drug - MPS Young Pharmacist Chapter

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OUTLINE
DEFINITION
• The elderly are defined as those who are 60
years old and above. – Malaysia
• This definition is based on that made at the
World Assembly on Aging in Vienna in 1982.
Malaysian-NATIONAL POLICY FOR THE ELDERLY.
GERIATRIC
EPIDEMIOLOGY
• The proportion of geriatric population is growing faster
than any other age group in worldwide. The most rapid
rise in the elderly population is taking place in developing
countries.
• The number of people older than 65 will doubling : 7 %
to 14 % of the world’s population in the next 30 years,
• “Low fertility rates, extended life expectancy and better
health conditions and care”
National Institute on Aging.
Malaysia: Persons Aged 60 and Above by Ethnic Group
and Residence 1991, 2000 and 2020
Source: Department of Statistics, Malaysia
(1998, 2001).
IMPACT TO NATION
HEALTHCARE
Impact
Impact of increasing number of older people:
• Increase the healthcare cost
• Challenges to healthcare provider
• Quality use of Medicine
Chronic Illness
• 88% of those over 65 years of age have at least
one chronic health condition
• More than half of all Americans show evidence of
osteoarthritis in at least one joint.
• Over half of Americans older have osteoporosis
or low bone mass, and cardiovascular disease,
cancer, and diabetes remain common among
older Americans.
.
Factors associated with chronic illness among the
elderly in a rural community in Malaysia.
Sherina MS, Rampal L, Mustaqim A.
Abstract
Chronic illness is one of the major causes of mortality
morbidity among
the
The and
prevalence
of chronic
elderly. To determine the prevalence and factorsillness
associated
with chronic
illness in
among
the elderly
among the elderly in a rural community setting. A cross sectional study design was
Mukim
was 60.1%
used. Stratified proportionate cluster sampling method
wasSepang
used to select
respondents in Mukim Sepang, Sepang, Selangor, Malaysia. Out-HPT
of 263 elderly
residents (6.2% of the total population), 223 agreed to participate
in the study
-DM
giving a response rate of 84.8%. The prevalence of chronic illness among the
-IHD
elderly in Mukim Sepang was 60.1%. Out of 223 respondents, 134
were diagnosed
as having chronic illness such as hypertension, diabetes mellitus,-BA
ischaemic heart
disease, bronchial asthma or gout. Chronic illness
was found
to be significantly
-Chronic
illness
was found to
associated with functional dependence among the elderly (chi2=6.863, df=1,
associated
p<0.05). The prevalence of chronic illness amongbe
thesignificantly
elderly in the rural
community is very high. Problems facing this age-group
should be addressed
with functional
dependence
comprehensively in order to formulate appropriate programmes
for the
health care
among the
elderly
of the elderly
Geriatrics is ...
a branch of medicine dealing with the
aged and the problems of aging.
Geriatrics deals with multiple, complex & interacting
physical and psychosocial conditions that compromise
the functioning of an individual and lessen her or his
chances of acting independently and maintaining a
preferred style or quality of life.
Geriatric Giants
5 I’s
5 major problems often faced by geriatric
patients who were identified as
GerIatrIc Syndrome (5‘ I’S)
–I -ntellectual impairments
( cognitive impairment, poor memory)
( lack of NFORMATION)
Medication History
MISSDIANOSIS:
Medication adherence
Delirium
Identify PCI
Dementia/ AD
Depression
GerIatrIc Syndrome (5‘ I’S)
–I –ncontinence
(urinary / fecal)
Patient physiology
ADR- Drug related
I –nstability
-Patient physiology
( vision- PD– OA)
- drug
Fall
I -mmobility,
Eg; Stoke, fracture,
acute illness
Bed sore- infection,
Delirium,
depression
I -atrogenic
MULTIPLE
Health
Problem:
HPT, DM, OA,
ect
ADR
illness caused by medical examination or
treatment
Case 1
75 year old lady –
HF with edema sign
Add frusemide 80 mg
bd
ADR
Diuresis effect
(INCONTINENCE)
Iatrogenic
Fall then Fracture
(IMMOBILITY)
Depression
(INTELECTUAL
IMPAIRMENT)
developed severe
OH (INSTABILITY)
Hospitalized –
infection
Delirium
(INTELECTUAL
IMPAIRMENT)
Drugs & Elderly
• US - Elderly account for 1/3 of
prescription drug use, even their
comprise only 13% out of the
population.
