Rapid tranquillisation in a psychiatric emergency hospital in Lebanon: TREC-Lebanon - a pragmatic randomised controlled trial of intramuscular haloperidol and promethazine v. intramuscular haloperidol, promethazine and chlorpromazine.

BACKGROUND: Agitated patients constitute 10% of all emergency psychiatric treatment. Management guidelines, the preferred treatment of clinicians differ in opinion and practice. In Lebanon, the use of the triple therapy haloperidol plus promethazine plus chlorpromazine (HPC) is frequently used but no studies involving this combination exists. METHOD: A pragmatic randomised open trial (September 2018-July 2019) in the Lebanese Psychiatric Hospital of the Cross in Beirut Lebanon involving 100 people requiring urgent intramuscular sedation due to aggressive behaviour were given intramuscular chlorpromazine 100 mg plus haloperidol 5 mg plus promethazine 25 mg (HPC) or intramuscular haloperidol 5 mg plus promethazine 25 mg. RESULTS: Primary outcome data were available for 94 (94%) people. People allocated to the haloperidol plus promethazine (HP) group showed no clear difference at 20 min compared with patients allocated to the HPC group [relative risk (RR) 0.84, 95% confidence interval (CI) 0.47-1.50]. CONCLUSIONS: Neither intervention consistently impacted the outcome of 'calm', or 'asleep' and had no discernible effect on the use of restraints, use of additional drugs or recurrence. If clinicians are faced with uncertainty on which of the two intervention combinations to use, the simpler HP is much more widely tested and the addition of chlorpromazine adds no clear benefit with a risk of additional adverse effects.

Are eating disorders associated with bipolar disorder type I? Results of a Lebanese case-control study.

OBJECTIVES: To assess the association between disordered eating and bipolar disorder (BD). METHODS/DESIGN: A case-control study, conducted between April and September 2018, enrolled 50 patients and 50 controls. RESULTS: Higher eating attitude test scores were significantly associated with the presence of BD. This association remained after the introduction of other factors (marital status, family history of BD, shopping and gambling addictions, sleep quality, and insomnia severity) that were also associated with the presence of BD. PRACTICAL IMPLICATIONS: This study suggested that eating disorders are associated with BD type I, independent of mediating factors. Health care providers should consider pharmacological or psychotherapeutic interventions that could treat both syndromes sparingly.

Factors associated with anxiety disorders among patients with substance use disorders in Lebanon: Results of a cross-sectional study.

OBJECTIVES: Estimate the rate of anxiety disorders (AD) and associated factors among patients with substance use disorder (SUD) in Lebanon. METHODS: A cross-sectional study, conducted between April and September 2017, enrolled 57 inpatients with SUD. RESULTS: The rate of AD in patients with SUD was 61.4%. The university level of education compared to the primary level of education (ORa = 0.221) was significantly associated with lower anxiety among patients with SUD. Being sexually abused and having a family history of depression tended to significance. PRACTICAL IMPLICATIONS: AD is widespread in Lebanon and high rates of anxiety in patients with SUD were found, warranting the implementation of strategic interventions and establishing national policies and legislation for mental health services to provide optimal care.

Identification of Factors Affecting the Quality of Life Among Patients With Addiction in Lebanon.

Our objective was to assess factors associated with the physical (Short-Form 12-physical component summary [SF-12-PCS]) and mental (Short-Form 12-mental component summary [SF-12-MCS]) quality of life (QOL) in the Lebanese population. A cross-sectional study, conducted between July and September 2017, enrolled 57 patients with substance use disorder from the Psychiatric Hospital of the Cross. The SF-12 scale was used to assess the QOL among participants. A first stepwise linear regression, using the SF-12-PCS score as the dependent variable, showed that females compared with males (ß = -4.86) and having a family history of substance use disorder (ß = -4.70) were associated with lower physical QOL (lower SF-12-PCS scores). A second stepwise linear regression, using the SF-12-MCS score as the dependent variable, showed that having a generalized anxiety disorder (ß = -10.52) and having suicidal ideation (ß = -8.05) were associated with lower mental QOL (lower SF-12-MCS scores). Strategic interventions are needed to manage the health-related QOL in those with substance abuse.

