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Editor-in-chief Contents Dr. C. S. Shastry, M. Pharm, Ph.D A Review on Lassa Fever 2-3

Linezolid and Syndrome 4-5 Editorial board Safinamide for the Treatment of Dr. Uday Venkat Mateti, Pharm D, Ph.D Parkinson’s disease 6-7 Dr. Juno J. Joel, M. Pharm, MBA, Ph.D Dr. Javedh Shareef, M. Pharm, Ph.D Biomedical Waste Management 8 Dr. Rajesh K.S., M. Pharm, Ph.D Mr. Bharath Raj, M. Pharm List of New Drugs approved by U.S. Food and Drug Administration 9

Department of Pharmacy Practice List of New Drugs approved by Central Drugs Standard Control Organization, India 10 B-2, Justice K. S. Hegde Charitable Hospital, Deralakatte, Mangaluru Department of Pharmacy Practice News 11 Phone:0824–2204471, ext.: 2368- 69 Email: [email protected]

Published by Nitte Gulabi Shetty Memorial Institute of Pharmaceutical Sciences (A Constituent College of Nitte University) Paneer, Deralakatte, Mangaluru Ph: 0824 - 2203991 / 92 / 93 | Fax: 0824 - 2203992 Web: ngsmips.nitte.edu.in circulation only Private For

Pharmacy Practice Communicator 1 A REVIEW ON LASSA FEVER Gayathri Baburaj and Sneha S Dessai *

Background Lassa fever, also known as Lassa haemorrhagic fever (LHF), is a type viral haemorrhagic fever caused by the Lassa virus. The virus, a member of the virus family Arenaviridae, is a single-stranded RNA virus and is zoonotic, or animal- borne. Many of those infected by the virus do not develop symptoms.1 When symptoms occur they typically include fever, weakness, headaches, vomiting and muscle pain. Less commonly there may be bleeding from the mouth or gastrointestinal tract. The risk of death once infected is about one percent and frequently occurs within two weeks of the onset of symptoms. Among those who survive, have deafness, which improves over time. Lassa fever is transmitted to humans via contact with food or household items contaminated with rodent urine or faeces. Person-to- person infections and laboratory transmission can also occur. Lassa fever is endemic in Nigeria and other West African countries and causes outbreaks almost every year in different parts of the region, with yearly peaks observed between December and June.2

Epidemiology The illness was discovered in 1969 when two missionary nurses died in Nigeria. Lassa fever is endemic in parts of west Africa including Sierra Leone, Liberia, Guinea and Nigeria; however, other neighboring countries are also at risk, as the animal vector for Lassa virus, the “multimammate rat” (Mastomys natalensis) is distributed throughout the region. In some areas of Sierra Leone and Liberia, it is known that 10%-16% of people admitted to hospitals every year have Lassa fever, which indicates the serious impact of the disease on the population of this region.3

Transmission The host of Lassa virus is a rodent known as the “multimammate rat” (Mastomys natalensis). Once infected, this rodent is able to excrete virus in urine for an extended time period, maybe for the rest of its life. Transmission of Lassa virus to humans occurs most commonly through ingestion or inhalation. Mastomys rodents shed the virus in urine and droppings and direct contact with these materials, through touching soiled objects, eating contaminated food, or exposure to open cuts or sores, can lead to infection. Because Mastomys rodents often live in and around homes and scavenge on leftover human food items or poorly stored food, direct contact transmission is common. Mastomys rodents are sometimes consumed as a food source and infection may occur when rodents are caught and prepared. Contact with the virus may also occur when a person inhales tiny particles in the air contaminated with infected rodent . This aerosol or airborne transmission may occur during cleaning activities, such as sweeping. Direct contact with infected rodents is not the only way in which people are infected; person-to-person transmission may occur after exposure to virus in the blood, tissue, secretions, or excretions of a Lassa virus-infected individual. Casual contact (including skin-to-skin contact without exchange of body fluids) does not spread Lassa virus. Person-to-person transmission is common in health care settings (called nosocomial transmission) where proper personal protective equipment (PPE) is not available or not used. Lassa virus may be spread in contaminated medical equipment, such as reused needles.1

