pharmacy volume 1/2017 bulletin april 2017 1.2017 (for jkn).pdf · 10 role of sglt-2 inhibitors in...
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Streptokinase VS Tenecteplase in Acute Coronary Syndrome
Management
Role Of SGLT-2 Inhibitors In Glycaemic Control For Patients
With T2DM
Antimicrobial Stewardship Activity: Antibiotic IV To Oral
Switch
Adverse Drug Reactions of Allopurinol and Precautions
Lifestyle Intervention in Managing Asthma
Pain Management In Pediatrics
Updates on New Drugs
Available in Hospital Jasin
VOLUME 1/2017
APRIL 2017
PHARMACY
BULLETIN
2
Adverse Drug Reactions of
Allopurinol and Precautions
3
Lifestyle Intervention in
Managing Asthma
5
Pain Management In Pediatrics 7
Streptokinase VS Tenecteplase
in Acute Coronary Syndrome
Management
10
Role Of SGLT-2 Inhibitors In
Glycaemic Control For Patients
With T2DM
12
Updates on New Drugs Available
in Hospital Jasin Formulary 2016
14
Antimicrobial Stewardship
Activity: Antibiotic IV To Oral
Switch
17
Best Staff Of The Month
(July - Dec 2016)
20
Pharmacy Events/Activities 22
EDITORIAL BOARD ADVISOR
Dr Zaleha Bt Md NoorDr Zaleha Bt Md NoorDr Zaleha Bt Md NoorDr Zaleha Bt Md Noor
CHIEF EDITOR
Nursahjohana Md SahakNursahjohana Md SahakNursahjohana Md SahakNursahjohana Md Sahak
EDITOR
Tan Xin YiTan Xin YiTan Xin YiTan Xin Yi
Nurul Atika WahabNurul Atika WahabNurul Atika WahabNurul Atika Wahab
CONTRIBUTORS
Izrul Azwa Mohd LatiffIzrul Azwa Mohd LatiffIzrul Azwa Mohd LatiffIzrul Azwa Mohd Latiff
Hana RadhiahHana RadhiahHana RadhiahHana Radhiah
Ng Shy PyngNg Shy PyngNg Shy PyngNg Shy Pyng
Low Jia HuiLow Jia HuiLow Jia HuiLow Jia Hui
Shoniya A/P JayasegaranShoniya A/P JayasegaranShoniya A/P JayasegaranShoniya A/P Jayasegaran Nur Athirah Haziqah Mohamad Nur Athirah Haziqah Mohamad Nur Athirah Haziqah Mohamad Nur Athirah Haziqah Mohamad
SobriSobriSobriSobri
3
Allopurinol is one of the most effective medications to:
• Reduce the production of uric acid in patients who
have gout or certain types of kidney stones.
• Decrease levels of uric acid in people who are
receiving cancer treatment. (Patients have increased
uric acid levels due to release of uric acid from the
dying cancer cells)
However, allopurinol can lower blood cells that help your
body fight infections. This can make it easier for you to
bleed from an injury or get sick from being around others
INTRODUCTION
Adverse Drug Reactions of Allopurinol and
Precautions
HOW SHOULD I TAKE ALLOPURINOL? Take each dose with a full glass of water. To reduce risk of
kidney stones forming, drink 8-10 full glasses of fluid
every day, unless your doctor tells you otherwise.
You may have gout attacks more often when first start
taking allopurinol. Doctor may recommend other gout
medication to take with allopurinol.
Keep using your medication as directed and tell doctor if
symptoms do not improve after a few months of treatment
ADVERSE DRUG REACTIONS • The Malaysian Adverse Drug Reactions Advisory
Committee (MADRAC) has received 280 reports of
adverse reactions related to the use of allopurinol
since the year 2000. 12 reports involved fatality.
• Among the adverse reactions reported, 80% were skin
reactions, including mild reactions such as rash and
itchiness as well as severe life threatening reactions
such as Stevens Johnsons Syndrome and Toxic
Epidermal Necrolysis.
Mechanism of Action:
Allopurinol inhibits xanthine
oxidase, the enzyme that catalyses
the conversion of hypoxanthine to
xanthine then uric acid.
What is uric acid?
