1. A 38-year-old male presented with chronic joint pain and was found to have an elevated PSA of 4.79, which is abnormal for his age. Over the next several years he saw multiple providers but his abnormal PSA was never addressed, a digital rectal exam was never performed, and he was never educated on prostate cancer screening.
2. Five years later he presented with signs of metastatic cancer and a PSA of 2721. He died of prostate cancer six months later at age 44, leaving a $13.5 million malpractice claim from his widow. The documentation shows gaps in care coordination and patient education that likely contributed to his poor outcome.
Poster Presentation Title: A Phase 1 clinical trial of a therapeutic prostate cancer vaccine containing PSA/IL-2/GM-CSF in PSA defined biochemical recurrent prostate cancer patients
Meeting: CRI-CIMT-EATI-AACR: Inaugural International Cancer Immunotherapy Conference: Translating Science Into Survival
Immunotherapy for cancer has had two main approaches that have lead to clinical applications. The first is stimulating immune responses to tumor cells with cytokines or cellular immunotherapy and the second is blocking tumor immune evasion and the associated inhibition of T-cell activation with antibodies to the CTLA-4 receptor, PD-1 receptor or PD-L1. At OncBioMune, we have taken a different approach and have developed therapeutic cancer vaccines that are a combination of tumor antigens (whole cells or proteins) with biological adjuvants (the cytokines IL-2 and GM-CSF). This study is a Phase 1a/1b clinical trial of a PSA/IL-2/GM-CSF vaccine in recurrent prostate cancer in hormone-naïve and hormone-independent patients. Major inclusion criteria include adenocarcinoma of the prostate, rising serum PSA and no measurable disease. Phase 1a examines the rate of dose limiting adverse events (DLAEs) in an initial course of 6 vaccinations (“induction vaccination”). The Phase 1b examines the rate of DLAEs with a continued coarse of an additional 6 vaccinations (“maintenance vaccine”). All patients will receive intradermal injections of the PSA/IL-2/GM-CSF vaccine at weeks 1, 2, 3, 7, 11, and 15. In an additional 28 patients the six maintenance vaccines will alternate IL-2 and the complete vaccine (PSA/IL-2/GM-CSF) at weeks 23, 27, 31, 35, 39 and 43. To date, twelve of twenty patients in the Phase 1a portion of the trial have received at least one vaccine injection and ten patients have received all 6 vaccines. Seven of the ten patients that have received 3 vaccines had increased responses to PSA in a lymphocyte blastogenesis assay and five of the nine patients had an increase in their response after 6 vaccines. None of the patients vaccinated in the Phase 1a portion have had a DLAE and enrollment continues in the Phase 1a.
Stockholm Karolinska meeting: Graft histology - a marker of pain and sufferin...Maarten Naesens
In this presentation, I discuss the role for protocol kidney allograft biopsies and biopsies for cause, as opportunity for individualised immunosuppressive regimen and use of targeted therapeutic strategies, in order to prevent chronic allograft dysfunction and improve long-term graft outcome. I discuss how kidney transplant histology is re-emerging as the clinical key parameter for the fate of the graft, and display long-term implications of histological alterations. I finally discuss the value of histology as a surrogate study endpoint, and reiterate the urgent need to identify appropriate surrogate endpoints to improve long-term outcomes.
Banff 2017 meeting presentation - early versus late inflammationMaarten Naesens
My presentation at the Banff 2017 meeting in Barcelona on kidney transplant pathology on the impact of time after transplantation on transplant outcome, and the difference between diagnostic and prognostic use of the Banff scheme for allograft histopathology.