Signs and symptoms Signs and symptoms of Lassa fever typically occur 1-3 weeks after the patient comes into contact with the virus. For the majority of Lassa fever virus infections (approximately 80%), symptoms are mild and are undiagnosed. Mild symptoms include slight fever, general malaise and weakness, and headache. In 20% of infected individuals, however, disease may progress to more serious symptoms including haemorrhaging in gums, eyes, or nose, as examples, respiratory distress, repeated vomiting, facial swelling, pain in the chest, back, and abdomen, and shock. Neurological problems have also been described, including hearing loss, tremors, and encephalitis. Death may occur within two weeks after symptom onset due to multi-organ failure. The most common complication of Lassa fever is deafness. Various degrees of deafness occur in approximately one-third of infections, and in many cases hearing loss is permanent.1

Pharmacy Practice Communicator 2 Diagnosis Lassa fever is most often diagnosed by using enzyme-linked immunosorbent serologic assays (ELISA), which detect IgM, IgG antibodies and Lassa antigen. Reverse transcription-polymerase chain reaction (RT-PCR) can be used for the early detection. Immunohistochemistry, performed on formalin-fixed tissue specimens, can be used to make a post-mortem diagnosis.3

Treatment Ribavirin, an antiviral drug, has been used in Lassa fever patients. It has been shown to be most effective when given early in the course of the illness. Patients should also receive supportive care consisting of maintenance of appropriate fluid and electrolyte balance, oxygenation and blood pressure, as well as treatment of any other complications.4

Prevention • Primary transmission of the Lassa virus from its host to humans can be prevented by avoiding contact with Mastomys rodents, especially in the geographic regions where outbreaks occur. • Putting food away in rodent-proof containers and keeping the home clean help to discourage rodents from entering homes. • Trapping in and around homes can help reduce rodent populations. • Transmission of the disease through person-to-person contact or nosocomial routes can be avoided by taking preventive precautions against contact with patient secretions. Such precautions include:  Wearing protective clothing, such as masks, gloves, gowns, and goggles  Using infection control measures, such as complete equipment sterilization  Isolating the infected patients from contact with unprotected persons until the disease has run its course. Further, it is important to educate people in high-risk areas about ways to decrease rodent populations in their homes. Other challenges include developing more rapid diagnostic tests and increasing the availability of the only known drug treatment, ribavirin. Research is presently under way to develop a vaccine for Lassa fever.

References 1. Centers for Disease Control and Prevention. Lassa fever. Available from: https://www.cdc.gov/ncezid/dw-index.html. [Last accessed on 01 July 2017] 2. Gompf SG. Lassa fever. MedicineNet.com Available from: http://www.medicinenet.com/lassa_fever/article.htm. [Last accessed on 02 July 2017] 3. Lassa fever available from: www.who.int/mediacentre/factsheets/fs179/en/.[Last accessed on 02 July 2017] 4. Viral Haemorrhagic Fever Consortium. Available from: www.vhfc.org/lassa_fever. [Last accessed on 01 July 2017]

* Fifth Year Pharm.D, Department of Pharmacy Practice, Nitte Gulabi Shetty Memorial Institute of Pharmaceutical Sciences, Nitte University, Deralakatte, Mangaluru, Karnataka - 575 018

Pharmacy Practice Communicator 3 AND Ansha Mariya Abraham and Sneha Mathew *

Linezolid is an oxazolidinone antibiotic that is widely used in general hospitals. It was used as a psychotropic agent for the management of depression. It was also found to have antibiotic efficacy against drug resistant (gram-positive cocci, MRSA and VRE).1 In patients using linezolid along with serotonin agonists, there is a small but documented risk for serotonin syndrome. Serotonin syndrome is also known as serotonin toxicity, which is caused by excessive levels of circulating serotonin in the central nervous system (CNS) and the periphery.2 This syndrome is characterized by mental status changes, autonomic hyperactivity, and neuromuscular abnormalities ranging in severity from almost indiscernible to lethal.3 The majority of cases develop within 6 hours of initiation of or a change in medication that increases serotonin levels.

