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.

[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.

[2 cases of the diffuse form of Caroli disease]. / 2 cas de forme diffuse de la maladie de Caroli.

Report of two cases. The authors report two observations in what concern the diffused form of the Caroli's disease, one pure, the other mixed associating the congenital dilatation of the intra-hepatic bileducts with lesion of congenital hepatic fibrosis. They emphasize the efficiency of the echographia and computed tomography in diagnosing Caroli's disease. The surgical treatment of these diffused forms often complicated by acute recurrent cholangitis used with some success various methods of biliary drainage. But the radical treatment seems to be obliged to turn itself more likely toward liver transplantation.

[Isolated retroperitoneal hydatid cyst. Apropos of a case]. / Le kyste hydatique rétropéritonéal isolé. A propos d'un cas.

This is a report of a rarely observed localisation of hydatid cyst: the retroperitoneal space. The hypotheses of pathogenesis advanced are reviewed and the interest of intravenous urography and ultrasonography in the diagnosis is emphasized. Surgery the only treatment, consists of partial resection of the cyst.

[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.

[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.

[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.

[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.

[Spontaneous rupture of a mucinous cystadenoma of the pancreas and suppuration in the abdomen]. / Rupture spontanée et suppuration dans l'abdomen d'un cystadénome mucineux du pancréas.

The spontaneous rupture and the suppuration of a mucinous cystadenoma of the pancreas remain exceptional. The authors report about one case. The help provided by ultrasound and computed tomography for the diagnosis is indisputable. The condition is most often mistaken with a pseudocyst of the pancreas. This case is used as a basis to study the mechanism of suppuration and discuss the merits of an emergent histological diagnosis to choose an appropriate therapy.

[An unusual cause of colonic perforation: sinus haemophagocyte histiocytosis]. / Une cause exceptionnelle de perforation colique: l'histiocytose sinusale hémophagocytaire.

The authors report about one case of colic perforation due to sinus histiocytosis with massive lymphadenopathy. This observation has permitted us to give a point of view about this uncommon affection with unknown cause.

[A rare cause of massive upper digestive hemorrhage. Duodenal tuberculosis, apropos of two cases]. / Une cause rare d'hémorragie digestive haute massive. La tuberculose duodénale à propos de deux observations.

Tuberculosis of the duodenum was revealed in two patients by severe upper digestive tract bleeding. These cases illustrate the difficulties in diagnosing tuberculosis of the duodenum which can present as a simple bleeding ulceration. This "infectious" ulcer is an exceptional finding but certain diagnosis can be made at laparotomy with extemporaneous pathology of the lymph nodes. For non-complicated cases, the diagnosis may be suspected on the bases of routine laboratory tests. Surgery should be limited as much as possible since specific antibiotics are usually successful in cases of digestive tract tuberculosis.

[Pseudotumor form of hepatic tuberculosis. Apropos of a case]. / La forme pseudo-tumorale de la tuberculose hépatique. A propos d'une observation.

The authors report about one new case of hepatic tuberculosis in a pseudotumoral form, and emphasize the diagnostic difficulties even in a country where tuberculosis is endemic. Hepatic puncture, either with sonographic monitoring or during laparotomy, is the paraclinical examination of choice. The histological study supports the diagnosis. The medical treatment is that of any form of tuberculosis. The surgical treatment is most often indicated when a diagnosis of liver tumor is assumed.

[Fatal appendectomy caused by postoperative gas gangrene of the abdominal wall. 2 cases]. / Appendicectomie mortelle par gangrène gazeuse pariétale post-opératoire. 2 cas.

The authors report two cases of post-appendicectomy gas gangrene with a fatal outcome. Based on the study of these two cases they analyse the incidence, mechanism and prognosis of this serious post-operative complication. They stress the prophylactic measures necessary for prevention.

[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.

[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.