Perceptions on support, challenges and needs among parents and caregivers of children with developmental disabilities in Croatia, North Macedonia and Serbia: a cross-sectional study.

BACKGROUND: Parents/caregivers of children with developmental disabilities (CDD) have a wide range of support needs and there are various interventions available. Support, challenges, and needs among parents/caregivers of CDD likely vary in different geographical settings. This study aimed to analyze the perceptions of support, challenges, and needs among parents/caregivers of CDD in Croatia, North Macedonia, and Serbia. METHODS: We conducted a cross-sectional study in March-April 2023 within the Erasmus + SynergyEd project. The eligible participants were parents and caregivers of CDD in Croatia, North Macedonia, and Serbia, who filled out a modified Caregiver Needs Survey online. RESULTS: Among 953 participants, 542 (57%) were from Croatia, 205 (21%) were from North Macedonia and 206 (22%) were from Serbia. The most common diagnosis of participants' children was autism spectrum disorder (26%). The child most often received the first diagnosis at the median of 2 years, diagnosed by a team of professionals. More than half (58%) of children attended preschool and public school, while 22% did not attend any schooling. Additional support from the state/city/county was received by 66% of CDD. Most participants declared not participating in association/organization for family support. Participants mostly (68%) used experts who work with the child as a source of information about their child's condition, followed by the Internet (53%). In the last 12 months, 60% of participants had difficulties with the availability of services in their area or problems getting appointments. The biggest problem in getting support was ensuring the child's basic rights were protected. Participants stated that ensuring greater rights for CDD was the greatest need for their families. CONCLUSION: Parents/caregivers of CDD in Croatia, North Macedonia, and Serbia faced multiple challenges, but most of them were satisfied with the services provided to their children. Future efforts to develop policies and services related to CDD should consider the opinions of their parents/caregivers and disparities in access to services.

Tendencies towards emigration and their association with introversion and ethnocentrism among final-year medical students from Osijek, Croatia: a cross-sectional study.

BACKGROUND: The migration of healthcare workers is attracting growing attention worldwide. Attitudes towards emigration develop over the years, and it is possible that, in addition to social factors, they are influenced by the characteristics of a person's personality and the sense of belonging to the social environment. This study aimed to determine the tendencies of final-year medical students' from Osijek, Croatia, towards emigration after graduation and after specialization, as well as their specialty preferences and to investigate whether introversion and ethnocentrism have an impact on attitudes toward leaving the country in search of employment elsewhere. METHODS: A cross-sectional study was conducted among final-year (6th year) medical students from Osijek, Croatia, in two consecutive academic years - 2014/2015 and 2015/2016. Students completed a questionnaire about sociodemographic characteristics, academic and scientific performance, preferences about their future medical career, the medical specialty of choice, emigration tendencies after graduation and specialization, ethnocentrism and introversion. RESULTS: There were 124 students who participated in the study (response rate: 96%). A quarter of participants agreed that they are likely or very likely to emigrate after graduation (25.0%) or after specialization (23.39%). Variables associated with the intention to emigrate were specialty preferences (students that prefer endocrinology and psychiatry had the highest emigration tendencies), academic year in which the participants were included (students included in 2014/2015 were more prone to emigrate after specialization, p = 0.060), prior involvement in scientific projects (students with experience in scientific projects expressed higher tendencies to emigrate after graduation, p = 0.023), and ethnocentrism (higher ethnocentrism was associated with a lower tendency towards emigration after specialization, Spearman's rho = -0.191). CONCLUSION: Our finding that a quarter of final-year medical students from the Faculty of Medicine Osijek were considering emigrating from Croatia in search of employment elsewhere after graduation or specialization is not as high as in previous Croatian studies or studies conducted in other European countries. Even though these data may be encouraging, considering the lack of physicians in Croatia, interventions are needed to prevent permanent emigration to protect the future functioning of the Croatian health system. Furthermore, our study did not find significant associations between levels of introversion and ethnocentrism and tendency to emigrate from Croatia. It seems that the phenomenon covering the emigration of students is more complex and influenced by many other factors which were not included in our study.

Systematic reviewers used various approaches to data extraction and expressed several research needs: a survey.

