Burnout rates among Lebanese pre-final and final year medical students during the COVID-19 pandemic: A multi-centered survey-based study

BACKGROUND

Burnout among medical students has always been a major concern.

OBJECTIVE

To evaluate changes in the prevalence rates of burnout among Lebanese pre-final and final year medical students while taking into consideration the impact of coronavirus 2019 (COVID-19) on both the academical and clinical experiences.

METHODS

This is a multi-centered, survey-based, cross-sectional study conducted in October 2021. The Copenhagen Burnout Inventory questionnaire was used on 120 medical students from three different medical schools in Lebanon.

RESULTS

The overall burnout prevalence was 40.01%. When further dividing it into domains, 39.36% of students had personal burnout, 41.52% had work-related burnout, and 39.16% had pandemic-related burnout. Theoretical learning and clinical training were reported to be affected in respectively 66.70% and 71.70%. However, only 10.00% of the students have regretted choosing medicine and 67.50% felt comfortable to get to the next academic level.

CONCLUSION

High levels of burnout were reported among pre-final and final year medical students with a subsequent negative impact on their academic life and clinical training. Medical schools should start adopting a conscious view of how to guide medical students in finding adequate coping mechanisms during these times of crisis.

AB0846 HLA-B51 prevalence in patients with spondyloarthritis and impact on disease phenotype: a case-control study

Background

Spondyloarthritis (SpA) is a group of rheumatic diseases with a heritable component associated with Human Leucocyte Antigen B27 (HLA-B27). Although many studies have reported an overlap between the clinical features of SpA and Behcet’s disease (BD), as well as an increased prevalence of HLA-B27 in BD, the prevalence of HLA-B5 (namely B51 and B52, the split antigens of B5) in SpA, have been scarcely examined, particularly in countries with a low HLA-B27 prevalence.

Objectives

To estimate the prevalence of HLA-B51 and HLA-B52 in patients with SpA compared to healthy controls (HC), to identify the alleles found in HLA-B locus in patients with SpA compared to HC, and to evaluate the impact of HLA-B51 on SpA disease phenotype.

Methods

A case-control study included consecutive patients with a diagnosis of SpA (axial SpA (axSpA), peripheral SpA (pSpA), and psoriatic arthritis (PsA)) from three rheumatology clinics. HC were recruited among blood donors and medical students. Demographic data, as well as SpA and BD disease features, were collected through an interview with a trained medical student and file review (low back pain, peripheral joint disease, enthesitis, dactylitis, psoriasis, uveitis, inflammatory bowel disease, family history, oral and genital ulcerations, skin, vascular and neurologic manifestations, CRP, BASDAI, imaging of the spine and sacroiliac joints). The entire B locus was tested using molecular biology technique on Luminex with the possibility of precise B51/B52 differentiation. The prevalence of HLA-B51/B52 was calculated in patients and compared to HC using the Chi-square test. A complete HLA-B mapping was performed for patients and HC. A binary logistic regression identified factors associated with HLA-B51 in patients with axSpA.

Results

Data from 119 HC and 89 patients with SpA were available (66 axSpA, 16 pSpA, and 7 PsA). Mean age of the patients was 44.8 years [SD 13.5], 66.3% were males, disease duration was 12 years [SD 12.7], 72.4% had a history of elevated CRP, 30.3% were positive for HLA-B27, 53.9% had sacroiliitis on MRI, 47.2% had radiographic sacroiliitis, and 23.6% had syndesmophytes. Oral ulcerations were reported in 38.2% of patients, genital ulcerations in 3.4%, uveitis in 5.6%, skin lesions in 18%, and vascular lesions in 3.4%. Patients with SpA fulfilled the classification criteria for BD in 2.9% (International Study Group criteria for BD) and 38.2% (International Criteria for BD). HLA-B51/B52 were found more frequently in patients with SpA (20.2%/ 7.9%) compared to HC (11.8%/4.2%), although the difference was not statistically significant. The difference was mainly driven by ant association between HLA-B51 and axSpA (27.2% versus 11.8%, OR 2.8 [95%CI 1.3-6.1], p=0.008) (Table 1). The most frequent allele in SpA and HC was HLA-B35; complete HLA-B mapping is shown in Figure 1. In patients with axSpA, HLA-B51 was associated with radiographic damage in peripheral joints, while it was negatively associated with sacroiliitis. Uveitis was numerically associated with HLA-B51, but the association did not reach statistical significance.

