 Hello friends, Nishan here welcoming you to the sixth episode of Healthwise with Manipal Hospitals. So today we will be discussing about a very serious medical condition. Around estimated number of people dying because of this disease is around 2.5 million every year. Every minute you can see one person dying because of this disease. So this disease is none other than cancer. So what is blood cancer? How does it happen? Who does it affect? Is there any cure for this blood cancer? So to answer to all these questions of viewers we have with us a very well-known hematomecologist from Manipal Hospital Dr. Malikarjan Kalashtri. So I'd like to welcome Dr. Malikarjan Kalashtri to the show. Hello sir. How are you sir? I'm fine, thank you. How are you? Yeah, I'm doing great sir. So without wasting any more time I'll just go to all the questions which we have got from the viewers. So what is BND? This is the first question and I'm sure like many of us may not be knowing what is BND. So bone marrow transplantation is one of the complex medical procedures that we use to treat various both benign and malignant disorders of the blood. So just now I've heard you talking about the cancers. So cancers are broadly divided into liquid cancers which affect the blood and solid tumors which are basically solid organ cancers. So I being an hematomecologist will deliberate more on the liquid tumors. So the liquid cancers are divided again into leukemias, lymphomas, and leukemias are acute and chronic leukemias. And bone marrow transplantation is used in treating some of these. So majority of them can be treated with only chemotherapy. So the acute malar leukemia which is intermediate to high risk, lymphomas which are relapsed or multiple myeloma where we use analogous tensile transplantation are some of the common blood cancers where we use bone marrow transplantation. Now the bone marrow transplantation word itself is a historic term. Now we're moving away from it and we more aptly call it as hematopoietic stem cell transplantation because what we use are the stem cells and it is not necessary that we have to collect them from the bone marrow. So initially people were collecting all the stem cells from the bone marrow where in the patient would be taken to an operation theatre, would be given a general anesthesia and then we would aspirate lots of the bone marrow stem cells and then use them as the cells for treating the recipient or a patient. Now in majority of the hematological malignancies the stem cells are collected from the peripheral blood. So we give them a medicine to mobilize the stem cells and then we collect them like collecting platelets for example and those are called as peripherally mobilized stem cells which is done through atheroses and so now we more aptly call it as hematopoietic stem cell transplantation and not as bone marrow transplantation because you can essentially collect the stem cells from the peripheral blood too. Doctor I had a question what exactly is a stem cell? Right, so stem cell is kind of a mother cell which is different from more differentiated cells. Now in fact as we know the stem cells can give way to many organs and stem cells in many cells. So when we talk about stem cell in hematology we are talking about hematopoietic stem cell which kind of give rise to white blood cells, give rise to red blood cells, give rise to platelets. So stem cells not only can differentiate into more specialized cells and organs but they can also divide and what is called a self-renewal. They can also divide into more stem cells so that makes them different from other cells. So if it is a differentiated cell for example a neutrophil or a red cell or a platelet they can't go back and make other cells whereas a stem cell can differentiate into other cells and also divide into more stem cells. So they have both self-renewal and differentiated capacity. Okay, so moving towards the next question like what are the other words which describe what we have. Right, so historically we always used to call that as bone marrow transplantation. So now we also call it as peripheral blood transplantation. Some people say blood and marrow transplantation but I think the term which is more apt is called as hematopoietic stem cell transplantation wherein we basically are using hematopoietic stem cells and helping regeneration of a disease marrow with the healthy stem cells. So I think we should just call it as hematopoietic stem cell transplantation. And one more question doctor like I'm sure many are confused. Is BMD a disease? Is it a surgery? Is it a procedure? What exactly is it? So bone marrow transplantation is in fact a treatment for many diseases. So it could be some of the common diseases that we use which are treated by the bone marrow transplantation. Arachyporeal leukemia, multiple myeloma, lymphomas which are elapsed, thalassemia, some rare primary immunodeficiency disorders. So bone marrow transplantation is a procedure. It is not a disease and it is done to treat many disorders. Now it is also called as hematopoietic stem cell transplantation as I've told you and there is no surgery involved. So many people have this misconception that this is a very painful thing, that we are going to break the bones of a donor and then fix something into the recipient. No, none of that happens. So basically we collect the stem cell which in majority of the cases is like collecting platelets on an ultrasound machine where you don't even have to go to operation theater, right? And those collected stem cells are transfused back into the recipient after what is called as a conditioning chemotherapy which is essentially destroying the diseased bone marrow and then giving them the stem cell and the process of giving the stem cell is also like