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Case presentation - SOAP Format

Case presentation in SOAPME format highlighting the prescriptive role of a pharmacist in Critical and Ambulatory care.

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Case presentation - SOAP Format

  1. 1. CASE PRESENTATION The Prescriptive role of Pharm.D Dr. Deepak Kumar Bandari RPh, PharmD, CGPH, CPPC Elsevier Student Ambassador – South Asia Department of Pharmacy Practice Vaagdevi College of Pharmacy
  2. 2. Dr. Palat has also contributed to the development of the curriculum for the Indian Association for Palliative Care (IAPC) course on palliative care, and has been involved in opioid availability activities though the IAPC and the Pain and Palliative Care Society, Calicut (a WHO Demonstration Project). She facilitated the development of the Department of Palliative Medicine and the Diploma in Palliative Medicine, the first of its kind in the country, at Amrita Institute of Medical Sciences, Kochi. With a special interest in pediatric palliative care, Dr. Palat has played an important role in developing a unique pediatric palliative care Dr. Gayatri Palat, MD Anaesthesiology and Palliative Medicine Associate Professor, Pain and Palliative Medicine, MNJ Institute of Oncology and Regional Cancer Center Hyderabad. palliative care, Dr. Palat has played an important role in developing a unique pediatric palliative care fellowship program at MNJ Institute of Oncology and currently leads the Special Interest Group – Pediatric Palliative Care of the Indian Association of Palliative Care. Internationally, through her involvement with the IAEA (International Atomic Energy Agency), Dr. Palat has participated in the initial planning of palliative care in the National Cancer Control Program for Sri Lanka, Indonesia and the Philippines. She is a director of the palliative care initiative in SE Asia of Two World Cancer Collaboration, the Canadian branch of International Network for Cancer Treatment and Research (INCTR), which works with healthcare professionals in resource-challenged countries to reduce the burden of cancer in South East Asian and African countries. She has also participated in the development of the EPEC-India curriculum to facilitate the implementation of palliative care in various institutions throughout the country.
  3. 3. Case Presentation – Patient’s Profile  Patient: Shantha  Age: 56-year-old Weight: 115 kgs Height : 155cms BMI : 56 kg/m2 Date : 13-Jan-2016  Sex: Female This Case was reported in the Out patient Department of Critical care unit in Continental Hospitals, Hyderabad Referred to the Clinical Pharmacist for Pharmacotherapy Assessment & Diabetes Management BMI : 56 kg/m2
  4. 4. Case Presentation – Patient’s Profile Multiple medical conditions - 1. Type 2 diabetes diagnosed - 2005 2. Hypertension diagnosed – 2012 3. Hyperlipidemia 4. Asthma 5. Coronary Artery Disease 6. Persistent - Peripheral Edema & 7. Longstanding Musculoskeletal Pain secondary to a motor vehicle accident.  Her medical history includes – Atrial fibrillation Anemia Knee Replacement & Multiple emergency room (ER) admissions for Asthma
  5. 5. Case Presentation - Patient’s Profile Her diabetes is currently being treated with-  (Humalog 75/25) Premixed preparation  75% Insulin Lispro Protamine Suspension ( Intermediate acting ) +  25% Insulin Lispro Preparation (Rapid 25% Insulin Lispro Preparation (Rapid acting)  33 units before breakfast &  23 units before supper  She says she occasionally “takes a little more” insulin when she notes high blood glucose readings
  6. 6. Case Presentation - Patient’s Profile  Her other routine medications - 1. INSULIN 75 /25 (lispro protamine suspension + lispro preparation) 2. FLUTICASONE - MDI - two puffs twice a day 3. SALMETEROL MDI - two puffs twice a day 4. NAPROXEN - 375 mg twice a day 5. ASPIRIN - Enteric-coated, 325 mg daily 6. ROSIGLITAZONE , 4 mg daily 7. FUROSEMIDE , 80 mg every morning 8. DILTIAZEM , 180 mg daily 9. LANOXIN , 0.25 mg daily9. LANOXIN , 0.25 mg daily 10. POTASSIUM CHLORIDE, 20 meq daily 11. FLUVASTATIN , 20 mg at bedtime.  Medications she has been prescribed to take “AS NEEDED” include 1. NITROGLYCERIN - Sublingual for chest pain (has not been needed in the past month) 2. FUROSEMIDE, additional 40 mg later in the day if needed for swelling (on most days the additional dose is needed) & 3. ALBUTEROL - MDI , two to four puffs every 4–6 hours for shortness of breath.  She denies use of nicotine, alcohol, or recreational drugs  No known drug allergies  Up to date on her immunizations.
