PATIENT GROUP DIRECTION (PGD) FOR:

Similar documents
PATIENT GROUP DIRECTION (PGD) FOR:

Name Job Title Signed Date

Approval of Patient Group Direction

PATIENT GROUP DIRECTION FOR AZITHROMYCIN

PATIENT GROUP DIRECTION (PGD) FOR Metronidazole 400mg Tablets

Expiry Date: January 2009 Template Version: Page 1 of 7

Expiry Date: January 2009 Template Version: Page 1 of 7

Job Title Name Signature Date

Patient Group Direction for ACICLOVIR (Version 02) Valid From 1 October September 2019

PATIENT GROUP DIRECTION (PGD) FOR THE SUPPLY OF DOXYCYCLINE 100MG CAPSULES / TABLETS FOR THE FIRST- LINE TREATMENT OF CHLAMYDIA TRACHOMATIS INFECTION

THE TREATMENT OF BACTERIAL VAGINOSIS (BV) OR TRICHOMONAS VAGINALIS

Name Job Title Signed Date. This Patient Group Direction is operational from: Oct 2017 Review date: Aug 19. Expires on 31 st October 2019

GG&C PGD ref no: 2011/841 YOU MUST BE AUTHORISED BY NAME, UNDER THE CURRENT VERSION OF THIS PGD BEFORE YOU ATTEMPT TO WORK ACCORDING TO IT

PATIENT GROUP DIRECTION (PGD) FOR

PATIENT GROUP DIRECTION (PGD) FOR Amoxicillin 250mg/5ml Suspension

PATIENT GROUP DIRECTION

Please call the Pharmacy Medicines Unit on or for a copy.

Consultation Group: See relevant page in the PGD. Review Date: October 2015

Document Details. Patient Group Direction

Patient Group Direction (PGD) template

GG&C PGD ref no: 2017/1426 YOU MUST BE AUTHORISED BY NAME, UNDER THE CURRENT VERSION OF THIS PGD BEFORE YOU ATTEMPT TO WORK ACCORDING TO IT

Appendix 3 Cardiac Catheter Lab at Musgrove Park Hospital PATIENT GROUP DIRECTION (PGD)

Supply of Fusidic acid 2% cream for impetigo by Community Pharmacists Protocol Number 472 version 1

NHS Lothian Patient Group Direction Version: 001

NHS Fife. Patient Group Direction for Named Community Pharmacists to Supply

Patient Group Direction For the supply of Fusidic Acid 2% Cream

Supply of Fusidic acid 2% cream for impetigo by Community Pharmacists Protocol Number 472 version 2

Supply of Fusidic Acid Cream 2% by Community Pharmacists for the treatment of impetigo in patients 2 years of age and over.

NHS Greater Glasgow & Clyde Patient Group Direction (PGD) for Healthcare Professionals Typhoid vaccine (intra muscular administration)

Document Details. notification of entry onto webpage

GG&C PGD ref no: 2018/1562 YOU MUST BE AUTHORISED BY NAME, UNDER THE CURRENT VERSION OF THIS PGD BEFORE YOU ATTEMPT TO WORK ACCORDING TO IT

Patient Group Direction for the supply of Fusidic Acid Cream 2% to patients aged over 2 years old receiving treatment from NHS Borders.

xrfslt \j,3 0+ {6^1 Otc(L!?i:lr+ NHS FIFE PRIMARY CARE THIS PATIENT GROUP DIRECTION HAS BEEN APPROVED BY:

Patient Group Direction for Aspirin 300mg Version: 02 Start Date: 1 st October 2017 Expiry Date: 30 th September 2019

IBUPROFEN PATIENT GROUP DIRECTION CHILD HEALTH 1. Aim/Purpose of this Guideline

PATIENT GROUP DIRECTION. Hepatitis A + B Vaccine (Twinrix, Twinrix paediatric, Ambirix )

PROTOCOL FOR THE ADMINISTRATION OF SENNA. Formulary and Prescribing Guidelines

SUPPLY BY PHARMACISTS OF A NON-PRESCRIPTION MEDICINAL PRODUCT CONTAINING LEVONORGESTREL (NORLEVO 1.5MG TABLETS) AS EMERGENCY HORMONAL CONTRACEPTION

PATIENT GROUP DIRECTION (PGD)

PGDs are permitted for use only by registered health professionals (see enclosed link for full list

Improving sexual health is a key national public health priority (Healthy Lives, Healthy People, Department of Health, 2010).

