05 at 1 40 tawfikpvx web conferencing
TRANSCRIPT
![Page 1: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/1.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 1/45
INTERACTIVEMULTIDISCIPLINARY WEB
CONFERENCING:The Use of the Aperio and
PolyCom PVX SystemsOssama Tawfik, MD, PhD
ProfessorDirector of Anatomic and Surgical Pathology
The University of Kansas Medical CenterPathology Vision Conf, Oct 2008
![Page 2: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/2.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 2/45
![Page 3: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/3.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 3/45
![Page 4: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/4.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 4/45
OBJECTIVES
1. Why going digital is valuable?2. What is wrong with the current
system?
3. Can we do better? And why do wehave to?
![Page 5: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/5.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 5/45
Why Digital Conferencing?
– Problem...
• Medicine is changing.
• Medical Practice and Teaching is moving away
from the Major Medical Centers into CommunitySettings.
• Medical Centers are redesigning themselves -clinics, surgi-centers, nursing homes anddoctor’s practices.
• Great majority of patient care will be outpatient,located outside the main Campus.
![Page 6: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/6.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 6/45
Why Telepathology?
– Problem...
• The growing physical separation betweenClinician and Pathologist is problematic incommunication...
• Traditional Pathology Reports will havelimitations in communication.
• How will we communicate with our clients
when they are across town, across the state oracross the world?
![Page 7: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/7.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 7/45
Why Telepathology?
– Problem...
• As medicine becomes distributed, it will becomeincumbent upon us as pathologists to find new
ways of communicating for clinical work,research and education.
• The primary mode of communication has alwaysbeen the pathology report.
• We may now have to rethink the way we report...
![Page 8: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/8.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 8/45
![Page 9: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/9.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 9/45
![Page 10: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/10.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 10/45
![Page 11: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/11.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 11/45
![Page 12: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/12.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 12/45
• Pathologists, radiologists, and surgeons
• digital slide/radiology conferencing on aweekly basis
• 500 breast needle core biopsies
• ERROR REDUCTION!!!!
• Evaluation of significantabnormalities/discrepancies
• Correlation with treatment plans for each
patient
INTERACTIVE MULTIDISCIPLINARY
CONFERENCE
![Page 13: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/13.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 13/45
Microcalcifications of the breast:
size matters!
A mammographic-histologic correlation studyX Liu, M Inciardi, JP Bradley, F Fan, P Thomas, W Smith, O
Tawfik
Pathologica 2007;99:5-10
![Page 14: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/14.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 14/45
Core Needle Biopsy Protocol
Specimen radiography
Calcification
Absent
Calcification
Present
< 100 um > 100 um
Proceed w Dx
Tissue block
radiography
Radiologically
negative
Radiologically
positive
Malignant DxBenign Dx
Cut deeper in block
Additional
studies are
required!!
Ca Absent Ca Present
Ca SIZE
![Page 15: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/15.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 15/45
Medical Error Statistics
• Colorado and Utah s tudy
– Adverse events (AE) in 2.9% of hospitalizations
– 8.8% of AE’s led to death (about 44Kdeaths/annually
• New York study
– AE’s in 3.7% of hospitalizations – 13.6% of AE’s led to death (98K deaths annually)
• Eigh th leading cause of death in USA
![Page 16: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/16.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 16/45
Dollar Cost of Medical Error
• Between $17 to $29 billion/year
– Half directly attributable to health care costs
– Other half combination of lost productivity, lostincome and disability
![Page 17: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/17.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 17/45
Goals of the IOM report
• Break “cycle of inaction’ concerning patient
safety and medical error
• Enhance knowledge base about medical error• Breakdown legal and cultural barriers which
impede safety improvement
• Shift from blaming individuals for past errors to afocus on preventing future errors by designingsafety into the health care system
![Page 18: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/18.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 18/45
Goals of the IOM Report (cont.)
• Improve knowledge base about medicalerror and safety improvement
• Develop tools to improve safety
• Cause significant monetary investments toachieve these goals
![Page 19: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/19.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 19/45
Institute of Medicine mandate
• Threshold improvement in quality
– 50% reduction in medical error in five years
![Page 20: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/20.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 20/45
“ARE WE LISTENING?”
