Home Medication Review (HMR)

HOME MEDICATION REVIEW

Duration; 14th November 2011

At 14th of November which is Monday, I followed the pharmacist in charge, Mr. Chan Chee Meng (U44) for the home medication review program. We went to the psychiatric ward located outside HTAR which is at Jalan Pegawai, Klang where the Klang Health Clinic and Klang Dental Clinic located about 10am. We were accompanied by a staff nurse Pn. Dermia, a medical assistant En. Amri, and a driver Mr. Kumar. In this program, we will go to the patient’s home to check for his/her compliance towards medicine and their progress. However, some patients went out when we did the visit. Mr. Chan said that they will contact the patients to notify them the next visit to their house. Some patients which are in critical condition will be given Clopixol Depot® 200mg/ml Inj. (Zuclopenthixol Decanoate) intramuscularly by the nurse or medical assistant. Among all the 12 patients visits, I found an interesting case of patient A which her mother complained the patient wake up very late in the morning because she sleep about 2am, and she would’t be able to move her body up after wake up from the sleep. After Mr. Chan checked the medicine dosage while the medical assistant checked the blood pressure and heart of the patient, they discussed with the doctor on phone to change the dosage of clozapine tablet 100mg OM and 500mg ON to 200mg OM and 400mg ON. Propanolol dosage reduced from 20mg BD to 20mg ON. The dosage of fluoxetine remains 60mg. Some patient’s family members really thanked us because patients developing positive progress on their mental health. We ended our visit about 2pm. Then, I followed Mr. Chan to his office and I started to ask him several questions. Next page is the explanation about Home Medication Review (HMR).

 

Introduction

Home Medication Review (HMR) is a patient-focused process which advocates the optimal and quality use of medication at the patient’s home. It involves systematic assessment of the patient’s medication in order to identify and meet the medication-related needs as well as to identify, resolve and prevent drug related problems.

This service is a continuation of patient’s care from health facilities to their home. It is a comprehensive activity which involves clarification of the indication for use and administration details of all prescription and non-prescription medicines (including nutritional supplements, vitamins, herbal/complementary medicine and other remedies) with access to medication storage.

Pharmacist as one of the important service providers in the health care system, are responsible for provision of information and advising patient or (care giver) regarding medications and therapeutic devices. They play a major role in monitoring and advocating patient’s awareness about safety, appropriate and quality use of medications and encourage compliance, in order to optimize therapeutic outcomes.

 

Objectives

Primary Objective

The objective of HMR is to improve health outcomes and quality of life of the patient by emphasizing the Quality Use of Medication, which is appropriate, safe, judicious and efficacious. The pharmacist works with the patient, doctors and other health care providers to evaluate medication related information as well as identifying, preventing and optimizing health outcomes. The best outcome of HMR is achieved by reconciling all medication related information including Prescription and Over the Counter (OTC) medicines, traditional medicines, health supplements as well as therapeutic devices and aids.

Secondary Objectives

• To monitor patients’ adherence towards medications especially patient suffering from chronic illness.

• To educate patients and their care givers pertaining to the importance of medication adherence and to address other medication related issues such as side effects and adverse drug reaction

• To ensure the right medication and the right amount are stored properly at patient’s home.

• To identify and resolve possible drug interaction involving all medicines involving all medicines including prescribed medicine, over the counter (OTC) medications, traditional as well as health supplements.

• To counsel patients and their care givers in order to improve their insight towards medication and overall well being.

• To facilitate a cooperative working relationship between the pharmacist and other members of the health care team in order to benefit the well being of the patient,

• To facilitate care givers involvement in the management of patient’s illness

Scope of Service

The HMR service is to be extended to patients who are currently seeking treatment in Ministry of Health Hospitals ans Community Health Clinics only.

Manpower Requirement

All appointments for HMR should be conducted by a qualified pharmacist. The HMR Pharmacist may accompany other health care team members if needed.

Appointment

Appointments or the number of visits for patients under the HMR program will be determined by the Pharmacist conducting the HMR.

Procedures

Patient Inclusion Citeria

The need of HMR lies on the treating doctor but any member of the health care team may trigger a potential need for HMR.

The citeria which may be used to determine the need of HMR are as follows:

• Patient suffering from chronic illness and taking five or more medications for long term therapy.