Table: List of drugs that may increase serotonin levels and interact with linezolid3

Class of Drugs Examples

Selective Serotonin Reuptake Inhibitors , , , , ,

Serotonin Reuptake Inhibitors , Mirtazapine,

Tricyclic antidepressants , , , , , Imipramine, ,

Monoamine Oxidase Inhibitors , ,

Analgesics , , Meperidine, , ,

Antitubercular drugs

Antineoplastic drugs

Dopamine agonist

Migraine Sumatriptan and other triptans

Anxiolytics Buspirone

Hypnotics l-

Stimulants and derivatives

Norepinephrine Reuptake Inhibitor ,

Pharmacy Practice Communicator 4 Diagnosis of serotonin toxicity There are no tests to confirm the diagnosis of serotonin syndrome, Sternbach’s criteria and Boyer’s criteria are the two criteria sets have been developed to identify the presence of serotonin toxicity.4

Mechanism of serotonin toxicity The mechanism of serotonin toxicity is not fully known, it is believed to involve an excess of agonism of 5-HT receptors in the CNS and peripheral tissues through elevated synaptic concentrations of serotonin.3 Drugs in MAO-inhibitor class— for example, linezolid—cause increases in synaptic concentrations of biogenic amines (eg, , norepinephrine, and serotonin). When these agents are combined with proserotonergic agents, synaptic concentrations of serotonin rise to toxic levels and precipitate the syndrome.

Treatment for serotonin toxicity The treatment of serotonin toxicity includes removal of the offending agents, control of agitation, administration of 5-HT2A antagonists, and autonomic stabilization.5 Cases usually of the offending agents.

Prevention of serotonin toxicity If the clinical situation warrants the use of linezolid in a patient receiving an SSRI, linezolid may be used concomitantly with SSRIs, without a 14-day washout period and with careful monitoring for signs and symptoms of serotonin syndrome. Serotonergic agents should be promptly discontinued if serotonin syndrome is suspected.6

References 1. Moellering RC. Linezolid: the first oxazolidinone antimicrobial. Ann Intern Med. 2003; 138(2):135–142.

2. Sternbach H. The serotonin syndrome. Am J Psychiatry. 1991; 148(6):705–713.

3. Quinn DK., Stern TA. Linezolid and Serotonin syndrome. Prim Care Companion J Clin Psychiatry 2009:11(6); 353.

4. Taylor JJ, Wilson JW, Estes LL. Linezolid and serotonergic drug interactions: a retrospective survey. Clin Infect Dis. 2006; 43(2): 180–187.

5. Gillman PK. The serotonin system and its treatment. J Psychopharmacol.1999; 13(1):100–109.

6. Taylor JJ, Wilson JW, Estes LL. Linezolid and serotonergic drug interactions: A retrospective survey. Clinical Infectious Diseases. 2006:43; 187.

* Fifth Year Pharm.D, Department of Pharmacy Practice, Nitte Gulabi Shetty Memorial Institute of Pharmaceutical Sciences, Nitte University, Deralakatte, Mangaluru, Karnataka - 575 018

Pharmacy Practice Communicator 5 SAFINAMIDE FOR THE TREATMENT OF PARKINSON’S DISEASE Dr. Rajesh K*

Indications and Usage Safinamide, an inhibitor of type B (MAO-B); indicated as adjunctive treatment to levodopa/ in patients diagnosed with Parkinson’s disease (PD) experiencing “off” episodes. (1) This drug did not show efficacy as monotherapy for Parkinson’s disease.