Table 1.

Prevalence of HLA-B5 genes in patients with spondyloarthritis (SpA) and healthy controls

ControlsSpAAxial SpAPeripheral SpAPsoriatic Arthritisp-value (SpA vs. Controls)p-value (axSpA vs controls)N1198966167HLA-B51+, N (%)14 (11.8)18 (20.2)18 (27.3)0 (0.0)0 (0.0)0.0940.008HLA-B52+, N (%)5 (4.2)7 (7.9)5 (7.6)2 (12.5)0 (0.0)0.2620.331HLA-B51 or HLA-B52+, N (%)19 (16)21 (23.6)19 (28.8)2 (12.5)0 (0.0)0.1670.039Figure 1.

Distribution of the HLA-B alleles in patients with spondyloarthritis and healthy controls (Statistically significant differences between patients and controls indicated with*)

Conclusion

HLA-B51/B52 were more numerically more prevalent in patients with SpA compared to HC. A statistically significant association was found between HLA-B51 and axSpA and correlated with more peripheral and less axial radiographic involvement.

Acknowledgements

The authors would like to thank the Research Council of Saint-Joseph University and NewBridge Pharmaceuticals FZ LLC for an unrestricted research grant to fund the study.

Disclosure of Interests

Nelly Ziade Speakers bureau: Roche, Abbvie, Eli Lilly, Pfizer, Janssen, Novartis, Pierre Fabre, Apotex, Pharmaline, Paid instructor for: Abbvie, Eli Lilly, Sanofi-Aventis, Pfizer, Janssen, Novartis, Grant/research support from: NewBridge Pharmaceutical FZ LLC (current study), Pfizer, Abbvie, Celgene, Rhea Nacouzi: None declared, Kamel Mroue’ Speakers bureau: Roche, Abbvie, Eli Lilly, Pfizer, Janssen, Novartis, Georges Merheb Speakers bureau: Roche, Abbvie, Eli Lilly, Pfizer, Janssen, Novartis, Pierre Ghorra: None declared

POS0275-HPR CONCORDANCE BETWEEN THE PHYSICIAN’S AND THE NURSE’S ASSESSMENT OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS USING DAS-28, CDAI AND SDAI IN SEVEN MIDDLE EASTERN ARAB COUNTRIES

Background:

Managing patients with chronic rheumatic diseases is increasingly relying on the collaboration of a multidisciplinary team, including the rheumatology nurse who can aid assessment of disease activity among other healthcare tasks.

However, this practice, although common in Europe and North America, is still poorly implemented in the Middle eastern Arab countries (MEAC).

Objectives:

To evaluate the concordance between the physician’s and the nurse’s assessment of disease activity in patients with rheumatoid arthritis (RA) in the MEAC.

Methods:

During a routine patient visit to one of 9 rheumatology clinics located in 7 Middle Eastern Arab countries, the physician and the rheumatology nurse (who was already working in the clinic) performed the disease activity score 28 (DAS), Clinical Disease Activity Index (CDAI) and Simple Disease Activity Index (SDAI) in a blinded manner. The concordance regarding the 3 continuous scores was calculated using paired t-test. The agreement between physician- and nurse-DAS categories (remission, low, moderate and high disease activity) was calculated using weighted kappa for category comparison. Predictive factors of positive concordance between physician- and nurse-DAS were identified using binary logistic regression.