• Patients who are taking more than 12 doses of medications daily.

• Patients suspected of non-adherence or not managing well with medication-related therapeutic devices (such as inhalers or insulin pen).

• Patients who are managing their own medication but at risk due to language difficulties, impaired insight, confusion/dementia or any other cognitive difficulties such as psychiatric and geriatric patients.

• Patients who are taking medications with narrow therapeutic index or requiring therapeutic drug monitoring such as warfarin, phenytoin,digoxin etc.

• Patients who are recently discharged from hospital with significant change in medication regimen.

• Patients who have defaulted treatment or fail to refill their medication especially for chronic illness.

• Patients attending number of different doctors from the same health facility or receiving treatment from multiple health facilities.

• Symptoms requiring pharmaceutical intervention such as occurrence of adverse drug reaction or sub therapeutic response toward treatment.

Patient Exclusion Citeria

• Patients who are not Malaysian citizens.

• Patients who are homeless.

• Patients who are aggressive.

• Patient’s family who signed the consent form regarding unwillingness to join HMR.

Administrative Requirement

• HMR pharmacist need approval from Head of Department- official letter

• All HMR visits should be conducted after obtaining consent for visit from patient/care giver.

• Risk assessment should be done by the HMR pharmacist prior to visit, especially if the home visit is not to be conducted along with the community home care team.

Activities

ENROLLMENT OF PATIENTS FOR HMR

Pharmacist select HMR patients from the referral form from doctor. Then obtain consent from patient/caregiver to participate by filling up the consent form. Risk assessment applicable if HMR done by pharmacist alone.

PREPARATION BEFORE HOME VISIT

Make appointment with the patient/caregiver. Note down the appointment in HMR Appointment Record. Then prepare medication identification chart based on the patient case record. Then ensure all procedures in the checklist are adhered.

CONDUCTING HOME MEDICATION REVIEW

1. Introduce yourself and explain the purpose of the visit to the patient/care giver.

2. Initial assessment by HMR pharmacist.

3. Medication Adherence Evaluation using Modified Morisky Medication Adherence Scale.

4. Pharmacotherapy review

a) Identify pharmaceutical care issues

b) Plan interventions to address all the identified drug related problems

c) Discuss with the doctor pertaining to any change of regimen or other suggested intervention. To alert patient to come for follow up visit in clinic if needed.

5. Remind patient to attend the clinic on the appointment date with the doctor.

6. Distribute related pamphlets/leaflets to patient/care giver.

7. Remind patient/care giver to bring all the balance medication on next appointment with the doctor and return to pharmacy unit to get new supply based on new prescription.

8. Follow up visit will be held upon another referral from prescriber or when deemed appropriate by the HMR pharmacist.

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Only 1 year Compulsory Service

For BPharm student, except JPA student...now the govt is reducing the service period from 1+3 to 1+1. Good or bad?

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SOP

How are you readers? Hope everything is fine. Good luck for the final examination for February 2011 session. I would like to share what is SOP today. SOP stands for standard operating procedures. SOPs are detailed written instructions to achieve uniformity of the performance of a specific function.


Standard Operating Procedures (SOPs) help maximum safety and operational efficiency for these kind of organisations:
- Pharmaceutical organizations
- Government organizations
- Emergency response operations
- Clinical research organizations
- Power producing organizations

A standard operating procedure (SOP) is a set of step by step written instruction on how to do the certain task. All important tasks performed in a compounding pharmacy should be covered by SOPs and documentation. SOPs can act as effective catalysts to drive performance-improvement and improve organizational results.
SOPs should be developed for:
 facility maintenance
 equipment calibration and maintenance
 personnel training and validation
 and the preparation, packaging and storage of compounded items
SOPs should also include sign-off or log sheets to document that the SOPs have been followed.
PURPOSE
SOPs can assure that:
 Supplies and chemicals are received, inventoried, compliant with compounding standards, stored properly and disposed off correctly
 The equipment is properly maintained and calibrated
 All procedures and tasks are performed consistently and documented

A well-written SOP can be used to satisfy compliance requirements. SOPs are recommended for all procedures that pose a potential risk to the health and safety of personnel.

Standard Operating Procedures (SOPs) lets you operationalize documents such as plans, regulation, compliance, and policies. SOPs distil requirements contained in these documents into a format that can be used by staff members in their work environment.