just a blood transfusion. So there is no surgery involved and it is not painful procedure at all. It is just a misconception. So when you extract the bone marrow, like there is no kind of pain or something? No, so as I said the stem cells can be collected by two types, two ways. One is peripherally mobilized stem cells, wherein we give them a growth factor to mobilize these stem cells which are essentially in the bone marrow to the peripheral blood and then we put them on the ultrasound machine and collect them. So there is no pain, there is no general anesthesia needed. So people may develop some pain, some discolorectomy up and we give them the growth factor but largely it is a safe procedure. So remember whenever we take stem cells from a donor who is essentially healthy, we give a lot of importance to the safety of the donor. So largely donors are absolutely safe and there is no short term or long term toxicity or side effect because of the procedure to the donor. Now in some disorders like bone marrow failures, like primary bone deficiency disorders and a plastic anemia, it is preferable to collect the stem cells from the bone marrow. So in such a case we take the donor who is a normal person after due diligence and after some pre-transplant workup if they are found healthy we give them general anesthesia, take them to the operation data, there we collect stem cells from the bone marrow. So if we need to collect the stem cells from the bone marrow only then which is largely in marrow failures and a plastic anemia and primary bone deficiency disorders but for most of the malignant disorders even that is not needed. So based on the source of collection it is very friendly collection or collected from the bone marrow. So moving to the next question that is what are the different types of VM? Right, so that is a very important question. Again many people have this confusion. So we largely divide the transplantation, bone marrow transplantation into an autologous transplantation wherein the source of stem cell is the patient himself. So this is then commonly done in disorders say like multiple myeloma, like relapsed lymphoma wherein we give them chemotherapy to minimize the disease that they have and the stem cells from the patient himself. So essentially those stem cells are of the patient only and then the patient is given a lot of high dose chemotherapy which would essentially destroy all of the bone marrow and then re-infuse the stem cells which are collected from the patient himself. So here there is no immune adverse event, there is no graft versus post disease and this is largely a safe transplantation. So this is called as autologous stem cell transplantation. Now the second type is called as allogenic bone marrow transplantation donor is somebody else. So this allogenic stem cell transplantation is divided again into matched sibling donor stem cell transplantation wherein the patient's own brother or sister will give the stem cells. So that is one of the safer... What is this called? It's called as matched sibling. So sibling is the brother or sister. So if they are actually identical we take the stem cells from them and they are the best donors if we have them. But what is happening unfortunately is with the families becoming smaller and smaller with lesser and lesser families the probability of finding a matched sibling is less. So then we do what is called as unrelated donor transplant. So there are donor registries across the globe. There is a European donor registry, there is an American donor registry and there is a German donor registry. So we do the actually typing of the patient and then submit that information to these donor registries. So if there is a good match, basically 10 by 10 match, then that voluntary donor can give this so that is unrelated donor allogenic stem cell transplantation. Now for a country like ours which is 1.2 billion people, we don't have robust donor registries who are working towards that. So sometimes because in American or German or European we don't have our own adequate representation and changing ethnicity we may not get a full matched donor. So then we have what are called as family half matched transplant or half load transplant where in the HL is not identical but half matched. So in some cases we have started doing what is called as half load transplant also. So essentially it is autologous transplantation where stem cells are from the donor. Match sibling donor transplantation which is a type of organic transplantation the stem cells are from a fully HL identical brother or sister. Match unrelated donor transplant where in it is not a family member it is not a brother or sister but somebody else whose HL is identical to you and they give the stem cell and the third one is partially matched donor stem cell transplantation. It would be half matched from the family donor. Yeah. So if you was there are three types of VMD as Dr. said. So moving towards the first question from Deepak Kumar. What happens after the bone marrow or stem cells having transplant planted to the patient? Right. So this is one of the most complicated and quite intense treatment. So it is important as physicians we give full information to the patient and to the caregivers because this is not something which is going to get over in a day. Oftentimes we call this as a marathon of treatment. So basically what we do is there is a disease which is basically a refractory or has come back or relapse. So basically we have to give you intense treatment to control the disease as much as possible. So that is called a salvage therapy in lymphomas. So once we do that once the disease and the maximal remission they will be taken to this highly sterile ward called as bone marrow transmission ward. They will