  7. 7. Case Presentation – Chief Complaints and History (Hx) Shantha’s chief complaints now 1. Increasing exacerbations of asthma & the need for prednisone tapers. 2. She reports that during her last round of prednisone therapy, her blood glucose readings increased to the range of 300–400 mg/dl despite large decreases in her carbohydrate intake. 3. She reports that she increases the frequency of her fluticasone MDI, salmeterol MDI, & albuterol MDI to four to five times/day when she has a flare-up. 3. She reports that she increases the frequency of her fluticasone MDI, salmeterol MDI, & albuterol MDI to four to five times/day when she has a flare-up. History (Hx): 1. Husband Out of work - Only source of income – State Government Pension. 2. Unable to purchase - fluticasone or salmeterol 3. Has only been taking prednisone & albuterol for recent acute asthma exacerbations.
  8. 8. Case Presentation – Chief Complaints and History (Hx) Shantha’s chief complaints • Not been able to exercise routinely because of bad weather & asthma • The memory printout from her blood glucose meter for the• The memory printout from her blood glucose meter for the past 30 days shows a total of 53 tests with a mean blood glucose of 241 mg/dl - 90% above target.
  9. 9. Case Presentation – Subjective Findings Physical Exam • Well - appearing but obese • Weight: 115kgs ; Height 5′1″ • Blood pressure: 130/78 mm Hg • Pulse 88 beats /min• Pulse 88 beats /min • Lungs: clear • Lower extremities - pitting edema bilaterally Shantha reports that- 1. On the days her feet swell the most, she is active & in an upright position throughout the day. 2. Swelling worsens throughout the day, but by the next morning they are “ skinny again.” 3. She states that she makes the decision to take an extra furosemide tablet if her swelling is excessive and painful around lunch time; 4. Taking the diuretic later in the day prevents her from sleeping because of nocturnal urination.
  10. 10. Case Presentation – Objective Findings Lab Results • Hemoglobin A1c (A1C) = 7.0% (target: < 7%) • Potassium: 3.4 mg/dl (3.5 – 5.3 mg/dl) • Calcium: 8.2 mg/dl (8.3 –10.2 mg/dl) • Lipid panel – Total cholesterol: 211mg/dl (<200 mg/dl)– Total cholesterol: 211mg/dl (<200 mg/dl) – HDL cholesterol: 52 mg/dl (>55 mg/dl, female) – LDL cholesterol: 128 mg/dl (<100 mg/dl) – Triglycerides: 154 mg/dl (<150 mg/dl) • Liver function panel: within normal limits • Urinary albumin: <30 μg/mg(<30 μg/mg) Glycosylated Hemoglobin
  11. 11. Case Presentation – Pharmacist’s Assessment Pharmacist - Assessment 1. Asthma - Poorly Controlled, Severe, Persistent 2. Diabetes - control recently worsened by asthma exacerbations & treatment 3. Dyslipidemia - elevated LDL cholesterol despite statin therapy 4. Edema - Persistent lower-extremity edema despite diuretic therapy 5. Hypokalemia - most likely drug-induced5. Hypokalemia - most likely drug-induced 6. Hypertension - blood pressure within target & stable 7. Coronary Artery Disease - stable 8. Obesity - ? 9. Chronic pain - secondary to previous injury – stable 10. Financial constraints - affecting medication behaviors 11. Insufficient patient education 12. Wellness, preventive, & routine monitoring issues
  12. 12. Case Presentation – Physician’s Plan 1. FLUTICASONE - MDI - two puffs twice a day 2. SALMETEROL MDI - two puffs twice a day 3. NAPROXEN - 375 mg twice a day 4. ASPIRIN - Enteric-coated, 325 mg daily 5. ROSIGLITAZONE , 4 mg daily 6. FUROSEMIDE , 80 mg every morning 7. DILTIAZEM , 180 mg daily 8. LANOXIN , 0.25 mg daily 9. POTASSIUM CHLORIDE, 20 meq daily9. POTASSIUM CHLORIDE, 20 meq daily 10. FLUVASTATIN , 20 mg at bedtime. 11. INSULIN 75 /25 (lispro protamine suspension + lispro preparation)  Medications she has been prescribed to take “AS NEEDED” include 1. NITROGLYCERIN - Sublingual for chest pain (has not been needed in the past month) 2. FUROSEMIDE, additional 40 mg later in the day if needed for swelling (on most days the additional dose is needed) & 3. ALBUTEROL - MDI , two to four puffs every 4–6 hours for shortness of breath.