Affective temperaments in Lebanese people with substance use disorder.

PURPOSE: To examine these temperaments among patients with substance use disorder (SUD) in the Lebanese population. DESIGN: Case-control. METHODS: Fifty-seven controls and 57 patients with SUD were enrolled between April and September 2017. RESULTS: A significantly higher mean of depressive, irritable, and anxious temperaments was found in addicted patients as compared with the nonaddicts. However, the results of the multivariate analysis showed that anxious, hyperthymic, irritable temperaments would significantly increase the odds of addiction in participants (ORa = 25.20, 1.057, 1.168, 1.241, and 1.275). Cyclothymic temperament would significantly decrease the odds of addiction in participants (ORa = 0.817). Furthermore, suicidality was associated with depressive, anxious, and irritable temperaments. PRACTICE IMPLICATIONS: Hyperthymic, irritable, and anxious temperaments were the main temperaments found in patients with SUD in Lebanon.

Study protocol for a randomised controlled trial of haloperidol plus promethazine plus chlorpromazine versus haloperidol plus promethazine for rapid tranquilisation for agitated psychiatric patients in the emergency setting (TREC-Lebanon).

Background: Agitated and aggressive behaviours are common in the psychiatric setting and rapid tranquilisation is sometimes unavoidable. A survey of Lebanese practice has shown that an intramuscular haloperidol, promethazine and chlorpromazine combination is a preferred form of treatment but there are no randomised trials of this triple therapy. Methods: This is a pragmatic randomised trial. Setting - the psychiatric wards of the Psychiatric Hospital of the Cross, Jal Eddib, Lebanon. Participants - any adult patient in the hospital who displays an aggressive episode for whom rapid tranquilisation is unavoidable, who has not been randomised before, for whom there are no known contraindications. Randomisation - stratified (by ward) randomisation and concealed in closed opaque envelope by independent parties. Procedure - if the clinical situation arises requiring rapid tranquilisation, medical residents overseeing the patient will open a TREC-Lebanon envelope in which will be notification of which group of treatments should be preferred [Haloperidol + Promethazine + Chlorpromazine (HPC) or Haloperidol + Promethazine (HP)], along with forms for primary, secondary and serious adverse effects. Treatment is not given blindly. Outcome - primary outcome is calm or tranquil at 20 minutes post intervention. Secondary outcomes are calm/tranquil at 40, 60 and 120 minutes post intervention, asleep, adverse effects, use of straitjacket and leaving the ward. Follow-up will be up to two weeks post randomisation. Discussion: Findings from this study will compare the HPC versus HP combination used in Lebanon's psychiatry emergency routine practice. Trial registration: ClinicalTrials.gov NCT03639558. Registration date, August 21, 2018.

Managing acutely aggressive or agitated people in a psychiatric setting: a survey in Lebanon.

Background: Violent patients constitute 10% of all psychiatric admissions. Treatment options and clinical practice interventions vary across the globe and no survey of practice in a Middle Eastern setting exists. Surveying treatments in Lebanon will show treatment interventions used in this part of the world and, most importantly, provide the treatment options that could potentially be used for clinical trials pertaining to emergency psychiatry. Methods: A survey of clinicians' opinions and practice was conducted between July and August 2017 at the largest psychiatric hospital in Lebanon. Results: Five of seven experienced psychiatrists provided opinions when interviewed of their preferred intervention when dealing with an emergency psychiatric episode. Whilst this varied in detail, there was a consistent view that there should first be verbal control, then use of medications, and finally physical restrain of the patient. A total of 39 emergency episodes (28 people) occurred in the one month (64% men in their 30s). Bipolar disorder was the most frequent single diagnosis behind the aggression (n=16, 41%; 12 people 43%) but the combined schizophrenia-like illnesses underlay 18 of the 39 episodes (46%; 13/28 people 46%). In clinical life, we found evidence of high family involvement, but little attempts made at initial verbal control in the hospital. All 39 episodes involved administration of pharmacological interventions. Medications were used in 29 of cases (74%) and non-medication interventions used in the remaining 10/39 (26%). Conclusion: This survey provides some evidence that clinicians' preferences may not fully reflect clinical practice but also that experienced clinicians are using several clearly effective techniques to manage these very difficult situations. However, as for other parts of the world, treatment in Lebanon has limited or no underpinning by evidence from well-designed, conducted and reported evaluative studies.