Results:

The study included 373 patients’ measurements over a period of two years (2018 to 2019). The mean age of the patients was 49.6 years (±28.2), 82.6% were females, and the mean disease duration was 11.3 years (±7.5).

The mean physician-DAS was slightly higher (3.97 (±1.52)) than the nurse-DAS (3.90 (±1.54)) (p=0.002), with a mean difference of +0.08 [95%CI 0.03; 0.12] (Table 1). The difference in the DAS individual items, the CDAI and the SDAI were not statistically significant.

Table 1.

Comparison of the disease activity measures reported by the physician and by the nurse.

PhysicianNursep-valueTotal Joint Count4.87 (2.26)5.02 (6.20)0.152Swollen Joint Count2.13 (3.88)2.15 (3.83)0.790Global Assessment3.30 (2.41)3.32 (2.43)0.702DAS-283.97 (1.52)3.90 (1.54)0.002CDAI14.26 (12.53)14.38 (12.59)0.515SDAI21.51 (23.57)21.61 (21.66)0.527

When analyzing DAS as a categorical 4-items variable, the agreement between the physician and the nurse was present in 79.36% of the cases (weighted kappa was 0.77 [95%CI 0.73;0.83] which is considered as excellent, and was higher in patients with high disease activity (Figure 1).

A positive concordance between the physician- and the nurse-DAS was associated with the country (higher in Egypt, p<0.001) and the status of higher disease activity (p<0.001).

Conclusion:

The agreement between the DAS-28 performed by the physician and by the nurse was excellent and was associated with the country and a higher disease activity. The present study confirms that the support of a trained nurse for evaluating disease activity in RA is feasible in the Arab countries and may save some valuable time in the clinic, whilst maintaining the quality of care for patients with RA.

Figure 1.

Agreement between physician- and nurse-DAS categories

Acknowledgements:

The authors would like to acknowledge the patients for participating in the study and the assistants/ students/ nurses who assisted in the data collection: Dr. Fatima Abdul Majeed Al Hawaj, M. Atef Ahmed, M. Mohammad Alhusamiah, Ms Raquel De Guzman, Ms Lina Razzouk.

Disclosure of Interests:

None declared

AB0104 CONCORDANCE BETWEEN THE PHYSICIAN’S AND THE PATIENT’S ASSESSMENT OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS: RESULTS OF THE AUTODAS-MEAC STUDY AT ONE YEAR

Background:

Involving the patients with rheumatoid arthritis (RA) in the assessment of their disease may increase their adherence to treatment, improve the disease outcomes and facilitate the application of telehealth. We previously reported an excellent concordance between the Disease Activity Score (DAS-28) performed by physicians and patients at the baseline visit of this prospective study (1).

Objectives:

To evaluate the persistence of the concordance between the physician’ and the patient’s assessment of disease activity in RA using DAS-28 after one year.

Methods:

At the baseline visit, patients with RA from 7 Middle Eastern Arab Countries (MEAC) were briefed about DAS-28 by their rheumatologist during a routine consultation and given smartphone access to a video in Arabic language explaining the performance of DAS-28. At 3, 6 and 12 months (± 3 months), the patients were asked to self-report DAS-28, blinded to the physician’s assessment. Concordance between the continuous DAS-28 at each visit was calculated using paired t-test numerically and the Bland-Altman method graphically. Agreement between physician- and patient-DAS categories (remission, low-, moderate- and high disease activity) was calculated at each visit using weighted kappa for category comparison. Weighted kappa of the different agreements were compared over time using their respective confidence intervals (CIs). Predictive factors of positive concordance between physician and patient-DAS were identified using binary logistic regression.

Results:

The study included 428 patients over a period of three years (2018 to 2020). The mean age of participants was 49.8 years, 82.5% were females, 44.3% had a university degree and the mean disease duration was 11.4 years.