PARACETAMOL PATIENT GROUP DIRECTION CHILD HEALTH 1. Aim/Purpose of this Guideline

National Emergency Medicine Programme. Protocol for the administration of Paracetamol (Acetaminophen) at Triage in the Emergency Department

CLINICAL PROTOCOL FOR THE DEVELOPMENT AND IMPLEMENTATION OF PATIENT GROUP DIRECTIONS (PGD)

Uncontrolled when printed NHS AYRSHIRE & ARRAN CODE OF PRACTICE FOR MEDICINES GOVERNANCE. SECTION 9(a) UNLICENSED MEDICINES

GROUP PROTOCOL FOR THE MANAGEMENT OF SIMPLE INDIGESTION. Version 5 December 2017

PROCESS FOR INITIATING A SYRINGE DRIVER FOR COMMUNITY NURSE PATIENTS OUT OF HOURS

CLINICAL GUIDELINE FOR IPRATROPIUM BROMIDE NEBULISER INHALER PATIENT GROUP DIRECTION CHILD HEALTH 1. Aim/Purpose of this Guideline

PROCEDURE FOR THE ADMINISTRATION OF HOMELY REMEDIES IN COMMUNITY HOSPITALS

Unlicensed Medicines Policy

PGD5417. Clinical Performance Director of Nursing Allison Bussey

Appendix 2. Community Pharmacy Emergency Hormonal Contraception Service

Non Medical Prescribing Policy Register No: Status: Public

Consultation Group: See relevant page in the PGD. Signature: 1. Review Date: November 2019

Croydon Health Services NHS Trust (Working in Partnership) Shared Care Guideline: Prescribing Agreement

Best Practice Statement ~ March Patient Group Directions

Patient Group Direction

Newfoundland and Labrador Pharmacy Board

Chlamydia Screening. Specification for a Pharmacy Local Enhanced Service Date: 1 st June st March 2012

All areas of the Trust All Trust staff All Patients Deputy Chief Nurse & Chief Pharmacist Final

The Services. Tender for. The Provision of Sub Dermal Contraceptive Implant Devices [Long Acting Reversible Contraception]

Non-Medical Prescribing Passport. Reflective Log And Information

Medicine Protocol for the Administration of Inactivated Influenza Vaccine (Split Virion) BP Version 1, June 2017

SERVICE SPECIFICATION FOR THE PROVISION OF LONG-ACTING REVERSIBLE CONTRACEPTION SUB-DERMAL CONTRACEPTIVE IMPLANTS IN BOURNEMOUTH, DORSET AND POOLE

Patient Group Direction For The Administration Of Sodium Chloride (0.9%) Via Nebulisation By Physiotherapists Working Within NHS Grampian

SELF - ADMINISTRATION OF MEDICINES AND ADMINISTRATION OF MEDICINES SUPPORTED BY FAMILY/INFORMAL CARERS OF PATIENTS IN COMMUNITY NURSING

Consultation Group: See relevant page in the PGD. Review Date: October 2016

Prescribing Policy between Nottinghamshire Commissioning Organisations and local providers of NHS Services

Dispensing Medications Practice Standard

FOR MEDICINE ADMINISTRATION IN COMMUNITY NURSING

The Newcastle Upon Tyne Hospitals NHS Foundation Trust. Unlicensed Medicines Policy

SHARED CARE GUIDELINE: Unlicensed use of Mercaptopurine for the treatment of Inflammatory Bowel Disease.

Community Pharmacy Emergency Hormonal Contraception Service

AMPH-PGN-10 (Part of NTW(C)29 Trust Standard for Physical Assessment and Examination Policy

NHS Lanarkshire Policy for the Availability of Unlicensed Medicines

This guideline is for nursing staff within the Pain Services assisting with the administration of botulinum toxin.

Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM PAZOPANIB. Patient s first names.

