BackgroundThere is a lack of research addressing associations of antidiabetic drug combinations with COVID-19 deaths. We examined whether adding common second-line agents to metformin was associated with COVID-19 mortality risk to inform clinical decision-making when escalating diabetes treatment.MethodsThis is a nationwide retrospective analysis covering the years 2020 and 2021. Data from the National Diabetes Registry (CroDiab) were linked to primary healthcare data, Causes of Death Registry data, and the SARS-CoV-2 vaccination database. Multivariate logistic regression models were developed for each of the combinations to compare the combination with metformin monotherapy. To address confounders, inverse probability of treatment weighting (IPTW) analysis as well as analysis with stabilized weights was performed.ResultsOf 141014 analyzed patients, 1268 (0.90%) died of COVID-19 in 2 years. Weighted results of the drug combinations that showed statistically significant associations to COVID-19 death in comparison to metformin alone were metformin+DPP-4 inhibitor (OR 1.182, 95% CI 1.016-1.376), metformin+sulfonylurea (OR 1.195, 95% CI 1.015-1.406), and metformin+GLP-1 agonist (OR 2.992, 95% CI 2.117-4.229).ConclusionsSome combinations of metformin with second-line antidiabetic drugs might require caution in the context of chronic diabetes mellitus type 2 therapy and COVID-19 related deaths. Findings should be interpreted as hypothesis-generating signals from real-world data rather than evidence of causal drug effects. Further research is needed, especially for metformin+GLP-1 agonist, as well as head-to-head comparisons of combinations therapies.

Aim To examine the representation of nurses in Croatian graduate nursing programs and to explore its implications for academic equity, professional development, and nursing leadership.Design Cross-sectional descriptive study using document analysis.Methods Data on lecturers and course leaders for the 2022/2023 academic year were retrieved from all graduate and specialist nursing programs in Croatia. A total of 694 lecturers and 545 course leaders were analysed by professional background.Results Nurses accounted for 19% of lecturers in university graduate programs and 14% in specialist studies. As course leaders, they represented 11% in specialist studies and only 4% in university graduate programs. Thirty courses lacked assigned lecturers. The findings demonstrate a strong dominance of medicine and other professions in teaching roles.Conclusion Nurses remain markedly underrepresented in academic positions, which may limit their ability to shape curricula, influence educational standards and strengthen professional identity.Implications for the Profession and/or Patient Care Improving the academic presence of nurses could be important for advancing leadership capacity, curriculum relevance and professional equity. Stronger representation may help enhance the profession's authority and indirectly benefit patient care.Impact What problem did the study address?: The study explored limited nurse representation in graduate nursing education and its implications for equity and autonomy. What were the main findings?: Nurses are a small minority in lecturer and course leader roles, with most positions occupied by non-nursing professionals. Where and on whom will the research have an impact?: The findings are relevant to educators, regulators and policymakers in Croatia and internationally, particularly in countries where nurses face barriers to academic participation. The study supports ongoing policy efforts to strenghten nurses' academic representation and leadership in higher education.Patient or Public Contribution No patient or public contribution. This study relied exclusively on publicly available academic data and did not involve patients, service users or members of the public.

Introduction: Breaking, also known as breakdancing, has evolved from street culture to a structured sport, debuting in the 2024 Olympics. Despite its popularity, limited data exists on injury prevalence, types, and risk factors associated with acute and overuse injuries sustained from breaking. While existing studies offer insights into common injury patterns, they provide limited analysis of the specific mechanisms behind these injuries. This overview aims to classify acute and overuse injuries in breaking, reviewing 50 years of literature to identify risk factors and high-risk movements. Methods: The overview followed a predefined protocol using the PICO framework and was registered at OSF, targeting case reports and letters to the editor involving breakers. Databases searched included PubMed, ProQuest, Scopus, and EBSCO, covering literature from the 1970s to December 2023. Inclusion criteria were strictly case reports and letters to the editor that focused on injuries sustained from breaking. Results: A total of 41 papers were selected for inclusion after screening, reading and data extraction. Among these, 36 papers were reviewed in detail, encompassing acute and overuse injuries. The reported injuries involve high-impact movements, particularly affecting the upper extremities, head, neck, and back during spins, balancing, landing, and sliding. Acute injuries included fractures and dislocations, while chronic conditions involved soft tissue injuries, stress fractures, and nerve compressions. Risk factors identified in case reports included the lack of training supervision and specific breaking maneuvers like flips, spins, and balancing acts. Conclusion: This is the first overview of case reports and letters to the editor that categorizes breaking injuries based on these types of papers. It demonstrates the value of detailed medical diagnoses and standardized injury classification compared to self-reported injury data commonly found in surveys. Gaining a deeper understanding of injury mechanisms and risk factors could help promote safer practices as breaking continues to evolve as a competitive sport.

