Khalil El Asmar

Effect of postnatal home visits on maternal/infant outcomes in Syria: a randomized controlled trial.

OBJECTIVE Early postpartum home visiting is universal in many Western countries. Studies from developing countries on the effects of home visits are rare. In Syria, where the postpartum period is rather ignored, this study aimed to assess whether a community-based intervention of postnatal home visits has an effect on maternal postpartum morbidities; infant morbidity; uptake of postpartum care; use of contraceptive methods; and on selected neonatal health practices. DESIGN A randomized controlled trial was carried out in Damascus. Three groups of new mothers were randomly allocated to receive either 4 postnatal home visits (A), one visit (B), or no visit (C). SAMPLE A total of 876 women were allocated and followed up. INTERVENTION Registered midwives with special training made a one or a series of home visits providing information, educating, and supporting women. RESULTS A significantly higher proportion of mothers in Groups A and B reported exclusively breastfeeding their infants (28.5% and 30%, respectively) as compared with Group C (20%), who received no visits. There were no reported differences between groups in other outcomes. CONCLUSIONS While postpartum home visits significantly increased exclusive breastfeeding, other outcomes did not change. Further studies framed in a nonbiomedical context are needed. Other innovative approaches to improve postnatal care in Syria are needed.

Treating major depressive episodes with antidepressants can induce or worsen metabolic syndrome: results of the METADAP cohort