be given conditioning chemotherapy to destroy remaining abnormal or disordered bone marrow. And then we collect the stem cells either from a healthy related donor or unrelated donor and those cells are infused back to the patient. Now it may take about three to four weeks for those cells to home into the bone marrow and then what we call as engraftment meaning those healthy stem cells making the blood cells again. Now in this interim of stem cell infusion to engraftment the patient will be under strict surveillance. He may have infections. He may need prostate and pre-microbial agents. So he may have eucocytus leading parental nutrition and oftentimes the blood product support. If the platelet can't stop a lot he will be given platelet transfusion. If the hemoglobin drugs he will be given the red cell transfusion. He will do a good supportive care. We need to be careful about the infections. We have to support them if they have eucocytus and severe pain till the engraftment. Now once the engraftment occurs and once the patient is stable taking thoroughly moving around in the world then we discharge them from the bone marrow transplant room. There will also be on multiple medications some of them to prevent what is called as a graft versus whole disease. Some of them to prevent infections in them so we need to monitor them closely post transplant. So after about four to six weeks of transplantation they engraft they go back then we kind of keep them at a close surveillance for another 60 to 90 days. So first day hundreds are critical so we call it as first hundred days of transplantation and if people are well from there on there will be some potential toxicity but it will be much less. Yeah. So the first hundred days are very critical. Very critical. Yeah. So there's the next question from Deepak Kumar what are the possible side effects of BMT and PBSC? Right. So bone marrow transplantation can be largely divided into the early or short term and the long term toxities. The short term toxities could be because of the condition chemotherapy. Many of them will have nausea, will have ulcers in the mouth, will have severe pain. Some of them will have will lose the taste of the food. They will not eat well. They will lose some weight and some people may develop infections during what is called as neutropenia period which is called as neutropenic infections and some people will also have diarrhea and that's why fungal and viral infections too. And sometimes the engulfment may be laid in some people and then those issues can be more. But then there are enough medications to take patients through this critical period and also to make sure that we give them good supportive care. And in the long term they may have what is called as allogenic stem cell transplantation. The stem cells which are given to the recipient may mount an immune attack called as graft versus host disease which can be crippling 20 to 30% of these transplants and there can be organ toxities because of the conditions that we're given. So rarely it may affect their lungs, their heart, the GI system. But then with each passing year the transplantation is becoming better because we have better drugs, better supportive medication, better antimicrobial agent. So the TRM or what is called transplant related mortality which used to be 30 to 40% historically has come down to about 10 to 20% in the rest of the life. So it's getting better at it but there is still some potential for various complications both short term and long term. So this is one general question actually. I'm sure all the viewers out there will be having this question in mind. What is leukemia and what is thelesemium? How different it is? No, those are actually there is nothing similar to those. So leukemia is a blood cancer. So leukemia can be acute or chronic. So the acute leukemias are acute lymphoblastic leukemias are again chronic myeloid leukemia and chronic lymphocytic leukemia. So these are blood cancers. Thelesemia is not a blood cancer. So it's different types of blood cancers. Leukemia is no, no, no. Thelesemia is not a cancer at all. So leukemia is cancer. Thelesemia is a disorder of hemoclonopathy where the child cannot make good red cells. So that's why they will need red cell transfusions. So thelesemia again clinically is divided into thelesemia major, thelesemia intermediate and thelesemia minor. Thelesemia major is a dreadful condition wherein a child will have both thelesemia mutations inherited from father and mother. So that will be a homozygous state for the child. So he will need red cell transfusion soon after birth. So perhaps from six months to two years for the rest of the child's life. So that is the humongous thing for parents, for the child. So multiple transfusions have many complications and there are no medicines at this point in time which can cure child and make child transfusion independent. And the only way to treat thelesemia is by doing what is called as bone marrow transplantation. And lucky if the child has a mass sibling donor in which case the results are very good and the complications are much less. So again if there is a child with thelesemia major and if they have sibling we say as soon as possible we must do a HLA typing of the child and the siblings and if there is a sibling in the period. So again luckymia is a cancer thelesemia is not a cancer thelesemia is a condition where child will require chronic blood transfusion. Yeah. Okay. So the next question is from Raj how are BMT and VBS CT used in cancer treatment? Right. So I think And he has one more question from Raj himself. How is bone marrow donation different from blood donation? Right. Okay. So the VBS CT is peripheral blood stem cell transplantation so where in we have told you the stem cells