Background: Discharging patients from intensive care units (ICUs) poses significant risks for adverse events (AEs), contributing to hospital morbidity and mortality. To mitigate premature transitioning, an ICU discharge readiness checklist (ICU-DRC) was developed. Enhanced patient safety culture (PSC) is crucial for reducing AEs and improving outcomes. Given the pressing need to enhance PSC in ICUs, this study evaluates the impact of ICU-DRC implementation on PSC, aiming to address a critical gap in quality improvement. Methods: A prospective quasi-experimental study assessed PSC before and after a year-long ICU-DRC intervention at Merkur Clinical Hospital in Zagreb, Croatia. Healthcare providers from two distinct ICUs participated voluntarily in the Hospital Survey on Patient Safety Culture. The surgical ICU, where the intervention was applied, employed 106 providers, while the medical ICU, which did not implement the intervention, had 42 providers. Results: Initial response rates were 58% for the intervention group and 45% for the control group, with post-intervention rates of 53% and 48%, respectively. The ICU-DRC was utilized with a fidelity of 65.7%. Due to the non-normal distribution found for most variables, non-parametric analytical procedures were applied. In baseline measurements, the control group outperformed the intervention group in three out of fourteen PSC dimensions. Post-intervention, PSC scores in the intervention group significantly improved in one dimension, whereas three dimensions in the control group showed significant declines, resulting in superior PSC outcomes for four dimensions in the intervention group during the second measurement. Conclusions: Applying the ICU-DRC as an isolated safety intervention aimed at optimizing ICU patient throughput resulted in observable patterns of improvement in several PSC dimensions, with statistically significant changes in specific areas.

Introduction:Family medicine doctors play a crucial role in smoking cessation efforts but often lack adequate training and skills in this area. This study aimed to assess attitudes, knowledge, and behaviors regarding smoking cessation among family medicine residents using a newly developed instrument. Methods:A novel 29-item questionnaire called "Attitudes and Knowledge Assessing Tool on Smoking Cessation Methods" (SMOKE AKAT) was developed and administered online to 161 family medicine residents at the University of Zagreb. This cross-sectional survey assessed knowledge about smoking-related health risks, cessation methods, and harm reduction approaches, as well as attitudes and behaviors related to smoking cessation counseling. Descriptive statistics were used to analyze the responses. Results:93 residents completed the survey (57.76% response rate). Key findings include: 91.4% had never received formal education on smoking cessation methods; 62.4% incorrectly believed nicotine causes cancer; 84.9% incorrectly classified e-cigarettes as nicotine replacement therapy; only 57% correctly identified the definition of harm reduction; 51.6% reported spending 2-5 min on cessation counseling per patient visit; and 84.9% believed family doctors should be responsible for implementing smoking cessation interventions. Conclusion:In light of the European Commission's agenda to make the EU smoke-free by 2040, where healthcare professionals play an increasingly crucial role this study revealed significant knowledge gaps and misconceptions about smoking cessation among family medicine residents. Many lack formal training but express interest in further education. There is a need to enhance smoking cessation curricula in family medicine training programs, focusing on evidence-based cessation methods, pharmacotherapy options, and harm reduction approaches. Improving residents' knowledge and skills in this area could lead to more effective smoking cessation interventions in primary care settings. The SMOKE AKAT questionnaire addresses a critical gap in the current healthcare research landscape by providing an assessment tool to identify knowledge deficiencies, attitudinal barriers, and practice gaps among family medicine physicians in smoking cessation counseling and enables targeted educational interventions to correct specific deficiencies that might otherwise remain undetected in standard medical education assessments.

