Dr. Ashwinikumar A. Raut . MD (. Ayurveda-Kayachikitsa). Director Clinical Research & Integrative Medicine. Medical Research Centre of Kasturba Health Society. ICMR Advanced Centre of Reverse Pharmacology in Traditional Medicine. ID: 546000
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Presentations text content in Scope and potential of Integrative Medicine in current Heal
Slide1
Scope and potential of Integrative Medicine in current Healthcare Scenario
Dr. Ashwinikumar A. Raut MD (Ayurveda-Kayachikitsa)Director Clinical Research & Integrative MedicineMedical Research Centre of Kasturba Health SocietyICMR Advanced Centre of Reverse Pharmacology in Traditional MedicineVile-Parle, Mumbai – 400056, Indiaashuraut@gmail.com
Samyukti
2013An Evidence Based Approach in integrating Ayurveda and AllopathyOrganized by MS Ramaiah Academy of Health and Applied Sciences, Bangalore Institute of Transdisciplinary Health Science and Technology (IHST) - FRLHT, Bangalore
1/8/2013
1
Samyukti2013 Bangalore/AAR
Slide2
Presentation structure
Integration of Ayurveda & Allopathy: A Tale of Two CenturiesCurrent Healthcare Scenario: Facts and FiguresEvidence Based Medicine: Complementary to Ayurveda Ethos Integrative Drug Development: Reverse Pharmacology PathRenaissance in Ayurveda: Integrative EndeavourConclusion and Future Path
1/8/2013
Samyukti2013 Bangalore/AAR
2
Slide3
Integration of Ayurveda & Allopathy: A Tale of Two Centuries
1822 first integrated National medical Institute in Calcutta by East India Company with Bengal Vaidyas, 1827, 1833, 18351878 Dayanand Maharshi College at Lahor1877 Ayurvedic institute, 1896 Prabhuram college at Mumbai by Dr. Bhadkamkar, Dr. Bhau Daji Lad and Dr. Popat PrabhuramSeveral colleges across the country Ayurveda/Integrated started following Indian National Congress Resolution in 1920 at Nagpur 1927 at BHU, Ayurvedacharya with medicine and Surgery 1935 College of Indigenous Medicine at Madras1956 Integrated Medical Act by Govt. of Madras1969 CCRIMH, 1970 IMCC act, 1971 CCIM, Integrated/Ayurveda curriculum, 1973 Homeopathy ActDept of ISM&H (1995), Dept. of AYUSH (2003)
1/8/2013
Samyukti2013 Bangalore/AAR
3
Six formally recognized parallel Medical systems Modern Medicine & AYUSH systems
MMC 1835
GMC 1845
CMC 1907
Slide4
Current Healthcare Scenario: Facts & Figures
Western Allopathy Medicine transformed into Mainstream Modern MedicineGlobal uniformity in Allopathy practices, education, research & its publicationsMost of the advancing biomedical & paramedical branches subscribe to the tenets of AllopathyGlobal spending on prescription drugs; US $ 954billion (2011), expected to reach $ 1.1 trillion (2014)Iatrogenic diseases 3rd leading cause of deaths in US, estimated annual mortality (783,936), medical cost ($282 billion)Approximately 56 percent of the population of the United States, have been treated unnecessarily by the medical industry In many developed countries, 70% to 80% of the population has used some form of alternative or complementary medicine
1/8/2013
Samyukti2013 Bangalore/AAR
4
Slide5
Current Healthcare Scenario: Facts & Figures
In some Asian and African countries, 80% of the population depend on traditional medicine for primary health careMore than 100 countries have regulations for herbal medicines WHO has projected that the global herbal market will grow to $5 trillion by 2050In India more than 500 million people use AYUSH medicinesWorldwide, the Ayurvedic industry is put at US $3 billionAyurvedic doctors(>500,000), Drug companies (>8,000), Hospitals (>2500), Colleges (> 250) in IndiaStandardization of Ayurvedic products, practices, training demand more thrust in quality
1/8/2013
Samyukti2013 Bangalore/AAR
5
Scope for Integrative Medicine through Evidence Based Approach
Slide6
Evidence Based Medicine
The conscientious, explicit & judicious use of current best evidence in making decisions about the care of individual patients.The practice of evidence based medicine requires the integration of individual clinical expertise with the best available external clinical evidence from systematic research and patients unique values & circumstances
