Acinetobacter baumannii: assessing susceptibility patterns, management practices, and mortality predictors in a tertiary teaching hospital in Lebanon.

BACKGROUND: Acinetobacter baumannii is a major nosocomial pathogen capable of causing life-threatening infections. This bacterium is highly resistant to antibiotics and associated with high mortality rates. Therefore, this study aimed to evaluate A. baumannii's susceptibility patterns to antimicrobials, assess the appropriateness of the initiated antimicrobial therapy, determine the mortality rate, and identify predictors associated with mortality. METHODS: A retrospective observational study was conducted among patients infected with A. baumannii at a university hospital in Lebanon through the revision of medical records. Kaplan-Meier survival analysis and log-rank tests were used to analyze time-to-mortality. Binary logistic regression was performed to identify predictors of mortality. RESULTS: The records of 188 patients were screened, and 111 patients with A. baumannii infection were enrolled. Almost all isolates were resistant to carbapenem, and 43% of the isolates were extensively-drug resistant. Almost half of the patients received initial inappropriate antimicrobial therapy (n = 50, 45.1%). The 30-day mortality rate associated with A. baumannii infection was 71.2% (79/111). The time to mortality in patients who received inappropriate antimicrobial therapy (5.70 ± 1.07 days) was significantly shorter than in those who received appropriate antimicrobial therapy (12.43 ± 1.01 days, P < 0.01). Binary logistic regression revealed that inappropriate antimicrobial therapy (adjusted odds ratio [AOR] = 16.22, 95% CI 2.68-9.97, P = 0.002), mechanical ventilation (AOR = 14.72, 95% CI 3.27-6.61, P < 0.001), and thrombocytopenia (AOR = 8.82, 95% CI 1.12-9.75, P = 0.003) were more likely associated with mortality. CONCLUSIONS: A. baumannii exhibits an alarming mortality rate among infected patients. Thrombocytopenia, mechanical ventilation, and inappropriate antibiotic administration are associated with mortality in patients infected with A. baumannii. The prompt initiation of appropriate antimicrobial therapy, infection control measures, and effective stewardship program are crucial to reduce the incidence of A. baumannii and improve the treatment outcomes.

Oral contraceptive pills shortage in Lebanon amidst the economic collapse: a nationwide exploratory study.

BACKGROUND: The political instability, economic crisis, and devaluation of the national currency left Lebanese females suffering from a scarcity of oral contraceptive pills (OCPs). Therefore, we aimed to identify the incidence of OCPs shortage in Lebanon and its impact on women's sexual and reproductive health, as well as physical and psychological well-being. METHODS: Community pharmacies were selected randomly across Lebanon, using a stratified sampling approach, where female clients asking for OCPs were interviewed using a standardized data collection form. RESULTS: A total of 440 females were interviewed. More than three-quarters of the participants (76.4%) reported not finding their preferred OCPs brands, almost 40% were affected by the increased prices, and 28.4% declared stockpiling OCPs. More than half of the participants using OCPs for pregnancy prevention reported adopting alternative traditional contraceptive methods (55.3%). Unplanned pregnancy was reported by 9.5% of participants, where 75% of them disclosed intentional abortion while the remaining (25%) reported experiencing a spontaneous miscarriage. Other consequences of OCPs shortage included mood disturbances (52.3%), dysregulation of menses (49.7%), dysmenorrhea (21.1%), weight gain (19.6%), acne (15.7%), and hirsutism (12.5%). Of the participants taking OCPs for birth control, 48.6% reported a reduced frequency of sexual intercourse, which led to conflicts with their partners (46%) and a decreased libido (26.7%). CONCLUSIONS: OCPs shortage has seriously and negatively exposed women to various undesirable consequences including unplanned pregnancy and dysregulation of menses. Therefore, there is an urgent need to bring the attention of healthcare authorities to support the national pharmaceutical industry in manufacturing affordable OCPs generics to meet women's reproductive health demands.

Complementary and alternative medicine use during the COVID-19 pandemic: Community pharmacists' knowledge, attitudes, and practices.