Dosage and Administration Initially, 50 mg orally once daily at the same time of day; after two weeks, based on the tolerability and individual need, the dose may be increased to 100 mg once daily. The drug can be administered without regards to meals. No additional benefit was observed at doses above 100mg per day. Doses above 100mg per day increase the chances of adverse drug events. If the patient has moderate hepatic impairment, the dose should not exceed 50 mg once daily; administration of this drug is contraindicated if patient has severe hepatic impairment. If patient receiving 50 mg per day of the drug develops moderate hepatic impairment, the treatment should be discontinued.

Dosage forms and Strengths Tablets: 50 mg and 100 mg

Brand name: XADAGO Company: Newron Pharmaceuticals Contraindications • Concomitant use of other monoamine oxidase inhibitor (MAOI) class or the drugs that inhibits monoamine oxidase. Such use can result in increased blood pressure, including hypertensive crisis. • Concomitant use of drugs; serotonin-norepinephrine reuptake inhibitors (SNRIs), antidepressants; ; , amphetamine, and their derivatives, could result in life-threatening serotonin syndrome. • Concomitant use of dextromethorphan has been reported to cause episodes of psychosis or abnormal behavior. • Hypersensitivity to Safinamide: swelling of the tongue, oral mucosa, and dyspnea. • Severe hepatic impairment.

Warnings and Precautions Safinamide can induce hypertension or may exacerbate existing condition.

Serotonin syndrome Concomitant use of MAO inhibitors, serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, tetracyclic antidepressants, triazolopyridine antidepressants, cyclobenzaprine, opioid drugs, methylphenidate, amphetamine, and their derivatives can lead to the development of a potentially life-threatening serotonin syndrome.

Falling asleep while engaged in activities Patients have reported falling asleep while engaged in activities of daily living, including the operation of motor vehicles, which sometimes has resulted in accidents. Patients may not perceive warning signs, such as excessive drowsiness, or they may report feeling alert immediately prior to the event.

Pharmacy Practice Communicator 6 Safinamide may cause dyskinesia or exacerbate pre-existing dyskinesia.

Hallucinations / Psychotic behavior Should not be used in patients with a major psychotic disorder; associated with the risk of exacerbating the psychosis.

Adverse reactions • Hypertension • Serotonin Syndrome • Falling Asleep During Activities of Daily Living • Dyskinesia • Hallucinations; Psychotic Behavior • Impulse Control / Compulsive Behaviors • Withdrawal-Emergent Hyperpyrexia and Confusion

Use in specific populations Pregnancy No sufficient data available. In animals, developmental toxicity, including teratogenic effects was observed.

Nursing Mothers No data available

Pediatric Use The safety and effectiveness in pediatric patients have not been established. No juvenile toxicity studies have been performed in animals.

Hepatic Impairment Safinamide plasma concentrations are increased in patients with hepatic impairment. No study has been conducted in patients with severe hepatic impairment; contraindicated.

Over dosage There is no human experience with Safinamide overdose. No known antidote or specific treatment for Safinamide overdose.

References 1. https://www.drugs.com/newdrugs.html. (Last accessed on 5 April, 2017) 2. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm547852.htm. (Last accessed on 5 April, 2017) 3. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/207145lbl.pdf. (Last accessed on 5 April, 2017)

* Asst. Professor, Dept. of Pharmacy Practice, Nitte Gulabi Shetty Memorial Institute of Pharmaceutical Sciences, Nitte University, Deralakatte, Mangaluru, Karnataka - 575 018

Pharmacy Practice Communicator 7 BIOMEDICAL WASTE MANAGEMENT Dr. Vinay BC*

Biomedical waste is any waste generated during the diagnosis, treatment or immunization of human beings or animals, in research activities pertaining to or in the production of or testing of biologicals, and all other categories waste generated by healthcare activities. It includes a broad range of materials from used needles and syringes, soiled dressings, body parts, diagnostic samples, blood, chemicals, pharmaceuticals, medical devices, and radioactive materials and carries a higher potential for infection and injury than any other type of waste1.

Health care or biomedical waste, if not managed properly, can be of high risk to the hospital staff, the patients, the community, public health and the environment, especially in low and middle income settings where proper disposal norms are often not followed2.

