november 2017 page - sultanah aminah hospitalhsajb.moh.gov.my/versibaru/uploads/farmasi/bulletin...

BU

LE

TIN

VOLUME 4/2017

NOVEMBER 2017

EDITORIAL BOARD ADVISOR: DR. SITI NORLINA BT. MD SAID EDITORS: PN SITI ROSNAH BT. SURADI EN MOHD SHAFIE ZABIDI PN PATRICIA LIM MING HUA PN LI SHIN GIE

HOSPITAL SULTANAH AMINAH JOHOR BAHRU KEMENTERIAN KESIHATAN MALAYSIA JALAN PERSIARAN ABU BAKAR SULTAN 80100 JOHOR BAHRU TEL: 07-2257000 FAX: 07-2242694 EMAIL: [email protected]

IN THIS ISSUE LEPROSY

SKIN DISEASES

TOPICAL PREPARATIONS AND ITS COUNSELLING POINTS

TREATMENT AND PREVENTION OF DIPHTERIA

LAPORAN MINGGU KENALI UBAT ANDA DAN KESELAMATAN PENGUBATAN SEMPENA HARI FARMASI SEDUNIA 2017

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J A B A T A N F A R M A S I , H O S P I T A L S U L T A N A H A M I N A H J O H O R B A H R U P A G E 2

LEPROSY “Hansen's Disease”

By: Stephanie Tan

INTRODUCTION

Leprosy is also known as Hansen’s disease (Penyakit Kusta), was named after Gerhard

Armauer Hansen who discovered Mycobacterium leprae in 1873.

• The term ‘Leprosy’ is taken from a Latin word, ‘Lepra’ means scaly.

• Organism: Mycobacterium leprae.

• It is an infectious disease, NOT an inherited one.

• Incubation period: may take up to 2 to 10 years for symptoms to appear .

The disease mainly affects the skin, the peripheral nerves, mucosa of the upper respiratory tract and eyes.

CLASSIFICATION OF LEPROSY

WHO Clinical classification

Purpose of treatment

1. Paucibacillary Leprosy ( PB )

2. Multibacillary Leprosy ( MB )

Based on:

• Number of skin lesions

• Number of nerves involved


WHAT ARE THE TREATMENTS?

World Health Organization (WHO) recommends multi-drug therapy (MDT). Paucibacillary leprosy: Rifampicin + Dapsone. Multibacillary leprosy: Rifampicin + Clofazimine + Dapsone

ADULT treatment CHILD treatment

PB & MB Leprosy Treatments (Adult) PB & MB Leprosy Treatments (Child)

SIDE EFFECT OF MDT

Rifampicin

It may cause abnormal liver tests but the problem clears when the

medication is stopped. It may also cause a harmless orange color in the

urine, sweat or tears.

Dapsone May have a mild anemia.

Clofazimine It has virtually no side effects except some darkening of the skin which

slowly fades when the medication is stopped.

REFERENCES

1. Management of Leprosy Drug (Multidrug Therapy) from WHO to be Used at the Government's Healthcare Facilities.. (2017). Pharmaceutical Services Divisions. Retrieved from http://www.pharmacy.gov.my/v2/en/documents/management-leprosy-drug-multidrug-therapy-who-be-used-governments-healthcare-facilities..html

2. What is Hansen’s Disease?. (2017). Who.int. Retrieved from http://www.who.int/lep/mdt/MDT_Regimens.pdf?ua=1 3. Ngan, V. (2003). Leprosy. Retrieved from https://www.dermnetnz.org/topics/leprosy/ 4. Dr. Fuad Hashim. (2012). Leprosy. Retrieved from http://www.myhealth.gov.my/en/leprosy/ 5. Ministry of Health, Pengurusan Kusta Kebangsaan Edisi Kedua 2014 . Retrieved from http://www.moh.gov.my/


Acne, Atopic Dermatitis and Psoriasis

Skin Diseases

ACNE is a chronic skin disease that involves both non-inflammatory lesions and inflammatory lesions which affect mostly the face but can also happen at the back and chest.

It affects 85% of teenagers and have equal prevalence in both male and female although it tends to be more severe in males.

Risk factors of acne include a positive history of acne in family members. Obesity is also associated with acne in children. It is usually aggravated by smoking, stress and diet with high glycaemic load.