• Ambulatory elderly fill between 9-13
prescriptions a year (new and refills)
• One survey: Average of 5.7
prescription medicines per patient
• Average nursing home patient on 7
medicines
UCSF Division of Geriatrics Primary
Care Lecture Series May 2001
• Surveys indicate that elders take average of 2-4
nonprescription drugs daily
• Laxatives used in about 1/3-1/2 of elders
• Gender:
66% of men & 81% of women use at least 1
prescription drug weekly. (Kaufman, D.W. et al. 2002)
UCSF Division of Geriatrics Primary
Care Lecture Series May 2001
Medication for Hospitalized Elderly
Country
Average drug /
hospitalised patient
US
9.1
Canada
7.1
Isreal
6.3
New Zealand
5.8
Scotland
4.6
Bosker et al,, Geriatric Emergency Medicine, 1st ed, Mosby Year Book, St Louise, Missouri. 1990 pp33-61
Prescription Drug Use Among Elderly Admitted
to Medical Wards in a Malaysian Government
Hospital
SUMMARY
A cross-sectional study was
conducted
examine thedrugs,
use of
19.6%
- 1–2toprescription
prescription drugs among
elderly
patients
(> 60 years
old)
23.5%
- 3–4
prescription
drugs,
admitted to medical wards in Hospital Kuala Lumpur,
39.2%
- (101
5 ormen
more
Malaysia. A total of 204
elderly
andprescription
103 women)drugs.
were interviewed. Eighty two percent of the elderly were
taking at least one prescription drug, with 39.2% taking > 5
drugs. Prescription drugs commonly used were
antihypertensives (54.4%), antidiabetics (40.2%), drugs used in
haemostasis (36.8%), nitrates (33.3%) and diuretics (32.4%).
Factors associated with increased use of prescription drugs
were: more number of chronic diseases, self-rated health
status as poor, low Barthel score, and Chinese women
J Y Hor,MD.
Treatment Challenges
Patient
Drugs
HEALTHCARE
PROVIDER
Ref: Drugs for the elderly, WHO Publication, 1999
Drugs
Alteration of pharmacokinetic
& pharmacodynamic
Pharmacokinetics
Distribution
in the body
Metabolism
(Rubin 2003)
•
•
•
•
•
•
Anatomical/ functional changes
Decreased salivary production
Reducing splanchnic blood flow
Slowed GI motility, gastric emptying;
Decreased acid secretion; increased pH
Decreased absorption surface area
1. Fat composition
increase 30%
Increases the volume of
distribution for highly
lipophilic drugs
(eg, diazepam ) and
may increase their
elimination half-lives.
2. Dec lean body muscle
N Coni et al, Lecture notes on Geriatrics, 4th Ed. Blackwell Scientific Publications.
Water Composition
13-15%
Vancomycin, Digoxin – increase
concentration
N Coni et al, Lecture notes on Geriatrics, 4th Ed. Blackwell Scientific Publications.
Hepatic clearance:
• Over the age of 30 years, there is approximately 1
percent per year decline in liver blood flow and
liver mass.
• A decrease in first pass effect results in higher
serum levels of propranolol, metoprolol,
verapamil, nitrates, acetaminophen and tricyclic
antidepressants (TCA).
• The decreased hepatic microsomal enzyme
activity prolongs duration of action of
benzodiazepines, warfarin and phenytoin.
Elimination
After age 30, CrCl decreases
an average of 8 mL/min per
decade
 Decline CO may reduce ~ 40 50% renal perfusion
 Increased in numbers of
abnormal glomeruli

Eliminated primarily by the kidneys e.g.
aminoglycosides, atenolol, lithium and digoxin may
altered.
GCJ Bennet et al, The Essentials of Health Care in Old Age, 2nd Ed. Edward Arnold, London 1995
Which Medications to Avoid in People at Risk
of Delirium: A Systematic Review
Andrew Clegg; John B. Young
Abstract
Background: delirium is a common clinical problem and is associated with adverse health outcomes.
Many medications have been associated with the development of delirium, but the strength of the
associations is uncertain and it is unclear which medications should be avoided in people at risk of
delirium.