Patient preference
Research Evidence
Clinical state & circumstances
&
ana
bauiQdp`idpona
yaao naaivaSait t%vaivat .Aatursyaantra%maanaM na sa raogaaMiXcaik%sait ..ca iva 4.12
1/8/2013
6
Samyukti2013 Bangalore/AAR
Slide7
Current Reality : Need for Integration
Clinical expertise
Patient preference
Clinical state & circumstances
Research evidence
Clinical state & circumstances
Clinical expertise
Research evidence
Patient preference
Modern Medicine
Ayurveda
Pragmatic & practical
Futuristic medicine
1/8/2013
7
Samyukti2013 Bangalore/AAR
Slide8
Conventional Drug Development Path(Classical Pharmacology)
Hypothesis
Theory &
Postulation
Basic
ResearchBiology &chemistry
Preclinical testingInvitro & invivo
Clinical testing Human Trials
AccepteddrugFDA approval
Cost 1 to 1.8 billion dollars
Time 10 to 12 years
HTPS 100000 molecules to 1
Post marketing withdrawals
Need to look back at Nature
1/8/2013
Samyukti2013 Bangalore/AAR
Estimate 2007, 63% NCE developed were resourced/ inspired from Natural products
Definition: Reverse pharmacology is the science of integrating documented clinical/experiential hits, into leads by transdisciplinary exploratory studies and further developing these into drug candidates by experimental and clinical research. Scope: The scope of reverse pharmacology is to understand the mechanisms of action at multiple levels of biological organization and to optimize safety, efficacy and acceptability of the leads in natural products, based on relevant science.
Reverse Pharmacology
1/8/2013
Samyukti2013 Bangalore/AAR
Pragmatic integration of observational therapeutics, relevant science & drug discovery
11
Slide12
Reverse Pharmacology Discipline
Experience
Experiments
Evidence
Exploratory
Explanatory
Serendipity
Tradition
Translated Medicine
for community / clinical practice
Techno centric
Pharmacocentric
Therapy centric
Person centric
Dynamic, Self perpetuating Trans-Discipline
1/8/2013
Samyukti2013 Bangalore/AAR
12
Slide13
Significant Research Contributions
Plant / FormulationsIndicationActivityImpactArogyawardhini/ kutakiHepatitisHepato-protectivePicroliv - Product KapikacchuParkinson’s Diseases Motor activityCognitive corrections Plasma levelsPhase I - US FDADouble blind crossover studyYograj GugguluRheumatoid arthritisAnti-inflammatorySteroid withdrawalAmrut BhallatakOsteoarthritisChondroprotection better adherence than GSDisease modifyingHaridra Oral Submucous Fibrosis Micronuclei reductionAnticancer studies
Patient-relatedRugna Prakriti (Patient’s constitution) Shat-kriyakala (Stage of a disease) Samutthana-Vishesha (Causative/ precipitating factors)Dosh-Dushya-Adhishthan (Patho-physiological factors) Vyadhi Lakshana (clinical features)
Countable Determinants not Confounding Variables
1/8/2013
Samyukti2013 Bangalore/AAR
Slide18
Allopathy – Ayurveda: Enrichment Feedback
1/8/2013
Samyukti2013 Bangalore/AAR
18
REDUCTINISTModern MedicineHolistic
HOLISTICAyurvedaReductionist
Molecule–Cell–Organ–Individual–Ecosystem
Multidisciplinary Management
Chikitsadhikruta
Purusha
Molecular Biology
Anuparamanu
Sidhhanta
IntegrativeMedicine
Integrative
Ayurveda
Slide19
Integrative Ayurveda : Ayurvidya
Definition : It is an active and open ended interface of Ayurveda with advancing modern sciences, especially biomedical sciences to continuously facilitate the incorporation of emerging new knowledge in the mainstream of Ayurveda while maintaining the fidelity to Ayurvedic fundamental principlesScope : Such a heuristic approach would promote the global acceptance of Ayurveda’s “science of life” potentials which has the added ability to identify novel paths for further development of biomedicine
Ashwinikumar A Raut, J-A IM | Jan-Mar 2011 | Vol 2 | Issue 1
1/8/2013
19
Samyukti2013 Bangalore/AAR
Slide20
Integrative Medicine v/s Integrative Ayurveda