BY KAM WEN HANG

PATHOGENESIS of acne is usually started by follicular blockage due to in-creased sebum secretion and altered follicular keratinisation which subse-quently allows proliferation of P. acnes and follicular inflammation.

CLINICAL PRESENTATION

Open Comedo /Blackhead: Due to the exposure of skin pig-ment: melanin.

Closed Comedo /Whitehead: Due to complete blockage of follicles.

Papule: Solid, palpable elevated Inflammatory lesions with di-ameter less than 1 cm.

Pustule: Inflammatory lesions with pus.

Nodule: Solid, painful palpable elevated Inflammatory lesions with diameter more than 1 cm.

MANAGEMENT

Mild Acne Severe Acne Moderate Acne

Comedonal Papulo pustule

Comedonal Papulo pustule

Nodulocystic

[1 Topical Agent] [2 Topical Agents]

[Topical Agent + Oral Antibi-

otic]

[2 Topical Agents]

[2 Topical Agents]

OR [1 Topical

Agnet + Topi-cal Antibiotic]

[Topical Agents + Oral

Antibiotic]

[2 Topical Agents + Oral

Antibiotic] OR

[Topical Agent + COC]

(female only)

Refer to dermatology for Physical Therapy Refer to dermatologist for oral Isotretinoin ± Physical Therapy

Maintenance with topical retinoid or topical benzoyl peroxide

Second Line

First Line

Third Line

ATOPIC DERMATITIS, synonymous with atopic eczema is a chronic, pruritic inflammatory skin disease which is associated with elevated IgE levels. It affects up to 25% of children and 2-3% of adults. In children, its onset can be as early as 3 to 6 months of age. While majority of affected children’s disease will resolve by adult-hood but 10-30% will have symptoms persist in adulthood.

Strong risk factors are family history of atopic march (includes , atopic dermatitis,

Two main theories of PATHOGENESIS in atopic dermatitis have been proposed:

Primary Immunity dysregulation leading to IgE sensitization and secondary epithelial disturbance.

Erytherma Lichenification Xerosis Eczematous Lesions

PHARMACOTHERAPY

Topical Agent Benzoyl Peroxide

Tretinoin

Adapalene

Azelaic Acid

Salicylic Acid

Topical Antibiotic

Clindamycin (preferred)

Erythromycin

Oral Antibiotic

First line: Tetracycline, Doxycycline, Minocycline

Alternativee: Erythromycin, Azithromycin, Co-trimoxazole

Combined Oral Contraceptive (COC)

Ethinylestradiol with cyproterone

CLINICAL PRESENTATION of atopic der-matitis follows intermittent courses of flares and remission, often aggravated by food, dust mites or other allergy triggers.

Signs and symptoms include:

Pruritus (itch).

Lichenification (thickened skin due to con-tinuous rubbing and scratching).


MANAGEMENT of Atopic Dermatitis

Emollient (Moisturizer) and Good Skin Care Practice

Topical Corticosteroid (TCS)

Short burst of high potency TCS to rapidly control active disease followed by tapering down of TCS or taper up from least potency TCS

Topical Calcineurin Inhibitor

(Tacrolimus & Pimecrolimus)

Recalcitrance to steroids

Sensitive areas: face, anogenital, skin folds

Steroid-induced atrophy

Long-term uninterrupted use of topical corticosteroid

Systemic Immunomodulaters (Systemic Steroid)

ST

EP

UP

Other Therapy

Phototherapy

Systemic Antimicrobial

Antibiotic use with clinical evidence of bacterial infections

Antiviral use in eczema herpeticum

Systemic Antihistamine

Intermittent use of sedating antihistamine in sleep loss sec-ondary to itchiness

Maintenance Therapy

Emollient (moisturizer) alone

Emollient with intermittent use of TCS (1-2 times/week) or TCI (2-3 times/week) at flare up areas

PSORIASIS is a complex, chronic, multifactorial, inflammatory disease that primarily affects skin and joints. It affects 1-3% of worldwide population and presented as plaque psoriasis in 80-90% of patients. Severity of skin disease in psoriatic patient is associated with likelihood of co-morbidities de-velopment such as cardiovascular event.

CLINICAL PRESENTATION

Phenotypes of Psoriasis

Plaque psoriasis (85.3%) Erythematous plaque with dry thin silvery scale.

