Analysis of the drug formulary and the purchasing process at a Moroccan university medical center.

AIM: To give an overview of the pharmaceutical policy in the largest medical center in Morocco, a developing country in socio-economic transition. METHODS: This is an analytical descriptive study of the drug formulary and the purchasing process carried out at the Ibn Sina University Medical Center. RESULTS: Our formulary included 830 drugs belonging to 14 classes according to the Anatomical, Therapeutic and Chemical (ATC) Classification System. There was a respective predominance of class N (21.8%), class B (13.5%), and class J (12.6%). Injectable route was dominant (46%). Drugs had a significant actual benefit in 70% (according to the French Data), reimbursable in 42.8%, essential in 29.2% according to World Health Organization (WHO) list, and in 36.9% according to the Moroccan list. The calls for tenders included 542 drugs representing 65% of the formulary, and the attribution rate was 71%. The main reason for non-attribution was the lack of offers. Generics accounted for 45% by volume and 26.5% by value. CONCLUSION: With this first study, we were able to identify key indicators on drugs used in the largest medical center in Morocco. The current challenge is to introduce pharmacoeconomics in decision making concerning the updates of the drug formulary.

Tuberculous duodenal stenosis: report of two cases.

Duodenal tuberculosis is a rare clinical entity. The authors report and emphasize the lack of special clinical, radiological and endoscopic signs of duodenal tuberculosis. The diagnosis is affirmed, at laparotomy, out of the findings of peritoneal granulations or histology of lymphatic nodes. We report our experience of two cases of duodenal tuberculosis presenting with proximal intestinal obstruction and review the available literature.

[Clinical case of the month. Peritonitis after spontaneous rupture of pyonephrosis. A case report]. / Le cas clinique du mois. Péritonite secondaire à la rupture spontanée d'une pyonéphrose dans la grande cavité péritonéale. A propos d'un cas.

Peritonitis after spontaneous rupture of pyonephrosis is a rare complication, usually diagnosed intraoperatively. We report the case of a 35 year old woman who was admited for an acute abdomen. Ultrasound showed features of acute peritonitis, with left pyonephrosis, confirmed by a CT-SCAN. Treatment consisted of laparotomy with nephrectomy and abdominal washing and draining. The outcome was favourable.

[Retro-cost-xyphoid hernia and common mesentery: a case diagnosed in an adult]. / Hernie rétro-costo-xyphoïdienne et mésentère commun: un cas diagnostiqué chez l'adulte.

Authors analysed Morgagni's hernia pathogenesis through a new case associated to a common mesentery position and revealed by respiratory distress after delivery.

[Primary linitis plastica of the rectum]. / La linite plastique primitive du rectum.

One case of primary linitis plastica of the rectum is presented, it is a rare entity presentation in younger patients. The diagnosis was made by excluding the stomach as a primary source by peroperative palpation and fibroscopy examination. Because of potential for local invasion and infiltration, linitis is often detected only at the equivalent of stage C (Astler-Cller). The prognosis is poor, the mean survival time is about 9 months.

[Stromal tumor of the stomach with exo-gastric growth]. / Les tumeurs stromales du tube digestif. Réflexions à propos d'un cas à développement exo-gastrique.

A 60 year-old male patient presented with a giant stromal tumor of the stomach that showed predominant extragastric growth. Surgery consisted of total tumor resection with partial gastrectomy. The stromal origin of the tumor was established by immunohistochemistry. In spite of its large size and the presence of necrotic foci, the tumor was considered to be of low grade in view of the low mitosis index. The patient was maintained on careful surveillance. The histological features which characterize these tumors and their implications for prognosis and therapy are briefly discussed.

[Massive rectorrhagia and acute intestinal occlusion revealing Peutz-Jeghers syndrome: apropos of 3 cases]. / Rectorragie massive et occlusion intestinale aigueë révélant un syndrome de Peutz-Jeghers: à propos de trois cas.

Peutz-Jeghers syndrome is a rare hereditary disorder involving digestive polyposis with hamartomatous gastrointestinal polyps and mucocutaneous lentiginosis. We report three cases in which this syndrome was detected by complications: a massive rectal hemorrhage requiring a blood transfusion in one case and acute impaction of the bowel requiring emergency surgery in the other two. This work demonstrates the importance of the complications that may indicate that the patient has this syndrome. We also discuss the cancers of the digestive system and other organs that may be associated with PJS and recent progress in genetic research into this disease.

[Duodenopancreatic injuries. Apropos of 30 cases]. / Les traumatismes duodéno-pancréatiques. A propos de 30 observations.

We present a retrospective study of 30 cases of duodenopancreatic injuries seen between 1985 and 1995. All injuries were due to blunt trauma mostly in traffic accidents. They include 16 duodenal injuries, 7 pancreatic injuries and 7 combined duodenopancreatic trauma. All patient were operated for peritonitis or state of shock. Preoperative diagnosis was evoked in two cases (6%). Isolated duodenal trauma (30%) were treated by primary repair and drainage, while pyloric exclusion was performed for five patients (17%), distal pancreatectomy in one case (3%), duodenojejunostomy with pancreatic jejunostomy in one patient (3%). In three patients (10%) isolated pancreatic trauma were treated by drainage, cystogastrocotomy in two cases (6.6%). There were nine deaths (30%) due to the severity of associated injuries, a false diagnosis, or incomplete initial treatment. Poor outcome was mostly due to delay in the diagnosis and associated intra-abdominal injuries. A precise diagnosis of the duodenopancreatic trauma allows an appropriate therapeutic strategy avoiding subsequent complications.

[Treatment of bleeding duodenal ulcer. A study of mortality and indication of surgical treatment. Apropos of 557 cases]. / L'ulcère duodénal hémorragique. Etude de la mortalité et des critères d'opérabilité. A propos de 557 cas.

From 1986 to 1996, 557 patients are treated for acute ulcer bleeding. The sex ratio is five to one for men, the average age is 40 years old. The duodenal ulcer is revelated by haemorrhage in 25.8%. 181 patients underwent a surgical operation (32%). This percentage is higher that those encountered in the literature, due probably to our specific context (patients from low socioeconomic level, can not afford medical treatment, medical surveillance or control, lack of blood products in emergency. The most practiced surgical treatment is weinberg operation: "Troncular Vagotomy" with "pyroloplasty" and "ulcer sean" practiced in 86.1% of the cases; "Troncular Vagotomy" with "Gastro-intestinal anastomosis" is operated in 7.7% of the cases; "Superselective Vagotomy" and "Seromyotomy" is practiced in 3.8%, with the "Antroduodenectomy" is practiced in 1.1% of the cases. The overall death rate observed is about 4% this value increase to 11% after surgical treatment. This death rate is lower than the literature, that's probably anociated the fact that most of our patients are young and do not hold severe weaknesses. This study indicates that mortality was related to the patient's age, the patient's condition and recurrent haemorrhages.

[Immediate esophagojejunal anastomosis after total gastrectomy for caustic necrosis. Apropos of 5 cases]. / Anastomose oeso-jéjunale immédiate après gastrectomie totale pour nécrose caustique. A propos de 5 cas.

Five patients have had an immediate recovery of the continuity after total gastrectomy for caustic necrosis by an oesophago-jejunostomy. One patient died of post operative peritonitis no linked with the oesophago-jejunostomy. Two cases had a respiratory infection and one patient had presented a jejuno-jejunostomy fistula. Three healed without sequela. The immediate recovery of the continuity after total gastrectomy for caustic necrosis with moderate lesions of the oesophagus steals the ideal therapeutic attitude.