M Bouatia

REVIEW: FROM SCREENING TO APPLICATION OF MOROCCAN DYEING PLANTS: CHEMICAL GROUPS AND BOTANICAL DISTRIBUTION

Many dyes are contained in plants and are used for coloring a medium. They are characterized by their content of dyes molecules. They stimulate interest because they are part of a sustainable development approach. There are several chemicals families of plant dye which are contained in more than 450 plants known around the world. In this article, a study based on literature allowed us to realize an inventory of the main dyes plants potentially present in Morocco. A list of 117 plants was established specifying their botanical families, chemical Composition, Colors and parts of the plant used. Keywords: Natural dye, Morocco, Chemical structures, Plant pigments, Extraction

Inventory of Toxic Plants in Morocco: An Overview of the Botanical, Biogeography, and Phytochemistry Studies

Since they are natural, plants are wrongly considered nondangerous; therefore people used them in various contexts. Each plant is used alone or in mixture with others, where knowledge and the requirements of preparation and consumption are not mastered. Thus, intoxications due to the use of plants have become more and more frequent. The reports of intoxications made at the Antipoison Center and Pharmacovigilance of Morocco (ACPM) support this finding, since the interrogations suffered by the victims show that the use of plants is practiced irrationally, anarchically, and uncontrollably. Faced by the increase of these cases of poisoning in Morocco, it seemed necessary to investigate the nature of poisonous plants, their monographs, and the chemicals responsible for this toxicity.

Interactions between injectable anticancer drugs and polyvinyl chloride bags: Evaluation of the adsorption phenomenon after reconstitution

Introduction During the reconstitution of a drug and during its storage, there are risks of interactions between the drug and the bag used for the preparation. Polyvinyl chloride is a material used in the manufacture of a large part of chemotherapy infusion bags. It is subject to many interactions like sorption of drugs and release of phthalate additives. Material and Methods Seven anticancer drugs used in pediatric oncology were involved in our study. After reconstitution of the anticancer agents in polyvinyl chloride bags, the adsorption phenomenon between the container and the contents is evaluated by infrared spectroscopy by analyzing the inner surface of the polyvinyl chloride. Subsequently, for the anticancer agents which exhibited an adsorption–container–content, the analysis was carried out by ultraviolet–visible spectrophotometry in order to examine the kinetics of the concentration of reconstituted anticancer drugs. Results All the polyvinyl chloride bags gave a spectrum identical to the spectrum of the reference bag, except the bags used to reconstitute etoposide whose spectra showed 12 additional peaks. With the absorbances measured by ultraviolet–visible spectrophotometry at different times, the analysis of variance statistical analysis shows that there is a significant difference in absorbances between t0 and all the other measurement times. Conclusion This study testifies to the existence of a container–content interaction between etoposide and polyvinyl chloride. Thus, reconstitution of etoposide for intravenous infusion into a polyvinyl chloride bag should be used immediately. For etoposide preparations intended for storage beyond 24 h, it is recommended to use a container other than the polyvinyl chloride bag.

5PSQ-122 Contribution of the monitoring of quality indicators on improving paediatric’s hospital pharmacy’s performance

Background The implementation of quality indicators within the hospital pharmacy have a fundamental role in the creation of its value. It contributes significantly to the achievement of the strategic goals of the structure and allows managers to measure and manage in a better way their performance. Purpose The aim is to explore the hospital pharmacy practice in terms of the use of quality indicators and their relation to performance. Material and methods We have measured the internal process performance indicators and the support process efficiency indicators over the last 3 years, by measuring the customer satisfaction rate and calculating the rate of breakage, deterioration, expiry of drugs and medical devices and the rate of reactivity of corrective actions, whose formula has been previously determined in advance. The data needed for this calculation were collected using the nonconformity reporting sheets and the pharmacy database as well as a questionnaire sent to the hospital’s clinical departments. The calculated results were compared to the analysis threshold set for each indicator. Results Measuring the internal process indicators over the years 2015, 2016 and the first half of 2017 showed that the strategic objectives set for all the performance indicators have been achieved for the 3 years except breaking indicators of drugs has increased in August of 2016 by a rate of 13%, which exceeds the normal threshold: this is a breakdown of 17 products and an efficiency rate of immediate actions that has decreased slightly to 68.8% compared to the threshold (>70%) during the month of December of the same year. These non-conformities have pushed the pharmacy team to review the shortcomings and take corrective measures. And regarding the effectiveness of process indicators support, a significant improvement was observed in 2016 compared to the previous year. Conclusion We can say that performance is positively associated with quality indicators That allow us to achieve fixed goals and objectives, and to make immediate or long-term decisions in order to improve and increase the performance of the concerned structure. Reference and/or Acknowledgements 1. Meftah H, et al. Contribution of hospital pharmacy ISO certification 9001 on improving performance indicators: Experience of pharmacy of a paediatric hospital. Eur J Hosp Pharm2017. No conflict of interest