OBJECTIVE: Data extraction is a prerequisite for analyzing, summarizing, and interpreting evidence in systematic reviews. Yet guidance is limited, and little is known about current approaches. We surveyed systematic reviewers on their current approaches to data extraction, opinions on methods, and research needs. STUDY DESIGN AND SETTING: We developed a 29-question online survey and distributed it through relevant organizations, social media, and personal networks in 2022. Closed questions were evaluated using descriptive statistics, and open questions were analyzed using content analysis. RESULTS: 162 reviewers participated. Use of adapted (65%) or newly developed extraction forms (62%) was common. Generic forms were rarely used (14%). Spreadsheet software was the most popular extraction tool (83%). Piloting was reported by 74% of respondents and included a variety of approaches. Independent and duplicate extraction was considered the most appropriate approach to data collection (64%). About half of respondents agreed that blank forms and/or raw data should be published. Suggested research gaps were the effects of different methods on error rates (60%) and the use of data extraction support tools (46%). CONCLUSION: Systematic reviewers used varying approaches to pilot data extraction. Methods to reduce errors and use of support tools such as (semi-)automation tools are top research gaps.

Rapid reviews methods series: Guidance on team considerations, study selection, data extraction and risk of bias assessment.

This paper is part of a series of methodological guidance from the Cochrane Rapid Reviews Methods Group (RRMG). Rapid reviews (RRs) use modified systematic review (SR) methods to accelerate the review process while maintaining systematic, transparent and reproducible methods to ensure integrity. This paper addresses considerations around the acceleration of study selection, data extraction and risk of bias (RoB) assessment in RRs. If a RR is being undertaken, review teams should consider using one or more of the following methodological shortcuts: screen a proportion (eg, 20%) of records dually at the title/abstract level until sufficient reviewer agreement is achieved, then proceed with single-reviewer screening; use the same approach for full-text screening; conduct single-data extraction only on the most relevant data points and conduct single-RoB assessment on the most important outcomes, with a second person verifying the data extraction and RoB assessment for completeness and correctness. Where available, extract data and RoB assessments from an existing SR that meets the eligibility criteria.

Evidence to decision frameworks enabled structured and explicit development of healthcare recommendations.

OBJECTIVE: The aim of this study is to identify and describe the processes suggested for the formulation of healthcare recommendations in healthcare guidelines available in guidance documents. METHODS: We searched international databases in May 2020 to retrieve guidance documents published by organizations dedicated to guideline development. Pairs of researchers independently selected and extracted data about the characteristics of the guidance document, including explicit or implicit recommendation-related criteria and processes considered, as well as the use of evidence to decision (EtD) frameworks. RESULTS: We included 68 guidance documents. Most organizations reported a system for grading the strength of recommendations (88%), half of them being the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Two out of three guidance documents (66%) proposed the use of a framework to guide the EtD process. The GRADE-EtD framework was the most often reported framework (19 organizations, 42%), whereas 20 organizations (44%) proposed their own multicriteria frameworks. Using any EtD framework was related with a more comprehensive set of recommendation-related criteria compared to no framework, especially for criteria like values, equity, and acceptability. CONCLUSION: Although limited, the use of EtD frameworks was associated with the inclusion of relevant recommendation criteria. Among the EtD structured frameworks, the GRADE-EtD framework offers the most comprehensive perspective for evidence-informed decision-making processes.

Pain assessment in clinical trials: a narrative review.

Pain is a symptom measured in many clinical trials. For pain as an outcome domain, trialists need to choose adequate outcome measure(s), as there are myriad outcome measures for pain to choose from. To ensure consistency and uniformity in clinical trials and systematic reviews, core outcome sets (COS) have been defined; COS includes a predefined minimal list of core outcomes that should be measured within a trial, to ensure their consistency and comparability. COS is defined via consensus procedure, which includes relevant stakeholders such as experts from a specific field and patients. Along with outcomes, outcome measures for each outcome need to be defined to make sure that the outcomes will be measured consistently and uniformly. Hereby we reviewed studies that have examined use of recommended core outcome domains and outcome measures in clinical trials that would be expected to measure pain. Despite the existence of COS and defined core outcome measures (COMs), multiple studies have shown that these are not necessarily used in clinical trials, or in the relevant systematic reviews, which further increases heterogeneity of existing evidence, hinders evidence synthesis and trial comparability, and assessment of comparative effectiveness of interventions. Trialists are encouraged to use COS and COMs when designing clinical trials. Research community is encouraged to design interventions that will help with identifying barriers for using COS and COMs and interventions to foster their uptake. Use of consistent pain outcomes and pain outcome measures is in the interest of patients, research community, healthcare workers and decision-makers. For clinical conditions for which there are no COS and COMs, efforts to design them would be beneficial.