Methods: we conducted a systematic review to identify prospective studies that investigated the
association between medications and risk of delirium. A sensitivity analysis was performed to
construct an evidence hierarchy for the risk of delirium with individual agents.
Results: a total of 18,767 studies were identified by the search strategy. Fourteen studies met the
inclusion criteria. Delirium risk appears to be increased with opioids (odds ratio [OR] 2.5, 95% CI 1.2–
5.2), benzodiazepines (3.0, 1.3–6.8), dihydropyridines (2.4, 1.0–5.8) and possibly antihistamines (1.8,
0.7–4.5). There appears to be no increased risk with neuroleptics (0.9, 0.6–1.3) or digoxin (0.5, 0.3–
0.9). There is uncertainty regarding H2 antagonists, tricyclic antidepressants, antiparkinson
medications, steroids, non-steroidal anti-inflammatory drugs and antimuscarinics.
Conclusion: for people at risk of delirium, avoid new prescriptions of benzodiazepines or consider
reducing or stopping these medications where possible. Opioids should be prescribed with caution in
people at risk of delirium, but this should be tempered by the observation that untreated severe pain
can itself trigger delirium. Caution is also required when prescribing dihydropyridines and
antihistamine H1 antagonists for people at risk of delirium and considered individual patient
assessment is advocated.
Malaysian Journal of Medical Sciences, Vol. 11, No. 2, July 2004 (52-58)
Patient
Drugs
HEALTHCARE
PROVIDER
Ref: Drugs for the elderly, WHO Publication, 1999
Some changes in 70 y/o VS young in %
 Art O2 pressure
 Total body water
 Cerebral bld flow
 Kidney weight
 Max heart rate
 Resting oxygen consumption
 Muscle mass
 Max oxygen consumption
 Resting cardiac output
 Max urinary concentration
 Kidney bld flow
 Cardiac reserve
90
87
80
80
76
74
74
65
64
64
60
50
Kennedy RA (1985) Physiology of Ageing. Clinics in Geriatric Medicine, 1, 37-59
Treatment Challenges
Patient
Drugs
HEALTHCARE
PROVIDER
Ref: Drugs for the elderly, WHO Publication, 1999
Health care provider
Intellectual
impairment,
poor
memory,
language
barrier
• Difficulty - goal ,
Lack of
aim
information
Miss
diagnosis -
• wrong treatment
• Missed diagnoses more common in those with dementia
• 66% of demented pts vs 48% non-demented
Lopponen. Dement Geriatr Cogn Disord 2004
identify pt problem
1. Understand the
pt.’s problem &
condition
2. Cause
As an example, someone with an issue with
their thyroid may cause mental
confusion in an older person, but not a
younger person
Set therapeutic aim.
What do you want to
achieve with the
treatment? – set a goal
-
Pharmacotherapy must
be individual
Case 1
Mr. XYZ, 79 years old, during
hospitalization BP was gradually
increased. BP reading 140/80 –
160/89mmHg within 2 days…..
What to do ????
Ageing
Accumulated pathology
Chronic illnesses
Drug effects
Family
Social support
Physical, mental competence
Wish for independency
Kamal. A, Brocklehurst. JC. A colour Atlas of Geriatric Medicine 2nd ed, Wolfe Publication, 1992, Netherlands,
Multidisciplinary Team
Dr
PT
Pharmacy
OT
Soc
Work
Nurses
Dietician
WHY
PATIENTS NEED
PHARMACIST?