Standard Operating Procedures (SOPs) should be tranfered without every modification to insure the expected results. Every modification or divergence of a given standard, the Procedure should being served, while an investigation and results of the investigation documented according to the internal divergence procedure. All high-class processes and procedures should be put on in a Standard Operating Procedure.

This Standard Operating Procedure should be the base for the everyday training programme of every employee. The Standard Operating Procedure should be often updated to insure of obedience to the realisation conditions and the working practise.

A minimum review list of 3 years is recommended. Changes of the Standard Operating Procedure are activated generally by the process or the procedure changes or the adaptations. These changes should be led by the internal site controlling procedure. A part of the activity list of such changes should be to update the coherent standard operating procedure. Standard operating procedure should be in the place for all high-class systems plus the specific operational activities on the side.

The structure of a the Procedure System and the sum of all SOPs should be considered carefully. Too many standard operating procedure could lead to a breakdown of the SOP Sstem.



there is a documentary film which shared the same title

http://www.imdb.com/title/tt0896866/


SOP plays a vital role in our life. Imagine what is the life going to be without them. Hope you will get knowledge from this article.

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Coca-Cola and Pepsi Soft Drink Ingredient Can Cause Cancer

Coca-Cola and Pepsi deny their soft drinks cause cancer, but studies show that the caramel coloring ingredient used in Coca-Cola and Pepsi can cause cancer.

A widely consumed beverage, colas are known for their dark colors and fizzy taste. New revelations point to a hidden danger in those colas, that many consumers are unaware of. On February 22, 2011, Michael F. Jacobson, Ph.D and Executive Director for the Center for Science in the Public Interest, CSPI, appeared in the Huffington Post with accusations against both Coca-Cola and Pepsi soda drinks.

Caramel Food Colorings Contain 4-Methylimidazole: Carcinogen

Caramel food colorings are used in many dark beverages and some beers to give a darker and "caramelized" color to the product. As Jacobsen reports, there are four different types of caramel coloring that are used as additives in certain beverages.

The first caramel coloring is simply made by melting and browning sugar, thus creating a caramel color. However, the other three methods of producing a caramel color involves reacting sugar with other chemical compounds. Caramel coloring can be achieved when reacting sugar with sulfites, sugar with ammonium compounds, or, in Coca-Cola and Pepsi's case, reacting sugar with both ammonium and sulfite compounds. Coloring made from the last recipe is also called "Caramel IV" or "ammonia-sulfite process caramel."

When sugars are reacted with ammonia, byproducts such as 2-methylimidazole and 4-methylimidazole are able to form.

Coca-Cola and Pepsi Caramel Coloring 4-Methylimadazole Causes Cancer

4-Methylimadazole has shown to be harmful to health and is capable of causing cancer. The Office of Environmental Health Hazard Assessment has provided notice of intent to list 4-Methylimadazole as a chemical that can cause cancer.

The National Toxicology Program reports that a study involving rats and mice yielded mixed results when it came to ingesting 4-methylimidazole. Male rats who were exposed to the chemical showed no evidence that it caused cancer. However, female rats showed equivocal evidence of Monoluclear cell leukemia. The studies involving mice showed that both the male and female mice displayed clear evidence that 4-methylimidazole caused carcinogenic activity.

On January 7, 2011, The State of California put 4-Methylimadazole on the list of Proposition 65, which contains chemicals known to cause cancer.

FDA Asked to Ban Certain Caramel Colorings In Coca-Cola and Pepsi Drinks

The CSPI is asking the U.S Food and Drug Administration, FDA, to ban certain caramel colorings that are used in darker colored beverages. Those colorings that use sugar reacted with ammonia are the ones that produce the byproducts 2-methylimidazole and 4-methylimidazole and are the ones that the CSPI are asking the FDA to ban.

Manufacturers such as Coca-Cola and Pepsi can still use caramel colorings made from reacting sugars with sulfites, as they have not shown to produce cancer-causing byproducts.

American Beverage Association Denies Danger of 4-Methylimadazole

Opposing the CSPI's accusations, the American Beverage Association, ABE, has denied the dangers of the byproduct 4-Methylimadazole, 4-MEI, and indicates that there is no threat whatsoever to human health. The ABE further states that the CSPI is trying to scare the general public and that there is no proof that 4-MEI causes cancer in humans.

