Psychometric validation of the Arabic multiple sclerosis resiliency scale: Uncovering resilience factors in Lebanese MS patients for clinical and research advancements.

Background: Multiple sclerosis (MS) is an autoimmune demyelinating disease that involves the central nervous system (CNS). Individuals with Multiple Sclerosis (MS) may experience difficulty adapting to their diagnosis as the unpredictable nature of the disease can be challenging to cope with. Methods: The purpose of this study is twofold. First, we have culturally adapted and analyzed the Arabic version of the Multiple Sclerosis Resiliency Scale (MSRS) psychometric properties. Second, we aimed to explore resilience in a sample of Lebanese patients with MS in the face of the chronic disease and financial hardship that Lebanon is going through to evaluate their strengths and struggles. The sample consisted of 306 participants aged between 18 and 79 diagnosed with MS for at least one year. Results: After examining criterion validity, construct validity, internal consistency, and test-retest reliability, the Arabic version of the MSRS exhibited good psychometric properties. The study also revealed that resilience increases with age and lower disability scores. Additionally, individuals with higher resilience levels displayed lower levels of depression. The research revealed that MS patients have high resilience, mainly relying on cognitive and emotional strategies, social support from family and friends, MS peer support, and spirituality. Conclusion: These findings highlight the importance of emotional coping strategies and social support in building resilience among MS patients.

Assessing the outcomes of prescribing angiotensin converting enzyme inhibitors and angiotensin receptor blockers for COVID-19 patients.

Background: Patients with heart failure were affected severely by COVID-19. Most heart failure patients are on guideline directed medical therapy, which includes ACE inhibitors (ACEI) and ARBs. These medications were controversial at the beginning of the pandemic due to their interplay with the receptor that SARS-CoV-2 binds in the lungs. We investigated the effect that ACEI and ARB had on patients with hypertension, coronary artery disease, and heart failure. Methods: We recruited 176 patients with COVID-19 infection and cardiovascular comorbidities at the American University of Beirut Medical Center in Lebanon. Of these, 110 patients were taking ACEI or ARB and 66 were not. We collected clinical data and looked at inflammatory markers such as CRP and IL-6 and cardiac markers such as troponin T. We also reported the incidence of ARDS, sepsis, and death of each patient, and compared the 2 groups. Results: We found that patients taking ACEI and ARB had a statistically significant decrease in levels of troponin T, IL-6, and CRP compared to patients not taking these medications (p < 0.05). We found no difference in rates of ARDS, sepsis, or death between the 2 groups. Conclusion: Inhibition of the renin-angiotensin-aldosterone-system had no effect on the mortality of patients with COVID-19 and on their overall disease progression. However, it may be beneficial not to stop these medications as they decrease inflammation in the body and the levels of troponin, which are related to increased stress on the heart.

Unfolding parental knowledge, attitudes, and beliefs toward palliative care for children with cancer.

BACKGROUND: Parents' views toward pediatric palliative care (PPC) remain underexplored, especially in low/middle-income countries where care relies heavily on families. A better understanding of parents' perspectives would inform strategies to support PPC integration into the care of children with cancer. This multicenter study aimed to examine knowledge, attitudes, and beliefs toward PPC among parents of children with cancer in Lebanon to uncover areas for improvement and determine associated factors. METHODS: Using a quantitative cross-sectional descriptive design, 105 primary caregivers (RR = 95.4%) were recruited during the child's visit to one of three pediatric oncology centers in Lebanon. Data were collected through structured interviews using questionnaire items newly developed or taken from validated tools. Data were analyzed using descriptive statistics, correlational analysis, and multiple linear regression. RESULTS: Only 18/105 participants (17.1%) had heard about PPC and 2% had accurate information about it. When given a brief description, more than 90% endorsed PPC and recommended its integration upon the child's diagnosis. Respectively, "Religious and spiritual engagement" and "Overwhelming negative emotions" were the most cited facilitators and barriers to integrating PPC. Knowledge, attitudes, and beliefs were significantly associated with several demographic and clinical factors such as education level, number of persons living with the child, child's symptom count, and pain score. CONCLUSION: This research is among the very first studies conducted to examine parents' perspectives toward PPC for children with cancer in Lebanon. Study findings inform future directions to promote PPC in limited-resource settings through expanded research, policy, education, and practice initiatives.

Risk of thromboembolic events in non-hospitalized COVID-19 patients: A systematic review.