Poster Presentation Title: A Phase 1 clinical trial of a therapeutic prostate cancer vaccine containing PSA/IL-2/GM-CSF in PSA defined biochemical recurrent prostate cancer patients
Meeting: CRI-CIMT-EATI-AACR: Inaugural International Cancer Immunotherapy Conference: Translating Science Into Survival
Immunotherapy for cancer has had two main approaches that have lead to clinical applications. The first is stimulating immune responses to tumor cells with cytokines or cellular immunotherapy and the second is blocking tumor immune evasion and the associated inhibition of T-cell activation with antibodies to the CTLA-4 receptor, PD-1 receptor or PD-L1. At OncBioMune, we have taken a different approach and have developed therapeutic cancer vaccines that are a combination of tumor antigens (whole cells or proteins) with biological adjuvants (the cytokines IL-2 and GM-CSF). This study is a Phase 1a/1b clinical trial of a PSA/IL-2/GM-CSF vaccine in recurrent prostate cancer in hormone-naïve and hormone-independent patients. Major inclusion criteria include adenocarcinoma of the prostate, rising serum PSA and no measurable disease. Phase 1a examines the rate of dose limiting adverse events (DLAEs) in an initial course of 6 vaccinations (“induction vaccination”). The Phase 1b examines the rate of DLAEs with a continued coarse of an additional 6 vaccinations (“maintenance vaccine”). All patients will receive intradermal injections of the PSA/IL-2/GM-CSF vaccine at weeks 1, 2, 3, 7, 11, and 15. In an additional 28 patients the six maintenance vaccines will alternate IL-2 and the complete vaccine (PSA/IL-2/GM-CSF) at weeks 23, 27, 31, 35, 39 and 43. To date, twelve of twenty patients in the Phase 1a portion of the trial have received at least one vaccine injection and ten patients have received all 6 vaccines. Seven of the ten patients that have received 3 vaccines had increased responses to PSA in a lymphocyte blastogenesis assay and five of the nine patients had an increase in their response after 6 vaccines. None of the patients vaccinated in the Phase 1a portion have had a DLAE and enrollment continues in the Phase 1a.
Stockholm Karolinska meeting: Graft histology - a marker of pain and sufferin...Maarten Naesens
In this presentation, I discuss the role for protocol kidney allograft biopsies and biopsies for cause, as opportunity for individualised immunosuppressive regimen and use of targeted therapeutic strategies, in order to prevent chronic allograft dysfunction and improve long-term graft outcome. I discuss how kidney transplant histology is re-emerging as the clinical key parameter for the fate of the graft, and display long-term implications of histological alterations. I finally discuss the value of histology as a surrogate study endpoint, and reiterate the urgent need to identify appropriate surrogate endpoints to improve long-term outcomes.
Banff 2017 meeting presentation - early versus late inflammationMaarten Naesens
My presentation at the Banff 2017 meeting in Barcelona on kidney transplant pathology on the impact of time after transplantation on transplant outcome, and the difference between diagnostic and prognostic use of the Banff scheme for allograft histopathology.
Cовременное лечение ВИЧ : новые данные с конференции CROI 2017/ Contemporary...hivlifeinfo
Cовременное лечение ВИЧ : новые данные с конференции CROI 2017/ Contemporary Management of HIV. New Data From CROI 2017
In this downloadable slideset, Charles B. Hicks, MD, and Program Director Joseph J. Eron, Jr., MD, review key new HIV data presented at the Seattle 2017 meeting.
Topics include:
-Prevention
-New data on currently available ART
-Switch/simplification strategies for virologically suppressed patients
-Investigational ARV agents
-Treatment complications and comorbidities
Yan 2Yichao YanKara WilliamsESL 10696 April 2019 Rough.docxadampcarr67227
Yan 2
Yichao Yan
Kara Williams
ESL 1069
6 April 2019
Rough Draft Analysis of Argument Essay
In the article “What Else Can I Do to Get the School Supplies My Student Need?” the author discusses that, textbook still plays an important role in today’s class. There are so many debates about weather using online text book or physical textbook in school nowadays. The author as a college teacher claims that physical textbook helps her students have better understanding of knowledges. Also, she thinks physical textbook reduced the financial burden on students. However, online source or online textbook should have more benefit then the physical textbook.
First of all, the author claims that physical textbook could helps student read and understand better of new knowledges. The resources that teachers need for their teaching are so differently. It depended on student’s grade and their teaching style. Even people nowadays assume textbooks are outdated, inefficient and biased, author still think using textbook is very important for students to know about some academic basic information, which could help students master the course better.
APPENDIX I r Reports
DIAGNOSES include:
1. Chronic pelvic pain secondary to pelvic metastatic clear cell carcinoma
of unknown PrimarY location.