To identify
To resolve
To prevent
………drug-related problems
Roles of Clinical Pharmacist
…. to optimise
pharmaceutical
therapies for each
patient to improve
outcomes by
implementing the best
quality use of medicines
Roles of Clinical Pharmacy
1. medication history interview
2. participation in ward rounds and
meetings
3. selection of drug therapy
4. drug therapy monitoring
5. prevention, assessment and
management of drug interactions
6. provision of drug information
7. provide medication-use education to
patient/ caregiver
Roles
Rolesof
ofClinical
ClinicalPharmacy
Pharmacy
8. Provide in-service education to physicians,
nurses and other practitioners
9. Participate in the MUE program in the care of
geriatric patient
10.Preceptor as training centre for pharmacist
and student in geriatric care
11.Develop protocol for a new geriatric pharmacy
service
12.Perform study & Research
2. Participation in ward rounds/ MDM
• Gain improved understanding of patients clinical
details, planned investigations and therapeutic goals
• provide information
• optimise drug treatment by influencing therapy
selection, implementation and monitoring
• that untoward effects and interactions of drugs are
identified, resolved and where possible prevented
• cost effective use of medication
Clinical Pharmacist
1. Help prescribers choose the best
clinical therapy for each individual
patient
2. Offer guidance to drug switching - in a
way the most beneficial; tailor with
individual patient
3. Reduce the variability of prescribing
Medication History Review
• To obtain information on aspects of drug use
currently, that may assist in the overall care of
the patient
–
–
–
–
–
verify medication history taken by other staff
document allergies and adverse reactions
screen for drug interactions
assess patient compliance
assess rationale for prescribed and non prescribed
drugs
– assess evidence of drug abuse
– appraise drug administration techniques
– examine need for medication aids
Pharmacist Assessment
Adherence to each
medication - was
poor.
Average, patients
took their
medications for only
50% to 60% for all 3
medication classes
during the 36-month
study period.
Medication
Hist taking
Intellectual
impairment
nt / MCI
Asses
medication
adherence
Identify
PCI
Medication adherence by elderly after MI is low. Clinical Journal of the American
Society of Nephrology, HealthDay News reported.
 Ask patient Bring all medication
during each visit
 Drug Reconciliation
Dr. Yau Weng Kiong
Drug Regimen Review
• Work with physicians to optimize
pharmacotherapy
• Reducing risk of ADR/ SE
• Verify the appropriateness of the “drug
use to Avoid DRP
• Monitor Serum
Level
MAI index
1. Is there an indication for the drug?
2. Is the medication effective for the condition?
3. Is the dosage correct?
4. Are the directions correct?
5. Are the directions practical?
6. Are there clinically significant drug-drug interactions?
7. Are there clinically significant drug disease interactions?
8. Is there unnecessary duplication with other drug(s)?
9. Is the duration of therapy acceptable?
10. Is this drug the least expensive alternative compared to
others of equal utility?
Pharmaceutical care Issues
•Total number of PCI is 680
9.6%
11.4%
5.8%
•The mean of PCI in each patient was
11.33 ± 3.79
37.3%
35.9%
drug adm
ADE/DI
special monitoring
therapeutic choice
risk factor
Distribution of category PCI
Therapeutic of choice,
give a higher
proportion in
categories of PCI =
parallel with study done by
Janet Kraska (2001),
Therapeutic Drug choice
117
120
precaution /
monitoring
required (n=117,
17.2%), give a
higher proportion.
100
80
60
60
40
32
20
20
8
0
inappro drug
unneces s ary
precaution/m onitor
The distribution of therapeutic drug choice
Case 2
• 75 years old admitted to ward for c/o …..
In the ward physician was started madopar
125mg tds as impression he had parkinsonism
( since as described by her daughter he had
symptom as slowness when to start walking….
It is appropriate drug???
Malaysian Journal of Medical Sciences, Vol. 11, No. 2, July 2004 (52-58)
MEDICATION ERRORS AMONG GERIATRICS AT THE OUTPATIENT PHARMACY IN A
TEACHING HOSPITAL IN KELANTAN
Dellemin Che Abdullah, Noor Shufiza Ibrahim, Mohamed Izham .
The main aim of this study was to determine the medication errors among geriatrics at the
outpatient pharmacy in a teaching hospital in Kelantan and the strategies to minimize the
prevalence. A retrospective study was conducted that involved screening of prescription for a
one-month period (March 2001). Only 15.35% (1601 prescription) of a total 10,429
prescriptions were for geriatrics. The prescriptions that were found to have medication errors
was 403. Therefore, the prevalence of medication errors per day was approximately 20 cases.
Generally, the errors between both genders were found to be comparable and to be the highest
for Malays and at the age of 60-64 years old. Administrative errors was recorded to be the
highest which included patient’s particulars and validity of the prescriptions (70.22%) and drugs
that available in HUSM (16.13%). Whereas the total of prescribing errors were low. Under
prescribing errors were pharmaceutical error (0.99%) and clinical error (8.68%). Sixteen cases or
3.98% had more than 1 error. The highest prevalence went to geriatrics who received more than
nine drugs (32.16%), geriatrics with more than 3 clinical diagnosis (10.06%), geriatrics who
visited specialist clinics (37.52%) and treated by the specialists ( 31.07%). The estimated cost for
the 403 medication errors in March was RM9,327 or RM301 per day that included the cost of
drugs and humanistic cost. The projected cost of medication errors per year was RM 111,924.