The studies done by the National Toxicology Program did not, in fact, test any humans to determine carcinogenic activity. The study only involved mice and rats and did prove that 4-MEI is able to cause cancer, though it's not yet determined what species may be affected.

The concern was great enough for the State of California however, and the addition of 4-Methylimidazole to Proposition 65 was effective as of January 7, 2011.

The American Beverage Association further backs up their denial that 4-MEI causes cancer, by stating that " ...people have been safely drinking colas for more than a century....".

Human studies have not yet been concluded to determine if 4-MEI causes cancer in humans and whether or not individuals who consumer dark-colored beverages have a higher instance of cancer than those who do not consumer dark-colored beverages.

http://www.suite101.com/content/coca-cola-and-pepsi-soft-drink-ingredient-can-cause-cancer-a351495

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Industrial Visit to CCM Duopharma Biotech Bhd

Hello readers,

School of Pharmacy had an industrial visit to CCM Duopharma Biotech Berhad which is the 1st pharmaceutical company producing generic drugs in Malaysia. The visit was held at 21st of February 2011 which falls on Monday scheduled at 2pm. The industrial visit idea was generated from the project manager, Chua Pei Yong.

Target student is 20 students accompanied by the Head of Department Mr. Mohd Fadli, lecturers Mr. Mohd Nizam and Dr. Jiyauddin Khan. The group was greeted warmly by the representative of CCM Duopharma, Puan Nurhariati and Mr Affandi. An interesting presentation basically on CCM Duopharma was given to the students about the generic products production at our country. They even launching for refilling human vaccines five years later and the first south east Asia who got this contract signed. Q and A session was interesting because the students were curious about the job opportunites in pharmaceutical industries.

They offered some refreshments and we had a rest before they bought us touring around the company. Firstly, we were bought to the water treatment system. According to Mr. Satish which was the person in-charge for water treatment system, the water plays vital roles for providing the desired quality of pharmaceutical products. The water treatment were using reverse osmosis (RO) system. After that, we are brought to the production department while can observed the making of pharmaceutical products such as tablets in a sterilized conditions with HEPA filters at box.

Then, we proceed to the warehouse department and we got to know how the pharmaceutical products being stored and its precautions. After that, we proceed to QC and QA department which was the last part of the trip. This is an open mind and informative industrial visit for the students. Hope the School of Pharmacy will organize this meaningful event again.

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NATIONAL PHARMACY SPORT CARNIVAL 2011@ PENANG

Good day bloggers. First of all, do forgive me because under circumstances, i am not able to post this report as early as i expected. However, here is the report regarding one of our biggest event for 2011. :)

The history of National Pharmacy Sport Carnival (NPSC) started from February 2008 was organized by School of Pharmacy, University of Nottingham Malaysia Campus (UNMC) and continued with second NPSC was organized by Faculty of Pharmacy from UiTM Shah Alam as well as the third NPSC 2011 was organized by School of Pharmacy, Management and Science University (MSU)

For this year, University Sains Malaysia had been honoured to be the host for 4th NPSC 2011. This event was held on 29th till 30th January 2010. The universities involved were University Malaya (UM), University Kebangsaan Malaysia (UKM), International Islamic Univeristy of Malaysia (IIUM), University Teknology Mara (UiTM), Management and Science University (MSU), Masterskill College of Nursing and Health, Cyberjaya University (CUCMS), AIMST University and University Sains Malaysia (USM)

Our team reached USM Penang on Friday evening and received a warm welcome from the organizer. The event start on Saturday, 29th January with modern games which were netball, basketball, volleyball, tennis, futsal, ping pong and takraw as well as badminton. We able to have representatives for the modern games except for volleyball, takraw and basketball. All the games ended early than expected which gave advantages to all players as they can have a good rest and pull their strength for the next day.

On Sunday, 30th January, the traditional games started which included batu seremban, upih pinang, tuju kasut and taril tali as well as galah panjang. The closing ceremony placed at Dewan Utama Desasiswa. NPSC 2011 had been officiate by YB. Prof. Dato' Omar Osman, Vice Chancellor, Hal Ehwal & Pembangunan Pelajar USM and also attended by Prof. Syed Azhar Syed Sulaiman, Dean School of Pharmaceutical Sciences USM.