are essentially collected from after mobilization of the stem cells patients are put on a machine called as a fluorescence machine which removes the stem cell and gives the rest of the blood back to the donor. So this is just just take a procedure and there is no in this unit at all the donor does not even need anesthesia. So this is bone marrow collection, right? So if you give the donor the anesthesia take him to the operation theater and then they collect the same stem cells from a posture that is a hip bone so from the posture what is the hip bone if you collect stem cells so that is what is the bone marrow donation of the stem cell so that is done in few disorders but majority of the patients we do a very free blood stem cell collection only. Yes, so no so the blood grouping is what is commonly used, right? ABO grouping and RH typing for the blood transfusion but we use what is called tissue typing or HLA typing for the bone marrow transplantation so we basically have HLA system which has HLA, AB, DR, DQ and DQB1 so those are the various HLA antigens so we typically match sibling then even if he is a six by six match that is good enough present day and if it's unrelated donor would like to have at least ten antigen match no ten by ten or even nine by ten is okay in some of the disorders so that is also so the matching is called as HLA matching not the blood group matching in fact we can do the blood or bone marrow transplantation even if the blood group is not not matching so blood group matching is not necessary for the transplantation is there any benefits of donating a bone marrow like they say every six months if you donate blood there is lots of benefits on that yes no it is a great thing itself you are saving somebody's life I am sure that itself is of paramount importance apart from that if you are asking is there any health wise no I wouldn't say that perhaps many people do it once in six months which is great again so I wouldn't do a bone marrow donation just for being healthy but then there is no long term adverse event and you are actually giving a life to somebody that itself is a fantastic thing to do so the next question is from Dev Malia she has three questions first one is why does a patient need a bone marrow transplant how long does it take to recover from a bone marrow transplant can you donate a bone marrow if you have a sickle cell trait right yes very apt questions actually so bone marrow transplantation how long it takes for them to recover is a first question so as I said the first part of the challenge is to get adequately matching so once if that is done once we infuse we call that as a day zero or a stem cell infusion day which is typically done after conditioning so conditioning infusion typically takes about three to four or in fact three to five weeks for those cells to engraft engraft is they going to the bone marrow homing there and then making the normal cells so it may take about 20 to 30 days in majority of the cases so that is the first part which is called as engraftment now once that happens they will be discharged from the bone marrow unit but then they will be closely followed up for the next couple of months to see the drug level to look for any about 70 to 100 days so most of the acute issues are resolved but once the bone marrow transplantation is done we would want to keep them under close follow up for several months you know so if your question is doctor would they be 100% normal at the end of 100 days and can they do everything so we still think the immune reconstitutions the immune system is the system of the body which helps us find infections so it may take several months post 100 days too for it to become normal so during that point in time we still continue them on some prophylactic antimicrobials so for them to attain some kind of stability I would say it takes about 60 to 100 days but the engraftment itself you know discharge from the hospital itself will occur much sooner than that in about 3 to 4 weeks okay then the next question is from Faisal what are the risks associated with bone marrow transplant I think we have discussed that both short and long term talks so Faisal doctor has already answered this question so the next question that is from Krishnan right what diseases are treated most often bone marrow transplant yes so across the globe the common disorders which are treated with bone marrow transplantation are multiple myeloma which is one of the common indication for autologous transplantation acute myeloid leukemia which is a common indication for allogenic bone marrow transplantation relapsed and refractory lymphomas are commonly treated with transplantation but in in asian and other parts of the globe where thalassemia is a very very common condition so they account for a sizable number of transplants so there are lots of thalassemia major children in India and in asian specific region who need allogenic transplantation and unfortunately because of financial constraints because of not already of the donor because of lack of expertise many of these children continue to suffer in all their life so thalassemia is an important indication for transplantation there are certain problems with bone marrow transplantation so these are some of the common diseases that we treat with bone marrow transplantation so next question is from Anmol how does survival of patients receiving a transplant from an unrelated donor compared to those from a related donor very very very specific so I forgot to mention aplastic anemia in the last segment so aplastic anemia is another dreadful condition where in the bone marrow which is basically a factory which makes the cells kind of fail so aplastic anemia if they have if they have a good good donor right so his question