3PC-010 Chemical interactions between antibiotics and cations administered by injection

Background Simultaneous administration of drugs is a common gesture in different care units. This gesture may be causing some major complications for patients. In 1996, serious accidents in premature or newborns concomitantly treated with ceftriaxone and intravenous calcium gluconate were reported in France. In 2002, a death was reported in a newborn after administration of calcium gluconate plus ceftriaxone despite the difference in routes of drugs administration and the difference in time of injection. Purpose We tried to study the different physicochemical interactions that some antibiotics might have with cationic ions used in injectable form in hospital.Abstract 3PC-010 Table 1 Antibiotic Ca2+ Mg2+ Fe2+ Gentamicin 80 mg/2 mL * NP NP Flucloxacillin 1 g/2 mL 2.44 10–3 2.58 10–3 5.29 10–7 Amoxicillin+Clavulanic acid 500 mg/62. 5 mL NP NP ** Ceftriaxone 1 g/2 mL 7.93 10–4 7.94 10–3 1.32 10–3 Ceftazidime 1 g/2 mL NP NP 1.79 10–3 Colistin 1000000 IU NP NP NP Ampicillin+Sulbactam 1 g/500 mg NP NP ** Levofloxacin 500 mg/100 mL NP NP NP Teicoplanin 400 mg/2 mL NP NP NP Piperacillin+Tazobactam 4 g/500 mg NP NP ** Ertapenem 1 g/2 mL NP NP 5.10 10–4 Imipenem 500 mg NP NP ** NP: not precipitate. *:precipitation is caused by the salt of the antibiotic (sulphate). **:there is a precipitate but we do not know the antibiotic that is the cause. Material and methods We have selected the most consumed antibiotics in our university hospital and we tested them with bivalent cations commonly consumed in care services. The evaluation of the nature of the mixture was made using the solubility product of the melange of antibiotic and cation. We mix 0.5 mL of each cation solution concentrated to 5% and 0.5 mL of each antibiotic solution. Results The solubility product expressed in (mol/l)2 of the melange of each antibiotic with each cation are summarised in the table below: Conclusion Knowledge of drug interactions is essential for a better use of these drugs in hospital. Interactions of certain antibiotics commonly used with bivalent cations can lead to some precipitates undetected by nurses who administer the injectable treatments, which could cause serious accidents during the simultaneous use in patients. The summary of product characteristics of these antibiotics should incorporate these interactions to avoid those unforeseen accidents. References and/or Acknowledgements Acknowledgements to analytical chemistry team. No conflict of interest

3PC-034 Screening for physicochemical incompatibilities of cytotoxic drugs after reconstitution: the case of methotrexate

Background Physicochemical incompatibilities of parenteral drugs cause several problems in hospital practice. These incompatibilities can be represented by precipitation, complexation or colour change before or during administration to patients. Understanding these incompatibilities allow pharmacists to avoid many problems during preparation and administration. Purpose To determine physicochemical incompatibilities of a cytotoxic drug widely used in paediatric oncology (methotrexate) with certain trace elements existing in food and medicines, as well as in food supplements. Material and methods We performed several mixtures to study physicochemical reactions between methotrexate reconstituted in infusion bags (25 mg/ml) and five cations: calcium (Ca2+), copper (Cu2+), iron (bivalent and trivalent), magnesium (Mg2+) and zinc (Zn2+). An interaction was elucidated by formation of a precipitate visible to the naked eye. Infrared spectroscopy was the method of authentication of precipitates. Results Precipitates were formed with the copper, zinc, bivalent and trivalent iron. On the other hand, there was no precipitate with calcium and magnesium. Functional analysis of infrared spectra of precipitates showed the presence of methotrexate. Conclusion The study of the physicochemical incompatibilities of methotrexate can avoid possible interactions with medicines, food or nutritional supplements containing trace elements. Recording to the results, methotrexate precipitates in the presence of copper, zinc and iron ions. The absence of the precipitate or change of colour in the other mixtures does not exclude a possible complexation. Reference and/or Acknowledgements 1. Benaji B, et al. Compatibility study of methotrexate with PVC bags after repackaging into two types of infusion admixtures. Int J Pharma1994;105(1):83–87. No conflict of interest