![Page 21: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/21.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 21/45
“OUR PROBLEM”
![Page 22: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/22.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 22/45
“OUR PROBLEM”
KU Med Ctr is
Located 3 miles
From Cancer
Center
Man power
Time
Resources
![Page 23: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/23.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 23/45
“OUR PROBLEM”
![Page 24: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/24.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 24/45
![Page 25: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/25.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 25/45
![Page 26: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/26.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 26/45
• Aperio ScanScopeSystem
• PolyCom PVX videoconferencing System
“OUR SOLUTION”
![Page 27: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/27.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 27/45
• Pathologists, radiologists and surgeons
• Develop a web based pre-diagnostic work-up conference in which the pathologyslides and mammograms could beanalyzed together
• Goals:
– To insure adequate sampling
– To reach a proper diagnosis
– To determine the proper surgical/treatment
plans
Aperio/KUMC Pilot Project
![Page 28: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/28.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 28/45
Application Values
Tested Variables Measured
ConfirmationReviews with DigitalConferencing
Quality Concordance between glass
and digital reads Image quality Comfort level with using digital
slides Ease of use with digital slides
Service andEfficiency Pathologist/Radiologist/Surgeon
satisfaction Comparison of actions taken
based on digital consultationsvs. history of actions for thesame type of discrepancy
![Page 29: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/29.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 29/45
![Page 30: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/30.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 30/45
Telepathology/Teleradiology
Unit
• Server with high speed internet connection
• Personal computer w web camera
• Digital pathology system (AperioScanScope XT)
• Spectrum Plus™ digital pathology
information management software
• Web conferencing system (PolyCom PVX)
![Page 31: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/31.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 31/45
![Page 32: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/32.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 32/45
![Page 33: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/33.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 33/45
Values• Pathology side:Remote viewing and conferencing
Simultaneous view of multiple digital slides
Archiving and intelligent retrieval capabilities
• Radiology side:Remote viewing and conferencing
Simultaneous view of multiple digital images
Alive radiologic images w radiologist andpathologist input
![Page 34: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/34.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 34/45
• Pathology/Radiology:
Audio and Video conferencing while reviewingimages
No need to leave office
No phone calls or typing required
Values
![Page 35: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/35.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 35/45
Cases – Pathologic Diagnosis
• Invasive carcinoma (1 case)
• DCIS (1 case)
• Fibroadenoma (2 cases)
• Fibrocystic changes with microcalcifications (12cases)
• Fat necrosis (1 case)
• Fibrosis (3 cases)
• Intraductal papilloma (1 case)
• Sclerosing adenoma (1 case)
![Page 36: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/36.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 36/45
• Microcalcifications (11 cases)
• Abnormal mammogram, mass (6 cases)
• Fibroadenoma (2 cases)• Abnormal ultrasound, mass (2 cases)
• Spiculated mass (1 case)
Cases – Radiologic Diagnosis
![Page 37: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/37.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 37/45
Concordance
No Impact
100%concordance
MinorImpact
MajorImpact
13 6 3
• Excise lesion (1)
• Re-biopsy patient (2)
• Follow upmammograms (2)
• X-ray tissue blocks
(4)
![Page 38: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/38.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 38/45
Teleconferencing Challenges
![Page 39: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/39.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 39/45
Challenges
• It requires some training (learning curve)
• Psychological barrier!!!!
• Limitations in technology (view of smallarea of slide, length of transmission ofimages, internet connections, etc.)
• Image resolution, size of files transmitted
![Page 40: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/40.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 40/45
Benefits of telepathology
(telemedicine) • Better medical service
• More specialized service
• Primary diagnosis for frozen sections• Second opinion and consultations
(dermatopathology, neuropathology,cytopathology, etc.)
• Quality control
B fit f t l th l
![Page 41: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/41.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 41/45
Benefits of telepathology(telemedicine) cont.
• Cost saving/Time saving
• Exchange of ideas
• Improved collaboration with opportunity forresearch
• E-learning, clinicopathological mtg anddiscussion groups
![Page 42: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/42.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 42/45
CONCLUSIONS
• It can be cost effective solution to the
our university problem.
– It negated the need for an on-site
pathologist to staff the biopsy cases – Provided at-your-desk Telepath diagnosis
Digital Pathology Applications
![Page 43: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/43.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 43/45
Digital
photo-graphs
Tele-
pathology
(remotely
controlledscopes)
Time
S c o p e o
f U s a g e
Before digital slides After digital slides
Digital Pathology Applications Adoption will Occur in Niches
Tumor Board,
Proficiency
Testing, CME
Archival
&
Retrieval
Virtual
IHC
Peer Review,QA
Image
Analysis
Manual Read
of DigitalSlide
Remote
viewing
Secondary
Consults
![Page 44: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/44.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 44/45
AcknowledgmentsMarilyn Davis
Dennis FriesenMark Redick
Ryan Spaulding
Dennis SchuckmanSherri Heffner and Aperio Co.
![Page 45: 05 at 1 40 Tawfikpvx Web Conferencing](https://reader030.vdocuments.mx/reader030/viewer/2022021321/577cc83d1a28aba711a2490b/html5/thumbnails/45.jpg)
8/12/2019 05 at 1 40 Tawfikpvx Web Conferencing
http://slidepdf.com/reader/full/05-at-1-40-tawfikpvx-web-conferencing 45/45
?