Adaptation of the Strength and Difficulties Questionnaire for Use in the Republic of Georgia.

Background: Children in low-resource countries like Georgia often have limited access to assessment measures for mental health care services. This study adapts and validates the mental health screening tool the Strength and Difficulties Questionnaire for use in Georgian children. Methods: A total of 16 654 children were assessed by a parent and/or teacher using Georgian-adapted Strength and Difficulties Questionnaire. Receiver operating characteristic analyses were performed to assess the discriminative validity of the Strength and Difficulties Questionnaires and to establish an optimal cutoff score. Results: Data from 15 738 parents- and 13 560 teachers-administered Strength and Difficulties Questionnaire were analyzed. The internal consistency analysis showed Cronbach's alpha to be 0.625 and 0.621 for parent- and teacher-administered Strength and Difficulties Questionnaire, respectively. The area under the curve (95% CI) shows that the Strength and Difficulties Questionnaire can differentiate risk group children from typically developing peers: parent-administered questionnaires-0.629 (0.556-0.702) and teacher-administered questionnaires-0.680 (0.611-0.789). Parent-administered Strength and Difficulties Questionnaire has a cutoff value of 16 or more with 92.5% of sensitivity and teacher-administered Strength and Difficulties Questionnaire-14 or more with a sensitivity of 85.6%. Conclusion: The study finds that the Strength and Difficulties Questionnaire is a valid screening instrument and does not depend on the informant-parent or teacher. It suggests that with appropriate cultural adaptation, the SDQ can be used in the Republic of Georgia to identify children at risk for mental disorders and help guide resource allocation.

Validation of the Georgian version of a Stigma Scale of Epilepsy.

INTRODUCTION: Stigma Scale of Epilepsy (SSE), initially developed in Brazil, is accepted worldwide as a sensitive tool for assessing epilepsy-related stigma. We adapted and validated a Georgian version of SSE. MATERIALS AND METHODS: The SSE originated in Brazil and was translated into Georgian by three independent experts through forward and backward translation. The final version was generated for validation after handling gross or conceptual inconsistencies between the source and the new format. We used Cronbach's alpha to assess the internal consistency of the Georgian version of SSE. To explore the construct of SSE subscales in the Georgian version, we used principal components and factor analysis. Varimax rotation was applied. The Kaiser-Meyer-Olkin Measure and Bartlett's test of sphericity were employed to assess the sampling adequacy. A probability <0.05 was considered statistically significant. RESULTS: 87 adults, 32 (37 %) with epilepsy and 55 (63 %) without epilepsy were enrolled. The overall mean score of SSE was 19.5 (SD 10.1; min. 2, max. 53), and the differences between people with [20.7 (SD 8.9; min. 2, max. 53)] and without epilepsy [17.5 (SD 10.4; min. 3, max. 42)] were not statistically significant. Cronbach's alpha for the overall sample was 0.854; for the epilepsy cohort it was 0.876, and for individuals without epilepsy 0.823, indicating good SSE internal consistency. Kaiser-Meyer-Olkin Measure was 0.705 and Bartlett's test of sphericity was 926.2 (df 276; p < 0.001), suggesting acceptable sample adequacy. DISCUSSION: The Georgian version of the SSE is a valid and reliable measurement tool for assessing epilepsy-related stigma determinants among the country's population.

Comparison of Antimicrobial Susceptibility Profiles of Thermotolerant Campylobacter spp. Isolated from Human and Poultry Samples in Georgia (Caucasus).