2. Yeta cava sy.rdromi post placement of Hickman catheter'
3. Anemia due to chronic disease.
4. Hypertension.
HOSPITAL COURSE: The patient is a 78-year-old female whom we have
been following in our clinic ior hypertension and also chronic pudendal
nerve pain. Shie had been recently biagnosed with pelvic me,tastatic clear
cell caicinoma, which her primaiy location is unknown at this time' She
will be discussing this further after the pathology reports are, read. During
her hospital stalia Hickman catheter was placed in order to have IV access
for pain medication or future cancer therapy. She was also admitted for
chronic pain. she did develop swelling of her arms and neck. She was
broughtio interventional radiology and she did have venography and the
Hickman catheter was removed. Her swelling to her arms and neck have
decreased greatly. She denies any shortness of breath. No choking sensation
as previouily noted. Her pain has been managed well with fentanyl patch at
175 mcg. She has also been on IV heparin therapy for anticoagulation
followitig the vena cava syndrome. Today, the patient hasbeen having
complaiits of nausea. She did get some dexamethasone IV for her nausea,
which did improve later this morning. Her blood plessure has been under
good control. Her labs today include a wBC of 5.18, hemoglobin 7.8,
f,ematocrit 23.7, protime 74.4,INR 1'5, PTT 39'6, BUN 6, sodium 139'
potassium 4.2, CO2 27.2.
DISCHARGE, PLANS:
1. IV heparin is discontinued. She will be switched ovel to Lovenox
r mg/kg subcutaneously daily. The patient will have Home Health to
help her set uP these iniections.
2. She will continue with the fentanyl patch 175 mcg for the pain..
1. For me personally this can be both ways depending the the situa.docxambersalomon88660
1. For me personally this can be both ways depending the the situation that has to be dealt with. But if this circumstance has to be due to long term care is would most likely choose a nurse practitioner to deal this examination or procedure because they see patients at every phase of their lives, and typically don not specialize in any one area. They can function well as primary care providers because their background includes knowledge of both holistic and wellness oriented programs, which spotlight education, risk identification and preventive care. Any surgical has to be done by a physician no doubt but apart from that the nurse practitioner can handle the rest which is why most patients go to nurse practitioner to handle their care. Therefore, any condition that can be identified by treating acute and chronic illnesses, order and analyze labs and other diagnostic tests and prescribe medications then the nurse practitioner is ideal. And lastly would choose them because they have more time on their handle than physicians.
2. in some areas of the United States there is a shortage of doctor in primary care. Because of this, hospitals, urgent care centers and private clinics are looking for nurse practitioner to fill those needs. Nurse Practitioners are licensed and capable to treating illnesses and injuries and educating patients. They can also diagnose and treat acute and chronic conditions. The most common certification for NP’s is primary care so the majority of them do not have certification qualifications in specialties like cardiology, neurology, gastroenterology or surgical practice just to name a few. So for examinations in a primary care setting, I would be willing to have one done by a nurse practitioner or a physician depending on their appointment availability. Mostly it will be with a NP because you can get an appointment sooner. So when it comes to procedures, I would rather have one done by a physicians because they have more extensive and comprehensive training.
3. In reading this discussion forum question, I could tell you based on my experience working with a few (NP's)-Nurse Practitioners and the majority of patients who were seen by them, I would never want to be medically seen by an NP based on several problems that I have encountered which have made me biased, in my choices. To Illustrate, I have endured working alongside an Asian American NP, who made black patients uncomfortable with the treatment they received during their office visit, as the NP did not listen to their health concerns while rushing through their visit, not examining the patients and at times refusing to prescribe medications, like Vitamin D or Multivitamins when the patient requested them. They were also refused diagnostic testing which they wanted done, just to make sure there was nothing, to be worried about. As these black patients faced these health disparities, they vowed never to return to the clinic for medical services, as they f.
HIV Prevention: Combating PrEP Implementation ChallengesCHC Connecticut
Expert faculty present case-based scenarios illustrating common challenges to integrating HIV PrEP in primary care. As part of improving clinical workforce development, this session will delve into a variety of specific PrEP implementation challenges. Participants will leave with strategies to overcome these obstacles to establish or strengthen their PrEP program.
Panelists:
• Marwan Haddad, MD, MPH, AAHIVS, Medical Director, Center for Key Populations, Community Health Center, Inc.,
• Jeannie McIntosh, APRN, FNP-C, AAHIVS, Family Nurse Practitioner, Center for Key Populations, Community Health Center, Inc.