Erythrodermic Psoriasis (2.6%) Associated with chills, hypothermia, fever and malaise.

Guttate Psoriasis (4.7%) Drop-like salmon pink papules with fine scale.

Pustular Psoriasis (1.5%) Pustules on erythematous back-ground.

Inverse Psoriasis (0.5%) Lesions at skin fold.

MANAGEMENT of Psoriasis

Mild to Moderate Psoriasis

Combination of Topical Agents

Emollient Tar

(1st Line) Dithranol (Anthralin)

Salicylic Acid

Cortico- steroid

Vitamin D Analogue

Calcineurin Inhibitor

Moderate to Severe Psoriasis

Phototherapy

Systemic Immunomodulators

Acitretin Cyclosporine Methotrexate (1st Line)

Failure / Intolerance / Contraindication / Inaccessibility of Standard Therapy

Biologics Therapy

Infliximab Ustekinumab Adalimumab Etanercept

Precautions of Topical Agents

Corticosteroid

Super potent (eg: Clobetasol Propionate 0.05% cream) – use ≤ 30g/week for ≤ 2 weeks

Potent (eg: Betamethasone Dipropionate 0.05% cream) – use ≤ 60g/week for ≤ 4 weeks

Mild (eg: Hydrocortisone 1% cream) – application for face, genetalia and body folds

Vitamin D Analogue

Calcipotriol – use not more than 100g/week to avoid hypercalcemia

Calcineurin Inhibitor

Off label use for facial and flexural psoriasis only

Limited efficacy for the rest of the body

Precautions of Biologics Therapy

Associated with serious side effect

Eg: congestive heart failure, hepatotoxi-city, haematological disturbance

Potential risk of malignancy

Routine monitoring of weight, full blood count, erythrocyte sedimentation rate, c-reactive protein, liver function test, renal profile and tuberculosis assessment is necessary

REFERENCES:

1.Clinical Practice Guideline: Management of Acne. (2012). Ministry of Health Malaysia.

2.Clinical Practice Guideline: Management of Psoriasis Vulgaris. (2013). Ministry of Health Malaysia.

3.Emedicine.medscape.com. (2016). Acne Vulgaris: Practice Essentials, Background, Pathophysiology. [online] Available at: http://emedicine.medscape.com/article/1069804-overview [Accessed 26 Aug.

2017].

4.Emedicine.medscape.com. (2017). Atopic Dermatitis: Practice Essentials, Background, Pathophysiology. [online] Available at: http://emedicine.medscape.com/article/1049085-overview [Accessed 26 Aug.

2017].

5.Emedicine.medscape.com. (2017). Psoriasis: Practice Essentials, Background, Pathophysiology. [online] Available at: http://emedicine.medscape.com/article/1943419-overview#a3 [Accessed 26 Aug. 2017].

6.Guidelines of care for the management of acne vulgaris. (2016). American Academy of Dermatology.

7.Guidelines of care for the management of atopic dermatitis. (2013). American Academy of Dermatology.

BY ANURANI BALAKSRISNAN

TOPICAL PREPARATIONS & ITS COUNSELLING

Benzoyl Peroxide 5% Gel

Use it on all of the area where your spots occur and not just to each spot.

Try not to get any of the preparation on your hair or clothing, as it can cause bleaching. Consider wear-ing on old T-shirt to bed if applying to the back or chest overnight.

Can cause photosensitivity. Avoid strong sunlight or use a sun screen with a high sun protection factor.

If the skin become very dry, it may help to use a moisturizing cream. Do not use ointments or oil rich creams, as these could clog pores.

Adapalene 0.1% Gel

Apply in the evening or bedtime.

Can cause photosensitivity. Avoid strong sunlight or use a sun screen with a high sun protection factor.

Not recommended in pregnancy and breastfeeding.

Do not use the gel on any areas of skin which are sun burnt or sore. Avoid using make-up and moist-urizers at the same time.

Sulphur 2% & Salicylic acid 2% Cream

Do not use any topical mercury containing prepara-tion, such as ammoniated mercury ointment, on the affected area.

This is because they may cause a foul odor or irritate the skin or stain the skin black.

Tretinoin (Vitamin A)

Apply at night.

Retinoids is contraindicated in pregnancy– advice on use of effective contraception.

Avoid using in women who want to get pregnant or are pregnant.