Antimicrobial resistance remains a public health concern globally. This study presents antimicrobial resistance by microdilution and genetic diversity by the whole-genome sequencing of Campylobacter spp. from human and poultry samples isolated in Georgia in 2020/2021. The major species in poultry samples was C. coli, while C. jejuni was preferentially isolated from human samples. Resistance against tetracycline was highest (100%) in C. coli from industrial chicken and lowest in C. jejuni from clinical isolates (36%), while resistance against ciprofloxacin varied from 80% in C. jejuni from backyard chicken to 100% in C. jejuni and C. coli from industrial chicken. The point mutations in gyrA (T86I) and tet (O) genes were detected as resistance determinants for (fluoro-)quinolone or tetracycline resistance, respectively. Ertapenem resistance is still enigmatic. All isolates displayed sensitivity towards erythromycin, gentamicin and chloramphenicol. Multi-resistance was more frequently observed in C. coli than in C. jejuni, irrespective of the isolation matrix, and in chicken isolates compared to human isolates, independent of the Campylobacter species. The Georgian strains showed high variability of multi-locus sequence types (ST), including novel STs. This study provides the first antibiotic resistance data from Campylobacter spp. in Georgia and addresses the need for follow-up monitoring programs.

Predictors of outcome among 31 children with infantile spasms syndrome.

OBJECTIVE: Infantile spasms syndrome is a severe epileptic encephalopathy. Management of infantile spasms remains challenging because of pharmacoresistant forms and relapsing seizures. A high number of patients with this syndrome have neurodevelopmental delay. The main objective of our study was to determine predictors to measure the neurodevelopmental outcome of patients with infantile spasms. METHODS: We prospectively evaluated 31 patients with infantile spasms from 2014 to 2017 at three hospitals in Tbilisi, Georgia. Various demographic data were evaluated at the first visit; video-EEG, brain MRI and neurodevelopmental evaluation were performed upon admission. A diary to record spasms was provided and completed by all parents/caregivers. Seizures were recorded on video and the phenomenology of infantile spasms was studied. Children were followed for one and two years after the first assessment. RESULTS: Neurodevelopmental deterioration was revealed in 61.1% on the second and 53% on the third evaluation in patients with onset of spasms before seven months of age. The mean score on the ASQ communication domain was low among structural cases. Eleven patients with pre-existing delay had developmental regression based on the second evaluation (Fisher's exact test: 7.2; df 1; p=0.01). SIGNIFICANCE: Our study reveals that age at onset of infantile spasms at less than seven months, pre-existing developmental delay, low ASQ scores and structural abnormalities on MRI are predictors of poor developmental outcome. Our data suggest that clinicians should inform parents at the first clinical evaluation about prognosis, and intervention should be started as early as possible in order to improve development.

A six-year longitudinal study of neurocognitive problems in children with epilepsy.

INTRODUCTION: This study describes the specific neuropsychological abnormalities among children with epilepsy (CH-E) living in Georgia. METHODS: A cohort of CH-E and children without epilepsy (CH-NoE), aged 6-13 years, admitted to the epilepsy center of the Institute of Neurology and Neuropsychology from 1st January 2010 to 31st December 2015, was selected and investigated with a structured protocol. Neurological/epileptological assessments were made and neuropsychological testing was done on all study subjects. RESULTS: Abnormalities in praxis, verbal functions, verbal learning, visual-spatial matching, visual-motor ability, and fine motor skills, working memory, and phonological memory span were often revealed in CH-E as compared to CH-NoE. Early age of seizure onset, epilepsy duration, and anti-seizure medication (ASM) use, in combination with brain structural abnormalities on neuroimaging, and structural etiology were independent predictors of impaired functioning in various neuropsychological domains. DISCUSSION: More than half of children with epilepsy have a variety of cognitive impairments, which may increase with ASM therapy, especially when the cause of seizures is structural damage to the brain. Therefore, in the process of diagnosing epilepsy, evaluation of cognitive functions should become an integral part to ensure effective management of the disorder.

Initiating a new national epilepsy surgery program: Experiences gathered in Georgia.