Recent data (1–4) show a high comorbidity between major depressive disorder and metabolic syndrome (MetS) (5), a cluster of risk factors for cardiovascular diseases and type 2 diabetes including high waist circumference, high blood pressure, hypertriglyceridemia, low high-density lipoprotein (HDL) cholesterol, and high fasting plasma glucose. In a context of increasing prescription of antidepressant medication (6) and evidence of weight gain induced by antidepressants (7), the impact of antidepressant treatment on MetS has to be clarified. Indeed, there has been no prospective study of reasonable sample size and duration addressing the incidence of MetS in patients with major depressive episode treated with antidepressants. This question was addressed in the METADAP, a 6-month prospective, multicentric, real-world treatment observational cohort study of 624 patients with a diagnosis of major depressive disorder and a current major depressive episode. Data were collected from November 2009 to March 2013 in six university psychiatry departments in France. Consecutive in- or out-patients, aged 18 to 65 years, with a current major depressive episode in a context of major depressive disorder (with a minimum score of 18 at the Hamilton Depression Rating Scale-17, HDRS-17) were assessed for MetS at the start of the index antidepressant treatment (M0), and one (M1), three (M3) and six (M6) months later. All of them provided their written informed consent. Patients with psychotic symptoms, bipolar disorders, psychotic disorders, eating disorders, current substance abuse or dependence, pregnancy, organic brain syndromes or severe unstable medical conditions were not included. Patients receiving antipsychotics or mood stabilizers before inclusion and/or for 4 months or more during the last year were also excluded. Antipsychotics, mood stabilizers and stimulants were not permitted during the study, because of their metabolic effects. Benzodiazepines at the minimum effective dose and for the minimum time period and psychotherapies were allowed. The index antidepressant treatment had to be a monotherapy. The drug and its dose were left to the treating psychiatrist, using “real world” treatment options. MetS was diagnosed according to the International Diabetes Federation definition (8). Participants had to have fasted and abstained from strenuous physical activity for 8 hours before examination. Triglycerides, HDL cholesterol and fasting plasma glucose levels were assessed using routine standardized laboratory methods. Thereafter, an assistant investigator blind to the major depression assessment measured waist circumference and blood pressure. Mixed-effects multivariate models were used, because they are a well-accepted method for analyzing longitudinal clinical data in which missing or mistimed observations are present (9). All regression models included main effects for time since initiation of current antidepressant treatment, age, gender, HDRS-17 score at baseline, lifetime duration of prior major depressive disorder, lifetime duration of prior antidepressant medication, antidepressant-free period before inclusion, and current antidepressant classes. Of 689 pre-included patients, 643 were included, of whom 19 had major deviations to the protocol. Thus, 624 patients were analyzed. Six had missing data for MetS at baseline. Patients’ mean age was 45.6±13.2 years; 68.7% were women, 87.5% were inpatients at baseline. Their mean HDRS-17 score at baseline was 24.7±5.0. Their mean number of previous major depressive episodes was 1.9±2.1. The average lifetime duration of major depressive disorder before inclusion was 11.5±12.2 years. The lifetime duration of antidepressant drug treatment before inclusion was 2.3±4.1 years. Upon inclusion, 22.7% of patients were antidepressant naive. The administered antidepressant was a selective serotonin reuptake inhibitor (SSRI) in 38.9% of cases, a serotonin norepinephrine reuptake inhibitor (SNRI) in 38.3%, a tricyclic antidepressant (TCA) in 8.8%, and another one in 14.0%. The mean duration of follow-up was 4.9±4.6 months. The drop-out rate was 25.9% before M1, 21.8% between M1 and M3, and 14.3% later. The main reasons for drop-out were antidepressant change (28.4%), prescription of antipsychotics or mood stabilizers (29.4%), and lost to follow-up (20.4%). In patients without MetS at baseline (N=442, 70.8%), the incidence of MetS was 11.7% at M3 and 16.5% at M6. This increase was significant (mixed-effect multivariate logistic regression: OR=2.29, 95% CI: 1.69-3.10, p<0.0001). It was observed within both the SSRI (0% to 16.2%, p<0.001) and the SNRI group (0% to 16.1%, p=0.001). This increase was independent from other factors, such as age, lifetime duration of prior antidepressant medication, and presence of an antidepressant-free period at baseline. The number of altered components of MetS significantly increased with time (M0: 1.2±0.9, M3: 1.3±1.1, M6: 1.5±1.2; mixed-model multivariate Poisson regression: incident risk ratio, IRR=1.06, 95% CI: 1.02-1.09, p<0.0001). It was significantly higher in patients treated with SNRIs than in those treated with SSRIs (IRR=1.45, 95% CI: 1.16-1.80, p=0.001), and it was lower amongst patients who were antidepressant-free at baseline (IRR=0.81, 95% CI: 0.65-0.99, p=0.03). These effects were independent from each other, from age and gender. In patients with MetS at baseline, mixed-effect multivariate linear regressions showed significant increases over time of supine blood pressure (M0: 123.2±16.4 mmHg, M3: 124.8±13.9 mmHg, M6: 126.8±15.0 mmHg, p<0.05) and fasting plasma glucose (M0: 0.98±0.29 g/l, M3: 1.07±0.48 g/l, M6: 1.03±0.31 g/l, p<0.01), which were independent from other factors. The highlight of this study is the early and significant incidence of MetS after initiation of treatment with antidepressants. The majority of cases occurred in the first three months of treatment. A significant worsening of MetS was also observed in patients who already had the syndrome at baseline. Taken together, these results suggest that treating major depressive episodes with antidepressants can induce or worsen MetS. Specific recommendations for the prevention of MetS in patients with major depressive disorder receiving antidepressant medication are needed. Further studies assessing the underlying mechanisms of this phenomenon are warranted.

Is self-rated health a valid measure to use in social inequities and health research? Evidence from the PAPFAM women's data in six Arab countries.

IntroductionSome evidence from high-income countries suggests that self-rated health (SRH) is not a consistent predictor of objective health across social groups, and that its use may lead to inaccurate estimates of the effects of inequities on health. Given increased interest in studying and monitoring social inequities in health worldwide, the aim of the present study was to evaluate the validity of SRH as a consistent measure of health across socioeconomic categories in six Arab countries.MethodsWe employed the PAPFAM population-based survey data on women from Morocco, Algeria, Tunisia, Lebanon, Syria, and the Occupied Palestinian Territories (OPT). Multivariate logistic regression analyses were performed to assess the strength of the association between fair/poor SRH and objective health (reporting at least one chronic condition), adjusting for available socio-demographic and health-related variables. Analyses were then stratified by two socioeconomic indicators: education and household economic status.ResultsThe association between SRH and objective health is strong in Algeria, Tunisia, Lebanon, Syria, and OPT, but weak in Morocco. The strength of the association between reporting fair/poor health and objective health was not moderated by education or household economic status in any of the six countries.ConclusionAs the SRH-objective health association does not vary across social categories, the use of the measure in social inequities in health research is justified. These results should not preclude the need to carry out other validation studies using longitudinal data on men and women, or the need to advocate for improving the quality of morbidity and mortality data in the Arab region.