Medication Policy. Linked to National Quality Standards- Quality Area Two: Element Policy statement

Page 17. Medication Management Policy and Practice Guidelines

PRESCRIBING SUPPORT TECHNICIAN:

GUIDELINES FOR MANAGEMENT OF CHLAMYDIA POSITIVE CLIENTS AND THEIR PARTNERS

Medicine Management Policy

Appendix A4 Service Specification

Promoting Effective Immunisation Practice

Improving compliance with oral methotrexate guidelines. Action for the NHS

PHARMACIST INDEPENDENT PRESCRIBING MEDICAL PRACTITIONER S HANDBOOK

The Prescribing, Monitoring and Administration of Depot / Long Acting IM Medication within Community Mental Health Services

Martina Khundakar - Senior Clinical Pharmacist Teresa Barnes - Lead Clinical Pharmacist - Specialist Care. Timothy Donaldson, Trust Chief Pharmacist

Section Title. Prescribing competency framework Catherine Picton, Lead author

Adult Protocol Intermittent Catheterisation

First Aid and Medicine Policy. Date Adopted: May Next Review Date: May 2021

PATIENT GROUP DIRECTION (PGD) FOR THE

Non Medical Prescribing Policy

Consultation Group: See relevant page in the PGD. Review Date: May Expiry Date: May 2020

Repeat Prescribing for Practice Staff. Richard Hassett Prescribing Support Technician Inverclyde CHP

Non-Medical Prescriber Registration Policy

Consultation Group: See relevant page in the PGD. Review Date: November Expiry Date: November 2019

Best Practice Guidance for Supplementary Prescribing by Nurses Within the HPSS in Northern Ireland. patient CMP

An Evaluation of Extended Formulary Independent Nurse Prescribing. Executive Summary of Final Report

Managing medicines in care homes

Transcription:

YOU MUST BE AUTHORISED BY NAME, UNDER THE CURRENT VERSION OF THIS PGD BEFORE YOU ATTEMPT TO WORK ACCORDING TO IT Clinical Condition Indication For treatment of genital Chlamydia and / or epidemiological treatment of genital Chlamydia. May be used instead of azithromycin 1g stat PO in patients who are pregnant, or have a known risk of pregnancy or if azithromycin or doxycycline are contraindicated. Inclusion criteria Female patients with a laboratory confirmed diagnosis of genital Chlamydia trachomatis, including those with an equivocal result Female patients who are known contacts of an index patient who has had a positive test for genital Chlamydia, as epidemiological treatment Aged 13 years or over (those below 13 years must be referred to GP/ Multi-Agency Safeguarding Hub (MASH) if safeguarding issue is suspected) If aged under 16 years must be accompanied by a responsible adult/ parent or must satisfy Fraser Guidelines (Gillick competent) Please refer to Department of Health (DH) document Best practice guidance for Doctors and other Health Professionals on the provision of advice and treatment to young people under 16 on contraception, sexual and reproductive health Gateway Ref 3382 The child should be seen individually if assessed as Gillick competent. If aged under 16 years and not Fraser Guidelines (Gillick competent) and accompanied by adult/parent and treatment is indicated as above, dispense treatment and a referral to the specialist service should also be made for assessing risk If under 18 years of age or adult with learning difficulties ascertain as far as if possible that there are no unaddressed child protection or vulnerable adult issues As a second course may be given for the current episode for patients who have been at further risk of infection (e.g. who had genital, oral or anal intercourse with an index patient during the first 7 days of treatment) Contraindications Exclusion criteria Drug interactions Contraindications Patients with a known allergy to Erythromycin or any other macrolide antibiotic (Clarithromycin or Azithromycin) or any of the excipients in Erythromycin tablets or a history of another significant side effect with Erythromycin Patients with a history of hepatic or renal impairment Patients with known alcohol dependence Patients with porphyria Patients with myasthenia gravis Patients with conditions of unknown significance to the Page 1 of 10