  13. 13. SOAP ANALYSIS - PWDT  Pharmacist’s Work Up of DrugTherapy (PWDT)  Desired Outcomes Therapeutic Endpoints  Medication Related Problems Medication Related Problems  Pharmacist’s Interventions  Monitoring Plans  Patient Education
  14. 14. Pharmacist’s Work Up of Drug Therapy (PWDT)
  15. 15. What are reasonable outcomes for this patient? Based on current guidelines and literature, pharmacology, and pathophysiology, what therapeutic endpoints would be needed to achieve these outcomes? Are there potential medication related problems that prevent these endpoints from being achieved? Pharmacist’s Work Up of Drug Therapy (PWDT) these endpoints from being achieved? What patient self-care behaviours and medication changes are needed to address the medication-related problems? What patient education interventions are needed to enhance achievement of these changes? What monitoring parameters are needed to verify achievement of goals and detect side effects and toxicity, and how often should these parameters be monitored?
  16. 16. 1. Mortality outcomes Avoid respiratory, cardiovascular, thromboembolic,or diabetes-related premature death. 2. Morbidity outcomes a. Disease-related:Reduce morbidity resulting from uncontrolled blood glucose, blood pressure, dyslipidemia, and cardiovascular disease. • Retard the progression of disease. • Prevent, recognize, and treat early any complications of chronic conditions, Reasonable Outcomes • Prevent, recognize, and treat early any complications of chronic conditions, such as Neuropathy (autonomic or peripheral), Eye disease (e.g., retinal vascular narrowing, hemorrhages), cardiac disease (e.g., LVH, CHF, MI), Nephropathy (e.g., proteinuria), and lower-leg amputation. • Prevent chronic symptoms of asthma (e.g., coughing or breathlessness at night, in the early morning, or after exertion). • Retain recognition of hypoglycemia symptoms. • Maintain near-normal lung function. • Maintain normal activity levels (including exercise and physical activity). • Prevent recurrence of Atrial Fibrillation.
  17. 17. b. Drug-related: Prevent, minimize, or manage drug-related morbidity. • Monitor for side effects or toxicity. • Monitor for drug-drug, drug-disease, and drug-food interactions. 3. Behavioral outcomes a. Obtain annual eye exams. b.Adhere to a medication regimen. c. Get routine and timely medical examinations and laboratory tests. d.Avoid stimulants or over-the-counter products that may affect blood glucose, blood pressure, asthma, or circulation, such as alcohol, caffeine, nicotine, and decongestants. Reasonable Outcomes pressure, asthma, or circulation, such as alcohol, caffeine, nicotine, and decongestants. 4. Pharmacoeconomic outcomes a. Keep drug and treatment costs within patient resources. b. Make cost-effective and efficient use of health care resources. 5. Quality-of-life outcomes a. Match, or minimally change, patient lifestyle and activities with treatment. b.Aim for no interference with work or daily activities because of disease symptoms. c.Work to ensure patient satisfaction with the pharmaceutical care and health care team.