It is a protein metabolite that is
present in the blood and released in
INDICATIONS APPROVED
BY DRUG CONTROL
AUTHORITY (DCA)
1. Recurrent gouty arthritis attacks
2. Primary/secondary hy-
peruricaemia associated with
gouty arthritis
3. Uric acid nephropathy
4. Recurrent uric acid stone
formation
NOT indicated for:
• Moderately elevated uric acid or
non-gouty arthralgia or arthritis.
• Treatment of asymptomatic
hyperuricaemia
It has no pain or anti-inflammatory
activity. Therefore it has no value in
3
4
Summary of ADR Associated With Allopurinol
No Common Uncom-
mon
Rare Very rare
% 1% to 10% 0.1% to 1% < 0.1% < 0.01%
Dermatologic
1 Rash, maculopapular rash Ecchymosis Steven-Johnson
syndrome,
Lyell syndrome
Vasculitis
Hypersensitivity
2 Generalized
hypersensitivity
Anaphylaxis,
angioedema
Hepatic
3 Increases in alkaline
phosphatase & serum
transaminase
Hepatitis, hepa-
tomegaly, cholestatic
jaundice
Gastrointestinal
4 Diarrhoea, nausea,
vomiting
Intermittent
abdominal pain,
gastritis, dyspepsia
Steatorrhea, recurrent
hematemesis,
stomatitis, changed
bowel habit
Hematologic
5 Leukocytosis,
leukopenia,
eosinophilia,
thrombocytopenia,
Renal
6 Renal failure /
insufficiency
Xanthine crystalluria,
azotemia
Nervous system
7 Ataxia, somnolence,
coma, paralysis,
paresthesia,
neuropathy, taste
perversion
Metabolic
8 Diabetes mellitus,
hyperlipidemia
Cardiovascular
9 Angina, bradycardia,
hypertension
Endocrine 10 Gynecomastia
Genitourinary 11 Infertility, impotence,
nocturnal emission
Uremia, hematuria,
male infertility,
impotence, erectile
dysfunction
Respiratory 12 Epistaxis
1. https://www.drugs.com/sfx/allopurinol-side-effects.html
2. www.mps.org.my/view_file.cfm?
3. http://www.webmd.com/drugs/2/drug-8610/allopurinol-oral/details fileid=2059
5
What is ASTHMA?
Asthma is defined as a condition characterized by recurrent or
chronic wheeze and/or cough, with recognizable variable airway
obstruction due to bronchial hyper-reactivity secondary to airway
Lifestyle Intervention
in Managing Asthma
Although many people with asthma rely on medications to prevent
and relieve symptoms, you can do several things on your own to
maintain your health and lessen the possibility of asthma attacks.
1. AVOID TRIGGERS
Taking steps to reduce your exposure asthma triggers is a key part of
asthma control, including:
♦ Use your air conditioner
♦ Decontaminate your decor
♦ Maintain optimal humidity
♦ Prevent mold spores
♦ Reduce pet dander
♦ Clean regularly
♦ Cover your nose and mouth if it’s cold out
References
1. CPG Guidelines on Management of Asthma, Jan 2008 MClinic
2. www.mayoclinic.org/disease-conditions/asthma/basics/lifestyle,/Aug 30,2016
By Shoniya A/P Jayasegaran
6
2. STAY HEALTHY
3. ALTERNATIVE MEDICINE
Taking care of yourself can help keep your symptoms under control,
including:
• Get regular exercise
• Maintain a healthy weight
• Control heartburn & gastroesophageal reflux disease (GERD)
Certain alternative treatments may help with asthma symptoms.
However, keep in mind that these treatments are not a replacement for
medical treatment — especially if you have severe asthma. Talk to
your doctor before taking any herbs or supplements, as some may
interact with medications you take. E.g.
◊ Breathing exercises
4. COPING & SUPPORT
The best way to overcome anxiety and a feeling of helplessness is to
understand your condition and take control of your treatment. Here are
some suggestions that may help;
♦ Pace yourself
♦ Make a daily to-do list
♦ Talk to others with your condition
♦ If your child has asthma, be encouraging
6
7
Acute pain is one of the most adverse stimuli experienced by children,
occurring as a result of injury, illness and necessary medical procedures.
It is associated with increased anxiety, avoidance, somatic symptoms and
increased parent’s distress. Despite the magnitude of effects that acute
pain can have on children, it is often inadequately assessed and treated.