The risk of thromboembolism in non-hospitalized COVID-19 patients remains uncertain and was assessed in this review to better weigh benefits vs. risks of prophylactic anticoagulation in this population. A search was performed through three databases: Medline, Embase, and Cochrane Library until 2022. Self-controlled case series, case-control and cohort studies were included, and findings summarized narratively. Meta-analyses for risk of thromboembolism including deep vein thrombosis (DVT), pulmonary embolism (PE), and myocardial infarction (MI) between COVID-19 and non-COVID-19 non-hospitalized patients were conducted. Frequency, incidence rate ratio (IRR), and risk ratio (RR) of stroke were used to assess risk in non-hospitalized COVID-19 patients considering the lack of studies to conduct a meta-analysis. Ten studies met inclusion criteria characterized by adult non-hospitalized COVID-19 patients. Risk of bias was relatively low. Risk of DVT (RR: 1.98 with 95% CI: 1.03-3.83) and PE (OR: 6.72 with 95% CI: 4.81-9.39 and RR: 4.44 with 95% CI: 1.98-9.99) increased in non-hospitalized COVID-19 patients compared to controls. Risk of MI (OR: 1.91 with 95% CI: 0.89-4.09) is possibly increased in non-hospitalized COVID-19 patients with moderate certainty when compared to controls. A trend in favor of stroke was documented in the first week following infection. Our meta-analyses support the increase in risk of DVT and PE, and likely increase of MI, in non-hospitalized COVID-19 patients. The risk of stroke appears significant in the first week following infection but drops to insignificance two weeks later. More studies are needed to establish evidence-based recommendations for prophylactic anticoagulation therapy in non-hospitalized COVID-19 patients.

Predictors of quality of life in older adult patients in Lebanon: a cross sectional study.

BACKGROUND: The older adult population in Lebanon is anticipated to double by year 2030. The health care resources available for the geriatric population is limited and there is much reliance on the social support of family caregivers. Older adults have double the rate of hospital utilization in comparison to the regular Lebanese population where 4.5% are hospitalized more than once per year. This study aims to describe self-reported quality of life (QoL) among hospitalized patients "with palliative care needs" and investigate the relationship with its four health domains. METHODS: An observational survey design with a convenience sample of 203 hospitalized patients with palliative care needs above 65 years of age were recruited from three hospitals. Descriptive statistics and regression analysis were used to describe and determine the association between health domains and QoL. RESULTS: Mean age of participants was 78.5 years with the majority being male and married. Participants reported low overall QoL with a mean score of 35.43 (SD =23.45). Anxiety and depression were common findings. "Worrying" (83%), "Feeling nervous" (80%), "Feeling sad" (76%) were dominant psychological symptoms. Low scores were also observed for physical, role and social functioning. Participants suffered from lack of energy (94%), pain (72%), difficulty sleeping (73%) and shortness of breath (64%). CONCLUSIONS: The findings suggest that QoL in the aging Lebanese population is burdened with physical and psychological symptoms. A comprehensive approach that attends to the psychosocial as well as the physical problems in older adults with early integration of symptom management and palliation could improve QoL.

Blood Transfusion is Associated With Adverse Outcomes in Pediatric Solid Tumor Oncology Patients Following Tumor Resection.

BACKGROUND: Packed red blood cell (PRBC) transfusion is a lifesaving intervention that also has proinflammatory and immunosuppressive effects. Adults with a malignancy who receive PRBC transfusion have increased rates of infection, tumor recurrence, and decreased survival. The effect of PRBC transfusion among children with solid tumors is unknown. METHODS: We performed a retrospective review of all children who underwent operative resection of a solid tumor malignancy. Data collected included demographic information, location of operation, nadir hemoglobin, and any PRBC transfusion within 30 days of tumor resection. RESULTS: Three hundred sixty children underwent tumor resection at our institution between 2002 and 2013; 194 (54%) received a perioperative blood transfusion. After adjusting for stage at diagnosis, tumor location, preoperative chemotherapy and nadir hemoglobin, blood transfusion was associated with a higher rate of postoperative infectious complications, shorter disease-free interval, and a higher rate of tumor recurrence. Each additional transfused unit increased the risk of postoperative infection (odds ratio 3.83; 95% confidence interval 1.21, 14.22, P =0.031). CONCLUSIONS: Among children with solid tumor malignancies, PRBC transfusion within 30 days of operation is associated with higher rates of postoperative infection. If transfusion becomes necessary, single unit increments should be transfused. LEVEL OF EVIDENCE: Level III.