Extracurricular activities associated with stress and burnout in preclinical medical students

This study aims to assess the prevalence of stress and burnout among preclinical medical students in a private university in Beirut, Lebanon, and evaluate the association between extracurricular involvement and stress and burnout relief in preclinical medical students. A cross-sectional survey was conducted on a random sample of 165 preclinical medical students. Distress level was measured using the 12-item General Health Questionnaire (GHQ-12) while that of burnout was measured through the Maslach Burnout Inventory-Student Survey (MBI-SS). The MBI-SS assesses three interrelated dimensions: emotional exhaustion, cynicism, and academic efficacy. Extracurricular activities were divided into four categories: physical exercise, music, reading, and social activities. All selected participants responded. A substantial proportion of preclinical medical students suffered from stress (62%) and burnout (75%). Bivariate and multivariate regression analyses revealed that being a female or a 1st year medical student correlated with higher stress and burnout. Music-related activities were correlated with lower burnout. Social activities or living with parents were associated with lower academic efficacy. The high stress and burnout levels call for action. Addressing the studying conditions and attending to the psychological wellbeing of preclinical medical students are recommendations made in the study.

Validation of the 10/66 Dementia Research Group diagnostic assessment for dementia in Arabic: a study in Lebanon

Objectives: In the North Africa and Middle East region, the illiteracy rates among older people are high, posing a great challenge to cognitive assessment. Validated diagnostic instruments for dementia in Arabic are lacking, hampering the development of dementia research in the region. The study aimed at validating the Arabic version of the 10/66 Dementia Research Group (DRG) diagnostic assessment for dementia to determine whether it is suitable for case ascertainment in epidemiological research. Methods: A total of 244 participants older than 65 years were included, 100 with normal cognition and 144 with mild to moderate dementia. Dementia was diagnosed by clinicians according to Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria. Depression was diagnosed using the Geriatric Mental State. Trained interviewers blind to the cognitive status of the participants administered the 10/66 DRG diagnostic assessment to the participants and interviewed the caregivers. The discriminatory ability of the 10/66 DRG assessment and its subcomponents were evaluated against the clinical diagnoses. Results: Half of the participants had no formal education and 49% of them were depressed. The 10/66 DRG diagnostic assessment showed excellent sensitivity (92.0%), specificity (95.1%), positive predictive value (PPV, 92.9%), and low false-positive rates among controls with no formal education (8.1%) and depression (5.6%). Each subcomponent of the 10/66 DRG diagnostic assessment independently predicted dementia diagnosis. The predictive ability of the 10/66 DRG assessment was superior to that of its subcomponents. Conclusion: The 10/66 DRG diagnostic assessment for dementia is well suited for case ascertainment in epidemiological studies among Arabic-speaking older population with high prevalence of illiteracy.

Performance of the 16-item informant questionnaire on cognitive decline for the elderly (IQCODE) in an Arabic-speaking older population

Background/Aim: The North African and Middle Eastern region has high illiteracy rates among older people, making direct cognitive testing challenging. Validated screening instruments for dementia in Arabic are lacking. We aimed to validate the Arabic version of the 16-item Informant Questionnaire on Cognitive Decline for the Elderly (A-IQCODE 16) for screening for dementia through an informant. Methods: 236 Lebanese participants older than 65 years, 143 with normal cognition and 93 with mild-to-moderate dementia according to the DSM-IV criteria, and their informants were recruited. Half of the participants had no formal education. Interviewers blinded to the cognitive status of the participants administered the A-IQCODE 16 to the informants. The ability of the A-IQCODE 16 to screen for dementia was evaluated against the DSM-IV diagnoses. Results: The A-IQCODE 16 had excellent overall predictive power (area under the receiver operator characteristic curve = 0.96). A cutoff point of >3.34 yielded the best sensitivity (92.5%) and specificity (94.4%) for dementia screening. At this cutoff point, the discriminatory ability of the A-IQCODE 16 was comparable between participants with and those without formal education. Conclusion: The A-IQCODE 16 is not biased by education and is therefore useful as a brief screening tool for dementia among Arabic-speaking older adults with low education.