Misconceptions about pain and its management in children include the
fear of side effects like respiratory depression, cardiovascular collapse,
addiction and the notion that children especially infants and neonates
have an immature nervous system and do not feel or react to pain, and
therefore do not require analgesic like adults. It is now quite clear that
the development of the physiologic mechanism and pathways for pain
perception take place during the late fetal and neonatal life. Children of
all ages including newborns feel and react to pain. There is mounting
evidence that adequate pain relief after surgery reduces period of
recovery, lowers morbidity and improves outcome.
PRINCIPLES OF PAIN MANAGEMENT
There are differences between pediatric and adult pain relief : 1. For children, analgesics are calculated on mg/kg body weight basis. 2. Children do not like intramuscular (IM) injection. IM injection is
unpredictable, largely ineffective and children will deny having pain to avoid injection.
3. Pain is best prevented rather than treated. Requirements for analgesics are lower if children are allowed to wake up comfortable and pain free following surgery or are pretreated before painful procedures.
4. Severe pain is best treated with continuous methods of analgesic administration (e.g. infusion, PCA).
5. Neonates and some ex-premature infants (up to 60 weeks post-conceptual age) may be sensitive to opioids. After administration of opioids, they must be closely monitored in a high dependency unit or ICU.
6. Post-operative pain relief should be planned before the surgery.
PAIN MANAGEMENT IN PAEDIATRICS
OVERVIEW
By Hana Radhiah Mohd Din/
Tan Xin Yi
8
References: 1. Pain Management Handbook. Ministry of Health, Malaysia. 2013 October. 2. Pediatric Pain and Symptom Management Guidelines. Dana Farber Cancer Institute/
Boston Children’s Hospital. 2014. 3. WHO guidelines on the pharmacological treatment of persisting pain in children with
medical illnesses. World Health Organization. 2012.
Medication Route Initial Dose
(Maximum Daily Dose)
Escalation of
Analgesia
Non-Opioids
Acetaminophen PO
PR
Neonates to 3 months: 5-10mg/kg 6
hourly
> 3 months: 20mg/kg stat,
then 15mg/kg 6 hourly
(Max 4g/day)
Ibuprofen PO 3-6 months: 5mg/kg 8 hourly
>6 months: 10mg/kg 8 hourly
(Max 1.2g/day)
Diclofenac
Sodium
PO NOT RECOMMENDED IN
CHILDREN < 6 MONTHS
0.5mg to 1mg/kg 8 hourly
(Max 150mg/day)
Opioids
Morphine PO
<12 months: 50mcg/kg 4 hourly
>12 months: 100-300mcg/kg 4 hourly
(Max 15mg/day)
IV, SC 1-6 months: 100mcg/kg 6 hourly
>6 months: 100mcg/kg 4 hourly
Guideline for Paediatric Analgesia
Recommendations:
1. Paracetamol/ Acetaminophen and ibuprofen are the choice of analgesia
in first step for mild pain.
2. Morphine is the first-line strong opioid for treatment of persisting
moderate to severe pain in children with medical illnesses.
3. Tramadol is generally NOT registered for use in children below age of 12
years.
4. The least invasive and most effective routes of administration should be used in children, wherever possible.
9
CME ORGANIZED BY PHARMACY (JULYCME ORGANIZED BY PHARMACY (JULYCME ORGANIZED BY PHARMACY (JULYCME ORGANIZED BY PHARMACY (JULY----DEC 2016)DEC 2016)DEC 2016)DEC 2016)
DATE TITLE
10.08.2016 Tywnsta® (Telmisartan & Amlodipine)
26.08.2016 Catch Chronic Obstructive Pulmonary Disease (COPD)
01.09.2016 Taklimat Pelan Tindakan Kebakaran
02.09.2016 Atrial Fibrillation
14.09.2016 MIMS Gateway
05.10.2016 Biosimilar Insulin– Safety & Efficacy Among Malaysia Patients
28.10.2016 Updates in the Management of Iron Deficiency Anaemia
11.11.2016 Symbicort® with SMART Therapy
30.11.2016 Antibiotic Awareness & Hand Hygiene
(a) Care Bundle to Reduce Catheter-Related Bloodstream
Infection
(b) Appropriate Antibiotic Use
(c) Antibiotic Stewardship Guideline & Sharing of Hospital
Melaka Antibiotic Stewardship Team Experience
(d) Hand Hygiene
28.12.2016 Alahan Ubat
28.12.2016 Echo Training Pengendalian Bahan Psikotropik di Dewan
Bedah
10
BY :
NUR ATHIRAH
HAZIQAH BINTI
MOHAMAD SOBRI
ACS is a clinical spectrum of ischaemic heart disease ranging
from unstable angina, non-ST segment elevation myocardial
infarction(NSTEMI) to STEMI depending upon the degree
and acuteness of coronary occlusion.