INTRODUCTION:Patients with diabetes mellitus type 2 and chronic kidney disease (T2DM-CKD) have a 5 times higher risk of developing severe SARS-CoV-2 infection than those without these 2 diseases. The goal of this study is to provide information on T2DM-CKD and COVID-19 outcomes, with an emphasis on the association with anti-diabetic medications. METHODOLOGY:Study is designed as a retrospective cohort analysis covering the years 2020 and 2021. Data from the National Diabetes Registry (CroDiab) were linked to hospital data, primary healthcare data, Causes of Death Registry data, the SARS-CoV-2 vaccination database, and the SARS-CoV-2 test results database. Study outcomes were cumulative incidence of SARS-CoV-2 positivity, COVID-19 hospitalizations, and COVID-19 deaths. For outcome predictors, logistic regression models were developed. RESULTS:Of 231 796 patients with diabetes mellitus type 2 in the database, 7 539 were T2DM-CKD (3.25%). The 2-year cumulative incidences of all three studies' outcomes were higher in T2DM-CKD than in diabetes patients without CKD (positivity 18.1% vs. 14.4%; hospitalization 9.7% vs. 4.2%; death 3.3% vs. 1.1%, all p<0.001). For COVID-19 hospitalization, protective factors were SGLT-2 inhibitors use (OR 0.430; 95%CI 0.257-0.719) and metformin use (OR 0.769; 95% CI 0.643-0.920), risk factors were insulin use (1.411; 95%CI 1.167-1.706) and sulfonylureas use (OR 1.226; 95% CI 1.027-1.464). For SARS-CoV-2 positivity protective factors were SGLT-2 inhibitors (0.607; 95% CI 0.448-0.823), repaglinide use (OR 0.765; 95% CI 0.593-0.986) and metformin use (OR 0.857; 95% CI 0.770-0.994). DPP-4 inhibitors showed a non-significant decrease in risk for COVID-19 death (OR 0.761; 95% CI 0.568-1.019). CONCLUSION:T2DM-CKD are heavily burdened by COVID-19 disease. Our results suggest no association between antidiabetic drugs and COVID-19 death outcome while SGLT-2 and metformin show to be protective against COVID-19 hospitalization and infection, repaglinide against infection, and insulin and sulfonylureas show to be risk factors for COVID-19 hospitalization and infection. Further research in T2DM-CKD is needed.

Abstract Introduction Workplace violence is a multifaceted phenomenon that occurs when an individual or a collective entity engages in aggressive or harmful behavior within the organizational context. The occurrence of violence against nurses is observed to be perpetrated by various individuals within the healthcare setting, including patients, their family members, as well as doctors and fellow nurses. The overarching aim of this study is to provide a comprehensive description of the strategies and measures employed in the prevention of violence against nurses. The primary aim of this study is to ascertain and analyze distinct indicators of violence prevention strategies, with the ultimate goal of assessing their efficacy. Methods A literature search on the databases PubMed, WoS, and Scopus was performed. The study included systematic reviews (SR) and meta-analyses (MA) published in the last decade. The literature review was conducted in accordance with the PRISMA guidelines. The assessment of the articles’ quality was conducted utilizing the AMSTAR-R assessment tool. Results and discussion A total of six studies (4 SA and 2 MA) were deemed eligible based on the predetermined inclusion criteria. Research has demonstrated that the implementation of educational programs and effective communication strategies are the most efficacious measures for preventing violence. Conclusion This approach will effectively enhance the level of awareness among nurses and foster a culture of cooperation and mutual respect within the workplace. Changes in achieving desired outcomes can be facilitated through the implementation of educational initiatives, training programs focused on enhancing communication skills, and the establishment of a secure and collaborative work environment.