  18. 18. Therapeutic Endpoints • LDL cholesterol: <100 mg/dl HDL cholesterol: >55 mg/dl • Triglycerides: <150 mg/dl Hb A1C: <7.0% Self-monitoring of blood glucose: mean <140 mg/dl • No episodes of severe hypoglycemia requiring emergency assistance • Blood pressure: <130/80 mmHg, with minimal or no signs or symptoms of orthostatic hypotension • Biochemical measures, such as potassium, calcium, magnesium, uric acid,• Biochemical measures, such as potassium, calcium, magnesium, uric acid, serum creatinine, and blood urea nitrogen: within normal levels • Improvement in or no worsening of peripheral edema • Daytime asthma symptoms less than twice a week, night time symptoms no more than twice a month, and symptoms responsive to inhaled β 2-agonist within 15 min. • Attain/maintain control of ventricular rate to <100 bpm • Urinary albumin excretion: <30 g albumin/mg creatinine • Serum digoxin: 1.5–2.0 ng/ml
  19. 19. Case Presentation – MRP’s and PI’s Medication-Related Problems & Proposed Interventions 1. No indication for a current drug 2. Indication for a drug - but none prescribed 3. Wrong drug regimen prescribed / more efficacious choice possible 4. Too much of the correct drug 5. Too little of the correct drug 1. FLUTICASONE 2. SALMETEROL 3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZONE 6. FUROSEMIDE 7. DILTIAZEM 5. Too little of the correct drug 6. Adverse drug reaction/drug allergy 7. Drug-drug, drug-disease, drug-food interactions 8. Patient not receiving a prescribed drug 9. Routine monitoring (labs, screenings, exams) missing 10.Other problems, such as potential for overlap of adverse effects 7. DILTIAZEM 8. LANOXIN 9. POTASSIUM CHLORIDE 10. FLUVASTATIN 11. INSULIN 12. NITROGLYCERIN 13. FUROSEMIDE 14. ALBUTEROL 15. PREDNISOLONE
  20. 20. Medication Related Problems 1. FLUTICASONE 2. SALMETEROL 3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZONE 6. FUROSEMIDE 7. DILTIAZEM 8. LANOXIN 9. POTASSIUM CHLORIDE 1. Type 2 diabetes diagnosed in 2005 2. Hypertension 3. Hyperlipidemia 4. Asthma 5. Coronary Artery Disease 6. Persistent - Peripheral Edema & 7. Longstanding Musculoskeletal Pain No indication for a current drug 9. POTASSIUM CHLORIDE 10. FLUVASTATIN 11. INSULIN 12. NITROGLYCERIN 13. FUROSEMIDE 14. ALBUTEROL 15. PREDNISOLONE 7. Longstanding Musculoskeletal Pain secondary to a motor vehicle accident. 8. Atrial fibrillation 9. Anemia 10. Knee Replacement & 11. Multiple emergency room (ER) admissions for Asthma None No indication for a current drug
  21. 21. Medication Related ProblemsMedication Related Problems Indication for a drug (or device or intervention) but none prescribed  Peak flow meter  Calcium/vitamin D / HRT supplementation  Corticosteroid therapy  Postmenopausal woman  Furosemide can cause hypocalcemia.  Magnesium Supplementation 1. FLUTICASONE 2. SALMETEROL 3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZONE 6. FUROSEMIDE 7. DILTIAZEM 8. LANOXIN 9. POTASSIUM CHLORIDE Routine Use Of Magnesium In Diabetes.  Hypomagnesemia - Risk Factor - Atrial Fibrillation, Hypertension, Insulin Resistance, Glucose Intolerance, Dyslipidemia, Increased Platelet Aggregation  An added benefit - Constipation  Angiotensin-converting enzyme (ACE) inhibitor  Patients >55 years of age with diabetes & hypertension - ACE inhibitor - indicated  Diltiazem - calcium-channel blocker - addresses several needs  If additional antihypertensive, renal, or cardiac effects are indicated, an ACE inhibitor should be added to the drug regimen. 9. POTASSIUM CHLORIDE 10. FLUVASTATIN 11. INSULIN 12. NITROGLYCERIN 13. FUROSEMIDE 14. ALBUTEROL 15. PREDNISOLONE