Cовременное лечение ВИЧ : новые данные с конференции CROI 2017/ Contemporary...hivlifeinfo
Cовременное лечение ВИЧ : новые данные с конференции CROI 2017/ Contemporary Management of HIV. New Data From CROI 2017
In this downloadable slideset, Charles B. Hicks, MD, and Program Director Joseph J. Eron, Jr., MD, review key new HIV data presented at the Seattle 2017 meeting.
Topics include:
-Prevention
-New data on currently available ART
-Switch/simplification strategies for virologically suppressed patients
-Investigational ARV agents
-Treatment complications and comorbidities
Yan 2Yichao YanKara WilliamsESL 10696 April 2019 Rough.docxadampcarr67227
Yan 2
Yichao Yan
Kara Williams
ESL 1069
6 April 2019
Rough Draft Analysis of Argument Essay
In the article “What Else Can I Do to Get the School Supplies My Student Need?” the author discusses that, textbook still plays an important role in today’s class. There are so many debates about weather using online text book or physical textbook in school nowadays. The author as a college teacher claims that physical textbook helps her students have better understanding of knowledges. Also, she thinks physical textbook reduced the financial burden on students. However, online source or online textbook should have more benefit then the physical textbook.
First of all, the author claims that physical textbook could helps student read and understand better of new knowledges. The resources that teachers need for their teaching are so differently. It depended on student’s grade and their teaching style. Even people nowadays assume textbooks are outdated, inefficient and biased, author still think using textbook is very important for students to know about some academic basic information, which could help students master the course better.
APPENDIX I r Reports
DIAGNOSES include:
1. Chronic pelvic pain secondary to pelvic metastatic clear cell carcinoma
of unknown PrimarY location.
2. Yeta cava sy.rdromi post placement of Hickman catheter'
3. Anemia due to chronic disease.
4. Hypertension.
HOSPITAL COURSE: The patient is a 78-year-old female whom we have
been following in our clinic ior hypertension and also chronic pudendal
nerve pain. Shie had been recently biagnosed with pelvic me,tastatic clear
cell caicinoma, which her primaiy location is unknown at this time' She
will be discussing this further after the pathology reports are, read. During
her hospital stalia Hickman catheter was placed in order to have IV access
for pain medication or future cancer therapy. She was also admitted for
chronic pain. she did develop swelling of her arms and neck. She was
broughtio interventional radiology and she did have venography and the
Hickman catheter was removed. Her swelling to her arms and neck have
decreased greatly. She denies any shortness of breath. No choking sensation
as previouily noted. Her pain has been managed well with fentanyl patch at
175 mcg. She has also been on IV heparin therapy for anticoagulation
followitig the vena cava syndrome. Today, the patient hasbeen having
complaiits of nausea. She did get some dexamethasone IV for her nausea,
which did improve later this morning. Her blood plessure has been under
good control. Her labs today include a wBC of 5.18, hemoglobin 7.8,
f,ematocrit 23.7, protime 74.4,INR 1'5, PTT 39'6, BUN 6, sodium 139'
potassium 4.2, CO2 27.2.
DISCHARGE, PLANS:
1. IV heparin is discontinued. She will be switched ovel to Lovenox
r mg/kg subcutaneously daily. The patient will have Home Health to
help her set uP these iniections.
2. She will continue with the fentanyl patch 175 mcg for the pain..
1. For me personally this can be both ways depending the the situa.docxambersalomon88660
1. For me personally this can be both ways depending the the situation that has to be dealt with. But if this circumstance has to be due to long term care is would most likely choose a nurse practitioner to deal this examination or procedure because they see patients at every phase of their lives, and typically don not specialize in any one area. They can function well as primary care providers because their background includes knowledge of both holistic and wellness oriented programs, which spotlight education, risk identification and preventive care. Any surgical has to be done by a physician no doubt but apart from that the nurse practitioner can handle the rest which is why most patients go to nurse practitioner to handle their care. Therefore, any condition that can be identified by treating acute and chronic illnesses, order and analyze labs and other diagnostic tests and prescribe medications then the nurse practitioner is ideal. And lastly would choose them because they have more time on their handle than physicians.