nurse/pharmacist Patients with anxieties regarding treatment that cannot be alleviated by the nurse/pharmacist. Patient under the age of 16 years who is felt not to satisfy the Fraser Guidelines Exclusions Patients who are currently symptomatic e.g. urinary tract infection, abdominal or testicular pain, unusual vaginal/penile discharge. These patients require urgent referral to GUM clinic or GP Aged under 13 years Patient aged under 16 years who is not accompanied by a parent or felt not to satisfy the Fraser Guidelines No valid consent Patients with medical conditions associated with QT interval prolongation Drug Interactions (See BNF appendix 1 / manufacturers Summary of Product Characteristics) Antibacterial Rifabutin, fidaxomicin Antiviral Ritonavir, saquinavir, telaprevir, rilpivirine Anti malarials - Artemether with Lumefantrine, Piperaquine with Artenimol Antidepressant Reboxetine Anti-epileptics Carbamazepine, valproate, phenytoin Drugs that prolong QT interval e.g. anti-arrhythmic drugs (quinidine, procainamide, disopyramide, amiodarone, sotalol); alfentanil, pimozide, citalopram Ergotamine and Ergot derivatives Eltriptan Ciclosporin Cilostazol Colchicine Digoxin Bromocriptine, Cabergoline (Dopaminergics) Antihistamine Mizolastine, loratadine, rupatadine Anxiolytics & hypnotics Midazolam, buspirone, zopiclone Anti-muscarinics Tolteridone, darifenacin Oral anticoagulants (e.g. warfarin) Theophylline, aminophylline Antipsychotics Droperidol, amisulpride, clozapine, quietapine Lipid regulating drugs Simvastatin, atorvastatin, Page 2 of 10

rosuvastatin, pravastatin Calcium channel blokers Lercanidipine Cytotoxics Docetaxel, arsenic trioxide, vinblastine, everolimus, axitinib Sildenafil, tadalfil, vardenafil Ivacaftor, zafrilukast Ivabradine Domperidone, cimetidine Clopidogrel, ticagrelor Tacrolimus, sirolimus Eplerenone Oral typhoid vaccine Ulipristal Cautions Medication should NOT be supplied/administered to the patient if they have any medical condition or take any medication that is of unknown significance to the nurse/pharmacist. Cautions in use Erythromycin 500mg PO QDS for 7 days or 500mg PO BD for 14 days should not be used as first line treatment for genital Chlamydia unless there are specific contraindications to azithromycin or doxycycline A test of cure is recommended 5 weeks after treatment is completed during pregnancy Always refer to accompanying product information leaflet Action if patient declines Action if patient is excluded Advise on genital Chlamydia and the potential consequences of no treatment If a patient declines treatment s/he will be advised to attend a Genito-Urinary Medicine service or an integrated sexual health service or their GP If patient is symptomatic refer to Genito-urinary medicine service. The patient should be advised that they need to be seen urgently Document advice given in PMR or health record If a patient is excluded from the PGD treatment s/he will be referred to a Genito-Urinary Medicine service or an integrated sexual health service or to their GP If patient is symptomatic refer to Genito-urinary medicine service. The patient should be advised that they need to be seen urgently Document action taken in PMR or health record Page 3 of 10

Drug Details Name, form & strength of medicine, legal status Route/Method Dosage Frequency Duration of treatment/number of times treatment may be administered Quantity to supply/administer Side effects and potential adverse drug reactions Oral. Two x 250mg tablets (500mg total) Two 250mg tablets FOUR times a day for 7 days or, if difficulty tolerating this regime or if aged 12 18 years, two 250mg tablets TWICE a day for 14 days To be given once during current episode A second dose may also be given for the current episode if the patient is considered at risk of re-infection due to non-compliance with advice on avoiding sexual intercourse (e.g. the patient had genital, oral or anal sexual intercourse with or without a condom with an index patient within 7 days of taking initial dose) Fifty six (56) tablets of 250mg. Gastrointestinal disorders: nausea, vomiting, diarrhoea, abdominal discomfort and dyspepsia Hepatotoxicity and Cholestatic Jaundice Allergic skin reactions including pruritus, rash, photosensitivity, oedema, urticaria Rare serious allergic reactions including angioneurotic oedema and anaphylaxis have been reported Palpitations and arrhythmias have been reported Rarely Pancreatitis, Colitis, hearing loss and tinnitus (usually after high doses) This list is not exhaustive. Refer to BNF and SPC via www.medicines.org.uk/emc for complete list. All adverse drug reactions should be clearly reported in the patient s health record or PMR and with the patient s permission should be reported to their GP Report all serious and minor adverse reactions in children (under 18 years) and serious adverse reactions in adults to the MHRA by completing a yellow card. Yellow cards and guidance on their use are available in BNF or reports can be made online at www.mhra.gov.uk/yellowcard Page 4 of 10