TenetsIntegrative MedicineIntegrative AyurvedaEthosTherapeutic UtilityAyurvedic Validity Bridge CAM & TSM Remedies Advancing KnowledgeR & DUnderstanding Molecular MechanismsUnderstanding Systems BiologyGoalMolecules from Natural productsSynergy with Nature of ManExpertisePhysician – InvestigatorVaidya - Scientist
1/8/2013
Samyukti2013 Bangalore/AAR
20
Slide21
Epistemological Variance
ArthritisSandhivatDenotes inflammationDenotes pain & loss of functionGenetic predisposition/EnvironmentAgnimandya/ApathyaImmune complexesAama accumulationInflammatory cytokinesAmavisha & Vishiated DoshaBone & Cartilage DamageAsthi-Sandhi HananAntiinflammatory & ImmunosupresiveAmapachak & VatashamakSymptomatic & PalliativeSampraptivighatan & NidanparivarjanReparative & RehabilitativeRasayana & Apunarbhav Reconstructive Surgery Literature & Anecdotes Patient education & Group therapySatvavajay & Daivavyapashraya
Complement strengths and overcome weaknesses
1/8/2013
21
Samyukti2013 Bangalore/AAR
Slide22
Potentials:Interface of Ayurveda with Diverse Disciplines
Modified from figure published in ‘Vaidya-scientists: catalysing Ayurveda Renaissance’, CURRENT SCIENCE, VOL. 100, NO. 4, 25 FEBRUARY 2011 ;Bhushan Patwardhan, Vishnu Joglekar, Namyata Pathak and Ashok Vaidya
1/8/2013
Samyukti2013 Bangalore/AAR
22
Slide23
conclusion
India’s ‘Medical Pluralism’ should become a strength if we embark an integrative ethos of ‘Unity in Diversity’Current healthcare scenario has two sides; one is bright and another is dark! As stakeholders of healthcare sector we need to ensure that Brightness grows and Darkness subduesEvidence based approach is desirable to cultivate harmony between Community, Clinicians & ResearchersReverse Pharmacology would provide safe & predictable products and also facilitate integrative culture of Bedside to Bench & Vice versaIntegrative Medicine and Integrative Ayurveda are mutually enriching approaches which should accelerate the growth and development of Biomedical sciences
Download this presentation
DownloadNote - The PPT/PDF document "Scope and potential of Integrative Medic..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Presentations text content in Scope and potential of Integrative Medicine in current Heal
Scope and potential of Integrative Medicine in current Healthcare Scenario
Dr. Ashwinikumar A. Raut MD (Ayurveda-Kayachikitsa)Director Clinical Research & Integrative MedicineMedical Research Centre of Kasturba Health SocietyICMR Advanced Centre of Reverse Pharmacology in Traditional MedicineVile-Parle, Mumbai – 400056, Indiaashuraut@gmail.com
Samyukti
2013An Evidence Based Approach in integrating Ayurveda and AllopathyOrganized by MS Ramaiah Academy of Health and Applied Sciences, Bangalore Institute of Transdisciplinary Health Science and Technology (IHST) - FRLHT, Bangalore
1/8/2013
1
Samyukti2013 Bangalore/AAR
Slide2Presentation structure
Integration of Ayurveda & Allopathy: A Tale of Two CenturiesCurrent Healthcare Scenario: Facts and FiguresEvidence Based Medicine: Complementary to Ayurveda Ethos Integrative Drug Development: Reverse Pharmacology PathRenaissance in Ayurveda: Integrative EndeavourConclusion and Future Path
1/8/2013
Samyukti2013 Bangalore/AAR
2
Slide3Integration of Ayurveda & Allopathy: A Tale of Two Centuries
1822 first integrated National medical Institute in Calcutta by East India Company with Bengal Vaidyas, 1827, 1833, 18351878 Dayanand Maharshi College at Lahor1877 Ayurvedic institute, 1896 Prabhuram college at Mumbai by Dr. Bhadkamkar, Dr. Bhau Daji Lad and Dr. Popat PrabhuramSeveral colleges across the country Ayurveda/Integrated started following Indian National Congress Resolution in 1920 at Nagpur 1927 at BHU, Ayurvedacharya with medicine and Surgery 1935 College of Indigenous Medicine at Madras1956 Integrated Medical Act by Govt. of Madras1969 CCRIMH, 1970 IMCC act, 1971 CCIM, Integrated/Ayurveda curriculum, 1973 Homeopathy ActDept of ISM&H (1995), Dept. of AYUSH (2003)
1/8/2013
Samyukti2013 Bangalore/AAR
3
Six formally recognized parallel Medical systems Modern Medicine & AYUSH systems
MMC 1835
GMC 1845
CMC 1907
Slide4Current Healthcare Scenario: Facts & Figures