Surgery is the most effective therapeutic approach for medically refractory epilepsies and a safe and cost-efficient treatment in terms of long-term expenses of direct, indirect, and intangible costs. Georgia is a Caucasian low- to middle-income country with a remarkable effort to deal with epileptic diseases, but without an appropriate epilepsy surgery program. To address the needs for such a service in this country, two joint German-Georgian projects were initiated in 2017 and 2019. In the framework of these projects, a productive exchange program involving German and Georgian experts was undertaken in the past two years. This program included training and mentoring for Georgian clinical colleagues, as well as joint case conferences and workshops with the aim of optimizing presurgical diagnostics and preparing for an epilepsy surgery program in Georgia. Finally, a postsurgical medium- and long-term follow-up scheme was organized as the third component of this comprehensive approach. As a result of our efforts, the first patients underwent anterior temporal lobectomy and all of them remain seizure-free up to the present day. Hence, epilepsy surgery is not only feasible, but also already available in Georgia. In this report, we aim to share our experiences in the initiation and implementation of surgical epilepsy intervention in Georgia and illustrate our recent endeavor and achievements.

Validation of a Georgian version of the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E).

INTRODUCTION: This study aimed to validate a Georgian version of the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E). The distribution of psychiatric disorders was assessed among patients with epilepsy. METHODS: One hundred and thirty consecutive adult patients with epilepsy completed the NDDI-E and the Beck Depression Inventory (BDI). All patients were further assessed by a qualified psychiatrist. RESULTS: In 31 (23.8%) patients, a diagnosis of major depression was revealed. The internal consistency of the NDDI-E was 0.695. Receiver operating characteristics (ROC) showed an area under the curve of 0.975. A cutoff score of ≥16 resulted in a sensitivity of 0.90 and a specificity of 0.939. The screening questionnaire showed a significantly positive correlation with BDI scores (Spearman's rho - 0.684), indicating good concurrent validity. DISCUSSION: The Georgian version of the NDDI-E is a reliable tool for the detection of depressive disorders in individuals with epilepsy.

Cognitive functions in children exposed to antiepileptic drugs in utero - Study in Georgia.

OBJECTIVE: The cognitive teratogenicity of antiepileptic drugs (AEDs) has gained increasing attention in the last decade. The objective of the current study was to assess the effects of AED fetal exposure on the cognitive development of children of mothers with epilepsy from Georgia in a controlled study taking into consideration major confounding factors. METHODS: A prospective cohort group was formed from children and mothers registered in the Georgian National AED-Pregnancy Registry. The study group's age- and gender-matched control children without fetal AED exposure were selected retrospectively. The Intelligence Quotient (IQ) using the Wechsler Adult Intelligence Scale - revised (WAIS-R) was assessed in mothers. The Wechsler Preschool and Primary Scale of Intelligence (WPPSI-4) were used to assess intellectual functioning for children of both study and control groups. Linear regression analysis was performed to detect association of AED exposure on the cognitive performance of children. RESULTS: In total, 100 children aged 36 to 72months were evaluated. The IQ of WWE was significantly lower compared to women without epilepsy in all modalities. Exposure to valproate (VPA) (n=18) was associated with lowest cognitive performance regarding Full Scale IQ (FSIQ) (ß, -12.04; p=0.006) and verbal comprehension (VCI) (ß, -8.89; p=0.019). Maternal FSIQ, maternal performance IQ (PIQ), and child's age at first phrases were independent factors associated with the cognitive development of children. CONCLUSIONS: Multivariate analysis showed VPA to be an independent predictor for decreased cognitive performance. Maternal FSIQ, PIQ, and child developmental achievements were significant confounders for cognitive performance in children.

Focal EEG features and therapeutic response in patients with juvenile absence and myoclonic epilepsy.

OBJECTIVE: To investigate the characteristics of focal EEG features in patients with juvenile absence epilepsy (JAE) and juvenile myoclonic epilepsy (JME), and to assess their possible influence on therapeutic response. METHODS: Focal EEG features were prospectively scored in 168 consecutive patients. Ninety-six patients were drug-naïve and 72 patients were already on antiepileptic drugs (AEDs): 38 on adequate medication and 34 on inadequate medication. Therapeutic response was assessed one year after starting adequate therapy. RESULTS: One-hundred-eighteen patients (70.2%) had focal EEG features: 89 patients (53%) had focal epileptiform discharges, and 80 patients (47.6%) had focal slowing. Most often, these were multifocal and localized in frontal and temporal regions. Among patients already on AEDs, patients with focal EEG features were more often treated with inadequate medication due to misdiagnosis, than patients without focal features. Data on therapeutic response were available for 118 patients; most of them (90.7%) were seizure free. None of the focal EEG features affected therapeutic response. CONCLUSION: Focal EEG features are common in patients with JME and JAE, but they do not influence the therapeutic response. SIGNIFICANCE: It is important that physicians are aware of the focal EEG features in order to avoid misdiagnosis and inadequate therapy.