  22. 22. Medication Related Problems Too much of the correct drug • Patient is using excessive doses of Salmeterol & fluticasone as treatment for 1. FLUTICASONE 2. SALMETEROL 3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZONE 6. FUROSEMIDE 7. DILTIAZEM 8. LANOXIN fluticasone as treatment for asthma exacerbations (at times when she can afford them). 8. LANOXIN 9. POTASSIUM CHLORIDE 10. FLUVASTATIN 11. INSULIN 12. NITROGLYCERIN 13. FUROSEMIDE 14. ALBUTEROL 15. PREDISOLONE
  23. 23. Medication Related Problems Too little of the correct drug  Potassium Chloride Supplement 1. FLUTICASONE 2. SALMETEROL 3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZONE 6. FUROSEMIDE 7. DILTIAZEM 8. LANOXIN8. LANOXIN 9. POTASSIUM CHLORIDE 10. FLUVASTATIN 11. INSULIN 12. NITROGLYCERIN 13. FUROSEMIDE 14. ALBUTEROL
  24. 24. Medication Related Problems Adverse drug reaction/drug allergy 1. FLUTICASONE 2. SALMETEROL 3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZONE 6. FUROSEMIDE 7. DILTIAZEM 8. LANOXIN  None 8. LANOXIN 9. POTASSIUM CHLORIDE 10. FLUVASTATIN 11. INSULIN 12. NITROGLYCERIN 13. FUROSEMIDE 14. ALBUTEROL 15. PREDNISOLONE
  25. 25. Medication Related Problems Drug-drug, drug-disease, drug-food - interactions  Systemic Corticosteroid Therapy, Inhaled Corticosteroid Therapy, Loop Diuretics in postmenopausal woman: increased risk for development of osteoporosis  Furosemide, Prednisone in diabetes, w/ Insulin, Rosiglitazone: may increase blood glucose (DOSE-RELATED RESPONSE), thus diminishing the pharmacodynamic activity of antidiabetes agents 1. FLUTICASONE 2. SALMETEROL 3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZONE 6. FUROSEMIDE 7. DILTIAZEMdiminishing the pharmacodynamic activity of antidiabetes agents  Albuterol, Salmeterol in diabetes, w/Insulin, Rosiglitazone: sympathomimetics may increase blood glucose via stimulation of Beta 2-receptors, leading to increased glycogenolysis & diminished pharmacodynamic activity of antidiabetes agents  Albuterol, Naproxen, Prednisone, Fluticasone in hypertension: may increase blood pressure (DOSE-RELATED RESPONSE) 7. DILTIAZEM 8. LANOXIN 9. POTASSIUM CHLORIDE 10. FLUVASTATIN 11. INSULIN 12. NITROGLYCERIN 13. FUROSEMIDE 14. ALBUTEROL 15. PREDNISOLONE
  26. 26. Medication Related Problems Drug-drug, drug-disease, drug-food interactions 1. Naproxen in hypertension: INCREASE BLOOD PRESSURE 2. Naproxen in diabetes: may INCREASE RISK OF NEPHROPATHY 3. Furosemide – HYPOMAGNESEMIA / 1. FLUTICASONE 2. SALMETEROL 3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZONE 6. FUROSEMIDE 7. DILTIAZEM 3. Furosemide – HYPOMAGNESEMIA / HYPOKALEMIA 4. Furosemide, prednisone, fluticasone, salmeterol, albuterol w/DIGOXIN: - potential for DIGOXIN TOXICITY. 5. DILTIAZEM w/DIGOXIN: - ELEVATE DIGOXIN LEVELS. 7. DILTIAZEM 8. LANOXIN 9. POTASSIUM CHLORIDE 10. FLUVASTATIN 11. INSULIN 12. NITROGLYCERIN 13. FUROSEMIDE 14. ALBUTEROL
  27. 27. Medication Related Problems Patient not receiving a prescribed drug • Salmeterol & fluticasone: not 1. FLUTICASONE 2. SALMETEROL 3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZONE 6. FUROSEMIDE 7. DILTIAZEM 8. LANOXIN• Salmeterol & fluticasone: not purchased because of financial constraints 8. LANOXIN 9. POTASSIUM CHLORIDE 10. FLUVASTATIN 11. INSULIN 12. NITROGLYCERIN 13. FUROSEMIDE 14. ALBUTEROL
  28. 28. Outcomes & Endpoints – Monitoring Parameters Routine Monitoring (Labs, Screenings, Exams) Missing 1. FLUTICASONE 2. SALMETEROL 3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZONE 6. FUROSEMIDE 7. DILTIAZEM 8. LANOXIN  Annual dilated eye exam is due  Annual microalbuminuria test is due  Consider screening for depression 8. LANOXIN 9. POTASSIUM CHLORIDE 10. FLUVASTATIN 11. INSULIN 12. NITROGLYCERIN 13. FUROSEMIDE 14. ALBUTEROL 15. PREDNISOLONE