The effect of an enhanced recovery protocol in pediatric patients who undergo colostomy closure and Malone procedures.

PURPOSE: Pediatric colorectal studies have shown enhanced recovery after surgery (ERAS) protocols can safely improve outcomes. This study sought to determine the impact of an ERAS pathway on the outcomes of children with colorectal conditions who underwent colostomy closure or Malone procedure. METHODS: A single-institution, retrospective cohort study of children who underwent colostomy closure or Malone procedure between 2016 and 2020 was performed. Differences in outcomes between pre-ERAS and ERAS cohorts were tested. A sub-analysis based on procedure type was performed. RESULTS: There were 96 patients included: 22 prior to ERAS implementation and 74 after. Patients who underwent ERAS had shorter mean time (hours) to oral intake, mean days until regular diet, post-operative opioid volume, and median length of stay (p < 0.05). There was no difference in complication rates in the ERAS and pre-ERAS cohort (12.2 vs 9.1%, p = 0.99). Patients who underwent colostomy closure after ERAS had lower post-operative opioid use, but no differences were seen in those who underwent Malone. CONCLUSION: Implementation of an ERAS protocol resulted in quicker time to oral intake, normal diet, and decreased opioid use without increasing complication rates. Differences seen based on procedure type may reflect that the effect of an ERAS protocol is procedure specific.

Predictive Capacity of Beat-to-Beat Blood Pressure Variability for Cardioautonomic and Vascular Dysfunction in Early Metabolic Challenge.

Diabetic patients present established cardiovascular disease at the onset of diagnostic metabolic symptoms. While premature autonomic and vascular deterioration considered risk factors for major cardiovascular complications of diabetes, present in initial stages of metabolic impairment, their early detection remains a significant challenge impeding timely intervention. In the present study, we examine the utility of beat-to-beat blood pressure variability (BPV) parameters in capturing subtle changes in cardiac autonomic and vascular control distinguishing between various risk categories, independent of the average BP. A rat model of mild hypercaloric (HC) intake was used to represent the insidious cardiovascular changes associated with early metabolic impairment. Invasive hemodynamics were used to collect beat-to-beat BP time series in rats of either sex with different durations of exposure to the HC diet. Linear (standard deviation and coefficient of variation) and nonlinear (approximate entropy, ApEn, and self-correlation of detrended fluctuation analysis, α) BPV parameters were calculated to assess the impact of early metabolic impairment across sexes and feeding durations. HC-fed male, but not female, rats developed increased fat:lean ratio as well as hyperinsulinemia. Unlike linear parameters, multivariate analysis showed that HC-fed rats possessed lower ApEn and higher α, consistent with early changes in heart rate variability and blunting of parasympathetic baroreceptor sensitivity, particularly in males. Moreover, logistic regression demonstrated the superiority of nonlinear parameters of diastolic BPV in predicting a prediabetic disease state. Our findings support the use of nonlinear beat-to-beat BPV for early detection of cardiovascular derangements in the initial stages of metabolic impairment.

Longitudinal study on the effect of surgical weight loss on beat-to-beat blood pressure variability in patients undergoing bariatric surgery: a study protocol.

INTRODUCTION: Alterations in linear and non-linear parameters of beat-to-beat blood pressure variability (BPV) have been shown to predict disease prognosis and distinguish between risk categories in various pathological conditions, independently of average blood pressure levels. Obesity places subjects at elevated risk of vascular diseases, including hypertension, resulting in serious cardiac, respiratory and cerebral events. However, little is known about the status of vascular dynamics in obese and morbidly obese adults. METHODS AND ANALYSIS: In this present quasi-experimental longitudinal study, changes in beat-to-beat BPV, using continuous, non-invasive blood pressure monitoring, in obese subjects undergoing bariatric surgery are characterised. The capacity of linear and non-linear measures of BPV to detect differences between hypertensive, prehypertensive and normotensive obese subjects prebariatric and postbariatric surgery are tested. Additionally, potential correlations between beat-to-beat BPV and age, body mass index, gender and comorbidities will be investigated. In parallel, the impact of the unsteady fluctuations of beat-to-beat blood pressure on the dynamic stresses imparted by blood flow on blood vessel walls will be explored. We expect to find altered BPV profiles in hypertensive and prehypertensive subjects as compared with normotensive subjects. We also expect to see differential normalisation in BPV profiles between hypertensive, prehypertensive and normotensive subjects over time. ETHICS AND DISSEMINATION: The study has been approved by the Institutional Review Board at the American University of Beirut (IRB ID: BIO-2018-0040). Study results will be made available to the public through publications in peer-reviewed journals and conference papers and/or presentations.