2. in some areas of the United States there is a shortage of doctor in primary care. Because of this, hospitals, urgent care centers and private clinics are looking for nurse practitioner to fill those needs. Nurse Practitioners are licensed and capable to treating illnesses and injuries and educating patients. They can also diagnose and treat acute and chronic conditions. The most common certification for NP’s is primary care so the majority of them do not have certification qualifications in specialties like cardiology, neurology, gastroenterology or surgical practice just to name a few. So for examinations in a primary care setting, I would be willing to have one done by a nurse practitioner or a physician depending on their appointment availability. Mostly it will be with a NP because you can get an appointment sooner. So when it comes to procedures, I would rather have one done by a physicians because they have more extensive and comprehensive training.
3. In reading this discussion forum question, I could tell you based on my experience working with a few (NP's)-Nurse Practitioners and the majority of patients who were seen by them, I would never want to be medically seen by an NP based on several problems that I have encountered which have made me biased, in my choices. To Illustrate, I have endured working alongside an Asian American NP, who made black patients uncomfortable with the treatment they received during their office visit, as the NP did not listen to their health concerns while rushing through their visit, not examining the patients and at times refusing to prescribe medications, like Vitamin D or Multivitamins when the patient requested them. They were also refused diagnostic testing which they wanted done, just to make sure there was nothing, to be worried about. As these black patients faced these health disparities, they vowed never to return to the clinic for medical services, as they f.
HIV Prevention: Combating PrEP Implementation ChallengesCHC Connecticut
Expert faculty present case-based scenarios illustrating common challenges to integrating HIV PrEP in primary care. As part of improving clinical workforce development, this session will delve into a variety of specific PrEP implementation challenges. Participants will leave with strategies to overcome these obstacles to establish or strengthen their PrEP program.
Panelists:
• Marwan Haddad, MD, MPH, AAHIVS, Medical Director, Center for Key Populations, Community Health Center, Inc.,
• Jeannie McIntosh, APRN, FNP-C, AAHIVS, Family Nurse Practitioner, Center for Key Populations, Community Health Center, Inc.
1. 1. Situation: A 38 yearmale comesinfor an evaluationof chronicarthralgia. Outside of alonghistory
of arthralgiahe seemshealthy. Hisfamilyhistoryislistedasfatherwithcoloncancerand motherwith
diabetes. Thisisinxxxxx andhe seesanIMDoctor wholeavesapaperrecord forthe visit. IMDoctor
ordersx-raysandlabs to lookfora rheumaticprocess. Inaddition,althoughthe doctor doesnotchart
havingdone so,the doctor ordersa PSA and fastinglipids. The x-raysare negative exceptforarthritic
changesinthe jointsandthe labsare all negative exceptforthe PSA whichis4.79. Whenyou call up his
labin the electronicmedical record itcomesupwitha reference range of 0.0 to 5.0, so at firstglance
4.79 is withinnormal limits. Butthere isalsoan indicatorthatmore informationisavailable inthe
background and whenyouaccessthat informationissaysthatfor a 38 year oldthe reference range is
0.0 to 2.0. I have an electronicrecordwhichshows the exactdate andtime thatIM doctor markedthis
labas “reviewed”. Ihave anotherelectronic recordwhichshowsthe exactdate andtime of the next
appointmentwiththe patient,whichwas2days afterreviewing the lab,andshowsthatthe patientkept
the appointment,butthere isnorecordwhatsoeverof this orany subsequent visitwiththe IMDoc in
the chart. Outside of the electronicappointmentrecordthere isnootherindicationthisvisitever
happened. Thispredateselectroniccharting sothe recordsare all paper.
2. A yearlaterthe patientisseenbya PA foran “annual physical”. Familyhistoryislistedas“Father
coloncancer, Motherlupus”. Thisagain ispapercharting andthere isno electronicrecord. PA makes
no mentionof previousPSA resultbutordersamedand orderslabs,to include PSA. Noprostate exam
ischarted. Patientpicksupnewmedbutdoesnot complete labs. Labssitinthe cue x 1 year before the
orderis dumped. DoesNOTchart any indicationthatpatientunderstood the planof care.
3. 4 yearsafterinitial visitwithIMdoctor the patientisseenbya FNPfor an “annual physical”. Family
historyislistedasfathercoloncancer,motherdiabetes,sisterlupus. Thisisanelectronicencounterand
the FNPcopiesthe PSA of 4.79 from4 yearsearlierintothe note. The FNP makesno othermentionof
the PSA or anypatienteducationprovided. Noprostate examischarted. The FNPstates: “start Mobic.
