, Dunitz M. Medical Statistics Made Easy. London and New
York: Martin Dunitz; 2003.
2. Magnello E, Loon BV. Statistics, A graphic Guide. Icon Books, UK.
3. Mayer D. Essential Evidenced Based Medicine, Dan Mayer, Cambridge
medicine, 2nd edn. US: Cambridge University Press; 2009.
4. Nair T. Medical Statistics and Clinical Trials, 1st edn. Wiley Blackwell. 5. Sanjay
K, Diamond G. Trial and error: how to avoid commonly encountered limitations
of published clinical trials, J Am Coll Cardiol. 2010;55:415-27.
21. DO YOU KNOW WHAT DOES CITY MEAN ?
• C:Cutting
• I:Innocent
• T:Trees
• Y:Yatra