BACKGROUND: The challenges in COVID-19 treatment have driven patients to seek Complementary and Alternative Medicine (CAM) for the prevention and/or treatment of the disease. Pharmacists are uniquely positioned to promote the effective and safe use of CAM. OBJECTIVE: Assess the beliefs, practices, and knowledge of community pharmacists in Lebanon about existing evidence for the use of CAM for the prevention and/or treatment of COVID-19. METHODS: A national cross-sectional survey was conducted among community pharmacists during the COVID-19 pandemic in Lebanon (n = 310 respondents). Participants completed an online questionnaire addressing, in addition to the socio-demographic characteristics; the beliefs, practices, and knowledge of pharmacists regarding the existing evidence of CAM use for COVID-19 prevention and/or treatment. RESULTS: Pharmacists (70%) received frequent inquiries about CAM for COVID-19 prevention or treatment. Only 25.5% of the pharmacists reported having enough time to get information about CAM and COVID-19. Almost all participants believed that pharmacists have a major role in the fight against COVID-19 (98%) and that they have enough information to counsel patients in that regard (75%). For practices, the majority of pharmacists reported counseling their patients on proper use (98%) and possible adverse reactions (93%) of CAM, but only 51% reported toxic or undesirable effects. Regarding knowledge, although most pharmacists answered correctly the questions on the role of CAM in preventing COVID-19, few knew about its role in treating the infection. Pharmacists who trust the WHO website as a credible source had a higher knowledge score (ß = 0.52, 95%CI: 0.05-0.986). CONCLUSIONS: The positive beliefs and practices of pharmacists towards CAM during the pandemic were coupled with a few gaps, especially in their knowledge about existing evidence for CAM use. Concerted efforts ought to be dedicated to supporting pharmacists in playing a more prominent role during health crises such as the COVID-19 pandemic.

Assessing the pharmaceutical care provision to suspected COVID-19 patients in community pharmacies: a simulated patient study.

BACKGROUND: In the wake of COVID-19, community pharmacists (CP) were called upon to free up healthcare providers to treat more serious conditions and alleviate overcrowded healthcare centers. CPs were placed under tremendous pressure, where many patients primarily sought their health advice. This situation raised concerns about the preparedness of CPs in facing these challenges. Therefore, this study aimed to assess the appropriateness of pharmaceutical care provided by CPs to patients with suspected COVID-19 and to investigate their communication skills. METHODS: A simulated patient (SP) study was conducted among randomly selected community pharmacies in Beirut, Lebanon. Each pharmacy was visited by the SP who complained of fever and loss of smell sensation. Interactions between the attending pharmacist and the suspected COVID-19 patient were documented directly after each visit in a standardized data collection form. RESULTS: More than half of the CPs (56%) did not retrieve any relevant information to assess the patient's condition. While pharmacists' responses were limited to one to two recommendations, with the majority recommending the patient to perform the PCR test (90%). Inappropriate recommendations made by the CPs included mainly the confirmation that the patient had COVID-19 without prior testing (9%), and prescribing either an antimicrobial drug (5%) or dietary supplements (20%), claiming that the latter are essential to boost the patient's immunity. As for the pharmacist-patient communication skills, the mean total score was 2.25 ± 0.79 (out of 4), displaying nonoptimal and ineffective communication. CONCLUSION: An unsatisfactory and suboptimal provision of pharmaceutical care to a suspected COVID-19 case was evident. This may be a public health threat, particularly for developing countries that lack an efficient and unified healthcare system. The findings should alert health authorities to support and guide community pharmacists in assisting suspected COVID-19 patients.

Assessment of pharmacy students' knowledge, attitude, and practice toward herbal dietary supplements.

Objective: Although there has been an expanded use of herbal supplements worldwide, data concerning their consumption patterns and knowledge are limited. Consequently, the present study aimed to assess the knowledge, attitude, and practice of Lebanese pharmacy students toward herbal dietary supplements. Participants and methods: A cross-sectional observational study was conducted by administering a 23-items' survey to a convenient sample of pharmacy students. Results: Out of 355 pharmacy students assessed, 168 were using at least one dietary supplement, mainly to treat health problems. Their primary source of information was the Internet. Health benefits of Ginkgo Biloba were known by 63% while that of Glucosamine by 12%. Similarly, side effects of Ginkgo Biloba were recognized by 62% while that of St. John's Wort by only 2%. Conclusion: Despite the comprehensive coverage of herbal supplements in the pharmacy curriculum, some were weakly known namely; Glucosamine and St. John's Wort. Consequently, emphasis should be done to fill the gap.