There is a scarcity of information on the population with diabetes mellitus type 2 and cardiomyopathy (PDMC) in COVID-19, especially on the association between anti-diabetic medications and COVID-19 outcomes. Study is designed as a retrospective cohort analysis covering 2020 and 2021. Data from National Diabetes Registry (CroDiab) were linked to hospital data, primary healthcare data, the SARS-CoV-2 vaccination database, and the SARS-CoV-2 test results database. Study outcomes were cumulative incidence of SARS-CoV-2 positivity, COVID-19 hospitalizations, and COVID-19 deaths. For outcome predictors, logistic regression models were developed. Of 231 796 patients with diabetes mellitus type 2 in the database, 14 485 patients had cardiomyopathy. The two2-year cumulative incidence of all three studies' COVID-19 outcomes was higher in PDMC than in the general diabetes population (positivity 15.3% vs. 14.6%, p = 0.01; hospitalization 7.8% vs. 4.4%, p < 0.001; death 2.6% vs. 1.2%, p < 0.001). Sodium-Glucose Transporter 2 (SGLT-2) inhibitors therapy was found to be protective of SARS-CoV-2 infections [OR 0.722 (95% CI 0.610–0.856)] and COVID-19 hospitalizations [OR 0.555 (95% CI 0.418–0.737)], sulfonylureas to be risk factors for hospitalization [OR 1.184 (95% CI 1.029–1.362)] and insulin to be a risk factor for hospitalization [OR 1.261 (95% CI 1.046–1.520)] and death [OR 1.431 (95% CI 1.080–1.897)]. PDMC are at greater risk of acquiring SARS-CoV-2 infection and having worse outcomes than the general diabetic population. SGLT-2 inhibitors therapy was a protective factor against SARS-CoV-2 infection and against COVID-19 hospitalization, sulfonylurea was the COVID-19 hospitalization risk factor, while insulin was a risk factor for all outcomes. Further research is needed in this diabetes sub-population.

Background: Out-of-hospital cardiac arrest (OHCA) remains a pivotal health challenge globally. In Croatia, there has been a knowledge gap regarding the prevalence, predictors, and outcomes of OHCA patients. This study aims to determine the prevalence, prediction, and outcomes of OHCA patients in Croatia. Methods: An extensive one-year analysis was performed on all OHCA treated by the Emergency Medical Service in Croatia, based on the Utstein recommendations. Data were extracted from Croatian Institute of Emergency Medicine databases, focusing on adult individuals who experienced sudden cardiac arrest in out-of-hospital settings in Croatia. Results: From 7773 OHCA cases, 9.5% achieved spontaneous circulation pre-hospital. Optimal outcomes corresponded to EMS intervention within ≤13 min post-arrest onset AUC = 0.577 (95% CI: 0.56–0.59; p < 0.001) and female gender OR = 1.81 (95% CI: 1.49–2.19; p < 0.001). Northern Croatia witnessed lower success rates relative to the capital city Zagreb OR = 0.68 (95% CI: 0.50–0.93; p = 0.015). Conclusions: Early intervention by EMS, specifically within a 13-min period following the onset of a cardiac arrest, significantly enhances the probability of achieving successful OHCA outcomes. Gender differences and specific initial heart rhythms further influenced the likelihood of successful outcomes. Regional disparities, with reduced success rates in northern Croatia compared to the City of Zagreb, were evident.

IntroductionDespite several studies assessing job demands and burnout in countries from the Southeast European (SEE) region, there is still a lack of data about the psychological impact of the pandemic on health workers (HWs).AimsThe present study aimed to demonstrate and compare levels of burnout dimensions in HWs from SEE countries and to reveal the burnout–job demands/resources relationships in these workers during the pandemic.Materials and methodsDuring the autumn of 2020, this online multicentric cross-sectional survey studied a large group (N = 4.621) of HWs working in SEE countries. The Maslach Burnout Inventory was used for the measurement of burnout dimensions. We analyzed the job demands by using the Hospital Experience Scale. Remuneration and relationships with superiors were measured using the Questionnaire sur les Ressources et Contraintes Professionnelles (English version).ResultsA series of ANOVA comparisons of means revealed the countries in which respondents showed higher mean values of emotional exhaustion (Bosnia and Herzegovina, Bulgaria, Croatia, Moldova, Montenegro, and North Macedonia) and the countries in which respondents showed lower mean values of this burnout dimension (Israel and Romania) (Welch F = 17.98, p < 0.001). We also found differences among HWs from different countries in job demands and job resources. The testing of hierarchical regression models, which have been controlled for certain confounding factors, clearly revealed that emotional exhaustion was predicted by job demands (R2 = 0.37) and job resources (R2 = 0.16).ConclusionPreventive measures for the improvement of mental health in HWs during the pandemic and beyond have to take into account the differences between countries regarding the country context and current scientific knowledge. A modified stress test should be implemented in hospitals regarding future shocks that might include new pandemics, terrorism, catastrophes, or border conflicts.