Short-term outcomes and major barriers in the management of convulsive status epilepticus in children: a study in Georgia.

AIM: Convulsive status epilepticus is the most common childhood neurological emergency in developing countries, where poor healthcare organisation could play a negative role in the management of the condition. Unavailability of second-line injectable anticonvulsants is an additional hindering factor in Georgia. This report reflects the results of the first study aimed at evaluating the epidemiological features of convulsive status epilepticus, as well as identifying obstacles influencing the management of patients with convulsive status epilepticus in Georgia. METHODS: A prospective, hospital-based study was performed. Paediatric patients with convulsive status epilepticus, admitted to the emergency department of a referral academic hospital from 2007 to 2012, were included in the study. RESULTS: Forty-eight paediatric patients admitted to hospital met the criteria for convulsive status epilepticus. Seizure duration was significantly shorter among the group with adequate and timely pre-hospital intervention. Moreover, patients with appropriate pre-hospital treatment less frequently required mechanical ventilation (p=0.039). Four deaths were detected during the follow-up period, thus the case fatality rate was 8%. Only 31% of patients received treatment with intravenous phenytoin. CONCLUSION: The study results show that adequate and timely intervention could improve outcome of convulsive status epilepticus and decrease the need for mechanical ventilation. Mortality parameters were comparable to the results from other resource-limited countries. More than one third of patients did not receive appropriate treatment due to unavailability of phenytoin.

Perspectives of epilepsy surgery in resource-poor countries: a study in Georgia.

BACKGROUND: To identify patients with concordant seizure semiology, interictal epileptiform discharges on standard EEG and brain MRI changes to define the patients with pharmacoresistant epilepsy (PRE) who would be suitable for epilepsy surgery according to non-invasive protocol. METHODS: The medical records of the patients with epilepsy seen in Epilepsy Center of Institute of Neurology and Neuropsychology (ECINN) (Tbilisi, Georgia) were reviewed retrospectively. The diagnostic work-up included neurological examination, standard EEG, and MRI. The degree of concordance of the seizure semiology, EEG, and neuroimaging was used to determine the potential candidates for surgery. The probability of seizure freedom rate was estimated based on known predictive values of anatomical, electrophysiological, and semiological characteristics. RESULTS: A total of 83 (25 %) patients met the criteria of PRE. Fourteen (17 %) patients had complete concordance of seizure semiology, MRI, and EEG. Out of these patients, 11 had mesial temporal sclerosis on MRI and three had focal cortical dysplasia (FCD). Estimated seizure-free surgical success rate in this group was 75-95 % without the need for further investigations. Out of 25 (30 %) non-lesional MRI cases, the concordance of seizure semiology and EEG was in nine patients with probable success rate up to 60 %. Thirteen patients (16 %) had discordant EEG and MRI data and were not suitable for surgery without further testing. CONCLUSIONS: A significant portion of PRE patients with concordant anatomical, electrophysiological, and semiological characteristics can be treated surgically in resource-limited countries. Nevertheless, most patients will still require further investigation for proper localization of epileptogenic focus.

Premature mortality in a Georgian cohort of people with epilepsy.

Mortality in people with epilepsy has not previously been estimated in Georgia. We identified a prevalent cohort of people with epilepsy from a tertiary referral centre in Tbilisi, Georgia and attempted to establish survivorship status for all. One-way sensitivity analysis estimating mortality rates in those lost to follow-up was also used. Of 1952 people, 1250 (64%) were located; 93 (7%) had died over a median of 11 years follow up. The main cause specific Proportional Mortality Ratios were: underlying diseases (39%) and accidental death (9%). One SUDEP was confirmed with a further 4 possible, but the cause of death was unknown in 47%. The overall SMR was 1.4, with much higher SMRs (up to 12) in young people. The sensitivity analysis suggested an SMR of 3.0.