Acute Kidney Injury Related to Intravenous Colistin Use in Lebanese Hospitalized Patients: Incidence and Associated Factors.

BACKGROUND: Colistin use has increased because of the emergence of infections caused by resistant gram-negative bacteria. Acute kidney injury (AKI) remains a treatment-limiting factor for widespread colistin clinical use. This study aimed at determining the incidence and the factors associated with the development of colistin-induced AKI. METHODS: A retrospective observational study was conducted by reviewing files of adult patients with normal kidney function between January 2015 to March 2019 at a university hospital located in Beirut city. AKI was defined based on KDIGO criteria. Independent variables associated with colistin-induced AKI were also tested. RESULTS: In this study, a total of 113 patients were included. AKI occurred in 53 patients (46.9%). The Charlson Comorbidity Index (CCI) was found to be significantly greater in the AKI group (2.26, P-value = 0.026). In the multivariate analysis, low serum albumen was found as an independent significant predictor for AKI (OR=.065, 95%CI: .013-.337, P-value=0.001). Moreover, the risk for AKI increased by 2 folds (OR=2.019, 95%CI: 1.094-3.728, P-value: 0.025), when two or more nephrotoxic agents were administered simultaneously with colistin. The patient's age was also found as a significant predictor for AKI (OR=1.034, 95%CI:1-1.07), with a cut-off value of 58.5-year-old. CONCLUSION: This study demonstrated that the concomitant use of two or more nephrotoxic drugs, patient's age of 58.5 or above, and the presence of hypoalbuminemia were independent factors for the development of colistin-induced AKI. These factors should be therefore taken into consideration when prescribing colistin in clinical practice to decrease the risk of AKI.

The role of pharmacists in complementary and alternative medicine in Lebanon: users' perspectives.

BACKGROUND: Customers' expectations and satisfaction are critical to ensure a more effective role of the community pharmacists in promoting the safe use of Complementary and Alternative Medicine (CAM). The aim of this study is to examine the perceptions and practices of customers buying their CAM products from pharmacies and explore their satisfaction with CAM-related services offered by the community pharmacists in Lebanon. METHODS: A national cross-sectional study was conducted among users of CAM (age > =18 years) who obtained their CAM from community pharmacies in Lebanon (n = 832). Within the proximity of the pharmacy, subjects were invited to complete a multi-component questionnaire. The latter consisted of four sections related to CAM: general beliefs, perception of pharmacists' role, practices, satisfaction with services offered by the pharmacists. In addition, the questionnaire included questions about sociodemographic characteristics of participants. RESULTS: The majority of participants agreed to an active role of the pharmacists' in guiding CAM use, however over half of the participants (61.3%) did not agree that the pharmacist is more knowledgeable in this field than other healthcare providers. As for practices, one in two surveyed customers (47%) did not always give feedback to their pharmacists about the outcomes after using CAM, 20% did not often ask the pharmacists about the safe and effective mode of use of the products and 28.1% did not discuss their medical history. For services offered by the pharmacist, the majority of participants reported receiving good education about the CAM product (87.1%), its side effects (87.1%) and mode of use (93.4%), while significant proportions of participants reported that pharmacists were not asking questions about their medical history before dispensing CAM products (22%) nor were they providing information on CAM-drug interactions (30%). CONCLUSIONS: The results of this study highlighted important gaps between the perceptions of customers and the services they received from the pharmacists about CAM use. These findings could be used by concerned stakeholders, including public health authorities and educational bodies, to develop evidence-based interventions aimed at promoting the role of pharmacists in ensuring a safe and effective CAM use Lebanon.

Alloxan-induced diabetic thermal hyperalgesia, prophylaxis and phytotherapeutic effects of Rheum ribes L. in mouse model.

Rheum ribes L., known as Syrian rhubarb, is used in traditional Lebanese folk medicine for the treatment of diabetes. The present study aims to investigate the activities of R. ribes aqueous extract for glucose homeostasis, in vivo antioxidant and diabetic neuropathy protection in mice. The acute and the subacute effects of various doses of R. ribes on blood glucose and in vivo antioxidant activity utilizing serum catalase level (CAT) were studied in alloxan-diabetic mice. The high doses significantly lowered glucose level and increased serum CAT in alloxan-diabetic mice. Pretreatment with the extract prior to alloxination, protected the mice from acquiring diabetes and diabetic neuropathy. Treatment with the extract for 8 weeks alleviated hyperalgesia in diabetic mice. Our findings provide clinicians with promising drugs intended for the management of the symptoms of diabetic complications. The protective activity of R. ribes against acquiring diabetes and diabetic neuropathy might pave the way for preparing a prophylactic treatment for diabetes risk groups.