Istraživanje je provedeno na 409 željezničkih radnika koji su u razdoblju od 5 godina pregledavani u Ustanovi za zdravstvenu skrb dr. Mijač. Cilj je bio analizirati tip i vrstu zdravstvenog pregleda, ocjenu radne sposobnosti te ustanoviti razloge zbog kojih su radnici bili privremeno ili trajno nesposobni. Analizirani su broj i vrsta pregleda te broj i vrsta ocjene radne sposobnosti. Žene je uključivalo 3,3 % pregleda, a 96,7 % muškarce, vjerojatno zbog specifičnosti željezničkog posla te je najveći broj pregledanih pripadalo dobnoj skupini 41-62. Obavljena su 62 prethodna, 672 periodična, 10 ciljanih i 28 kontrolnih pregleda. Ocjene radne sposobnosti bile su 772 (88,23 %) sposoban, 27 (3,09 %) nesposoban i 76 (8,68 %) privremeno nesposoban. Najviše je obavljeno periodičnih pregleda, na kojima je najčešća ocjena bila sposoban. Na izvanrednim i kontrolnim pregledima također je najčešća ocjena bila sposoban. Ocjene sposoban, privremeno nesposoban te nesposoban najčešće su bile donesene na periodičnim pregledima. Neki radnici bili su samo jednom privremeno nesposobni jer je njihova dijagnoza zahtijevala kratkotrajno liječenje, a neki više puta, sve dok je njihova bolest bila u fazi liječenja te su po završetku liječenja mogli biti sposobni ili trajno nesposobni, ovisno o ishodu liječenja. Trajno nesposobni radnici proglašeni su nakon što je liječenje završeno te zdravstveno stanje radnika nije ispunjavalo uvjete zdravstvene sposobnosti radnog mjesta a u nekim slučajevima i zbog dobi. Bolesti koje su najčešće bile razlog onesposobljavanja bile su širokog spektra, a najčešće se radilo o kardiovaskularnim bolestima, psihičkim, poremećajima, nereguliranim endokrinim poremećajima, bolnim sindromima, neurološkim poremećajima, bolestima oka i bolestima uha. Uzimajući u obzir psihičku i fizičku zahtjevnost željezničkog posla, važno je pravovremeno utvrditi bolesti i stanja željezničara, ograničavajućih za obavljanje posla na siguran način za njih same, ali i za okolinu. Za istaknuti je i važnost prethodnih pregleda koji bi odmah trebali eliminirati neadekvatne radnike u smislu zdravstvene sposobnosti, a naknadno i periodičnih, kontrolnih i izvanrednih pregleda, kojima se prate eventualne promjene u zdravstvenom statusu te na taj način smanjuje mogućnost incidenata, ozljeda na radu i profesionalnih bolesti.