Hospital waste management has been brought into focus in India, particularly with the notification of the Biomedical Waste (Management and Handling) Rules, 1998, which make it mandatory for healthcare establishments to segregate, disinfect and dispose of their waste in an eco-friendly manner. The legal provisions (Biomedical Waste Management and Handling Rules 1998, amended 2003 and drafted 2011) are aimed at mitigating the impact of hazardous and infectious hospital waste on the community. These Rules are applicable to all persons who generate, collect, receive, store, transport, dispose or handle bio-medical waste1.

There many studies revealed that developing countries are facing great difficulties in managing the biomedical wastes and the reason for this are lack of adequate knowledge, awareness and motivation, lack of technological interventions, improper management- strategies and inadequate funds for health care waste management and this leads to healthcare associate infection. The process of biomedical waste management involves many issues like collection and segregation, timely removal and safe disposal, illegal scavenging, patient safety, occupational safety and environmental safety2.

Biomedical waste should be separated according to their source, type and risk factors associated with their management, handling, treatment and disposal. Biomedical waste must be handled and stored in a secure environment, because it causes serious health issues to environment3. So it very essential to create awareness about biomedical waste management among healthcare professionals and hospital management especially in developing countries so there should be regular monitoring and training is needed at all levels.

References 1. Sarotra P, Medhi B, Kaushal V, Kanwar V, Gupta Y, Gupta AK. Health care professional training in biomedical waste management at a tertiary care hospital in India. J Biomed Res. 2016;30(2):168-170. 2. Joshi SC, Diwan V, Tamhankar AJ, Joshi R, Shah H, Sharma M, et al. Staff Perception on Biomedical or Health Care Waste Management: A Qualitative Study in a Rural Tertiary Care Hospital in India PLoS One. 2015;10(5):e0128383. 3. Achuthan A, Ayyallu Madangopal V. A Bio Medical Waste Identification and Classification Algorithm Using Mltrp and Rvm. Iran J Public Health. 2016;45(10):1276-1287.

* Research Scholar, Department of Pharmacy Practice, Nitte Gulabi Shetty Memorial Institute of Pharmaceutical Sciences, Nitte University, Deralakatte, Mangaluru, Karnataka - 575 018

Pharmacy Practice Communicator 8 NEW DRUGS APPROVED BY USA FOOD AND DRUG ADMINISTRATION (FDA) (APRIL – JUNE 2017) Dr. Uday Venkat Mateti*

Specialty Drug Brand Company Uses Approved Name Name Name (Month, Year) Cardiology/ Betrixaban Bevyxxa Portola Prophylaxis of venous June 2017 Va-scular Diseases Pharmaceuticals thromboembolism Dermatology Delafloxacin Tablet & Baxdela Melinta Treatment of acute June 2017 Injection Therapeutics bacterial skin and skin structure infections Genetic Disease C1 Esterase Inhibitor Haegarda CSL Behring Prophylaxis to prevent June 2017 Subcutaneous hereditary angioedema [Human] attacks Cerliponase alfa Brineura BioMarin Treatment of late April 2017 infantile neuronal ceroid lipofuscinosis type 2 Ophthalmology Cetirizine ophthalmic Zerviate NicOx Treatment of ocular May 2017 solution 0.24% itching associated with allergic conjunctivitis Hematology Coagulation Factor Rebinyn Novo Nordisk Treatment of June 2017 IX (Recombinant), haemophilia B GlycoPEGylated Midostaurin Rydapt Novartis Treatment of FLT3 April 2017 positive acute myeloid leukemia and mastocytosis Musculoskeletal Sarilumab Kevzara Sanofi Treatment of active May 2017 rheumatoid arthritis Abaloparatide Tymlos Radius Health Treatment of April 2017 postmenopausal women with osteoporosis at high risk for fracture Neurology Edaravone Radicava Mitsubishi Treatment of May 2017 Tanabe Pharma amyotrophic lateral sclerosis Austedo Teva Treatment of chorea April 2017 Pharmaceuticals associated with Huntington’s disease Ingrezza Neurocrine Treatment of tardive April 2017 Biosciences dyskinesia Oncology Durvalumab Imfinzi AstraZeneca Treatment of advanced May 2017 or metastatic urothelial carcinoma Rheumatology Sarilumab Kevzara Sanofi Treatment of active May 2017 rheumatoid arthritis