Adequacy of risk of bias assessment in surgical vs non-surgical trials in Cochrane reviews: a methodological study.

BACKGROUND: Bias in randomized controlled trials (RCTs) can lead to underestimation or overestimation of the true effects of interventions. Surgical RCTs may suffer from the risk of bias (RoB) that is avoidable in trials of other interventions, and vice versa. We aimed to compare the adequacy of RoB assessments in surgical versus non-surgical RCTs included in Cochrane reviews and to assess the most common differences in those RoB assessments. Due to specificities of surgical trials, i.e. difficulties associated with blinding of surgical interventions, we hypothesized that assessments of surgical trials may be more adequate, compared to RCTs of non-surgical interventions. METHODS: This was a methodological study, analyzing methods of published Cochrane systematic reviews. Data were extracted from RoB tables in Cochrane reviews (judgments and accompanying explanatory comment) for the following four RoB domains used in the 2011 Cochrane RoB tool: randomization, allocation concealment, blinding of participants and personnel, and blinding of outcome assessors. We defined adequate assessments as those that were in line with instructions from the Cochrane Handbook for Systematic Reviews of Interventions. The prevalence of adequate assessments was compared in surgical versus non-surgical trials. The most common differences in both groups of reviews were presented. RESULTS: In 729 analyzed Cochrane reviews, there were 10,537 included trials. The prevalence of adequate RoB judgments made by Cochrane authors ranged from 87.9, 95%CI (87.3 to 88.6%) for randomization to 70.7, 95%CI (69.8 to 71.5%) for blinding of participants and personnel. For all analyzed RoB domains, the prevalence of adequate RoB domains was higher in surgical trials than in non-surgical trials. For two RoB domains assessing blinding, this difference between surgical and non-surgical trials was statistically significant (P < 0.001), while the difference was not significant for the RoB domain regarding randomization (P = 0.124) and allocation concealment (P = 0.039, ß < 0.8). CONCLUSIONS: RoB judgments were more in line with instructions from the Cochrane Handbook when Cochrane reviews assessed surgical trials, compared to those that analyzed non-surgical interventions. However, further steps are warranted to scrutinize RoB assessment in trials of both surgical and non-surgical interventions.

Awareness and acceptability of Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials core outcome set for chronic pain among surveyed neuropathic pain authors.

Aim: We assessed the knowledge and adoption of Initiative on Methods, Measurement and Pain Assessment in Clinical Trials (IMMPACT)-recommended core outcome set (COS) and core outcome measures (COM) among authors of systematic reviews (SR) and randomized controlled trials (RCT) about interventions for neuropathic pain (NeuP). Methods: NeuP SR and RCT authors identified via a systematic literature search were surveyed. Results: The response rate was low. Although majority of respondents were familiar with the IMMPACT COS, only 61% of SR authors and 40% of RCT authors used the COS. The main perceived obstacle that prevented the adoption of the COS was the lack of awareness of the full IMMPACT COS. Conclusion: The adoption of IMMPACT-recommended COS and COM among NeuP authors was inadequate and their appropriateness needs to be further evaluated.

Assessment of reporting quality of abstracts of systematic reviews with meta-analysis using PRISMA-A and discordance in assessments between raters without prior experience.