Non-pharmacological counseling points for ACNE

• Patient should cleanse their skin twice daily with mild cleanser to remove excess sebum.

• Avoid vigorous washing or use of soaps that contain oil or medications such as benzoyl peroxide.

• Minimize exacerbating factors including cosmetic prod-

STEPS TO APPLY TOPICAL PREPARATIONS FOR ATOPIC DERMATITIS

First Layer— Emollient Apply generous amount of emollient right after bath to lock up the moisture on skin.

Second Layer— Topical Corticosteroid Leave a gap of 5– 10 minutes in between application of moisturizer and topical corticosteroids which is applied spar-ingly to the affected area 2-3 times daily.

Third Layer— Topical Calcineurin Inhibitor After topical corticosteroid, apply topical calcineurin inhibi-tor at sensitive areas like face, genital, and skinfolds. Pro-tect skin from sun.

As a maintenance therapy, emollient will be used alone or with intermittent use of topical corticosteroid or topical calcineurin inhibitor at areas that commonly flare up.

Oral Pharmacotherapy Agents used in Acne

Isotretinoin Can cause teratogenicity. Be-fore therapy begins, the pa-tient must be proved that is not pregnant.

Frequent application of moisturizing agents is neces-sary.

Patients who wear contact lenses has to switch to eye-glasses because of eye dry-ness.

Reddening of the skin and increased photosensitivity may occur.

Oral Antibiotics like: Tetracycline Doxycycline Minocycline

Can harm a developing fetus. Therefore, it is contraindicat-ed in pregnancy.

It must be taken with a meal to avoid stomach discomfort or diarrhea.

Wear sunscreen every day to protect from photosensitivity.

It may cause tooth discoloration in children younger than 13 years old.

Erythromycin Azithromycin Co-trimoxazole

It should be taken with a meal to avoid stomach discomforts.

Non-pharmacological counseling points for DERMA-TITTIS

Bathing in warm water should last no more than 5-10 minutes by using use mild cleanser.

Wet compress such as Aluminum Acetate solution may be applied to the affected area for 20 minutes 4-6 times daily.

Avoid foods that trigger the condition.


References: 1. Guidelines of care for the management of psoriasis and psoriatic arthritis. (2008). American Academy of Dermatology. 2. Guidelines of care for the management of atopic dermatitis. (2013). American Academy of Dermatology. 3. Clinical Practice Guideline: Management of Psoriasis Vulgaris. (2013). Ministry of Health Malaysia. 4. Clinical Practice Guideline: Management of Acne. (2012). Ministry of Health Malaysia. 5. Dermnetnz.org. (2016). Topical steroids | DermNet New Zealand. [online] Available at: https://www.dermnetnz.org/topics/topical-

steroids/ [Accessed 26 Aug. 2017]. 6. Dermnetnz.org. (2014). Acne vulgaris| DermNet New Zealand. [online] Available at: https://www.dermnetnz.org/topics/acne-

vulgaris/ [Accessed 26 Aug. 2017]. 7. Dermnetnz.org. (2004). Atopic dermatitis | DermNet New Zealand. [online] Available at: https://www.dermnetnz.org/topics/atopic-

eczema/ [Accessed 26 Aug. 2017]. 8. Emedicine.medscape.com. (2017). Psoriasis: Practice Essentials, Background, Pathophysiology. [online] Available at: http://

emedicine.medscape.com/article/1943419-overview#a3 [Accessed 26 Aug. 2017].

Emollient Apply generous amount of emollient after bath. It will help to lock the moisture well. Leave a gap about 5-10 mins before 2nd layer application.

Coal tar First line topical therapy for mild psoriasis. It may stain cloths and bedding and have strong odour. Coal tar can be applied at night and should be allowed to dry on the skin for 10-15 minutes before getting into bed and showered off in the morning. It is not recommended in pregnancy. If allergy is suspected, patient should undergo patch testing to distinguish between an allergic and an irritant response.

Salicylic acid Patient should soak the affected area in warm water for 10 to 20 minutes before application. In addition, patients should use a non-medicated, non-residue shampoo. Stronger concentration of salicylic acid can be applied for about 2 weeks to remove the thick scale.