Get colonoscopy. Getlabs done. Come backfasting.” The FNP doesnot chart any indicationthatthe
patientunderstoodthe planof care. The patientgetsthe colonoscopyandstartsthe new med,but
nevergotthe labs done,whichagainsitinthe cue x 1 year before the orderisdumped.
4. 5 yearsaftervisitwithIMdoctorand 1 yearaftervisitwithFNPthe patient isseenagainforhippain
by a differentFNPwhoordersxrays. The filmscome backdescribingbroadlesionssuspiciousfor
metastasis. The FNPstartsorderingeverything,includingaPSA whichcomesback at 2721. In spite of
effortstothe contrary, 6 monthslaterhe isdead,at age 44. On hisintake formtothe regional cancer
centerhe listsfamilyhistoryas“Father,prostate cancer”.
5. Hiswidowisplacinga claimfor $13.5 million. He isdeposedacouple of monthsbefore he diesand
inhis depositionhe statesthat“Idid everylabtheyevertoldme todo.” He states “I was nevertoldI
had an abnormal PSA testand nobodyeverdidadigital rectal examonme.”
6. So,whoare you goingto believe? Boththe PA and the FNPphysicallyordered the labs. The proof is
inthe electronicmedical record. The FNPspecificallycharts“Getlabs done. Come backfasting.”
Neitherproviderchartsthatthe patientunderstoodthe instructionsandagreedtocomply. The patient
states“I dideverylabtheyevertoldme to do.” Who ismore credible?
2. a. On the day of the encounter in3. above,the dayof the visitwiththe firstFNP, the medical
technicianopensthe encounterat1458 hours. The FNPsignsthe encounterat1528 hours,
exactly30 minuteslater. The FNP lists“40 minutesface toface floortime.” Whois more
credible?
b. 107 dayslaterthe FNPamendsthe encounterat1317 hoursand adds the diagnosis“Blood
pressure isolatedelevated. Randomlycheckbloodpressure andfollow upif itremains
above parametersgiven.” The FNP signsthe encounter,closingitagain,alsoat1317, so the
entire transactiontakeslessthan1 minute. The FNP neversaw the patientpriortothe
initial encounterandthere isnorecord of any contact withthe patientafterthe initial
encounter. The FNP isstatingthat 107 days laterthat she remembersthisspecificpatient
well enoughtorememberthatshe had givenhimthese instructions? Whoismore credible?
c. The patientwastoldto getthe labsdone and start a new medby one provider,andtoget
the labsdone,start a newmed,and get a colonoscopybyanotherprovider. Inbothcases
he understoodwell enoughtostartthe new medandto get the colonoscopy,butnotwell
enoughtoget the labsdone? Who ismore credible?
d. The patientretiredand on25% disabilityfordamage tohislungsfroma single occupational
exposure in aclosedroomto noxioussmoke. He wasa 2 pack a day smokersince he was15
yearsoldand workedforyearsas a concrete worker,aprofessionwhichcreatesasignificant
exposure todustandfumes. Inspite of hisdisability,smoking,andprofession,he never
receivedasingle prescriptionforanybronchodilator,inhaledsteroid,orevenanantibiotic.
He neverhada respiratorycomplaintandwasnevertreatedforanylungproblems. How
real was hisdisability? Whoare yougoingto believe?
Summary.
1. Alwaysreviewyourplanof care withthe patientone lasttime.
2. Checkthe little box “Discussed:Diagnosis,Medication,Treatment,Alternatives,PotentialSide Effects
withthe patientwhoindicated understanding”.
3. It isprobablya goodideato document: “Patientverbalizedanunderstandingof the planof care”.
4. Accurate familyhistoryISimportant. Whatelse ina totallyasymptomaticpatientmighthave leda
providertochecka PSA priorto age 40?
5. Purpose of educationistomotivate patienttofollow the planof care. Don’tbe afraidto use the “c”
wordto motivate them,if thatison the listof possible explanationsforthe abnormal resultyouwant
themto f/uon. “The slightly elevatedPSA couldmeanyouhave prostate cancer. Youcouldhave a
heartattack or stroke because yourbloodpressure istoohigh.”
6. Don’tleave anydoubtsas to yourintegritybyobviousover-billingorpencil-whippeddiagnoses/plan
added107 days later.