In-Hospital Management
Acute Coronary Syndrome (ACS) ?
STREPTOKINASE VS TENECTEPLASE I
N
ACUTE CORONARY SYNDROME MANAG
EMENT
In myocardial infarction (MI) for both NSTEMI and STEMI : There is myocardial
injury, so cardiac biomarkers (Troponin) are raised
In unstable angina : Myocardial injury is absent so that the cardiac biomarkers
(Troponin) are normal.
Early management of STEMI are :
1. Pain relief.
2. Establishing early reperfusion, including fibrinolytic
therapy.
3. Treatment of complications.
11
♥ Fibrinolytic therapy has been shown to reduce mortality when given within the
appropriate time frame.
♥ When given within the “golden hour”, it is most beneficial and has been
shown to be able to abort the infarction and reduce mortality by up to 50%.
♥ Choice of fibrinolytic agents available in Hospital Jasin are :
1. Streptokinase
2. Tenecteplase
Fibrinolytic
Therapy
REFERENCES :
1) Clinical Practice Guideline : Management of Acute ST Segment Elevation Myocardial Infarction (Stemi) (3rd
Edition), 2014
2) Tenecteplase versus Streptokinase for thrombolysis; Sri Lanka Heart Association, 2015
3) Product insert of Metylase
4) Dundar Y, Hill R, Dickson R, Walley T, et al. 2003 Comparative efficacy of thrombolytics in acute myocardial
infarction: a systematic review
Derived from culture filtrate of
β-haemolytic Streptococci of Lancefield
group C
Origin Recombinant DNA technology
No Fibrin-specific
agent
Yes (High)
Forms a complex with plasminogen
which then converts plasminogen to
plasmin.
Plasmin breaks down clots as well as
fibrinogen and other plasma proteins.
Mechanism of
action
Converts plasminogen to plasmin.
Plasmin breaks down clots as well as
fibrinogen and other plasma proteins.
Within 12 hours of onset of acute MI
with persistent ST-segment elevation
or recent left bundle-branch block
“Golden
hour”
As soon as possible (within 30 mins)
after onset of acute MI
1.5 mega unit Dose Based on body weight
<60 kg: 30 mg ; 60-70 kg: 35 mg ;
70-80 kg: 40 mg ; 80-90 kg: 45 mg ; >90
kg: 50 mg
1 hour IV infusion Administration 5-10 secs slow IV bolus
Repeated treatment >5 days & <12
months from initial treatment, is not
effective because of the increase
likelihood of resistance due to
antistreptokinase antibodies.
Important
information
It is incompatible with dextrose
solution, so the pre-existing IV line may
be used in 0.9% sodium chloride solution
only. Other medicinal products should
not be added to the injection solution.
STREPTOKINASE
VS
TENECTEPLASE
11
12
ROLE OF SGLT-2 INHIBITORS IN
GLYCAEMIC CONTROL FOR PATIENTS WITH
TYPE 2 DIABETES MELLITUS By Low Jia Hui
How does SGLT-2 work?
Type 2 Diabetes is a progressive disease and a patient may end up
with a combinations of medicines with differing mechanism of action to
keep glucose level at bay.
Current antidiabetic agents sometimes have properties that appear undesirable
by the patients as well as the prescribers, for examples some agents predispose
the patients to hypoglycaemia, gastro-intestinal irritations, weight gain, renal
impairment etc. Agents with a different mechanism of action and properties can
minimise the occurrence of adverse events while helping patients in managing
One of the novel antidiabetics agents is classified as sodium-glucose
cotransporter 2 (SGLT-2) inhibitors.
Kidney reabsorbs most of the glucose (nearly 90%) from renal filtrate via SGLT-2
transporters which are primarily located in the proximal renal tubule.