At baseline, the average patient-DAS was higher (4.06 (±1.52)) than the physician-DAS (3.97 (±1.52)). The mean difference was -0.09 [95%CI -0.14; -0.04] and most of the pairs were within the limit of agreement in the Bland-Altman graph, indicating a good concordance, particularly in cases of remission.

During the study follow-up, 299 patients consulted for visit 2 (69.9% of the total population), 232 for visit 3 (54.2%) and 199 for visit 4 (46.5%). The weighted kappa was 0.80 [95%CI 0.76;0.85] at visit 1 and 0.79 [95%CI 0.72;0.88] at visit 4 (Figure 1 showing kappa for DAS-28, CDAI and SDAI as well). A minor numerical decrease in kappa was observed over time; however, the CIs were overlapping over the four visits and the agreement was considered stable, remaining in the excellent range. At visit 4, a positive concordance between the physician- and the patient-DAS was associated with the profession (lower in blue collar, p=0.001), the educational level (higher in high school and university, p=0.034) and the baseline physician’s DAS (higher in high disease activity, p=0.46).

Conclusion:

The agreement between the DAS-28 performed by the physician and by the patient was excellent at baseline and remained stable over one year. A positive concordance was associated with the profession, the educational level and the level of disease activity. The present study can help the rheumatologist make informed decisions about the patients who may be suitable for a remote evaluation of their disease activity, that can be of particular interest in the context of the COVID-19 pandemic.

References:

[1]Ziade N, Saad S, al Mashaleh M, et al. Perceptions of Patients with Rheumatoid Arthritis about Self-Assessment of Disease Activity after Watching an Educational Video: Qualitative Pilot Results from the Auto-DAS in Middle Eastern Arab Countries Study [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 10).

Acknowledgements:

The authors would like to acknowledge the patients for participating in the study and the assistants/ students/ nurses who assisted in the data collection: Dr. Fatima Abdul Majeed Al Hawaj, M. Atef Ahmed, M. Mohammad Alhusamiah, Ms Raquel De Guzman, Ms Lina Razzouk.

Disclosure of Interests:

None declared

Development of an Educational Video for Self-Assessment of Patients with RA: Steps, Challenges, and Responses

Objectives:

The primary objective was to develop an educational video to teach patients with rheumatoid arthritis (RA) self-assessment of their disease activity. Secondary objectives were to validate the video, identify the challenges in producing it, and the responses to these challenges.

Methods:

Rheumatologists from 7 Middle Eastern Arab countries (MEAC) discussed unmet needs in the education of patients with RA. They reviewed pre-existing educational audiovisual material and drafted the script for a new video in Arabic. The video was produced in collaboration with a technical team, then validated by patients using a standardized interview. At each step of production, challenges were identified.

Results:

Twenty-three rheumatologists from MEAC identified unmet needs in patients’ education. A video was produced, explaining the concepts of treat-to-target and showing a patient performing self-assessment using DAS-28. Sixty-two patients were interviewed for validation and found the video to be useful and easy to understand, albeit not replacing the physician’s visit. Most common challenges encountered included acceptance of patient empowerment, agreement on DAS-28 as composite measure, production of a comprehensible written Arabic text, and addressing the population cultural mix.

Conclusion:

Despite challenges, the video was well accepted among patients and can be used for clinical and research purposes. It is particularly useful in pandemic periods where social distancing is recommended.

Prevalence and pattern of comorbidities in chronic rheumatic and musculoskeletal diseases: the COMORD study