In conclusion, it is very clear that the role of pharmacist is very great in preventing and
minimizing the medication errors beside the needs of correct prescription writing and other
strategies by all of the heath care components.
1. Incidence of med error occur is 25 %
2. Administrative is the most common error
3. Estimated cost is RM 9,327 include cost of
drug and humanistic
4. No of item was prescribe > than 9 is 32%
Prescriptive Cascade
3. Provide Education
Counsel the family & Care giver :
 Explain why the drug needs
 Give information on drug side-effects
 Be sure patients aware of
medicine can cause harm and also
cure illness
 Avoid Communication Error
Aids for better
compliance
 Use table cards and pill box
Use
medication cards
Geriatric unit activity
Consultant/ specialist round – every day
Pharmacist : 2
Geriatric unit activity
• MULTIDICIPLINARY MEETING – every Monday
Geriatric unit activity
HOME VISIT – Every Friday
Ambulatory Care
Geriatric MTAC – 2.00 pm every MONDAY
No Pharmacist
involve, as part
time in GMTAC:
- 1
- 4
- 7
•Toward
Impact of
patient
Clinical
Pharmacist care
?
POLYPHARMACY AND UNNECESSARY DRUG THERAPY ON
GERIATRIC HOSPITALIZED PATIENTS IN YOGYAKARTA HOSPITALS,
INDONESIA
FITA RAHMAWATI 1,3, I DEWA PUTU PRAMANTARA 2, 3
1 ABSTRACT The elderly population in Indonesia continues to rise.
1. The
Unnecessary
drug therapy
pharmacologic management
of many acute
occurred in 63 % ( 63 out
of 117 incidence)
2. Total expense of
unnecessary drug therapy
equal to US 1,046).
and chronic conditions and the aging population have contributed to increase medication use among elderly patients,
these situation may lead to drug related problem (DRPs) especially unnecessary drug therapy. The aim of this study
was to identify unnecessary drug therapy on hospitalized geriatric patients, to calculate the waste of cost spent on
unnecessary drugs and to investigate whether polypharmacy is a suitable indicator for occurrence of unnecessary drug
therapy in a hospital sitting.
Research type was observational. Data taken through medical record in 100 geriatric patients hospitalized in two
hospitals in Yogyakarta Indonesia. The study was conducted by accidental sampling with inclusion criteria: patient with
65 year and above, complete medical record, patient admitted to Internal Medicine Department during 2006 - 2007.
Unnecessary drug therapy was identify through discussion forum involve clinical pharmacist and senior geriatric
consultant. Comparison were made between patients received five drugs or less/day (group A) and with more than
five drugs/day (group B) during the hospital stay.
Our research found unnecessary drug therapy occurred in 63 cases (63 %) with total 117 incidences. Total expense of
unnecessary
drug therapy
to Rp.12.553.349,00
(US$ 1.046,
11). Of can
the 100
24 % received
Prevention
of equal
unnecessary
drug therapy
problem
be patients,
conducted
throughmore than
five drugs/day during the hospital stay. Number of unnecessary drug therapy incidence in patients with five drugs or
reduction of drug use (it is recommended to eliminate all medications without
less/day was lower than patients with more than five drugs/day during the hospital stay: 0.78 vs 1.91 respectively (P =
0.000).therapeutic benefit, goal or indication). Prevention of unnecessary drug therapy
Prevention of unnecessary
drug contribute
therapy problem
can besaving
conducted
through
reduction
of drug use (it is recommended
will also
in cost
among
elderly
patients.
to eliminate all medications without therapeutic benefit, goal or indication). Prevention of unnecessary drug therapy
will also contribute in cost saving among elderly patients.
International Journal of Pharmacy and Pharmaceutical Sciences, Vol. 1, Suppl 1, Nov.-Dec. 2009
Clinical pharmacists improve patient
outcomes..