In addition to that, a small drop
in blood pressure can be observed
as a result of osmotic diuresis.
SGLT-2 doesn’t have a role in
stimulating the secretion of insu-
lin and it ceases to function when
the blood glucose drop. Thus,
hypoglycaemia is not likely to
occur.
Inhibition of SGLT-2 can reduce the reabsorption of glucose while increase the
elimination of glucose. This reduces the blood glucose concentration and the
loss of glucose also results in weight loss (1g of glucose= 4 cal).
12
13
The benefits of SGLT-2 Inhibitors
• Weight reduction
• Low risk of Hypoglycaemia
• Blood pressure reduction
• Reduction in serum uric acid
The undesirable effects
• Vaginal irritation in women
• Urinary tract infection
• Raised hematocrit
• Hypotension
• Volume depletion
The contraindications
• Type 1 Diabetes
• eGFR < 60ml/min (Dapagliflozin, Canagliflozin)
• eGFR < 45ml/min (Empagliflozin)
References:
1. Bailey, A.V.& Day, C (2014) The Role of SGLT2 Inhibitors in Type 2 Diabetes British Journal of Family Medicine [online]
2 4, July/August 2014. Available from: https://www.bjfm.co.uk/the-role-of-sglt2-inhibitors-in-type-2-diabetes.aspx [Accessed
17th December 2016]
2. Andrianesis, V& Doupis, J. (2013) The Role of Kidney in Glucose Homeostasis-SGLT-2 Inhibitors, A New Approach In
Diabetes Treatment Expert Review of Clinical Pharmacology [online] 6(5):519-539. Available from:
http://www.medscape.com/viewarticle/812072_2 [Accessed 17th December 2016]
3. MALAYSIA, MINISTRY OF HEALTH (2015) Clinical Practice Guidelines: Management of Type 2 Diabetes Mellitus
4. Rosenstock, J, Aggarwal, N et al (2012) Dose-Ranging Effects of Canagliflozin, a Sodium-Glucose Cotransporter 2 Inhibitor, as Add-On to Metformin
in Subjects With Type 2 Diabetes Diabetes Care [online] 35(6): 1232-1238. Available from:
http://care.diabetesjournals.org/content/35/6/1232.full [Accessed 17 December 2016]
5. Bakris,GL, Fonseka VA et al (2009) Renal Sodium-Glucose Transport: Role in Diabetes Mellitus and Potential Clinical
Implications [online] Kidney International Vol 75, Issue 12, 2 June 2009: 1272-1277. Available from:
http://www.sciencedirect.com/science/article/pii/S008525381553651X [Accessed 17 December 2016]
6. Faustino, BS, Reis Costa JR, Aj et al (2016) The Benefits of SGLT-2 Inhibitors in Cardiovascular Prevention, Glycemic
Control and Weight Loss, In The Treatment of Diabetes [online] Open Journal of Endocrine and Metabolic Disease 2016 (6):
87-94. Available from: http://file.scirp.org/pdf/OJEMD_2016012814411861.pdf [Accessed 17 December 2016]
14
No Drugs name Proformer Quota Status
Prescriber
Category
1
Dr. Ruhaiza
Bt Mohamad
10 In Stock A*
2
Dr. Ruhaiza
Bt Mohamad
20 In Stock A/KK
3
Dr. Ruhaiza
Bt Mohamad
10 In Stock A/KK
Updates on New Drugs Available in Hospital Jasin Formulary 2016
By: Izrul Azwa Mohd Latiff
In 2016, 12 new drugs were
requested via Proforma E form
and had been approved by
Hospital Jasin Director to be
listed in Hospital Jasin Formulary.
Most of them were listed under
List A category which should be
started by specialist.