Here are few pictures: :)

galah panjang

upih pinang

netball game

futsal team

Here are the results from the Games:

• Galah Panjang Lelaki : first place was MSU, second place was UiTM, third place was was UM
• Galah Panjang Perempuan : first place was UiTM

• Batu Seremban : first place was UiTM

• Tarik Tali : first place was UiTM

• Tuju Kasut Lelaki : first place was UiTM
• Tuju Kasut Perempuan : first place was UM

• Upih Pinang Lelaki : first place was UM
• Upih Pinang Perempuan : first place was USM A

• Ping Pong
• Men single : first place was MSU, second place was UIA
• Women single : first place was UM, second place was UiTM
• Men Double : first place was UIA, second place was CUCMS
• Women Double : first place was UM, second place was MSU

• Badminton
• Men single : first place was UM, second place was UIA
• Women single : first place was USM A , second place was USM
• Men Double : first place was USM A, second place was UIA
• Women Double :first place was UKM, second place was CUCMS

• Tennis
• Men single : first place was UiTM, second place was UM
• Women single : first place was AIMST, second place was USM A

• Basketball : first place was AIMST, second place was USM A, third place was UiTM

• Takraw : first place was UIA, second place was UiTM, third place was UM

• Futsal Lelaki : first place was USM A, second place was UIA, third place was UM and CUCMS
• Futsal perempuan : first place was CUCMS, second place was UIA, third place was UKM and UiTM

• Netball : first place was UIA, second place was UiTM, third place was USM A and UM

• Volleyball lelaki : first place was UIA, second place was CUCMS, third place was USM A
• Volleyball perempuan : first place was USM A, second place was UIA, third place was UiTM

Overall results are:

1. UIA with 4 golds and 6 silvers
2. USM A with 4 golds, 2 silvers and 2 bronzes
3. UM with 3 golds, 1 silver and 3 bronzes
4. AIMST with 2 golds
5. UiTM with 1 gold, 3 silvers and 1 bronze
6. CUCMS with 1 gold, 3 silver and 1 bronze
7. MSU with 1 gold and 1 silver
8. UKM with 1 gold and 1 bronze
9. USM B with 1 silver

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Industrial Visit

MSU School of Pharmacy will have its 1st Industrial Visit to CCM Dupoharma and Beryl's Choclate at 21st February. So far, Beryl's have approved and waiting for reply from CCM..pray that CCM will provide positive feedback

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Final Exam Nov 2011 Long Sem Draft

MSU - Final Examination Timetable for November 2011 session (DRAFT)

Monday February 14, 2011 - 10:39

Dear All MSU Students,

Please be informed that MSU, Final Examination Timetable for November 2011 session (DRAFT) is now available for download.

To download: Go to myCampus Tools Tab → file storage → MSU FINAL EXAM TT NOV 2010 SESSION (DRAFT) Folder → file →

1. DRAFT MSU FE TT NOV 2010 SESSION FBMP – STUDENT

2. DRAFT MSU FE TT NOV 2010 SESSION FHLS – STUDENT

3. DRAFT MSU FE TT NOV 2010 SESSION FISE – STUDENT

4. DRAFT MSU FE TT NOV 2010 SESSION IMS – STUDENT

5. DRAFT MSU FE TT NOV 2010 SESSION SPH – STUDENT

Those who have any issues with regards to subjects clashing, please refer to the examination department latest by Thursday, 17 February 2011.

Your attention and cooperation are highly appreciated.

Thank you.

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MSU Graduate Research Assistantships

Dear all MSU staff

It is my pleasure to announce the availability of the following research positions at MSU which were recently approved by Dato President. These are:

(1) MSU GRA (Graduate Research Assistantships)

(2) Mohd Shukri Yajid Research Fellowships (MSYRF) - similar to "Post Doc" position.

MSU GRA: suitable for RECENT graduates from any local IPTA & IPTS or overseas with a basic allowance of RM 1,500 per month to assist MSU Professors in their research activities which lead to MSc or PhD.

MSYRF: suitable for RECENT PhD graduates from foreign countries with a basic allowance of RM 36,000 per year + accomodation + annual air return ticket to assist MSU Professors in their research activities.

Please circulate this information to all your acquaintances in Malaysia and around the world. More detailed information about these research positions is available on MSU website.

WasSalam. Thank you.