Knowledge, attitudes, and stigma towards epilepsy in different walks of life: a study in Georgia.

We conducted a survey to assess public awareness of epilepsy and stigma expression in different social groups in Tbilisi, Georgia. Respondents were divided into those from a medical or paramedical background, those with a nonmedical professional background, and a group with unskilled workers or unemployed individuals. One thousand and sixteen people completed a Knowledge, Attitude and Perception questionnaire. Medical and paramedical professionals had a better general knowledge about epilepsy, its possible causes, and its nature, but their views on treatment and attitudes towards epilepsy were the same or worse when compared to the other groups. Of the respondent, 14% would not let their children play with people with epilepsy, and 75% would not allow their children to marry a person with epilepsy. Nearly a third of teachers considered epilepsy a psychiatric disorder. This suggests a high degree of stigma towards epilepsy in Georgia. Increasing awareness is crucial to ameliorate this.

The prevalence and treatment gap of epilepsy in Tbilisi, Georgia.

INTRODUCTION: Data on the prevalence of epilepsy and the extent of its treatment gap are important for planning health care delivery for people with epilepsy. The prevalence of active epilepsy in Georgia prior to the social and political re-organization in the early 1990s was estimated at around 5.7 per 1000. Changes to the social structure of the country may have affected this. There is no previous estimate of the treatment gap. METHODS: A door-to-door survey was carried out using a validated screening questionnaire to determine the prevalence of epilepsy and the extent of the treatment gap amongst a population of about 10,000 people in Tbilisi, the capital of Georgia. The diagnosis of epilepsy amongst those who screened positive was confirmed by a multidisciplinary team. RESULTS: Lifetime prevalence was 11.4/1000. The prevalence of active epilepsy was estimated at 8.8/1000, and 5/1000 had seizures in the previous 12 months. About two thirds of people with active epilepsy had not received appropriate antiepileptic treatment in the month prior to the survey. 89% had focal epilepsy and two thirds had co-morbidity (neurological deficits, behavioral, psychiatric or somatic problems). CONCLUSION: The prevalence of epilepsy was higher than previously estimated and the treatment gap was substantial. Results should inform the planning of epilepsy care delivery in the country.

Stroke incidence and 30-day case-fatality in a suburb of Tbilisi: results of the first prospective population-based study in Georgia.

BACKGROUND AND PURPOSE: Although stroke is one of the main public health problems worldwide, no study of stroke incidence has been performed in Georgia, and therefore, a population-based registry was established to determine the incidence and case-fatality rates of first-ever stroke. METHODS: We identified all first-ever strokes between November 2000 and July 2003 in a defined population of 51,246 residents in the Sanzona suburb of Tbilisi, the capital of Georgia, using overlapping sources of information and standard diagnostic criteria. RESULTS: A total of 233 first-ever strokes occurred during the study period. The crude annual incidence rate was 165 (95% CI, 145 to 188) per 100,000 residents. The corresponding rate adjusted to the standard "world" population was 103 (95% CI, 89 to 117). In terms of stroke subtype, the crude annual incidence rate per 100,000 inhabitants was 89 (95% CI, 74 to 106) for ischemic stroke, 44 (95% CI, 34 to 57) for intracerebral hemorrhage, 16 (95% CI, 10 to 25) for subarachnoidal hemorrhage, and 16 (95% CI, 10 to 25) for unspecified stroke, and the corresponding case-fatality rates at 1 month were 19.2%, 48.4%, 47.8%, and 69.6%. CONCLUSIONS: The overall stroke incidence rate in an urban population of Georgia is comparable to those reported in developed countries. As for the stroke subtypes, there is an excess of hemorrhagic strokes compared with other registries. Geographical and lifestyle variations may explain these findings, whereas inadequacy of the stroke care system in Georgia might contribute to the high case-fatality.