  29. 29. Pharmacist Interventions Pharmacist Interventions ASTHMA 1. Change Fluticasone & Salmeterol prescriptions to a single combination product 2. Limit use of albuterol inhaler (short-acting beta- agonist) to rescue only.agonist) to rescue only. 3. Consider addition of Leukotriene Inhibitor if symptoms are not controlled 4. Begin use of Peak Flow Meter every morning upon arising. 5. Develop & Implement - Asthma Action Plan
  30. 30. Pharmacist Interventions Pharmacist Interventions DIABETES Algorithms  Change Insulin Regimen  Bedtime - Glargine &  Premeal - Lispro  Rapid Acting  Long Acting
  31. 31. Pharmacist Interventions Pharmacist Interventions Dyslipidemia Change Fluvastatin to Atorvastatin  Drug Interactions  Potency – LDL lowering ability  Half life
  32. 32. Pharmacist Interventions Pharmacist Interventions Persistent lower-extremity edema  Elevate Extremities – 20 – 30 minutes, two to three times / day  Wear Support Stockings - anticipating being on her feet most of the day  Limit Salt Intake  Minimize use - NSAIDs
  33. 33. Pharmacist Interventions Pharmacist Interventions HYPOKALEMIA • Increase potassium chloride supplement temporarily; reassess potassium level in 7–10 days.potassium level in 7–10 days. • Titrate potassium dosage with decreasing use of Albuterol, Furosemide & Prednisone to attain & maintain potassium level of 3.5–5.0 mEq/l
  34. 34. Outcomes & Endpoints Pharmacist Interventions  HYPERTENSION  No changes at this time / consider addition or change to ACE inhibitor  CORONARY ARTERY DISEASE  No changes at this time  OBESITY  Refer - Santha for nutrition counseling & weight loss.  CHRONIC PAIN  Change ongoing pain medications to ACETAMINOPHEN 500–650 mg three times a day. Minimize use of NSAIDs by limiting it to “breakthrough” pain only  naproxen, 250 mg, or ibuprofen, 200 mg, as needed.
  35. 35. Outcomes & Endpoints Pharmacist Interventions FINANCIAL CONSTRAINTS • Apply for manufacturers’ indigent drug programs and State Health Insurance Programs for combination asthma productPrograms for combination asthma product & other expensive medications.  Generic Equivalent  Direct – Manufacturer  Samples
  36. 36. Pharmacist Interventions Wellness , Preventive & Routine Monitoring Issues  Initiate calcium/vitamin D supplementation  Initiate magnesium supplementation  Reduce daily aspirin from 325 to 81 mgReduce daily aspirin from 325 to 81 mg  Screen for depression  Refer for annual eye exam  Refer for bone density scan  Refer for nutritional counseling
  37. 37. Patient Education Pharmacist Interventions Patient Education  AsthmaAsthma  Diabetes  Lower-extremity edema  Nutrition  Medication education
  38. 38. References  Textbook of Clinical Skills for Pharmacists, 2nd Edition, Karen J.Tietze.  Textbook of Current Medical Diagnosis andTreatment (CMDT) – 2014.  Textbook of AppliedTherapeutics : 2nd Edition, Koda and Kimble.  British National Formulary (BNF), 61st edition  Glen Lewis Stimmel, Professor, University of Southern California, US.  Dr. Navin Loganathan,Cover story : New SundayTimes, Malaysia.  Prof. Syed Azhar Syed Sulaiman, Dean – University Sains, Malaysia.  Jennifer Pham, University of Illinois, Chicago, US : Short profile.  Dr. Gayatri Palat, Director & Co founder, PRPCS – Two World’s Cancer Collaboration (TWCC), India.
  39. 39. QUESTION HOUR Thank You…

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