Tablet Levofloxacin 250mg
Tablet Fenofibrate 145mg
Symbicort Turbohaler
(Budesonide 320mcg/
Formoterol 9mcg)
15
No Nama Ubat Proformer Quota Status
Prescriber
category
6
Tablet Rifampicin 150mg,
Isoniazide 75mg (Akurit-2)
Dr. Ruhaiza Bt
Mohamad
1 In Stock B
7 Tablet Primaquine 7.5mg
Dr. Ruhaiza Bt
Mohamad
5 In Stock B
8 Tablet Artemether 20mg/
Lumefantrine 120mg (Riamet)
Dr. Ruhaiza Bt
Mohamad
5 In Stock B
4 Tablet Dabigatran 150mg
(Pradaxa) Dr. Ruhaiza Bt
Mohamad 10 In Stock A*
5 Dr. Ruhaiza
Bt Mohamad 3 Tablet Rivaroxaban
20mg (Xarelto)
In Stock A*
16
No. Nama Ubat Proformer Quota Status
Prescriber
category
10 Anti RhD Gamma
Globulin 300mcg/
2ml (Rhogum)
Dr. Masyitah
Bt Md Radzi 10 In Stock B
11 Tenecteplase
10,000 unit (50mg)
Injection (Metalyse)
Dr. Ruhaiza
Bt Mohamad 5 In Stock A*
12 Hepatitis B Immu-
noglobulin (Human)
Injection (200U/ml)
Dr. Ruhaiza
Bt Mohamad 4 In Stock A
9 Tablet Ticagrelor
90mg (Brilinta)
Dr. Ruhaiza Bt
Mohamad 5 In Stock A*
17
Antimicrobial Stewardship Activity:
Benefits Of Early Switch To Oral
Therapy
■ Reduced risk of cannula-related
infections
■ Reduced risk of thrombophlebitis
■ Less expensive than IV therapy
■ Earlier discharge
■ Reduced hidden cost
Criteria For IV To Oral Switch
Inclusion criteria:
1. Oral alternative available
2. In the absence of positive culture, the alternative
oral agent empirically covers the commonly sus-
pected organism
3. Tolerating food or enteral feedings
BY NG SHY PYNG
18
Exclusion Criteria For IV To Oral
1. Patient is unstable or their clinical condition is worsening as
evidenced by any of the following in the past 24 hours:
♦ Fever >38°C
♦ Abnormal WBC count that is not improving
♦ Systolic blood pressure ≤ 90mm Hg
♦ Heart rate > 90 bpm
♦ RR > 20/min
♦ Worsening chest X-ray
2. Deep seated infection
♦ Endocarditis ♦ Brain abscess
♦ Osteomyelitis ♦ Endophtalmitis
♦ Sepsis ♦ Melioidosis
♦ Severe cellulitis ♦ Meningitis
3. IV antibiotic used for less than 48 hours or is scheduled to be discontin-
ued in the next 24 hours.
4. Active GI bleed
5. GI obstruction, ileus or malabsorption syndrome
6. Hematological maglinancy (e.g leukemia, lymphoma) or documented
neutropenia
7. Nothing by mouth
8. Severe or persistent nausea or vomiting
9. Used of vasopressor in the past 24 hours (e.g dobutamine)
18
19
IV To Oral Switch Protocol
References:
1. Malaysia,Pharmaceutical Services Division, MOH (2014) Protocol On
Antimicrobial Stewardship Program In Healthcare
2. Omnicare CVS Health Company. Focus On Coverting IV to PO Antibiotic Therapy
[Internet]. [updated 2016] Available from: https://www.omnicare.com/ me-
dia/1093/4_iv_to_po_antibiotic_therapy.pdf
20
En Mohamad Khamis
August 2016
En Suhaimi Sulaiman
July 2016
En Rosli Dris
September 2016
Cik Shoniya Jayasegaran
October 2016
Pn Juliana Mahat
November 2016
Pn Ruslinda Mat Termizi
December 2016
BEST STAFF OF
THE MONTH
21
Pn Ruslinda Mat Termizi
EN ABDUL AZIZ MOHD
PENOLONG PEGAWAI FARMASI U36
SELAMAT BERSARA! :)
PN ADILLAH AHMAD
PEGAWAI FARMASI UF44
SELAMAT BERTUGAS DI
TEMPAT BARU
KEMASUKAN STAFF BARU
Cik Nurul Atika
Wahab (PF UF41)
En Navinshankar
A/L Gnanaseharan
PF UF41 (PRP)
Cik Sarohmena
Rawisandran
PF UF41 (PRP)
23
MEDICATION SAFETY ROAD SHOW
21 OCTOBER 2016
ANTIBIOTIC
AWARENESS WEEK
11 November 2016:
Exhibition and Counseling
30 November 2016: CME
on Antibiotic Awareness
and Hand Hygiene
24
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