Role of community pharmacists in weight management: results of a national study in Lebanon.

BACKGROUND: Ideally situated within the community, pharmacists can be involved in a broad range of health promotion campaigns including prevention of obesity. Limited evidence is available regarding their involvement in weight management in Lebanon, a country with escalating prevalence rate of obesity. OBJECTIVE: To examine the role of community pharmacists in weight management in Lebanon, specifically studying their beliefs, current practices, services, and knowledge. METHODS: Using a stratified random sampling approach, a cross sectional national survey of community pharmacists was conducted (n = 341, response rate 89%). At the pharmacy, and through a face-to-face interview, pharmacists completed a multi-component questionnaire that addressed, in addition to socio-demographic and work characteristics, their beliefs, practices, knowledge in relation to weight management. Frequencies and proportions were used to describe the data. Simple and multiple linear regression analyses were used to examine the determinants of knowledge in the study population. RESULTS: Over 80% of study participants agreed that they have an important role to play in weight management. However, 50% of pharmacists did not agree that weight loss products are well regulated and 81.1% thought that companies marketing weight loss products are making false promises. The majority of pharmacists always/often sold weight loss products (84.7%) and counseled their patients for diet (86.3%) and physical activity (91.7%). Despite taking weight and height measurements, 50% of pharmacists rarely/never calculated BMI. Among the pharmacists who reported side effects of weight loss products (46.5%), the majority (91.3%) did so to the pharmaceutical company. The knowledge of pharmacists was better for the use of weight loss products as opposed to their side effects and interactions. Significant predictors of knowledge were holding a Masters/ PhD degree in Pharmacy, graduating from a university inside Lebanon, obtaining weight management training within the academic degree, and receiving inquiries about weight management in the pharmacy more than once daily. CONCLUSIONS: The results of the study provided important insights on the beliefs, practices and knowledge of community pharmacists in weight management in Lebanon. These findings could be used to inform the development of future evidence-based community pharmacists led weight management service provision nationally and internationally.

Phytochemical and anti-neuropathic investigations of Crocus sativus via alleviating inflammation, oxidative stress and pancreatic beta-cells regeneration.

Objective: The aim of this study is to investigate the phytochemical and the long-term anti-neuropathic potentials of Crocus sativus cultivated in the University botanical garden, and explore its most bioactive compounds and their underlying mechanisms of action. Methods: Phytochemical analysis and bio-guided isolation-procedures including RP-HPLC and 1H and 13C NMR utilizing biological models of diabetes, inflammation, and diabetic-neuropathy were used. Cultivated saffron (S-RCED) and Spanish-saffron stigma (S-SP) alone or in combination with Camellia sinus (CS) were investigated. Results: The RP-HPLC analyses showed the presence of picrocrocin, crocin I, crocin II, crocin I', crocin II', and safranal (SAF) in both S-SP and S-RCED extracts with higher-concentrations. It had been shown that SAF was the most bioactive-compound in Crocus sativus. Both S-SP and S-RCED possessed significant (P < 0.05) anti-diabetic activities in acute (6 h), subchronic (8 d) and chronic (8 weeks) models. S-RCED had been proven with more hypoglycemic potentials when compared to S-SP and SAF. S-SP, S-RCED, and SAF produced significant anti-inflammatory and anti-nociceptive activities against carrageenan-induced inflammatory, hyperalgesic and tactile diabetic-neuropathy models, respectively. S-SP, S-RCED, and SAF elevated serum catalase, reduced glutathione, and insulin serum levels, ameliorated lipid peroxidation and HbA1c levels, and histopathologically regenerated the pancreatic beta-cells. Combinations with CS showed more significant efficacy than the single component. Conclusion: The oxidative stress reduction, insulin secretagogue, and pancreatic beta-cells regeneration potentials might be responsible for the mechanism underlying the anti-diabetic, anti-inflammatory and anti-diabetic neuropathy activities. Thus, the cultivated Crocus sativus might be clinically useful for protecting against many serious-disorders.