Beat-to-beat blood pressure variability: an early predictor of disease and cardiovascular risk.

Blood pressure (BP) varies on the long, short and very-short term. Owing to the hidden physiological and pathological information present in BP time-series, increasing interest has been given to the study of continuous, beat-to-beat BP variability (BPV) using invasive and noninvasive methods. Different linear and nonlinear parameters of variability are employed in the characterization of BP signals in health and disease. Although linear parameters of beat-to-beat BPV are mainly measures of dispersion, such as standard deviation (SD), nonlinear parameters of BPV quantify the degree of complexity/irregularity- using measures of entropy or self-similarity/correlation. In this review, we summarize the value of linear and nonlinear parameters in reflecting different information about the pathophysiology of changes in beat-to-beat BPV independent of or superior to mean BP. We then provide a comparison of the relative power of linear and nonlinear parameters of beat-to-beat BPV in detecting early and subtle differences in various states. The practical advantage and utility of beat-to-beat BPV monitoring support its incorporation into routine clinical practices.

Pesticide practices in coastal agricultural farms of Lebanon.

The agricultural sector in Lebanon relies heavily on agrochemicals for crop protection; thus exposing humans and the environment to the harmful effects of pesticides. This study investigated Lebanese farmers' pesticide use practices and explored the underlying factors associated with farmers' choices. Of the 104 surveyed farmers, around 87% were willing to use pesticides that are less toxic to humans and the environment than those currently using, if available. The majority of these farmers (92%) planted their crops in greenhouses. Willingness to use less toxic pesticides was significantly associated with farmers using greenhouses as opposed to open fields, after adjusting for demographic and behavioural characteristics (OR = 7.50; p = 0.010). There was no association between willingness to use less toxic pesticides and perceptions of pesticides' health effects. Policies banning the import and sale of internationally banned pesticides must be enforced. Farmers must be supported to make informed choices about pesticides and their use.

Cardiac Autonomic Neuropathy: A Progressive Consequence of Chronic Low-Grade Inflammation in Type 2 Diabetes and Related Metabolic Disorders.

Cardiac autonomic neuropathy (CAN) is one of the earliest complications of type 2 diabetes (T2D), presenting a silent cause of cardiovascular morbidity and mortality. Recent research relates the pathogenesis of cardiovascular disease in T2D to an ensuing chronic, low-grade proinflammatory and pro-oxidative environment, being the hallmark of the metabolic syndrome. Metabolic inflammation emerges as adipose tissue inflammatory changes extending systemically, on the advent of hyperglycemia, to reach central regions of the brain. In light of changes in glucose and insulin homeostasis, dysbiosis or alteration of the gut microbiome (GM) emerges, further contributing to inflammatory processes through increased gut and blood-brain barrier permeability. Interestingly, studies reveal that the determinants of oxidative stress and inflammation progression exist at the crossroad of CAN manifestations, dictating their evolution along the natural course of T2D development. Indeed, sympathetic and parasympathetic deterioration was shown to correlate with markers of adipose, vascular, and systemic inflammation. Additionally, evidence points out that dysbiosis could promote a sympatho-excitatory state through differentially affecting the secretion of hormones and neuromodulators, such as norepinephrine, serotonin, and γ-aminobutyric acid, and acting along the renin-angiotensin-aldosterone axis. Emerging neuronal inflammation and concomitant autophagic defects in brainstem nuclei were described as possible underlying mechanisms of CAN in experimental models of metabolic syndrome and T2D. Drugs with anti-inflammatory characteristics provide potential avenues for targeting pathways involved in CAN initiation and progression. The aim of this review is to delineate the etiology of CAN in the context of a metabolic disorder characterized by elevated oxidative and inflammatory load.

Macrophage responses associated with COVID-19: A pharmacological perspective.