Reference: http://www.centerwatch.com/drug-information/fda-approved-drugs/. (Last accessed on 1 July, 2017)

* Asst. Professor, Department of Pharmacy Practice, Nitte Gulabi Shetty Memorial Institute of Pharmaceutical Sciences, Nitte University, Deralakatte, Mangaluru, Karnataka - 575 018

Pharmacy Practice Communicator 9 NEW DRUGS APPROVED BY CENTRAL DRUGS STANDARD CONTROL ORGANIZATION (CDSCO), India (APRIL – JUNE 2017)

Dr. Uday Venkat Mateti*

Drug Name Strength Indication Date of issue

Prucalopride 1mg/2mg Tablet Treatment of chronic idiopathic constipation 13th April 2017 (Prucalopride in adults in whom laxatives fail to provide Succinate) adequate relief

Pomalidomide 1mg/2mg/3mg/4mg In combination with dexamethasone, for 01st May 2017 Capsules patients with multiple myeloma who have received at least two prior therapies including lenalidomide and a proteasome inhibitor and have demonstrated disease progression on or within 60 days of completion of the last therapy.

Sofosbuvir 400 mg +Velpatasvir Treatment of adult patients with chronic 04th May 2017 100 mg Tablet & Bulk Hepatitis C virus, Genotype 1, 2, 3 ,4, 5 or 6 infection without cirrhosis or with compensated cirrhosis or decompensated with use in combination with Ribavirin

Osimertinib 40 mg/80 mg Film Treatment of patient with metastatic epidermal 29th May 2017 (Osimertinib coated Tablets growth factor receptor (EGFR) T790 M Mesylate) mutation-positive non-small cell lung cancer (NSCLC), as detected by an appropriate test, whose disease has progressed on or after EGFR TKI therapy.

Argatroban Injection 250 mg/2.5 For prophylaxis or treatment of thrombosis 30th May 2017 Hydrate ml in adult patients with Heparin induced thrombocytopenia (HIT). As an anticoagulant in adult patients with or at risk for heparin-induced thrombocytopenia undergoing percutaneous coronary intervention (PCI)

Reference: http://www.cdsco.nic.in/forms/list.aspx?lid=2034&Id=11. (Last accessed on 1 July, 2017) * Asst. Professor, Department of Pharmacy Practice, Nitte Gulabi Shetty Memorial Institute of Pharmaceutical Sciences, Nitte University, Deralakatte, Mangaluru, Karnataka - 575 018

Pharmacy Practice Communicator 10 DEPARTMENT OF PHARMACY PRACTICE NEWS

Guest Lecture on “TeleHealth - A Technology Based Solutions for Chronic Disease Patients”

The Department of Pharmacy Practice, NGSM Institute of Pharmaceutical Sciences (NGSMIPS), Nitte University, Mangaluru organised a guest lecture on “TeleHealth - A Technology Based Solutions for Chronic Disease Patients” on 15th May 2017 at the Department of Pharmacy Practice, Justice K.S Hegde Charitable Hospital, Deralakatte. The guest speaker was Mr. Chris Noronha, President-Business Services, Gateway 2 Health, Philadelphia, United States of America (USA). In his talk, he explained about the importance of Telehealth solutions for diagnosis and monitoring of patients with co-morbid conditions of diabetes and hypertension. The purpose of technology is to integrate with medical devices (Colour Doppler, Retina Scan, ECG, BP Monitor, Glucometer and Analyser) and medication adherence to support the team of physician, pharmacist, nurses and medical technicians. The guest lecture received an overwhelming response from the students (Pharm. D & M. Pharmacy) and faculty members.