BACKGROUND: Reporting quality of systematic reviews' (SRs) abstracts is important because this is often the only information about a study that readers have. The aim of this study was to assess adherence of SR abstracts in the field of anesthesiology with the reporting checklist PRISMA extension for Abstracts (PRISMA-A) and to analyze to what extent will the use of PRISMA-A yield concordant ratings in two raters without prior experience with the checklist. METHODS: We analyzed reporting quality of SRs with meta-analysis of randomized controlled trials of interventions published in the field of anesthesiology from 2012 to 2016 by using 12-item PRISMA-A checklist. After calibration exercise, two authors without prior experience with PRISMA-A scored the abstracts. Primary outcome was median adherence to PRISMA-A checklist. Secondary outcome was adherence to individual items of the checklist. We analyzed whether there was improvement in reporting of SR abstracts over time. Additionally, we analyzed discrepancies between the two raters in scoring individual PRISMA-A items. RESULTS: Our search yielded 318 results, of which we included 244 SRs. Median adherence to PRISMA-A checklist was 42% (5 items of 12). The majority of analyzed SR abstracts (N = 148, 61%) had a total adherence score under 50%, and not a single one had adherence above 75%. Adherence to individual items was very variable, ranging from 0% for reporting SR funding, to 97% for interpreting SR findings. Overall adherence to PRISMA-A did not change over the analyzed 5 years before and after publication of PRISMA-A in 2013. Even after calibration exercise, discrepancies between the two raters were found in 275 (9.3%) out of 2928 analyzed PRISMA-A items. Cohen's Kappa was 0.807. In the item about the description of effect there were discrepancies in 59% of the abstracts between the raters. CONCLUSION: Reporting quality of systematic review abstracts in the field of anesthesiology is suboptimal, and did not improve after publication of PRISMA-A checklist in 2013. We need stricter adherence to reporting checklists by authors, editors and peer-reviewers, and interventions that will help those stakeholders to improve reporting of systematic reviews. Some items of PRISMA-A checklist are difficult to score.

Minor differences were found between AMSTAR 2 and ROBIS in the assessment of systematic reviews including both randomized and nonrandomized studies.

OBJECTIVE: To compare A Measurement Tool to Assess Systematic Reviews (AMSTAR 2) with a tool to assess risk of bias in systematic reviews (ROBIS) in terms of validity, reliability, and applicability. STUDY DESIGN AND SETTING: We analyzed 30 systematic reviews (SRs) that included randomized and nonrandomized studies, with Cochrane and non-Cochrane SRs sampled in 1:1 ratio. Four reviewers assessed independently all 30 SRs with AMSTAR 2, followed by ROBIS. We calculated Fleiss' Kappa as a measure of inter-rater reliability (IRR) across 4 raters. RESULTS: The IRR for scoring the overall confidence in the SRs with AMSTAR 2 and the overall domain in ROBIS was fair (AMSTAR 2: κ = 0.30, 95% [confidence interval] CI: 0.17 to 0.43; ROBIS: κ = 0.28, 95% CI: 0.13 to 0.42). AMSTAR 2 confidence in review ratings strongly correlated with the overall domain rating in ROBIS (Spearman rs = 0.84). Mean time for scoring AMSTAR 2 was slightly higher than for ROBIS (18 vs. 16 min), with huge differences between the reviewers. CONCLUSION: Both AMSTAR 2 and ROBIS can be applied to SRs including both randomized controlled trials (RCTs) and non-RCTs. Measurement properties of ROBIS seemed not to be much different when comparing with other studies that include only SRs of RCTs.

Legal and Ethical Aspects of Pain Management.

In this manuscript we presented legal and ethical aspects of pain management. Pain is a global public health problem because the burden of acute and chronic pain is considerable and is continuously increasing. It has been postulated that pain management is a fundamental human right, and that health systems are obliged to ensure universal access to pain management services. The suggestion that pain management is a right was fuelled by ample evidence about inadequate treatment of pain. Undertreatment and underprescribing in the context of pain can potentially have serious legal consequences, including charges about negligence, elder abuse, manslaughter and euthanasia. Multiple international declarations by professional societies have outlined pain management as a core ethical duty in medicine. Therefore, healthcare professionals need to be aware of multiple facets of pain-related ethics, including appraisal of patient's decision-making capacity. The worldwide opioid crisis also calls for careful consideration of specific ethical issues. Finally, healthcare workers need to be aware of the the risks associated with promoting pain management as a human right because patients and their caretakers can mistakenly perceive that they have right to total analgesia. CONCLUSION: Patients do have the right to pain management, but patient rights have limits, which may interfere with other competing rights, and also rights of their physicians. Treatment of pain must be medically, ethically and economically justified. Healthcare workers have an obligation to continuously improve their knowledge about pain management, including medical, legal and ethical aspects of pain.