Increased risk of comorbidities has been reported in Rheumatic and Musculoskeletal Diseases (RMD). We aimed to evaluate the prevalence and pattern of comorbidities in RMD patients nationwide, to identify multimorbidity clusters and to evaluate the gap between recommendations and real screening. Cross-sectional, multicentric nationwide study. Prevalence of comorbidities was calculated according to six EULAR axes. Latent Class Analysis identified multimorbidity clusters. Comorbidities' screening was compared to international and local recommendations. In 769 patients (307 RA, 213 OA, 63 SLE, 103 axSpA, and 83 pSA), the most frequent comorbidities were cardiovascular risk factors and diseases (CVRFD) (hypertension 36.5%, hypercholesterolemia 30.7%, obesity 22.7%, smoking 22.1%, diabetes 10.4%, myocardial infarction 6.6%), osteoporosis (20.7%) and depression (18.1%). Three clusters of multimorbidity were identified: OA, RA and axSpA. The most optimal screening was found for CVRF (> = 93%) and osteoporosis (53%). For malignancies, mammograms were the most optimally prescribed (56%) followed by pap smears (32%) and colonoscopy (21%). Optimal influenza and pneumococcus vaccination were found in 22% and 17%, respectively. Comorbidities were prevalent in RMD and followed specific multimorbidity patterns. Optimal screening was adequate for CVRFD but suboptimal for malignant neoplasms, osteoporosis, and vaccination. The current study identified health priorities, serving as a framework for the implementation of future comorbidity management standardized programs, led by the rheumatologist and coordinated by specialized health care professionals.

Added Value of Anti-CD74 Autoantibodies in Axial SpondyloArthritis in a Population With Low HLA-B27 Prevalence

Axial spondyloarthritis (axSpA) is often diagnosed late due to the non-specific nature of its main symptom [chronic back pain (CBP)] and to the paucity of diagnostic markers, particularly in regions with low HLA-B27 prevalence, such as the Middle-East. We tested the performance of IgG4 and IgA anti-CD74 antibodies as an early diagnostic marker for axSpA, compared with the performance of HLA-B27, in Lebanon. Sera of axSpA patients diagnosed by the rheumatologist and also fulfilling the imaging arm of the ASAS criteria (patients) and of blood donors (BD) (controls) were analyzed for HLA-B27, IgG4 and IgA anti-CD74, blinded to clinical characteristics. Receiver Operating Characteristic curves were constructed to identify an optimal cut-off point for anti-CD74 antibodies. Diagnostic properties were calculated (sensitivity, specificity, positive, and positive predictive values (PPV, NPV), Likelihood ratios) for each marker. Forty-nine axSpA patients and 102 BD were included in the final analysis. IgA anti-CD74 correlated poorly with axSpA (Area Under the Curve (AUC) 0.657), whereas IgG4 anti-CD74 had a good discriminative value (AUC 0.837). Respectively, for HLA-B27, IgG4 anti-CD74, and the combination of both, we found a sensitivity of 33-92-33%, specificity of 96-79-98%, PPV 80-68-89%, NPV 75-95-75%, and LR+ 8.2-4.4-16.5. IgG4 anti-CD 74 were positive in 88% of HLA-B27 negative axSpA patients, and correlated with BASDAI. In this first study in a population with low HLA-B27 prevalence, IgG4 anti-CD74 antibodies combined with HLA-B27 showed higher diagnostic value than HLA-B27 alone for early axSpA. IgG4 anti-CD74 should be considered for further evaluation as an early axSpA diagnostic marker in future dedicated research, particularly in patients with CBP.

HLA-B27 prevalence in axial spondyloarthritis patients and in blood donors in a Lebanese population: Results from a nationwide study

AIM

To calculate the prevalence of human leukocyte antigen (HLA)-B27 in axial spondyloarthritis patients (axSpA) compared to blood donors (BD) in Lebanon, to identify the clinical and radiological findings associated with HLA-B27 and to estimate the proportion of patients fulfilling the clinical arm of the Assessment of the Spondyloarthritis International Association (ASAS) criteria.

METHOD

Consecutive Lebanese adult axSpA patients fulfilling the ASAS classification criteria were included from 12 rheumatology clinics across Lebanon. BD served as controls. A binary logistic regression was used to study the association between HLA-B27 and the disease features.