Corticosteroids Most widely used treatment for psoriasis due to their anti-inflammatory . Drawback: tachyphylaxis occurs. It can be minimized by switching patients to less potent corticosteroids. To minimize systemic absorption, a patient should not be use more than 40-50g per week. Direction : Use 5 minutes after emollient. Apply it sparingly on the affected area 2-3 times. Important: 1 FTU = 0.5g = treats 2% BSA

Vitamin D Analogs (Calcipotriene) Fixed dose combination of Vitamin D and corticosteroid may be used for short-term treatment of psoriasis. Total amount if vitamin D should not exceed 100g /week to avo id hypercalcemia. Contraindicated in pregnancy. Topical Retinoids (Vitamin A) Increased sensitivity to sunlight. So while using the medication apply sun-screen before going outdoors. Unlike Calcipotriene, Retinoids can be used to treat psoriasis of the face. It is teratogenic, women of child bear-ing age should be warned of the po-tential fetal risk. Therapy can start during a normal menstrual period.

Precaution Continuous use of super potent corticosteroids should not exceed two weeks whereas for potent corticosteroids use should not exceed four weeks. Prolonged use of corticosteroids is associated with serious side effects such as scabies, hypertrichosis, hypopigmentation, hyperpigmentation and contact dermatitis.

Anthralin It can stain hair, skin, nails, clothing and bedding a brownish to purplish color. To minimize staining, patients should be advised to apply the medication wearing plastic gloves and to use old sheets and nightclothes. Anthralin can irritate normal skin and must be applied only to the affected skin.



Treatment and Prevention of Diphtheria

By Sindhu Panirselvam

What is DIPHTHERIA?

Serious bacterial infection that affects the mucous membranes of the throat, nose and sometimes the skin. Caused by the bacterium Corynebacterium diphtheria by penetration of the bacteria through mucous of upper respiratory tract or conjunctivas or skin.

Period of Communicability •Once infected, untreated persons can shed bacteria from the respiratory tract or from skin lesions for 2–6 weeks. •Once treatment with an effective antibiotic has been initiated, affected persons are communicable for up to 4 days. •Isolation should be maintained until two cultures have shown an absence of the or-ganism.

Incubation Period •2 – 5 days (Range 1 -10 days)

Reservoir •Infected Humans

a. Travel to areas where the disease is endemic. b. Compromised immune system. c. Live in overcrowded or unsanitary living conditions d. People who are not vaccinated.

Risk Factors

How does it spread? Direct physical contact with:

Droplets breathed out into the air.

Secretions (mucus or saliva) from the nose and throat.

Infected skin lesions.

Objects such as bedding or clothes of an infected person.

Types of Diphtheria

Anterior Nasal Diphtheria Signs and symptoms is almost similar to common cold but is distinguishable by a mucopurulent nasal discharge. A white membrane usually forms on the nasal septum. This type is mild because of apparent poor systemic absorption of toxin in this location and it can be terminated rapidly by treatment.

Pharyngeal and Tonsillar Diphtheria Most common sites of diphtheria and they are associated with substantial sys-temic absorption of toxin.

Early symptoms include malaise, sore throat, anorexia, and low-grade fever (<38°C). A bluish-white membrane forms and extends that covers a small patch on the tonsils to most of the soft palate. Firmly adherent to the tissue, and forcible remove it can cause bleeding This type is more severe as extensive pseudomembrane formation can lead to respiratory obstruction.

Cutaneous (skin) Diphtheria Symptoms include scaling rash or by shallow skin ulcers with clearly demarcated edges and membrane. Other possible sites of infection include the conjunctiva, vulvovagi-nal area and external auditory canal. Any chronic skin lesion may also harbour C. diphtheriae along with other organisms such as Staphylo-coccus aureus and Streptococcus pyogenes which may lead to delayed diagnosis of diphtheria. It is also more common in environments with poverty, poor hygiene and overcrowding


TREATMENT OF DIPHTHERIA

1. ANTITOXIN Diphtheria antitoxin (DAT) is made from blood plasma of horses that have been immunized against diphtheria toxin. It neutralises the circulating toxin prior to its entry into the cells. Route of Administration Severe cases : Intravenous (IV) is preferred. The antitoxin dose should be mixed in 250 –500 mL of normal saline and administered owly over 2 – 4 hours, closely monitoring for anaphylaxis. Mild or Moderate cases : Intramuscular (IM). 2. ANTIBIOTICS Start prompt antibiotics coverage with macrolides (e.g: Erythromycin) as first line agents for patients older than 6

months of age. Patients < 6 months of age OR intolerant to erythromycin course , intramuscular penicillin is recommended.