The Medical School of the Catholic University of Croatia: Principles, Goals, Standards and Organization.

The aim of the study was to present the concept on which the School of Medicine at the Catholic University of Croatia (CUC) will be established. The new School will alleviate the shortage of physicians in Croatia and introduce an innovative form of medical education focused on principles of patient-centered care and social accountability. At the same time, the students will acquire all relevant competencies and levels of knowledge, skills and attitudes that are required by current evidence in medical education, European standards and guidelines for quality assurance at higher education institutions. The four pillars of the CUC Medical School are: 1) distributed medical education that involves health institutions outside major medical centers, 2) the concept of transformative learning, 3) teaching and practicing evidence-based medicine, and 4) implementation of quality management principles supported by information technology solutions for effective management of learning, research and practice. The overall aim of the CUC School of Medicine is to educate and train physicians capable of using best available medical evidence to deliver economically sustainable healthcare that can improve equity and health outcomes in the communities they serve, particularly those that are currently underserved. CONCLUSION: The proposed programme is introducing an original system of modern medical education that insists on developing humanistic aspects of medicine, patient-centred care and social accountability, while maintaining all competencies and knowledge levels that a physician should have according to the current understanding of medical education.

Effectiveness and efficacy of nutritional therapy: A systematic review following Cochrane methodology.

BACKGROUND & AIMS: Disease-related malnutrition has deleterious consequences on patients' outcome and healthcare costs. The demonstration of improved outcome by appropriate nutritional management is on occasion difficult. The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed the Nutrition Education Study Group (ESPEN-NESG) to increase recognition of nutritional knowledge and support in health services. METHODS: To obtain the best available evidence on the potential effects of malnutrition on morbidity, mortality and hospital stay; cost of malnutrition; effect of nutritional treatment on outcome parameters and pharmaco-economics of nutritional therapy, a systematic review of the literature was performed following Cochrane methodology, to answer the following key questions: Q1) Is malnutrition an independent predictive factor for readmission within 30 days from hospital discharge? Q2) Does nutritional therapy reduce the risk of readmission within 30 days from hospital discharge? Q3) Is nutritional therapy cost-effective/does it reduce costs in hospitalized patients? and Q4) Is nutritional therapy cost effective/does it reduce costs in outpatients? RESULTS: For Q1 six of 15 identified observational studies indicated that malnutrition was predictive of re-admissions, whereas the remainder did not. For Q2 nine randomized controlled trials and two meta-analyses gave non-conclusive results whether re-admissions could be reduced by nutritional therapy. Economic benefit and cost-effectiveness of nutritional therapy was consistently reported in 16 identified studies for hospitalized patients (Q3), whereas the heterogeneous and limited corresponding data on out-patients (Q4) indicated cost-benefits in some selected sub-groups. CONCLUSIONS: This result of this review supports the use of nutritional therapy to reduce healthcare costs, most evident from large, homogeneous studies. In general, reports are too heterogeneous and overall of limited quality for conclusions on impact of malnutrition and its treatment on readmissions.

National survey of pain clinics in Croatia: Organization and services.

OBJECTIVE: To analyze organization and therapeutic procedures administered in tertiary outpatient pain clinics in Croatia. METHODS: Data about organization of pain clinics, its personnel, equipment, continuing medical education, therapeutic procedures, research activities and relations with pharmaceutical industry were collected using questionnaires. RESULTS: Twenty-two Croatian pain clinics were included in the study. Most of the pain clinics employ exclusively anesthesiologists and nurses. The most frequently prescribed therapeutic procedures in pain clinics were pharmacotherapy, transcutaneous electrical nerve stimulation, acupuncture and trigger point injections. Almost all pain clinics provide educational material for patients. Most of the pain clinics have regular interactions with pharmaceutical companies. Prescribing decisions were based mostly on information from scientific meetings, research articles and consultations with colleagues. Information sources which are considered to be the gold standard--the systematic reviews of The Cochrane Collaboration--were used less frequently (n=12; 57%) than advertising materials from pharmaceutical companies (n=16; 76%). Few physicians and other pain clinics staff had scientific degrees or academic titles or were involved in a research project. CONCLUSION: The national study about pain clinics in Croatia pointed out that there is room for improvement of their organization and services. Pain clinics should employ health-care professionals with diverse backgrounds. They should offer treatments backed by the highest-level of scientific evidence. Since pain is a major public health issue, pain clinic staff should engage more in research to contribute to the growing field of pain research, to enhance capacities for pain research in Croatia, to incorporate scientific evidence into their daily decision-making and to enable evidence-based practice.