was was I'm sorry what was that it is a big question yes how does survival of patients receiving a transplant from an unrelated donor differ from a matched case so when we started transplantation right so we would always say it is preferred to have a full matched HLA identical sibling donor but as you know the probability that a sibling is a full match to a recipient is one in four that is because we inherit one HLA haplotype from mother and one HLA haplotype from father so with a shrinking family size it is becoming lesser and lesser to find a fully matched HLA sibling donor so when the transplants started historically the sibling donor full matched transplants were always better than the unrelated donor transplant now we are getting to a stage where a 10 by 10 matched unrelated donor transplant is almost as good as HLA identical sibling donor and that is because we are getting better at transplants so to answer this question in short so yes to answer this question in short now there is not much difference between a 10 by 10 matched unrelated donor to a fully matched sibling donor they both fare very well yeah okay so the next question is from Krithika what is the treatment for bone marrow edema she has three more questions can smokers donate bone marrow why can't we use a bone marrow treatment for the pancreas in case of type 2 diabetes right yeah no so I think she is going out of my area of expertise so one as a physician I should never say it is okay to smoke right no please don't smoke second no so smoking is not a contra indication for bone marrow donation or stem cell donation so we can if the patient is healthy has no other comorbid illnesses we can surely collect stem cells from the smoker too and the other problem other question that she had what is the treatment for bone marrow edema no we don't the bone marrow edema is not a condition there are 10 clinical conditions or in fact more than that which can cause bone marrow edema so that does not need a specific treatment we have to treat the underlying cause another question which can we use a bone marrow transplant for the pancreas in case of type 2 diabetes no so we will have to do eyelid cell transplantation which we don't do and bone marrow transplantation has got nothing to do with pancreatic disorders okay yeah so next question is from Alfea does the bone marrow of all bones produce immune cells right you know the misconception shall I say is that where do you take the bone marrow from and is it qualitatively same as everywhere else is it not yes so we don't have to do you know 10 pricks and 10 bones to collect stem cells we basically do it from the high hip bone called as posthumiaxpine in fact as I said in vast majority we don't even do that we do the peripheral blood stem cells now right and poke into multiple bones that is not needed so and essentially they are the same stem cells which will give rise to a robust new hematopoietic system in the recipient yeah next question is from Prachi are there any adverse effects of removing bone marrow for stem stem cell treatment to the donor is it not so that is one of the one of the questions that we get repeatedly asked is there a short term complication of the donor will the donors bone marrow fail no none of that happens actually so when we take the stem cells from the donor there is no long term adverse event to him in the short term some of them may have local pain some of them have dropping hemoglobin because we collect significant amount of the blood and the stem cells in it so we give them some medicines for the pain in the short term and also perhaps there are no other you know short or long term toxic to the donor as physicians we always try to make sure that the donor safety is of paramount importance yes and unlike many organ transplants where in you know there is some potential risk for the recipient because they undergo surgery the organ needs to be harvested not here so here it is like giving a blood you know in measure of the cases where I'm sure all of them know how to donate us a platelet which is used for stem cell collection so there is no difference at all the next question is from Ayush what is the difference between a stem cell transplant and a bone marrow transplant he has one more question alright so I think we will answer one more question can you see we will answer that question yeah so there is so if you collect the stem cells from the bone marrow which is done in some bone marrow phyllo conditions like a plastic anemia and primary immunodeficient disorder bone marrow transplantation which is what everybody you know knows about but now we we can collect the stem cells from the peripheral blood mobilized stem cells through the operation machine so in which case it is called as peripheral blood stem cell you know transplantation so it depends on where we collect the stem cells from okay and one more question from him was can we use this bone marrow transplant to treat any other diseases other than cancer so yes so for example thalassemia for example primary immunodeficient disorder for example sickle cell anemia which are not cancers but we can use there are certain rare metabolic disorders where we can use it so surely we can use it but many people will ask you know there is something called stem cell therapy for degenerative disorder which is a different field altogether and which is still in nascent stage where people are doing clinical trials but we are not talking about that yeah so we are talking about basically immunological conditions which could be benign meaning non-cancerous conditions like acute leukemia myeloma lymphoma where you can use bone marrow transplantation so next question is from Priyanka why do we need a donor for the bone marrow when we can harvest from our