3PC-031 The influence of dead volume on reconstitution of injectable drugs

Background Parenteral drug administration plays an important role in hospitals. It is well known that a certain amount of a drug remains at the end of the infusion and is not administered to the patient because of the dead volume: this dead volume could be the origin of an underdosing. Purpose The aim of this study is to determine the dead volume of the injectable delivery system including the serum bag, perfusion tubulure, syringe and short catheter used for the reconstitution and administration of injectable drugs, and its impact on variation of the prepared doses. Material and methods We weighed, using an analytical balance, all the medical devices (serum bag, perfusion tubulure, syringe and short catheter) used in the administration of an injectable drug before and after the passage of an antibiotic solution. We can thus determine the dead volume remaining in each material. Statistical analysis were performed with SPSS 13. 0. Results The table shows that the dead volume differed between medical devices (p<0.001). It was significant for the serum bag and perfusion tubulure, and low for syringes and short catheters. The overall dead volume is estimated at 4.5±1.7 mL.Abstract 3PC-031 Table 1 Medical device Dead volume mean± SD (mL) (n =30 ) Serum bag 2.61±1.71 Syringe 2.5 mL 0.06±0.003 Syringe 5 mL 0.07±0.003 Syringe 10 mL 0. 07±0. 003 Syringe 50 mL 0.09±0.003 Perfusion tubulure 1.74±0.02 Short catheter G22 0.01±0.001 Short catheter G24 0.01±0.003 Conclusion A considerable amount of the infusion volume, and therefore of the antibiotic, depending on the concentration, is lost at the end of the infusion due to the dead volume depending on the medical devices used as demonstrated in this study and in other studies.1 Loss of a potential amount of a drug can constitute a problem regarding safety and efficacy of therapy, especially for drugs with narrow therapeutic margins. This is especially important for the serum bag and perfusion tubulure, where the dead volume is about 2.61 mL and 1.74 mL respectively. References and/or Acknowledgements 1. Cheikh A, Rhali Y, Mefetah H, Sbai I, Mojemmi B, Draoui M, Bouatia M. The influence of the dead volume of the closed system (spike–connector–syringe) on the reconstitution of injectable drugs. Eur J Hosp Pharm24(1):A214–A216. No conflict of interest

4CPS-174 Evaluation of the knowledge of nurses in the management of pain and analgesics in a university hospital

Background Pain has become one of the most common symptoms in care settings and even outpatients. Pain is experienced preoperatively and postoperatively, and it is also felt chronically in certain pathologies such as cancers. Nurses, like other health professionals, are at the heart of the management of pain and analgesics in hospitals. Purpose The objective of our work is to make an inventory of nurses’ knowledge concerning the assessment and management of pain in hospitals in order to draw conclusions about the continuing education plans to be established for these nurses by hospital pharmacists. Material and methods A questionnaire survey was conducted in nurses (n=30) by conducting a face-to-face interview. The data were entered and analysed with SPSS 13.0. Results The majority (65%) are represented by resuscitating anaesthesiologist nurses, all of whom have already taken care of patients suffering from pain, mainly postoperative pain. Seventy per cent of participants reported that they had received training in pain management. Seventy per cent use the visual analogue scale (VAS) to evaluate the pain of their patients versus 30% who use other tools such as the Simple Numeric Scale (SNS) and Simple Verbal Scale (SVS). Sixty per cent say the 5 min duration is enough for them so they can assess a patient’s pain. Fifty five per cent of the participants have difficulties in assessing pain. Fifty five per cent find that material difficulties are an obstacle to the management of pain (dispensing of drugs, communication with patients, patient understanding of pain scale, confidence of physicians and patients). Eighty per cent of the participants express that there is no protocol for pain management at the service level. The majority of participants know that painkillers are used for pain management, but are not always aware of their availability at the hospital pharmacy and their adverse effects, negative indications and conditions of use. Conclusion The results of the study show that a training programme should be put in place by hospital practitioners in order to better inform nurses about pain management and the handling of analgesics available in the hospital pharmacy. References and/or Acknowledgements Acknowledgements to the Directorate of nurses No conflict of interest

5PSQ-130 Multiforme erythema in children: vigilance of health professionals to strengthen