Advice to patient/carer Patients should be given the product information leaflet and the patient advice sheet and possible side effects should be discussed Patients should be advised about the possibility of an allergic reaction to erythromycin. They should be advised to see their GP if they develop a rash or photosensitivity while taking the medications, or alternatively A&E if wheezing, severe urticaria or oedema develop Patients should be advised of the possibility of nausea, vomiting and diarrhoea while taking this medication. If nausea and vomiting occur suggest taking medication after food. If nausea persists suggest taking 500mg BD for 14 days. If vomiting persists the patient should be advised to return for further advice (they may be treated with a STAT dose of azithromycin see PGD for azithromycin) The patient should be advised to finish the course of medication Patients should be advised no sexual intercourse (included protected and oral) whilst taking treatment and until partner(s) have completed treatment (and waited 7 days if treated with Azithromycin) Appropriate sexual health promotion advice should be given. This should include the advisability of, and how to access screening for other sexually transmitted infections and advice about the use of condoms If patient has a past history of C difficile infection or glutamate dehydrogenase (GDH) positive please tell patient to seek medical advice should they develop diarrhoea following treatment Emphasise importance and need for patient s sexual partner(s) to be treated. Staff Characteristics Class of Qualified Health Professional for whom PGD is applicable Qualifications Additional requirements considered relevant to the medicines to be supplied/administered according to this PGD 1. Registered Nurse on the NMC Register. 2. Pharmacist registered with the GPhC. 1. First level nursing qualification with current NMC Registration. 2. Degree in pharmacy with current GPhC registration. All named nurses/pharmacists should be able to demonstrate: Training and experience in sexual health & Chlamydia screening Confidence and competence in identifying the signs and symptoms of an upper genital tract infection The ability to identify the risk of pregnancy Confidence and competence in treating asymptomatic genital Chlamydia and the epidemiological treatment of genital Chlamydia A knowledge and understanding of the use of erythromycin for the Page 5 of 10

treatment of genital Chlamydia and as epidemiological treatment A knowledge and understanding of the contraindications, specific considerations and possible side effects of erythromycin 500mg four times daily for 7 days or twice daily for 14 days An ability to supply 56 erythromycin 250mg tablets with relevant information and advice Adequate standards of documentation that meet the requirements listed below under Method of Recording That they have undertaken appropriate training and successfully completed the competencies to undertake the clinical assessment of individuals leading to diagnosis that requires treatment according to the indications listed in this PGD That they have undertaken appropriate training for working under PGDs for the supply and administration of medicines That they have undertaken training appropriate to this PGD Continuing training & education Referral Arrangements and Audit Trail Referral arrangements Method of Recording supply/administration sufficient to enable audit trail A commitment to continuing professional development in the speciality, including maintenance of PREP/CPD requirements and a Personal and Professional Portfolio. As per local arrangements The following should be clearly documented in the patient s health record where available or in the PMR with the patient s consent: Patient s name, address, date of birth and consent given Note if off label use (e.g. pregnancy) Contact details of GP (if registered) Diagnosis or working diagnosis Details of any adverse drug reaction and actions taken including documentation in the patient s health record The date, medication name, dose and form administered or supplied, signature/name of the health professional providing treatment That the product information leaflet has been given to the patient That the patient has been given instructions regarding the taking of the medication when the patient declines to take it at the treatment centre That the patient has been given advice on how long they should abstain from sexual intercourse That the patient has been given verbal and written advice on how to access GUM sexual health services or an integrated sexual health service The arrangements that have been made for test of cure Page 6 of 10