own body right so we have talked about that right so in some disorders we actually collect from the same patient which are called autologous stem cell transplantation so in which case we don't need a donor but there are other donors how do we understand which are the diseases which are the diseases right so that is based on the large number of clinical trials so we know now that multiple for example we commonly do an autologous transplantation because this disease affects the elderly people they are quite fragile and frail and if you were to do an autogenic stem cell transplantation there is a very high risk of transplant related mortality and morbidity on the contrary a young fellow doesn't have any so there we have to collect stem cells from the other donor so there you can't do an autologous transplantation you have to go for allergy transplantation so it depends on the disease it depends on the stage and it largely depends on the circumstances yes okay so we have two questions from Pallavi what is the difference between a general stem cell transplant and a bone marrow transplant and the other two things again to the recipient yes so the immune reconstruction is what we call so the immune system becoming normal after the autogenic transplantation may take several months it will take 24 months and after that it will be as good as normal but in the interim they will have some immune compromise so that's the reason why so we have to be very careful they need to be under surveillance they will have to take certain antimicrobial so the three more questions from Rohit what is stem cell mobilization right what are the health complications for the donor yes I can just briefly touch on stem cell mobilization so we have certain growth factors now basically what they do is they help in detachment of the stem cells from the bone marrow network and then help them mobilizing them into the peripheral blood where they can be easily collected on an FRSS machine so this largely helps us of taking the donor to operations that are doing those multiple you know iliac bone punctures so this is made things very easy and the product that we get after peripheral blood stem cell mobilization is also helps us in early engraftment so if you were to collect the stem cells from the bone marrow and compare that with the peripherally collected stem cells the engraftment is much earlier in the peripherally collected stem cell which is fantastic okay and the last you know transplant oh absolutely so all this effort is of little worth if there are no long lasting time so depending on the disease depending on the condition of the patient some of these people you know to the tune of 6 to 7 percent can have a long-term dc3 survival so depending on what kind of disease we treat so there is what kind of their fitness level is you know so it's multiple factors so I don't think it makes sense for me to say all of them will do well so similarly we can't say that you know nobody will do well so majority of them will do well but then it depends on an individual to individual case and the fitness and what kind of conditioning we can use and what is the dc status okay so we have come towards the end of the questions from the viewers so moving towards the next segment of the show the first one is the success rate is more only when you collect the bone marrow from a family member is it true or false well so it is again so it is not false totally in the sense the results are best if we have an HLA identical brother or sister that is sibling donor there is no doubt so the outcome is always superior if there is a fully matched HLA identical donor but now we are moving to an era where 10 by 10 matched unrelated donor the results are as good so that way it is a little myth right so kind of it is both yes and no okay yeah so it is a myth right okay so next with number 2 is bone marrow is taken from the spine or they have been taken out from the chunk of our bone no so we don't move close to the spine at all we don't want to injure the spine we actually take it where we actually insert so the spine is left untouched so there is no damage to the spine of the donor now we take it from the idea bone commonly okay okay okay now the next myth number 3 is can I donate marrow because I am not what can I donate a marrow because I am not can I donate a marrow because I am an alcoholic I smoke is it okay if I donate well it is not okay to smoke and drink but yes if you are healthy then surely you can donate yeah and this is myth number 4 the last one the final the last one Dr. Skaout donor Dr. Skaout donor to get the bone marrow and it's the bones are left with cracks is it true no we don't we don't break bones we use small needle to make small puncture bones and then operate yes yes no we have never had a broken bone nobody ever I think you know it's just a small needle used to make small it's not a surgery even you know okay so viewers we have come to the end of the show and I'm sure Dr. Malik Arjun has answered all your questions related to BMT blood cancer and now you're sure that there is a cure and the cure what is being done is really effective and yeah probability of success rate is really more yes so just just to emphasize when in doubt seek the help from an expert early diagnosis of paramount importance and going to the bone marrow transplantation and have no misconceptions about the bone marrow transplantation it is not surgery that is it is not a painful procedure and even if there is a blood group mismatch we could still go ahead and do the bone marrow transplantation so remember that don't go to a Google doctor go to a specialized consult thank you all we'll be coming up with other episodes of health wives thank you see you stay fit stay healthy stay happy thank you