Background Multiforme erythema is an acute eruptive dermatosis, sometimes recurrent, reaction to various causes of unknown mechanism, characterised by maculopapular skin lesions. It occurs at any age. Purpose The aim of this work is to assess the causality of suspected adverse drug reactions in patients with multiforme erythema. Material and methods We report two cases of multiforme erythema in children. A 10-years-old boy, without significant pathological history. The patient had flu-like symptoms treated with ibuprofen and ivy extract (product of homeopathy). Six days’ later, the patient had erythematous skin lesions spread on the back, lower limbs and face associated with fever, conjunctivitis and gingivostomatitis. The differential viral diagnosis was eliminated and the cutaneous histology revealed a toxidermia tending to a multiforme Erythema. After 21 days of hospitalisation and symptomatic treatment, the evolution was favourable. A 4-years-old girl, epileptic treated with valproic acid for 9 months and lamotrigine for 21 days. The onset of symptomatology followed the association of lamotrigine with valproic acid. After 3 weeks of combination, the patient has erythematous rash and an attack of the mucosa. The diagnosis of the multiforme erythema of drug origin was retained on the anamnestic, clinical and histological elements, and the elimination of the differential diagnosis. Following hospitalisation and symptomatic treatment, the evolution was favourable. The causality assessment of adverse drug reactions was conducted according to the French method. Results For the first case, the results showed that the intrinsic imputability is an I4 score for the two drugs and the extrinsic imputability is a B4 score for ibuprofen and B1 for the ivy extract. In the second case, lamotrigin was incriminated with an I5 and B4 imputability score. Conclusion In order to optimise the detection and the management of this toxidermia and to improve the prognosis there are two rules to follow. Close monitoring of products and drugs interactions described in the literature that may cause severe toxidermia. Early consultation of any dermatological, post-drug symptoms and hospitalisation of the patient in case of any suspicion of a link between the drug intake and the adverse effect. Reference and/or Acknowledgements 1. Moore N, et al. Adverse drug reaction monitoring: Doing it the French way. The Lancet1985;326(8463). www.who.int/medicines/areas/quality_safety/safety_efficacy/trainingcourses/2imputabilitefr.pdf No conflict of interest

5PSQ-085 The role of the pharmacist in reporting a case of lyell’s syndrome in the paediatrics hospital

Background Lyell’s syndrome is one of the most severe mucocutaneous diseases, which can be life-threatening. However, it is rare, with a child mortality rate estimated at 7.5%. Purpose We report a case of a child who developed Lyell’s syndrome after taking carbamazepine and who was aggravated by amoxicillin, and the result of the causality assessment of the adverse drugs reaction. Material and methods A 12-year-old boy with no significant pathological history presented 20 days after taking carbamazepine, conjunctivitis and cheilitis. On the same day, the child presented with a fever and rapidly widespread generalised erythematous lesions after taking amoxicillin, which led the doctor to prescribe aspirin. The lesions evolving in a context of alteration of the general state and a fever measured at 39°C, necessitated the hospitalisation of the child. The skin histology revealed a toxic epidermal necrosis leading to Lyell’s syndrome. The diagnosis of Lyell’s syndrome of drug origin was confirmed by the anamnestic, clinical and histological elements. After a hospital stay of 21 days and symptomatic treatment, the evolution was favourable. Results In response to this acute toxidermia, we conducted a drug investigation to establish the causality assesment of the adverse drugs reaction according to French pharmacovigilance rules by the Poison Control and Pharmacovigilance Centre. After eliminating any infectious origin, the results showed that the intrinsic imputability was an I2 score for carbamazepine, an I1 score for amoxicillin and the extrinsic imputability was a B4 score for both drugs. However, the occurrence of Lyell’s syndrome is probably due to the intake of carbamazepine manifested by conjunctivitis, cheilitis and influenza-like illness at the beginning of its installation, resembling an infection leading to a prescription of amoxicillin which caused an aggravation of Lyell’s syndrome, which can be further potentiated by aspirin. Conclusion This observation illustrates the importance of the awareness of pharmacists and doctors of the risks of drug prescription that can cause Lyell’s syndrome, particularly carbamazepine. Thus, management should be systematic with any post-drug dermatological symptoms in order to prevent and further reduce the incidence of this condition and to improve the vital prognosis. Reference and/or Acknowledgements 1. Roujeau, et al. Toxic epidermal necrolysis. Journal of the American Academy of Dermatology1990;23(6):1039–1058. No conflict of interest