IV Erythromycin 500mg followed by PO Erythromycin 800mg BD for a total of 14 days OR

IV Benzylpenicillin 50,000 units/kg to a maximum of 1.2 MU BD followed by PO Phenoxymethylpenicillin 250mg QID for a total of 14 days.

PREVENTION OF DIPHTHERIA

1. VACCINATION Vaccines are available for diphtheria: 1)DTaP :Paediatric diphtheria, tetanus, and acellular pertussis (whooping cough) vaccine

2)DT: Paediatric diphtheria and tetanus vaccine

3)Td : Older children & adults tetanus and diphtheria vaccine

4)Tdap: Older children and adults tetanus, diphtheria, and acellular pertussis (whooping cough) vaccine

DTaP / DT -For infants and children: Children should get (DTaP) vaccine, one dose at the fol-lowing ages: 2nd, 3rd and 5th month AND one more at 18th months old. -DT does not contain pertussis and is used as a substitute for DTaP for children who cannot tolerate pertussis vaccine.

Td / Tdap -For Adolescents and Adults: as a booster shot every 10 years or after an exposure to tetanus. Tdap should be given as a one-time booster in place of Td. Tdap is especially important for those in; • Close contact with infants. • Adolescents more than 11 years old. • Pregnant women should receive a

dose of Tdap during each pregnancy. • New mothers who have never gotten

Tdap should get a dose as soon as possible after delivery.

References 1. WHO Statistics on Vaccine-Preventable Disease. [Cited on 2017 September 15]. Available from URL : http://apps.who.int/immunization_monitoring/

globalsummary/incidences?c=MYS

2. 2.Mayo Clinic Staff. Mayo Clinic.Treatment of Diphtheria. [Cited on 2017 September 15]. Available from URL :http://www.mayoclinic.org/diseases-conditions/diphtheria/home/ovc-20300505

3. 3.American Academy of Pediatrics. Diphtheria. In: Pickering LK ed. Redbook 2012 Report of the Committee on Infectious Diseases 29th ed. Elk Grove Vil-lage, IL: American Academy of Pediatrics, 2012; 307-311. 7.

4. National Antibiotic Guideline 2014, KKM.

To assure eradication: > 24 hours after the completion of antimicrobial prophylaxis, repeat cultures with two consecutive sets of nose and throat swabs collected >24 hours apart with the second set collected at a minimum of two weeks after the antibiotic treatment.

J A B A T A N F A R M A S I , H O S P I T A L S U L T A N A H A M I N A H J O H O R B A H R U P A G E 1 0

Program minggu Kenali Ubat Anda dan Keselamatan Pengubatan Sempena Hari

Farmasi Sedunia 2017 anjuran Jabatan Farmasi dan Jawatankuasa Keselamatan Pen-

gubatan di Hospital Sultanah Aminah Johor Bahru. Objektif program tersebut adalah un-

tuk meningkatkan kesedaran dan pengetahuan mengenai penggunaan ubat secara

rasional di kalangan anggota hospital dan orang awam. Pameran telah diadakan pada 25-

28 September 2017 manakala ceramah diadakan pada 26 September 2017.

Program ini telah dirasmikan oleh Dr. Noorraudah binti Abdul Rahman, Ketua

Penyelaras Unit Kualiti mewakili Pengarah HSAJB pada 26 September 2017. Majlis

perasmian turut dihadiri oleh Dr Masliza binti Zaid (Pakar penyakit Berjangkit), Mr Hans

LAPORAN MINGGU KENALI UBAT ANDA DAN KESELAMATAN PENGUBATAN SEMPENA HARI FARMASI SEDUNIA 2017

Ceramah yang bertajuk Ubat Ber-

daftar telah disampaikan oleh Cik

Program ini dirasmikan oleh Dr Noorraudah Bt Abdul

Rahman, Ketua Penyelaras Unit Kualiti mewakili

Pengarah. Majlis perasmian turut dihadiri oleh Dr Masli-

Persembahan lakonan dan nyanyian turut

disampaikan oleh anggota-anggota farmasi Gambar anggota-anggota farmasi yang diambil

di tapak pameran

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