Western Allopathy Medicine transformed into Mainstream Modern MedicineGlobal uniformity in Allopathy practices, education, research & its publicationsMost of the advancing biomedical & paramedical branches subscribe to the tenets of AllopathyGlobal spending on prescription drugs; US $ 954billion (2011), expected to reach $ 1.1 trillion (2014)Iatrogenic diseases 3rd leading cause of deaths in US, estimated annual mortality (783,936), medical cost ($282 billion)Approximately 56 percent of the population of the United States, have been treated unnecessarily by the medical industry In many developed countries, 70% to 80% of the population has used some form of alternative or complementary medicine
1/8/2013
Samyukti2013 Bangalore/AAR
4
Slide5Current Healthcare Scenario: Facts & Figures
In some Asian and African countries, 80% of the population depend on traditional medicine for primary health careMore than 100 countries have regulations for herbal medicines WHO has projected that the global herbal market will grow to $5 trillion by 2050In India more than 500 million people use AYUSH medicinesWorldwide, the Ayurvedic industry is put at US $3 billionAyurvedic doctors(>500,000), Drug companies (>8,000), Hospitals (>2500), Colleges (> 250) in IndiaStandardization of Ayurvedic products, practices, training demand more thrust in quality
1/8/2013
Samyukti2013 Bangalore/AAR
5
Scope for Integrative Medicine through Evidence Based Approach
Slide6Evidence Based Medicine
The conscientious, explicit & judicious use of current best evidence in making decisions about the care of individual patients.The practice of evidence based medicine requires the integration of individual clinical expertise with the best available external clinical evidence from systematic research and patients unique values & circumstances
Patient preference
Research Evidence
Clinical state & circumstances
&
ana
bauiQdp`idpona
yaao naaivaSait t%vaivat .Aatursyaantra%maanaM na sa raogaaMiXcaik%sait ..ca iva 4.12
1/8/2013
6
Samyukti2013 Bangalore/AAR
Slide7Current Reality : Need for Integration
Clinical expertise
Patient preference
Clinical state & circumstances
Research evidence
Clinical state & circumstances
Clinical expertise
Research evidence
Patient preference
Modern Medicine
Ayurveda
Pragmatic & practical
Futuristic medicine
1/8/2013
7
Samyukti2013 Bangalore/AAR
Slide8Conventional Drug Development Path(Classical Pharmacology)
Hypothesis
Theory &
Postulation
Basic
ResearchBiology &chemistry
Preclinical testingInvitro & invivo
Clinical testing Human Trials
AccepteddrugFDA approval
Cost 1 to 1.8 billion dollars
Time 10 to 12 years
HTPS 100000 molecules to 1
Post marketing withdrawals
Need to look back at Nature
1/8/2013
Samyukti2013 Bangalore/AAR
Estimate 2007, 63% NCE developed were resourced/ inspired from Natural products
8
Slide9Traditional Medicine Drug Development Path
Classical
texts & references
Basic principles
Analogy & inferences
Para-clinical
testing
Clinical
testing
Accepted drug
FDA Approval
Evidence base
through
relevant science
yaui>p`maaNa
Sabd
Anaumaana va ]pmaana
p`%yaxa
vyavahar
Demand to move forward
1/8/2013
Samyukti2013 Bangalore/AAR
Home remedies
NutraceuticalsOTC productsTM products( QA,QC & SOP )
9
Slide10Need for Different Path in Drug Development
Demand to go forward
Need to look back at nature
Reduction in Total costTotal duration Undesired screening Toxicity & withdrawal
Reverse Pharmacology Path
Application ofConventional correlatesRelevant scienceModern Technology Predictability & reproducibility
TM
MM
1/8/2013
Samyukti2013 Bangalore/AAR
10
Slide11Definition: Reverse pharmacology is the science of integrating documented clinical/experiential hits, into leads by transdisciplinary exploratory studies and further developing these into drug candidates by experimental and clinical research. Scope: The scope of reverse pharmacology is to understand the mechanisms of action at multiple levels of biological organization and to optimize safety, efficacy and acceptability of the leads in natural products, based on relevant science.