The COVID-19 pandemic has put inordinate pressure on frontline healthcare workers (HCWs) and hospitals. HCWs are under chronic emotional stress, affected by burnout, moral distress and interpersonal issues with peers or supervisors during the pandemic. All of these can lead to lower levels of patient safety. The goal of this study was to examine patient safety culture values in a COVID-19 frontline hospital. Patient safety represents action, while patient safety culture represents the beliefs, values and norms of an organization that support and promote patient safety. Patient safety culture is a prerequisite for patient safety. A cross-sectional study on healthcare workers (228, response rate of 81.43%) at a COVID-19 frontline hospital was conducted using the Hospital Survey on Patient Safety Culture (HOSPSC), which had PSC dimensions, single question dimensions and comments. Our research revealed that, during the COVID-19 pandemic, a number of patient safety issues have been identified: low communication openness and current punitive response to errors, which might have incapacitated HCWs in the reporting of adverse events. Although participants expressed high supervisor/management expectations, actual support from the supervisor/management tier was low. Poor teamwork across units was identified as another issue, as well as low staffing. The infrastructure was identified as a potential new PSC dimension. There was a lack of support from supervisors/managers, while HCWs need their supervisors to be available; to be visible on the front line and to create an environment of trust, psychological safety and empowerment.

1Department of Maxillofacial and Oral Surgery, University Hospital of Split, Split, Croatia; 2Department of Anesthesiology and Intensive Care, University Hospital of Split, Split, Croatia; 3Study of Dental Medicine, School of Medicine, University of Zagreb, Zagreb, Croatia; 4Study of Dental Medicine, School of Medicine, University of Split, Split, Croatia; 5Department of Neuroscience, School of Medicine, University of Split, Split, Croatia; 6Sleep Medicine Center, School of Medicine, University of Split, Split, Croatia; 7Department of Social Medicine and Organization of Health Care, Andrija Stampar School of Public Health, School of Medicine, University of Zagreb, Zagreb, Croatia Aim: To evaluate the health-related life quality of patients after surgically treated midface

Aim: To evaluate the health-related life quality of patients after surgically treated midface fractures. Patients and Methods: This retrospective cohort study compared the 36-Item Short Form Health Survey (SF-36) scores of 42 male patients following surgically treated maxillary or zygomatic fractures with the reported normative data of the SF-36 for the Croatian population. Results: The current study showed that the health-related life quality of surgically treated patients was comparable to similar age, gender, and regional demographics in the Croatian population norm. However, we revealed a significant deterioration of the "Emotional well-being" domain in younger patients (P = 0.03) and a severely affected domain of "Physical functioning" in older patients (P = 0.049). Conclusion: There was a significant negative psychological impact from facial trauma on younger patients. In contrast, older patients were more prone to physical impairment. Therefore, follow-up visits are an opportunity to screen and refer younger patients to mental health services in a timely manner to prevent severe psychological difficulties and an opportunity to identify older patients who require physical therapy.

BACKGROUND Psychological reactions may adversely affect recovery after major cardiac events. This study investigates the role and frequently negligible importance of ambulatory cardiac rehabilitation (ACR) in improvement of quality of life (QoL), anxiety and depression at patients with various cardiac pathology. SUBJECTS AND METHODS This prospective study included subjects treated for acute coronary syndrome (ACS), those with performed elective revascularization, and OTHERS (after valve replacement, implanted pacemaker or other device, with stable heart failure and coronary artery disease). Their anxiety (State Trait Anxiety Inventory (STAI) questionnaire), depression (Beck Depression Inventory (BDI-II) questionnaire) and QoL data (Short Form Health Survey-36 (SF-36) questionnaire, for physical and mental QoL components) were collected initially and after 3-month of ACR. RESULTS ACR underwent 170 patients, aged 59 (53-66 years), predominately males (74.7%). At both genders, median duration of ACR was 12 weeks, with reduction of anxiety and depression scores and improvement in almost all components of QoL (P<0.05), except in mental health and bodily pain in males and females, respectively. After ACS (63.5%), ACR lasted 12 weeks, with reduction of anxiety and depression scores and improvement in all components of QoL (P<0.05). After elective revascularization (14.1%), ACR lasted 12 weeks, with reduction of anxiety score and improvement in almost all components of QoL (P<0.05), except mental health. At OTHERS (22.4%), ACR lasted 4 weeks, with improvement in almost all components of QoL (P<0.05), except mental health; ACR duration negatively correlated with anxiety and depressive scores (P<0.05). CONCLUSION ACR during 3-month results with improvement of anxiety, depression and QoL at patients with various cardiac pathology.