This is based on a study of the impact of pharmacists in 8
Australian teaching hospitals that documented the clinical
impact of pharmacist-initiated drug therapy. 25%
25%
intervention
determined as
percent of the interventions were
determined
to be of major
significance (preventing or addressing
verysignificant
serious drug (prevention of
major
related
DRP)
problems). Thirty-eight percent of
the interventions
were of moderate significance (prevented
major
temporary
•
38
%
intervention
moderate
injury, enhanced the effectiveness of drug therapy, or
significant
produced
minor decreases in patient morbidity or a <20%
• 30% is minor significant
chance of noticed effect), and 30.4% were of minor
significance
(small adjustments and optimizations of therapy).
One percent of the interventions documented were lifesaving.
• The results of the study show that participation in a pharmacy care
program dramatically improves elderly patients' ability to correctly
continue their medication regimens: Before participation in the
pharmacy care program, patients' rate of medication adherence
was 61.2%. During participation in the pharmacy care program,
patients demonstrated a medication adherence rate of 96.9%.
Improve medication adherence
"We were surprised by the greatly increased adherence rate,"
96.9
% from
61.2%
states Lee, who said
the team
had initially
hoped for an
improvement rate of 85%. "We customized blister packs according
to each patient's medication regimen because some patients had so
many - a few patients had as many as 19 medications - they just had
no idea what to take when. We reviewed with patients what their
medications were, what they treated, the frequency and dose to
take and the possible side effects to expect. We also made
medication charts for them and updated them each time their
medications changed.”
Does pharmacist-led medication review help to reduce
hospital admissions and deaths in older people? A
systematic review and meta-analysis.
Holland R, Desborough J, Goodyer L, Hall S, Wright D, Loke YK.
Abstract
We set out to determine the effects of pharmacist-led medication review in older people by means of
Conclusion:
a systematic review and meta-analysis covering 11 electronic databases. Randomized controlled trials
1. (mean
Medication
review
interventions
in any setting, concerning older people
age > 60 years),
were &
considered,
aimed at optimizing
drug regimens and improving patient outcomes. Our primary outcome was emergency hospital
do not have any effect on reducing
admission (all cause). Secondary outcomes were mortality and numbers of drugs prescribed. We also
mortality
or hospital
admission
in 32 studies
recorded data on drug knowledge, adherence
and adverse
drug reactions.
We retrieved
which fitted the inclusion criteria. Meta-analysis of 17 trials revealed no significant effect on all-cause
older people
admission, relative risk (RR) of 0.99 [95% confidence interval (CI) 0.87, 1.14, P = 0.92], with moderate
2. Iinterventions
may
drug
heterogeneity (I(2) = 49.5, P = 0.01). Meta-analysis
of mortality data
fromimprove
22 trials found
no significant
benefit, with a RR of mortality of 0.96 (95% CI 0.82, 1.13, P = 0.62), with no heterogeneity (I(2) = 0%).
knowledge and adherence, but
Pharmacist-led medication review may slightly decrease numbers of drugs prescribed (weighted mean
are insufficient
data
to(I(2)
know
difference = -0.48, 95% CI -0.89, -0.07), there
but significant
heterogeneity was
found
= 85.9%, P <
0.001). Results for additional outcomes could not be pooled, but suggested that interventions could
whether quality of life is improved.
improve knowledge and adherence. Pharmacist-led medication review interventions do not have any
effect on reducing mortality or hospital admission in older people, and can not be assumed to provide
substantial clinical benefit. Such interventions may improve drug knowledge and adherence, but there
are insufficient data to know whether quality of life is improved.
Br J Clin Pharmacol. 2008 Oct;66(4):575; author reply 576
What we should do ?
We should expand our activity and
Research to reach the
public and physicians
exposing them to the usefulness of
pharmaceutical care in the aspect
of health and economy
R
E
Certified of Pharmacist Specialties
• To credential and recognize those pharmacists who
have expertise and knowledge of drug therapy
principles for older adults
• BPS- Board of Pharmacist Specialties
• Certified Geriatric Pharmacist (CGP)
– Incentive
Take Home Message
A mnemonic for evaluating the medication regimen
for an older patient is the “MASTER” Rules for
Rational Geriatric Drug Therapy.
– M-inimize number of drugs used
– A-lternatives should be considered
– S-tart low and go slow
– T-itrate therapy
– E-ducate patient
– R-eview regularly
Thank you

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