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

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

5. 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.

7. 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

8. 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

9. 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

10. 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.

11. 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.

12. 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.

13. 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.

14. 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

15. 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

16. 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.

17. 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

18. Pharmacist’s Work Up of Drug Therapy (PWDT)

19. 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?

20. 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.

21. 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.

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. Pharmacist Interventions
Pharmacist Interventions
DIABETES
Algorithms
 Change Insulin Regimen
 Bedtime - Glargine &
 Premeal - Lispro
 Rapid Acting
 Long Acting

35. Pharmacist Interventions
Pharmacist Interventions
Dyslipidemia
Change Fluvastatin to
Atorvastatin
 Drug Interactions
 Potency – LDL lowering ability
 Half life

36. 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

37. 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

38. 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.

39. 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

40. 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

41. Patient Education
Pharmacist Interventions
Patient Education
 AsthmaAsthma
 Diabetes
 Lower-extremity edema
 Nutrition
 Medication education

42. 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.

45. QUESTION HOUR
Thank You…