Reverse Pharmacology
1/8/2013
Samyukti2013 Bangalore/AAR
Pragmatic integration of observational therapeutics, relevant science & drug discovery
11
Slide12Reverse Pharmacology Discipline
Experience
Experiments
Evidence
Exploratory
Explanatory
Serendipity
Tradition
Translated Medicine
for community / clinical practice
Techno centric
Pharmacocentric
Therapy centric
Person centric
Dynamic, Self perpetuating Trans-Discipline
1/8/2013
Samyukti2013 Bangalore/AAR
12
Slide13Significant Research Contributions
Plant / FormulationsIndicationActivityImpactArogyawardhini/ kutakiHepatitisHepato-protectivePicroliv - Product KapikacchuParkinson’s Diseases Motor activityCognitive corrections Plasma levelsPhase I - US FDADouble blind crossover studyYograj GugguluRheumatoid arthritisAnti-inflammatorySteroid withdrawalAmrut BhallatakOsteoarthritisChondroprotection better adherence than GSDisease modifyingHaridra Oral Submucous Fibrosis Micronuclei reductionAnticancer studies
13
1/8/2013
Samyukti2013 Bangalore/AAR
Slide14Significant Research Contributions
Plant / ProductIndicationActivityImpactParijatMalariaAnti-parasiteAnti-cytokineDisease modifyingMamejawaType 2 DMLipemic control Anti-oxidantDNA protectionComplication PreventionPanchavalkalLeucorrhoeaVaginal infectionsAyurvedic Vaginal CreamAshokaMenorrhagiaOvulatory DUBSubset identificationYashtimadhuAshwagandhaPerimenopausal syndromeVasomotorAntioxidantNon-hormonal product
14
1/8/2013
Samyukti2013 Bangalore/AAR
Slide15Cellular Effects Of Ayurvedic plants
Ayurvedic PlantActive PrinciplesCellular effectsMucuna pruriens L-dopa, indole alkaloidsDA receptors in CNSPicrorrhiza kurroaPicrosides, cucurbitacinsHydrocoloretic & aquaporinsTinospora cordifoliaPolysaccharides,alkaloidsB lymphocytes, AGF Curcuma longaCurcuminoids,turmeronepolysaccharidesNFkB, GSH & COX-1Commiphora wightiiGuggulsterones, Myrrhanone FXR,BSEP,CytokinesGlycyrrhiza glabraGlabridin, glycyrrhizinE2 & Aldost recptors,
1/8/2013
15
Samyukti2013 Bangalore/AAR
Slide16RP Drug Development: Prerequisites & Spectrum
Analogues & Derivatives
TraditionalFormulations
Traditional
Extracts
Non Traditional
Extracts
Bioactive
Fractions
Active
Principles
Pharmaceutical Excellence
Safety & Efficacy
Formally Regulated
Picrosides
Picroliv
Arogyawardhini
Kutaki
NCE
Diverse Utility and Safety profile
1/8/2013
16
Samyukti2013 Bangalore/AAR
Slide1717
Protocols for Ayurvedic Clinical TrialsUnique / pertinent
Product-relatedAyurvedic kalpa (Classical form) Aushadhi prayoga (Dosage regimen) Aushadhi kala (Dosage schedule) Anupana (Vehicle for administration) Ahara – Vihara (diet & behavioral regimen)
Patient-relatedRugna Prakriti (Patient’s constitution) Shat-kriyakala (Stage of a disease) Samutthana-Vishesha (Causative/ precipitating factors)Dosh-Dushya-Adhishthan (Patho-physiological factors) Vyadhi Lakshana (clinical features)
Countable Determinants not Confounding Variables
1/8/2013
Samyukti2013 Bangalore/AAR
Slide18Allopathy – Ayurveda: Enrichment Feedback
1/8/2013
Samyukti2013 Bangalore/AAR
18
REDUCTINISTModern MedicineHolistic
HOLISTICAyurvedaReductionist
Molecule–Cell–Organ–Individual–Ecosystem
Multidisciplinary Management
Chikitsadhikruta
Purusha
Molecular Biology
Anuparamanu
Sidhhanta
IntegrativeMedicine
Integrative
Ayurveda
Slide19Integrative Ayurveda : Ayurvidya