COVID-19 has caused worldwide death and economic destruction. The pandemic is the result of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has demonstrated high rates of infectivity leading to great morbidity and mortality in vulnerable populations. At present, scientists are exploring various approaches to curb this pandemic and alleviate its health consequences, while racing to develop a vaccine. A particularly insidious aspect of COVID-19 is the delayed overactivation of the body's immune system that is manifested as the cytokine storm. This unbridled production of pro-inflammatory cytokines and chemokines can directly or indirectly cause massive organ damage and failure. Systemic vascular endothelial inflammation and thrombocytopenia are potential consequences as well. In the case of COVID-19, the cytokine storm often fits the pattern of the macrophage activation syndrome with lymphocytopenia. The basis for the imbalance between the innate and adaptive immune systems is not clearly defined, but highlights the effect of SARS-CoV-2 on macrophages. Here we discuss the potential underlying basis for the impact of SARS-CoV-2 on macrophages, both direct and indirect, and potential therapeutic targets. These include granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin 6 (IL-6), interferons, and CXCL10 (IP-10). Various biopharmaceuticals are being repurposed to target the cytokine storm in COVID-19 patients. In addition, we discuss the rationale for activating the macrophage alpha 7 nicotinic receptors as a therapeutic target. A better understanding of the molecular consequences of SARS-CoV-2 infection of macrophages could lead to novel and more effective treatments for COVID-19.

Worsening baroreflex sensitivity on progression to type 2 diabetes: localized vs. systemic inflammation and role of antidiabetic therapy.

Cardiac autonomic neuropathy (CAN) is an early cardiovascular manifestation of type 2 diabetes (T2D) that constitutes an independent risk factor for cardiovascular mortality and morbidity. Nevertheless, its underlying pathophysiology remains poorly understood. We recently showed that localized perivascular adipose tissue (PVAT) inflammation underlies the incidence of parasympathetic CAN in prediabetes. Here, we extend our investigation to provide a mechanistic framework for the evolution of autonomic impairment as the metabolic insult worsens. Early metabolic dysfunction was induced in rats fed a mild hypercaloric diet. Two low-dose streptozotocin injections were used to evoke a state of late decompensated T2D. Cardiac autonomic function was assessed by invasive measurement of baroreflex sensitivity using the vasoactive method. Progression into T2D was associated with aggravation of CAN to include both sympathetic and parasympathetic arms. Unlike prediabetic rats, T2D rats showed markers of brainstem neuronal injury and inflammation as well as increased serum levels of IL-1ß. Experiments on PC12 cells differentiated into sympathetic-like neurons demonstrated that brainstem injury observed in T2D rats resulted from exposure to possible proinflammatory mediators in rat serum rather than a direct effect of the altered metabolic profile. CAN and the associated cardiovascular damage in T2D only responded to combined treatment with insulin to manage hyperglycemia in addition to a nonhypoglycemic dose of metformin or pioglitazone providing an anti-inflammatory effect, coincident with the effect of these combinations on serum IL-1ß. Our present results indicate that CAN worsening upon progression to T2D involves brainstem inflammatory changes likely triggered by systemic inflammation.

Decentralization of solid waste management services in rural Lebanon: Barriers and opportunities.

Rapid urbanization, closure of dumps, and insufficient infrastructure funding in Lebanon have resulted in improper municipal solid waste management (MSWM), creating a continuing trash crisis in recent years. In Beirut and Mount Lebanon, MSWM was carried out in centralized waste processing and disposal facilities operated by the government. The trash crisis and failure of the centralized system prompted several municipal authorities to decentralize MSWM by establishing local facilities, paid by the council taxes charged to beneficiary households. To study the feasibility of decentralized MSWM, a survey of 228 households in a rural village in Lebanon explored households' willingness to pay (WTP) for a local MSWM service. For data analysis, a multivariate Tobit model was used to examine the determinants of the WTP amount. Results showed that 79% of surveyed households in the studied village were willing to support local MSWM improvements by contributing an average yearly fee of US$48, representing a 30% increase in their current council taxes. Analysis showed a significant positive association between the WTP amount and the household monthly income level, the residents perceived needs for urgency to act on solid waste management, and the households' responsibility to be involved in MSWM. An interview with the municipality mayor later revealed that financial, technical, and land resources are lacking to enable consideration of a decentralized project for MSWM in the village. Municipalities in rural areas have limited resources and are unable to sustain a decentralized MSWM service unless adjacent towns join effort in supporting and financing MSWM initiatives.

Quality of care, spirituality, relationships and finances in older adult palliative care patients in Lebanon.