following completion of treatment, if the patient is pregnant References/Resources and comments Summary of Product Characteristics. Aurobindo Pharma - Milpharm Ltd. Last update 26.11.15 https://www.medicines.org.uk/emc/medicine/23032 Joint Formulary Committee (2016) British National Formulary. September 2016 edition. London: British Medical Association and the Royal Pharmaceutical Society https://www.evidence.nhs.uk/formulary/bnf/current Paediatric Formulary Committee (2016) BNF for children September 2016 edition. London: British Medical Association, the Royal Pharmaceutical, the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group https://www.evidence.nhs.uk/formulary/bnfc/current BASHH (2015) UK National Guideline for the Management of Infection with Chlamydia trachomatis http://www.bashhguidelines.org/media/1045/chlamydia-2015.pdf FSRH and BASHH Guidance (February 2012) Management of Vaginal Discharge in Non-Genitourinary Medicine Settings (Update due by February 2017) https://www.fsrh.org/standards-andguidance/documents/cec-ceu-guidance-vaginal-discharge-feb-2012/ Nursing and Midwifery Council (2008) Standards for Medicines Management http://www.nmc-uk.org/documents/nmc-publications/nmc-standardsfor-medicines-management.pdf Nursing and Midwifery Council (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives http://www.nmcuk.org/documents/standards/nmcthecodestandardsofconductperfor manceandethicsfornursesandmidwives_largeprintversion.pdf National Institute for Health and Care Excellence. Medicines Practice Guidance. Patient Group Directions August 2013 http://www.nice.org.uk/guidance/mpg2 Royal Pharmaceutical Society of GB (2008) Patient group Directions - A Resource pack for pharmacists Please direct comments specifically relating to information on this PGD to the Prescribing and Medicines Management Team NEL Commissioning Support Unit 01603 257132 Page 7 of 10

This patient group direction must be agreed to and signed by all health care professionals involved in its use. NEL (Anglia) will hold the original signed copy on behalf of Norfolk County Council. The PGD must be easily accessible in the clinical setting This PGD has been agreed to be appropriate, necessary and an advantage to patient care by Norfolk County Council PGD Development and Authorisation Group Organisation Norfolk County Council This PGD is developed and peer reviewed by the following on behalf of Norfolk County Council Public Health Lead Doctor Dr Augustine Pereira Consultant in Public Health Medicine NCC Lead Nurse Lead Pharmacist Signature: Date: 21.12.2016 Sue Marshall Registered Nurse Signature: Date: 21.12.2016 Françoise Price Senior Pharmacist NEL CSU Signature: Date: 12.12.2016 Patient Group Direction prepared and peer reviewed by Name Position Date Augustine Pereira Consultant in Public Health Medicine 24.10.2016 Sue Marshall Registered Nurse 10.11.2016 Tracey Milligan Registered Nurse 24.10.2016 Sarah Barnes Sexual Health Commissioner and registered nurse 24.10.2016 Françoise Price Senior Pharmacist NEL CSU 19.10.2016 Tony Dean CEO Norfolk Local Pharmaceutical Committee 8.11.2016 Body with delegated authority to develop and review PGDs on behalf of NCC Body with delegated authority to develop and review PGDs on behalf of NCC 24.10.2016 and via email communication Patient Group Direction Authorisation This PGD is authorised by Norfolk County Council Dr Augustine Pereira Consultant in Public Health Medicine and Chair of the PGD group Signature: Date: 21.12.2016 Page 8 of 10

Individual Authorisation PGDs DO NOT REMOVE INHERENT PROFESSIONAL OBLIGATIONS OR ACCOUNTABILITY. It is the responsibility of each professional to practice only within the bounds of their own competence and in accordance with their own Code of Professional Conduct. Note to Authorising Managers: authorised staff should be provided with an individual copy of the clinical content of the PGD and a photocopy of the document showing their authorisation. I have read and understood the Patient Group Direction and agree to supply/administer this medicine only in accordance with this PGD. Name of Professional Signature Authorising Manager Date Page 9 of 10

Patient Advice Leaflet The medicine that you have been given is an antibiotic called Erythromycin 250mg. You will be advised to take:- or Erythromycin 500mg four times a day for 7 days Erythromycin 500mgs twice a day for 14 days Either way you should finish all the tablets. The infection will not have been completely treated until all the tablets are taken. Even then you should have another test 5 weeks after completing the tablets to check that the infection has been treated. We would advise that you do not have sex (not even with a condom or oral sex) until you have finished the tablets. Otherwise you could still pass the infection on. If your partner was not treated at the same time as you we would advise you not to have sex with them until they have finished their treatment, otherwise you could become infected again. A Health Adviser from the Chlamydia Screening Office will telephone you in about 2 weeks to make sure that you didn t have any problems with your medication. If you have any urgent concerns about your medicine then you should contact: Your GP (family doctor) NHS 111 Page 10 of 10