Beliefs, practices and knowledge of community pharmacists regarding complementary and alternative medicine: national cross-sectional study in Lebanon.

INTRODUCTION: Pharmacists are uniquely positioned to provide patients with evidence-based information in order to ensure effective and safe use of Complementary and alternative medicine (CAM) products. OBJECTIVE: Assess beliefs, practices and knowledge related to CAM products among community pharmacists in Lebanon. DESIGN, METHODS AND SETTING: Using stratified random sampling, a nationally representative survey was conducted among community pharmacists in Lebanon. Through face-to-face interviews, pharmacists completed a multicomponent questionnaire consisting of four sections: (1) sociodemographic characteristics; (2) beliefs related to regulation of CAM products, role of media in promoting their safe use, availability of resources and continuing education; (3) practices including selling CAM products, providing advice for patients and reporting adverse effects and (4) knowledge about specific CAM products, their uses, side effects and interactions. RESULTS: A total of 341 pharmacists agreed to participate (response rate: 86%). Only pharmacists with complete data were included in this study (n=310). Pharmacists agreed that CAM products are effective (63.8%) and that they should be exclusively sold in pharmacies (80.3%), but disagreed that commercially marketed CAM products are well regulated (63.5%) and that media plays a positive role in educating users about these products (55.8%). As for practices, 64.5% of pharmacists were always or often advising patients on safe use; however, 74.2% of participants rarely or never reported adverse effects. Regarding knowledge, although the majority of pharmacists were aware of the uses of CAM products, fewer knew about their side effects and their interactions with drugs. After adjustment for covariates, receiving education/training on CAM products during university was the sole predictor of higher knowledge score (ß=0.68, 95% CI 0.29 to 1.07). CONCLUSIONS: This study revealed positive beliefs of pharmacists in Lebanon towards CAM products and indicated important gaps in their practice and knowledge. Deliberate efforts to enhance the education of pharmacists are warranted to ensure the safe integration and use of CAM products in Lebanon.

Combination of Rheum ribes and Metformin Against Diabetes, Thermal Hyperalgesia, and Tactile Allodynia in a Mice Model.

CONTEXT: The prevalence of diabetes mellitus (DM) is increasing. Because of its progressive nature, therapeutic shifts and combinations are often required to reduce the risk of glucose toxicity and avoid serious side effects. To treat DM and its related complications, a combination therapy may offer a promising remedy to counteract those issues. OBJECTIVES: The study was established to evaluate the phytochemical content of a standardized aqueous extract of Rheum ribes (RR) and to determine the antidiabetic, antihyperalgesic, and antimechanical allodynic effects of 50 mg/kg of RR alone, 25 mg/kg of metformin (MTF) alone, and a combination of the 2 substances (MTF+RR) in mice with alloxan-induced diabetes. DESIGN: The research team designed an animal study. SETTING: The study was performed at the facilities of the faculty of pharmacy at Beirut Arab University (Beirut, Lebanon). ANIMALS: The animals were male, Swiss-Webster mice, weighing 22-30 g and aged 12-16 wk. INTERVENTION: DM was induced in experimental animals by an IP injection of alloxan every 48 h for 3 injections at a total dose of 180 mg/kg. Substudy A measured the acute-0, 0.5, 2, and 6 h-and subchronic-1, 3, 5, and 8 d-effects of a water extract of the RR alone, of the MTF alone, and of the MTF+RR combination on blood-glucose levels (BGLs), body weights, and catalase (CAT) serum levels. The mice were divided into 6 groups of 7 mice each, and each group received various IP injections of the tested samples: (1) group 1, a vehicle control group of normal mice (NORM group) received sterile, cold, 0.9% saline; (2) group 2, a vehicle control group of diabetic mice (VEH group) received sterile, cold, 0.9% saline; (3) group 3, a positive control group of diabetic mice (GB group) received 5 mg/kg of glibenclamide; (4) group 4, an intervention group of diabetic mice (MTF group) received 25 mg/kg of MTF only; (5) group 5, an intervention group of diabetic mice (RR group) received 50 mg/kg of RR only; and (6) group 6, an intervention group (MTF+RR group) of diabetic mice received 25 mg/kg of MTF and 50 mg/kg of RR. Substudy B measured the subchronic-0, 2, 4, 6, and 8 wk-effects of the RR only, of the MTF only, and of the MTF+RR combination on the hot plate and tail flick latencies and on the von Frey paw withdrawal thresholds. Again, they were divided into 6 groups of 7 mice each (groups 7 through 12), and each group received various IP injections of the tested samples, with all of the groups receiving the same treatments as for substudy A, except that group 9, a positive control group of diabetic mice, received 10 mg/kg of tramadol. OUTCOME MEASURES: The BGLs of the mice were monitored acutely for 6 h and subchronically for 8 d. Glycated hemoglobin (HbA1c), inhibition of α-glucosidase, and effects on serum insulin were evaluated. Using tail flick, hot plate latencies, and von Frey paw withdrawal thresholds, thermal hyperalgesia and tactile allodynia were assessed. Using a natural antioxidant, in vivo antioxidant activity was used to evaluate CAT and lipid peroxide (LPO) levels. RESULTS: The reductions in blood glucose, HbA1c, α-glucosidase, and LPO were statistically significant for the MTF+RR. The body weight, serum insulin, tail flick, hot plate latencies, paw withdrawal thresholds, and CAT increased significantly in diabetic mice treated with the combination. Consequently, the combination's potent inhibitory effect on α-glucosidase and serum insulin elevation might be responsible for its hypoglycemic potential, whereas its antioxidant effects might be responsible for the amelioration of painful hyperalgesia and allodynia, suggesting that the combination has better antidiabetic and antinociceptive effects and fewer side effects than treatment with MTF alone. No adverse events were reported. CONCLUSION: When combined with MTF, RR might be a promising adjuvant for amelioration of DM and related nociceptive complications.