Definition : It is an active and open ended interface of Ayurveda with advancing modern sciences, especially biomedical sciences to continuously facilitate the incorporation of emerging new knowledge in the mainstream of Ayurveda while maintaining the fidelity to Ayurvedic fundamental principlesScope : Such a heuristic approach would promote the global acceptance of Ayurveda’s “science of life” potentials which has the added ability to identify novel paths for further development of biomedicine
Ashwinikumar A Raut, J-A IM | Jan-Mar 2011 | Vol 2 | Issue 1
1/8/2013
19
Samyukti2013 Bangalore/AAR
Slide20Integrative Medicine v/s Integrative Ayurveda
TenetsIntegrative MedicineIntegrative AyurvedaEthosTherapeutic UtilityAyurvedic Validity Bridge CAM & TSM Remedies Advancing KnowledgeR & DUnderstanding Molecular MechanismsUnderstanding Systems BiologyGoalMolecules from Natural productsSynergy with Nature of ManExpertisePhysician – InvestigatorVaidya - Scientist
1/8/2013
Samyukti2013 Bangalore/AAR
20
Slide21Epistemological Variance
ArthritisSandhivatDenotes inflammationDenotes pain & loss of functionGenetic predisposition/EnvironmentAgnimandya/ApathyaImmune complexesAama accumulationInflammatory cytokinesAmavisha & Vishiated DoshaBone & Cartilage DamageAsthi-Sandhi HananAntiinflammatory & ImmunosupresiveAmapachak & VatashamakSymptomatic & PalliativeSampraptivighatan & NidanparivarjanReparative & RehabilitativeRasayana & Apunarbhav Reconstructive Surgery Literature & Anecdotes Patient education & Group therapySatvavajay & Daivavyapashraya
Complement strengths and overcome weaknesses
1/8/2013
21
Samyukti2013 Bangalore/AAR
Slide22Potentials:Interface of Ayurveda with Diverse Disciplines
Ayurvedic FundamentalsInterfacing Scientific DisciplinesIntegrative Ayurveda DisciplinesSankhya SiddhantaCosmogenesisAyurontologyPanchamahabhutaElemental-PhysicsAyurphysicsPrakrutiGenomicsAyurgenomicsDosha-Dhatu-MalaSystems BiologySystems AyurvedaPradnyaparadhPsyco-SomaticsAyurcyberneticsDravya-Guna-KarmaPharmaco Kinetic-DynamicAushadhi DynamicsBheshaja AnubhavaEpidemiologyAy Pharmaco-epidemiologyBheshaja Nirupana Drug Discovery SciencesReverse PharmacologyPathyapathya AaharNutritional BiochemistryAyurceuticsPramana ManaQuantitative BiostatisticsAyurvedic Statistics
Modified from figure published in ‘Vaidya-scientists: catalysing Ayurveda Renaissance’, CURRENT SCIENCE, VOL. 100, NO. 4, 25 FEBRUARY 2011 ;Bhushan Patwardhan, Vishnu Joglekar, Namyata Pathak and Ashok Vaidya
1/8/2013
Samyukti2013 Bangalore/AAR
22
Slide23conclusion
India’s ‘Medical Pluralism’ should become a strength if we embark an integrative ethos of ‘Unity in Diversity’Current healthcare scenario has two sides; one is bright and another is dark! As stakeholders of healthcare sector we need to ensure that Brightness grows and Darkness subduesEvidence based approach is desirable to cultivate harmony between Community, Clinicians & ResearchersReverse Pharmacology would provide safe & predictable products and also facilitate integrative culture of Bedside to Bench & Vice versaIntegrative Medicine and Integrative Ayurveda are mutually enriching approaches which should accelerate the growth and development of Biomedical sciences
1/8/2013
Samyukti2013 Bangalore/AAR
23
Slide241/8/2013
Samyukti2013 Bangalore/AAR
24
Aa naao Bad`a: k``tvaao yantu ivaSvat:
Slide2525
Thank You !
1/8/2013
Samyukti2013 Bangalore/AAR
Slide26Slide27