Invited Speaker at National Seminar Dr. Uday Venkat Mateti, Asst. Professor, Dept. of Pharmacy Practice, NGSMIPS, Nitte University delivered a talk on “Role of Clinical Pharmacist in the Management of Chronic Kidney Disease” as Speaker in the “One Day National Seminar on Roles & Responsibilities of Pharmacist in Clinical Practice” held on 12th April 2017, Warangal, Telangana State, organized by the Dept. of Pharmacy Practice, Vaagdevi College of Pharmacy.

Pharmacy Practice Communicator 11 Nitte Institutions

Health Science Institutions, Hospitals and Research Centres Management Institutions 1. K.S. Hegde Medical Academy, Mangaluru 21. Justice K. S. Hegde Institute of Management (Dept. of Management Studies, NMAMIT, Nitte), Nitte 2. A.B. Shetty Memorial Institute of Dental Sciences, Mangaluru 22. Nitte School of Management, Bengaluru 3. Nitte Gulabi Shetty Memorial Institute of Pharmaceutical Sciences, Mangaluru 23. Sarosh Institute of Hotel Administration, Mangaluru 4. Nitte Usha Institute of Nursing Sciences, Mangaluru 24. Nitte Institute of Banking & Finance, Mangaluru 5. Nitte Institute of Physiotherapy, Mangaluru 25. Nitte Institute Communication, Mangaluru 6. Nitte Institute of Medical Laboratory Sciences, Mangaluru Technical Instituions 7. Nitte Institute of Speech and Hearing, Mangaluru 26. Nitte Rukmini Adyanthaya Memorial Polytechnic, Nitte 8. Justice K. S. Hegde Charitable Hospital, Mangaluru 27. Mulki Ramakrishna Punja Industrial Training Institute, Thokur 9. Nitte Meenakshi Institute of Craniofacial Surgery, Mangaluru 10. Leela Narayana Shetty Memorial Cancer Institute, Mangaluru Science and Commerce Institutions 28. Dr. Nitte Shankara Adyanthaya Memorial First Grade College, Nitte 11. Nitte-Gajria Hospital, Karkala 29. Dr. Nitte Shankara Adyanthaya Memorial First Grade College, Bengaluru 12. Kshema-IVF: Fertillity & Reproductive Medicine Centre, Mangaluru 30. Dr. Nitte Shankara Adyanthaya Memorial Pre-University College, Nitte 13. Nitte Rural Psychiatry Centre, Nitte. 31. Dr. Nitte Shankara Adyanthaya Memorial Pre-University College, Mangaluru 14. Kowdoor Gopal Hegde & Smt. Manorama Hegde Hospital, Bailur. 32. Dr. Nitte Shankara Adyanthaya Memorial Pre-University College, Bengaluru 15. Nitte University Centre for Science Education & Research (NUCSER), Mangaluru Schools 16. Nitte University Centre for Animal Research & Experimentation (NUCARE), Mangaluru 33. Dr. Nitte Shankara Adyanthaya Memorial Senior Secondary School, Nitte 17. Nitte University Centre for Stemcell Research & Regenerative Medicine 34. Dr. Mundkur Ramanna Shetty Memorial English Medium High School, Thokur (NUCSReM), Mangaluru 35. Nitte International School, Bengaluru 36. Dr. Nitte Shankara Adyanthaya Memorial Higher Primary School, Bolakodi Engineering Institutions Satellite Health Centres: 18. Nitte Mahalinga Adyanthaya Memorial Institute of Technology, Nitte Bailur | Bellikoth | Bengre | Dabbekatte | Farangipet | Hejamadikodi | Kadri 19. Nitte Meenakshi Institute of Technology, Bengaluru | Karkala | Mangalagangothri | Madikeri | Mukka | Mulki | Mundkur | Nada 20. Nitte Institute of Architecture, Mangaluru | Nitte | Sasihithlu | Sringeri | Subrahmanya | Thalipadi

Pharmacy Practice Communicator 12