Access to public healthcare services and waiting times for patients with chronic nonmalignant pain: feedback from a tertiary pain clinic.

Evaluation of healthcare services by patients is an essential component of quality improvement. We studied association between patient satisfaction and accessibility of healthcare services to patients with chronic nonmalignant pain. A hundred patients from the Pain Clinic, Split University Hospital Center, Split, Croatia, completed a 27-item questionnaire about their condition, duration of chronic pain treatment, access to healthcare, waiting times for various healthcare services, and their satisfaction with the pain clinic and health system. Patients were referred to the pain clinic after median of 4.5 years of chronic nonmalignant pain duration. Median waiting time for pain clinic appointment, seeing a specialist and performing diagnostic procedures was 10, 30 and 90 days, respectively. However, some patients waited for an appointment to a specialist and diagnosis for up to one year. Negative association was found between waiting time for pain clinic appointment and healthcare system grade (r = -0.34, P = 0.02). Patient suggestions for improving pain clinic were more staff, better approach to each patient, and better organization. In conclusion, access to public healthcare for patients with chronic nonmalignant pain should be better to improve patient satisfaction and provide better care.

Assessing clinical and life sciences performance of research institutions in Split, Croatia, 2000-2006.

AIM: To evaluate publications of clinical and life scientists from research institutions in Split, Croatia, and the publication output from government-funded research projects of the University of Split School of Medicine. METHODS: We analyzed the number of publications from research institutions in Split, Croatia, in the 2000-2006 period, relative impact factors, predominant research fields, output of researchers from the University of Split School of Medicine receiving government research grants, and the average price of published article. RESULTS: From 2000 to 2006, clinical and life scientists published 350 articles indexed in Thomson Scientific database Current Contents. The number of articles increased from 30 in 2000 to 76 in 2006, and the average impact factor of journals where these articles were published increased from 2.03 in 2000 to 2.89 in 2006. Twenty percent of articles (72/350) were published in the Croatian Medical Journal. Principal investigators of the 12 research projects receiving government grants published 0 to 8 articles related to the project topic in the 2002-2006 research grant cycle. The research grantees published 78 original research articles, with an average price per article of euro 29.210 euros. CONCLUSION: Although the number and impact factor of research articles published by clinical and life scientists from Split, Croatia, is increasing, it is still low when the number of scientists is taken into account. There should be better mechanisms of control and evaluation of research performance of government-funded research projects.

An overlooked source of physician-scientists.

A shortage of physician-scientists in the United States is an ongoing problem. Various recommendations have been made to address this issue; however, none of them have ameliorated the situation. Foreign medical school graduates with postdoctoral training in the United States are an overlooked and untapped resource for combating the dearth of physician-scientists. Evaluation of the scientific staff at the University of Texas Southwestern Medical Center revealed that 11% of all postdoctoral fellows were international medical graduates. Interestingly, a survey taken by these individuals revealed a lack of institutional and/or mentor support for career development and preparation for becoming physician-scientists. Foreign postdoctoral fellows with medical degrees are not even eligible for physician-scientist grants and awards since they are not US citizens. Although physicians educated in the United States usually matriculate from medical school with high educational debt that prevents most of them from entering into scientific careers, doctors trained outside the United States generally have minimal, if any, debt. Furthermore, many of them have a keen interest in remaining in the United States once they complete their postdoctoral training. Thus, foreign-trained medical professionals who have pursued scientific training in the United States can be one of the solutions for the current dearth of physician-scientists.