Impact of psychosis in bipolar disorder during manic episodes.

OBJECTIVES: To evaluate the effect of psychosis on prognosis as measured by the course of a manic episode, symptoms severity and time to remission and identify existing differences in positive and negative symptoms between psychotic and non-psychotic patients. STUDY DESIGN: 40 bipolar patients presenting with a diagnosis of acute mania were enrolled (18 psychotic patients and 22 non-psychotic patients) in this cross-sectional study. Subjects were required to complete two self-reported questionnaires, the Young Mania Rating Scale (YMRS) for manic symptoms, and Positive and Negative Symptoms Scale (PANSS) for psychotic symptoms. Rating scales were administered at baseline and then again after three weeks of pharmacologic treatment. RESULTS: There were no differences in socio-demographic characteristics between psychotic and non-psychotic subjects. Psychosis was associated with higher scores on the YMRS and PANSS (increased symptoms severity), compared to non-psychotic patients. Both groups demonstrated clinical improvement and remission, with scores amongst psychotic patients remaining higher. Groups were similar in symptomatology except with regards to psychotic symptoms (the content, insight, delusions, hallucinations, grandiosity, poor rapport and unusual thoughts). CONCLUSIONS: Psychosis can be considered a severity index in bipolar disorder, with decreased severity and overall clinical improvement and remission taking place in response to pharmacotherapy.

Risk Factors for Salmonella, Shiga Toxin-Producing Escherichia coli and Campylobacter Occurrence in Primary Production of Leafy Greens and Strawberries.

The microbiological sanitary quality and safety of leafy greens and strawberries were assessed in the primary production in Belgium, Brazil, Egypt, Norway and Spain by enumeration of Escherichia coli and detection of Salmonella, Shiga toxin-producing E. coli (STEC) and Campylobacter. Water samples were more prone to containing pathogens (54 positives out of 950 analyses) than soil (16/1186) and produce on the field (18/977 for leafy greens and 5/402 for strawberries). The prevalence of pathogens also varied markedly according to the sampling region. Flooding of fields increased the risk considerably, with odds ratio (OR) 10.9 for Salmonella and 7.0 for STEC. A significant association between elevated numbers of generic E. coli and detection of pathogens (OR of 2.3 for STEC and 2.7 for Salmonella) was established. Generic E. coli was found to be a suitable index organism for Salmonella and STEC, but to a lesser extent for Campylobacter. Guidelines on frequency of sampling and threshold values for E. coli in irrigation water may differ from region to region.

Impact of maximum levels in European legislation on exposure of mycotoxins in dried products: case of aflatoxin B1 and ochratoxin A in nuts and dried fruits.

In this study the impact of setting European criteria on exposure to aflatoxin B1 via nuts and figs and ochratoxin A via dried fruits is evaluated for the Belgian population, as an example of the European population. Two different scenarios were evaluated. In scenario 1 all collected literature data are considered, assuming that there is no border control nor legal limits in Europe. In the second scenario, contamination levels above the maximum limits are excluded. The results from scenario 1 demonstrated that if no regulation is in place, AFB1 and OTA concentrations reported in the analysed food can have potential health risk to the population. The estimated exposure of OTA for scenario 2 is below the TDI of 5 ng/kg BW⋅day, indicating that OTA concentrations accepted by EU legislation pose a low risk to the Belgian population. For AFB1, the MOE values of scenario 2 are above 10,000 and can be considered to be of low health concern, based on BDML10 for humans, except for figs (MOE = 5782). This means that for all matrices, with exception of figs, the maximum values of AFB1 in the European legislation are sufficient to be of a low health concern for consumers.