RESULTS

A total of 247 individuals were included (141 axSpA patients and 106 BD). The prevalence of HLA-B27 was 3.8% in BD and 41.1% in axSpA. Overall, 39.7% of the axSpA patients fulfilled the clinical arm of the ASAS classification criteria. Sensitivity of HLA-B27 for axSpA was 41.1%, specificity was 96.2%, positive predictive value was 93.6%, and negative predictive value was 55.13%. Positive likelihood ratio (LR) was 10.9 and negative LR was 1.63. We found a positive association of HLA-B27 with family history of SpA and psoriasis.

CONCLUSION

Our study confirmed a low prevalence of HLA-B27 in axSpA patients and BD in this Lebanese population, However, we found a high specificity and positive LR, as well as the same number of axSpA patients fulfilling the clinical arm of the ASAS criteria as in European studies. HLA-B27 is therefore valuable for identification of axSpA in Lebanese patients despite the overall low prevalence in this population. Our results may guide future evaluations the role of HLA-B27 in planning local referral strategies.

Patient preferences for rheumatoid arthritis treatments: results from the national cross-sectional LERACS study

INTRODUCTION

To investigate the treatment preferences of patients with rheumatoid arthritis (RA) and determine whether these preferences are related to specific disease characteristics.

METHOD

A national survey was designed to collect demographic, disease, treatment, and preference data on RA patients enrolled in 7 private and university hospital clinics in Lebanon. Associations between patient factors and treatment preferences for RA were analyzed by χ² or Mann-Whitney U test.

RESULTS

A total of 693 patients (83% female; 67% aged 41-70 years) consulting 7 trained rheumatologists completed the survey. Most patients (80%) had established RA >24 months, and approximately one-third (34%) were in remission according to the disease activity score in 28 joints (DAS28). Most (87%) were receiving oral agents (60% oral only). Almost two-thirds of patients (64%) expressed a preference for oral treatments, and more than half (53%) ranked doctor's advice as the most influential factor when choosing treatment. In univariable analysis, health coverage, radiographic damage, disease duration, current therapy, and previous side effects were significantly associated with treatment preference. In multivariable analyses, only radiographic damage and current route of administration were independently associated with preference (both P<0.001), with patients with no radiographic damage and those on oral-only therapy being more likely to prefer oral agents.

CONCLUSION

RA patients expressed a preference for oral rather than subcutaneous/intravenous-administered drugs. Understanding patients' preferences may help to inform policymaker decisions.

Severity of rheumatoid arthritis: the SEVERA study

This study aims to assess the severity of rheumatoid arthritis (RA) in rheumatology practice in our population. All outpatients and inpatients with RA seen by registered rheumatologists over a 1-year period were included. Severity was measured using the Larsen score for hands and wrists and the Modified Health Assessment Questionnaire (M-HAQ). Two hundred ninety-eight RA cases were included. Mean age was 51.5 years. Among them, 261 (87.6%) were females. Disease duration was less than a year in 26 subjects (8.7%) and 10 years and above in 108 (36.2%) with a mean of 8.9. There were 220 (73.8%) subjects who had M-HAQ score <1. In 61 (20.5%) subjects, M-HAQ score was > or =1 and <2, and 17 (5.7%) had M- HAQ score > or =2. In relation with disease duration, M-HAQ starts with an average (SD) value of 0.7 (0.6) during the first year, decreases to 0.4 (0.4) at 5-year disease duration and increases after 10 years of disease progression to an average of 0.9 (0.8). Mean (SD) Larsen score was 51.9 (29.5) and median was 45. A total of 25% had a Larsen score > or =50% of maximum. Larsen score increased significantly (p<0.0001) with disease duration, starting at an average (SD) of 36.1 (14.9) during the first year, rising to 42.5 (15.8) around 5 years and reaching 73.9 (36.9) after 10 years. RA severity in our practice is comparable to that reported in Western populations in terms of radiological damage; however, functional status differs, possibly reflecting cultural differences.