BACKGROUND: Despite making up a big proportion of the world population, older adults received little palliative care services. Moreover, palliative quality of care provided to older adults has been shown to be poor. Adequate clinician communication, familial support, and religious/spiritual support have been identified as main factors in providing good quality of care. The purpose of our study on Lebanese older adult palliative care patients is to assess the quality of palliative care in terms of access to care, patient-clinician relationship, and clinician-clinician communication, assess the degree of spirituality/religiousness of patients and their sense of purpose, to explore patients' relationships including friendships and social support and to assess the degree of financial hardship during the illness. METHODS: An observational cross-sectional design was used in this study of hospitalized older adults in three major medical centers in Lebanon over a period of 2 years from 2015 to 2017. Key physicians from each of the three medical centers recruited participants into the study to obtain a convenience sample (N=203). Quality of care was measured using 20 selected items from the Needs at the End of life Screening Tool (NEST). RESULTS: Patients reported easy access to care expressed by low median item scores ranging from the lowest 1.0 pertaining to lack of a problematic doctor choice to the highest 3.0 for ease of securing a hospital bed. Difficulty expressing their feelings to their healthcare providers had an average median of 5.0 with other items on communication having higher medians. The sample considered themselves to be highly religious or spiritual with a median score of 9.0 and identified an inclination to be more religious or spiritual after their illness with a median of 7.0. Social support was found to be good and financial hardships had low median scores ranging from 3.0 to 5.0. CONCLUSIONS: Older adults receiving palliative care reported ease of access to medical care, average communication, good spiritual and social status and minimal financial hardships. The authors recommend integrating spiritual and social aspects into the patients' palliative care to improve quality of care and quality of life.

The translation and cultural adaptation validity of the Actual Scope of Practice Questionnaire.

BACKGROUND: Information on the scope of nursing practice is urgently needed in the Eastern Mediterranean region to help policy makers and directors of nursing develop informed workforce plans. AIMS: This study aimed to validate the Arabic translation and cultural adaptation of the Actual Scope of Practice Questionnaire (A-ASCOP). METHODS: The process of translation and cultural validation adhered to WHO guidelines. The process involved forward translation, review by an expert panel, back-translation, pre-testing and cognitive interviewing. RESULTS: The clarity, meaningfulness and relevance of the first Arabic version of the A-ASCOP has been validated. CONCLUSION: Subject to psychometric analysis, the A-ASCOP is suitable for use in Lebanon and countries of the Middle Eastern region.

Multidimensional Rasch Analysis of the Arabic Occupational Fatigue Exhaustion Recovery Subscales.

BACKGROUND AND PURPOSE: Investigation of the psychometric properties of the Arabic version of the Occupational Fatigue Exhaustion Recovery (A-OFER) subscales. METHODS: Partial credit model (PCM) analyses of 2037 Lebanese nurses' responses to the chronic fatigue (CF), acute fatigue (AF), and intershift recovery (IR) subscales. RESULTS: The data were a better fit to the three-dimensional Rasch PCM; difference, χ2 = 2199.3, df = 5, p = .01; unidimensional Akaike information criterion (AIC) = 107355; multidimensional AIC = 105166. Rating categories were disordered and there was item dependence among negatively-keyed items. All items were free of subgroup bias. Inter-subscale correlations were contrary to expectations. CONCLUSION: The CF subscale has sufficient reliability for screening nurses in Lebanon and the Eastern Mediterranean region for low to moderate levels of occupational fatigue. The construct validity of the A-OFER requires further investigation.

The relationship between work-related musculoskeletal disorders, chronic occupational fatigue, and work organization: A multi-hospital cross-sectional study.

AIMS: To identify the prevalence of work-related musculoskeletal disorders, levels of chronic occupational fatigue, and how they vary with individual and work organization factors. DESIGN: A multi-hospital cross-sectional survey. METHODS: Nurses from 39 hospitals completed self-reported questionnaires from June to September 2015. Descriptive statistics were used to summarize hospitals and nurses' characteristics, fatigue levels and prevalence, and type of musculoskeletal disorders. Linear and logistic regression analyses were used to identify correlational factors. RESULTS: The results revealed that 71.3% of participants reported a work-related musculoskeletal disorder in the previous 12 months, mainly back pain. The reported musculoskeletal disorders were significantly correlated with years of experience, nurse to patient ratios, and chronic occupational fatigue. Higher chronic occupational fatigue levels were associated with education, age, years of experience, nurse to patient ratio, and model of care. CONCLUSION: Preventive work organization strategies are needed to ensure healthier occupational environment for nurses.