Anti-Inflammatory and Antioxidant Activities of Salvia fruticosa: An HPLC Determination of Phenolic Contents.

Objectives. Salvia fruticosa Mill. (S. fruticosa) is widely used in folk medicine. Accordingly, the present study was designed to evaluate the antioxidant and anti-inflammatory activities of S. fruticosa, and to determine the phenolic constituents of its extracts. Methods. The antioxidant activity was determined using 2,2-diphenylpicrylhydrazyl assay. Total phenolic contents were estimated using Folin-Ciocalteu reagent, and high-performance liquid chromatography was performed to identify phenolic constituents. To evaluate the anti-inflammatory activity, carrageenan-induced mouse paw edema was determined plethysmographically. Key Findings. Different plant extracts demonstrated strong radical scavenging activity, where the ethyl acetate extract had the highest value in the roots and the lowest in the aerial parts. This antioxidant activity was correlated to the total phenolic content of different extracts, where rutin and luteolin were the most abundant constituents. Interestingly, both the roots and aerial parts revealed a significant anti-inflammatory activity comparable to diclofenac. Conclusions. This study is the first to demonstrate pharmacologic evidence of the potential anti-inflammatory activity of S. fruticosa. This activity may partly be due to the radical scavenging effects of its polyphenolic contents. These findings warrant the popular use of the East Mediterranean sage and highlight the potential of its active constituents in the development of new anti-inflammatory drugs.

A new validated HPTLC method for quantitative determination of 1, 5-dicaffeoylquinic acid in Inula crithmoides roots.

1, 5-Dicaffeoylquinic acid (1, 5-DCQA), a potent HIV-1 integrase inhibitor, is currently undergoing an evaluation as a promising novel HIV therapeutic agent. This work aims at developing an accurate, rapid, repeatable and robust HPTLC method for the determination of 1, 5-DCQA in its natural sources. 1, 5-DCQA is the major component of the n-butanol fraction, the most biologically active hepatoprotective fraction, of Inula crithmoides roots extract. Thus, it will be of interest to evaluate the plant roots as a potential source of 1, 5-DCQA using a fully validated HPTLC method. The percentage of 1, 5-DCQA in the studied plant (0.035% w/w) was found to be approximately similar to those previously determined in other antioxidant herbal drugs, in which 1, 5- DCQA is the main phenolic constituent. The results obtained showed that the described HPTLC method is suitable for routine use in quality control of herbal raw material, extracts and pharmaceutical preparations containing 1, 5-DCQA. No HPTLC method has been reported in literature for the determination of 1, 5-DCQA in medicinal plants.