Dementia prevalence, care arrangement, and access to care in Lebanon: A pilot study

In North Africa and the Middle East, studies about dementia prevalence are scarce. A pilot study was conducted in Lebanon to assess dementia prevalence, using the Arabic‐validated 10/66 Dementia Research Group (DRG) diagnostic assessment for case ascertainment. The study also examined care arrangement and access to care.

Malocclusion in Elementary School Children in Beirut: Severity and Related Social/Behavioral Factors

Aim. To assess severity of malocclusion in Lebanese elementary school children and the relationship between components of malocclusion and sociodemographic and behavioral factors. Methods. Dental screening was performed on 655 school children aged 6–11 from 2 public (PB) and 5 private (PV) schools in Beirut. A calibrated examiner recorded occlusion, overjet, overbite, posterior crossbite, midline diastema, and crowding. Another examiner determined the DMFT (Decayed/Missing/Filled Teeth) score. A questionnaire filled by the parents provided data on sociodemographic and behavioral factors. Multinomial, binomial, and multiple linear regressions tested the association of these factors with occlusal indices. Results. Malocclusion was more severe in PB students. Age and sucking habit were associated with various components of malocclusion. Crowding was more prevalent among males and significantly associated with the DMFT score. Income and educational level were significantly higher (P < 0.05) in PV pupils and deleterious habits were more frequent in PB children. Conclusions. Children of lower socioeconomic background had more severe malocclusions and poorer general dental health. Compared to Western and WHO norms, the findings prompt health policy suggestions to improve dental care of particularly public school children through regular screenings in schools, prevention methods when applicable, and cost effective practices through public and private enabling agencies.

Should a routine genotyping of CYP2D6 and CYP2C19 genetic polymorphisms be recommended to predict venlafaxine efficacy in depressed patients treated in psychiatric settings

AIM The antidepressant venlafaxine (VEN) is metabolized by CYP2D6 and CYP2C19. The aim of this study was to assess the relevance of generalizing to daily practice the genotyping of CYP2D6 and CYP2C19 to predict VEN efficacy in depressed patients treated in psychiatric settings. PATIENTS & METHODS This study was nested in a naturalistic cohort, with 206 patients requiring a new antidepressant treatment and genotyped for CYP2D6 *3, *4, *5 del, *6, *2xN, *10, *41 and CYP2C19 *2, *3, *4, *5, *17 alleles. RESULTS CYP2D6 and CYP2C19 phenotypes were associated neither with the Hamilton depression rating scale score improvement, nor with response and remission. CONCLUSION Routine CYP2D6 and CYP2C19 genotyping cannot be recommended to predict VEN efficacy in depressed patients treated in psychiatry settings.

Severe insomnia is associated with hypertriglyceridemia in women with major depression treated in psychiatry settings

BACKGROUND Hypertriglyceridemia (HTG) is a cardiovascular risk factor. In the general population, elevated fasting triglyceridemia (TG) is associated with insomnia. Since insomnia is a core symptom of Major Depressive Episodes (MDE), we studied the association of severe insomnia with HTG in major depression. METHODS We used the baseline data of the METADAP cohort, comprising 624 patients with a current MDE in a context of Major Depressive Disorder treated in psychiatry settings, without current alcohol use disorders. Patients were screened for severe insomnia, defined by a score of four or more on the three Hamilton Depression Rating Scale (HDRS) sleep items, and for HTG characterised by TG≥200mg/dL. RESULTS Severe insomnia was observed in 335(54%) patients with a current MDE, of whom 234(70%) were women; 49(8%) patients had HTG, of whom 25(51%) were women. 69(11%) patients were treated with lipid-lowering drugs. Severe insomnia was associated with a higher frequency of HTG in the whole sample (9.9% vs 5.6%, p=0.046) and in the subgroup of women (9.0% vs 2.0%, p=0.002). Multivariate logistic regression analyses adjusted for age, education levels, BMI and total HDRS scores confirmed the association between severe insomnia and HTG in the whole sample (OR=2.02, 95%CI [1.00-4.08], p=0.05) as well as in the subgroup of women (OR=4.82, 95%CI [1.5-15.5], p=0.008). No association was shown in men. PERSPECTIVES HTG should be systematically investigated in depressed patients with severe insomnia and particularly in women. Further studies are needed to explain the association we observed between severe insomnia and HTG.