Prof Dato' Dr ASBI B ALI, PhD

Vice President Research & International Relations

Management & Science University (MSU)

University Drive, Off Persiaran Olahraga

40100 Shah Alam, Selangor

Malaysia

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Clinical Pharmacy

Hello readers, how have you been recently??

I am going to encounter my mid semester paper in one more weeks, lazy to prepare myself as this is my last theory semester.

One of the subject I encountered this semester is Pharmacy Practice 3 which mainly focuses on Clinical Pharmacy.


Pharmacy??? Clinical????

Is it a pharmacy in a clinic???

NO


Clinical pharmacy is a field where the health care providers teamed up with the pharmacist and pharmaconomist to promote cost efectiveness and the correct usage of the medicines.

how is it different from pharmacy??


pharmacy is a WIDE field focusing not only pharmaceutical care, but involving pharmaceutics, organic synthesis and pharmacology as well as pharmacognosy.

clinical pharmacy focuses on the treatment for pateints in terms of cost, adverse drug reactions, route of administration,patterns of usage,population of patients, pharmacotherapeutics and also pharmacoeconomics.

clinical pharmacy mostly found in hospital setting, but the term 'clinical' does not imply that clinical pharmacy needed to be practice at hospital pharmacy only. they also provides advices and counselling services.


In some states, clinical pharmacists are given prescriptive authority under protocol with a medical provider (i.e., MD or DO), and their scope of practice is constantly evolving. In the United Kingdom clinical pharmacists are given independent prescriptive authority.


Basic components of clinical pharmacy practice
*Prescribing drugs
*Administering drugs
*Documenting professional services
*Reviewing drug use
*Communication
*Counseling
*Consulting
*Preventing Medication Errors


Scope of clinical pharmacy:
+Drug Information
+Drug Utilization
+Drug Evaluation and Selection
+Medication Therapy Management
+Formal Education and Training Program
+Disease State Management
+Application of Electronic Data Processing (EDP)

Activities of Clinical Pharmacists
The principle activities of a clinical pharmacist include:

Consulting
Analysing therapies, advising health care practitioners on the correctness of drug therapy and providing pharmaceutical care to patients both at hospital and at community level.

Selection of drugs
Defining "drug formularies" or "limited lists of drugs" in collaboration with hospital doctors, general practitioners and decision makers.

Drug information
Seeking information and critically evaluating scientific literature; organising information services for both the health care practitioners and the patients.

Formulation and preparation
Formulation and preparation of medicinal products and devices according to acceptable standards to meet specific patients' needs.

Drug use studies and research
Drug use studies/ pharmacoepidemiology/ outcome research/ pharmacovigilance and vigilance in medicinal devices: collecting data on drug therapies, their costs and patient outcome through structured and scientific methods.

Pharmacokinetics/ therapeutic drug monitoring
Studying the kinetics of drugs and optimising the dosage.

Clinical Trials
Planning, evaluating and participating in clinical trials.

Pharmacoeconomy
Using the results of clinical trials and outcome studies to determine cost- effectiveness evaluations.

Dispensation & Administration
Dispensing and administration of medicinal products and devices: studying and developing systems for the dispensing and administration of medicinal products and devices that can guarantee a higher security in administration, a reduction of expenditure and a reduction in medication errors.

Teaching & Training
Pre- and post-graduate teaching and activities to provide training and education programmes for pharmacists and other health care practitioners.


Clinical pharmacy, anyone????

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Long Sem Draft Timetable Mid Sem Exam Nov 2010

MSU - MID EXAMINATION TIMETABLE FOR NOVEMBER 2010 SESSION (DRAFT)

Monday December 27, 2010 - 16:03

Dear All Students,

Please be informed that MSU, MID EXAMINATION TIMETABLE (DRAFT) for NOVEMBER 2010 SESSION is now available for download.

To download: Go to myCampus Tools Tab → file storage → MSU MID SEM NOV 2010 (DRAFT) Folder → DRAFT MID SEM NOV 2010 (DIPLOMA).xls & DRAFT MID SEM NOV 2010 (BACHELOR).xls →

You are required to verify your examination timetable and make sure your examination timetable is similar with your subject registration.

Those who have any issues with regards to subjects clashing, please refer to the examination department latest by Thursday, 30 December 2010.

Your attention and cooperation are highly appreciated.

Thank you.

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