Epidemiological features of traumatic brain injuries from a first-level trauma care national medical center in Georgia.

Introduction: Traumatic brain injuries is a significant public health issue in both developed and developing countries. In Georgia, traumatic brain injuries remains one of the leading causes of mortality and disability. Traumatic brain injuries affect families, communities and societies in Georgia and have far-reaching human, social and economic costs, manifested in increased emergency department visits, hospitalizations, disability and deaths.The aim of this study is to retrospectively analyze the epidemiological features of Traumatic Brain Injuries on the example of Medical Centre in Georgia which provides a first level trauma care for patients in the country. Materials and Methods: Retrospective observational study was conducted from August 1 to October 31, 2018. The study included patients who were admitted with a Traumatic Brain Injuries diagnosis and S00-S09.0 codes (ICD 10). SPSS 20 was used for statistical analysis. Results: A total of 96 TBI-related hospitalizations were studied. 56.3% (n=54) of hospitalized patients were males. The average age of patients was 40.7 years. Furthermore, patients aged 25-44 years were more represented in the number of TBI-related hospitalizations (39.6%). 95.8% of all Traumatic brain injuries hospitalizations were as a result of unintentional injuries. Unintentional falls were shown to be the predominant mechanism of injury accounting for over half of TBI-related hospitalizations (56.2%). The second most common mechanism of injury is the road traffic injury, mostly occurring among males (63.9%). Conclusion: This study offers an insight into understanding the epidemiological features of Traumatic Brain Injuries on the example of the National Medical Center from Georgia.

Emerging Treatments for Disorders of Consciousness in Paediatric Age.

The number of paediatric patients living with a prolonged Disorder of Consciousness (DoC) is growing in high-income countries, thanks to substantial improvement in intensive care. Life expectancy is extending due to the clinical and nursing management achievements of chronic phase needs, including infections. However, long-known pharmacological therapies such as amantadine and zolpidem, as well as novel instrumental approaches using direct current stimulation and, more recently, stem cell transplantation, are applied in the absence of large paediatric clinical trials and rigorous age-balanced and dose-escalated validations. With evidence building up mainly through case reports and observational studies, there is a need for well-designed paediatric clinical trials and specific research on 0-4-year-old children. At such an early age, assessing residual and recovered abilities is most challenging due to the early developmental stage, incompletely learnt motor and cognitive skills, and unreliable communication; treatment options are also less explored in early age. In middle-income countries, the lack of rehabilitation services and professionals focusing on paediatric age hampers the overall good assistance provision. Young and fast-evolving health insurance systems prevent universal access to chronic care in some countries. In low-income countries, rescue networks are often inadequate, and there is a lack of specialised and intensive care, difficulty in providing specific pharmaceuticals, and lower compliance to intensive care hygiene standards. Despite this, paediatric cases with DoC are reported, albeit in fewer numbers than in countries with better-resourced healthcare systems. For patients with a poor prospect of recovery, withdrawal of care is inhomogeneous across countries and still heavily conditioned by treatment costs as well as ethical and cultural factors, rather than reliant on protocols for assessment and standardised treatments. In summary, there is a strong call for multicentric, international, and global health initiatives on DoC to devote resources to the paediatric age, as there is now scope for funders to invest in themes specific to DoC affecting the early years of the life course.

Establishing Stroke Services in the Republic of Georgia.

INTRODUCTION: This article summarizes the medical experience in establishing stroke units and systemic thrombolysis in Georgia, which, like many other post-Soviet countries, still faces problems in organizing stroke care even after 30 years of independence. PATIENTS AND METHODS: We created an example of treating acute stroke with systemic thrombolysis and introduced stroke units in several hospitals in the country, including standardization of the diagnostic and treatment process, consistent evaluation, and monthly feedback to the stroke unit staff. RESULTS: Systemic thrombolysis has become a clinical routine in some large hospitals and is meanwhile reimbursed by the state insurance. The data of consecutive 1,707 stroke patients in 4 major cities demonstrated significant time lost at the prehospital level, due to failure in identifying stroke symptoms, delay in notification, or transportation. The consequent quality reports resulted in a dramatic increase in adherence to the European and national guidelines. A mandatory dysphagia screening and subsequent treatment led to a decrease in pneumonia rates. DISCUSSION: We discuss our experience and suggestions on how to overcome clinical, financial, and ethical problems in establishing a stroke services in a developing country. CONCLUSION: The Georgian example might be useful for doctors in other post-Soviet countries or other parts of the world.

Poly(ester amide) microspheres are efficient vehicles for long-term intracerebral growth factor delivery and improve functional recovery after stroke.

Growth factors promote plasticity in injured brain and improve impaired functions. For clinical application, efficient approaches for growth factor delivery into the brain are necessary. Poly(ester amide) (PEA)-derived microspheres (MS) could serve as vehicles due to their thermal and mechanical properties, biocompatibility and biodegradability. Vascular endothelial growth factor (VEGF) exerts both vascular and neuronal actions, making it suitable to stimulate post-stroke recovery. Here, PEA (composed of adipic acid, L-phenyl-alanine and 1,4-butanediol) MS were loaded with VEGF and injected intracerebrally in mice subjected to cortical stroke. Loaded MS provided sustained release of VEGF in vitro and, after injection, biologically active VEGF was released long-term, as evidenced by high VEGF immunoreactivity, increased VEGF tissue levels, and higher vessel density and more NG2+ cells in injured hemisphere of animals with VEGF-loaded as compared to non-loaded MS. Loaded MS gave rise to more rapid recovery of neurological score. Both loaded and non-loaded MS induced improvement in neurological score and adhesive removal test, probably due to anti-inflammatory action. In summary, grafted PEA MS can act as efficient vehicles, with anti-inflammatory action, for long-term delivery of growth factors into injured brain. Our data suggest PEA MS as a new tool for neurorestorative approaches with therapeutic potential.

Violent Behavior.

Violence is a significant public health problem representing one of the leading causes of death worldwide for people aged 15-44 years. Although violence and aggression are more frequent in adolescence and early adult life and decline with advancing age, these conditions can still develop for the first time in old age especially in association with organic brain disorder. Rates of violent death vary according to country income levels and are twice as higher in low- to middle-income countries than in high-income countries. Males are more affected than females. Violence is a multifactorial condition. A combination of biologic, psychodynamic, and social factors may play a role in development of violence and aggression. Since it may accompany or be result of different medical conditions it is important to determine the underlying condition or disease including mental illness for targeting the proper therapeutic strategy. In the acute setting with a behavioral emergency the primary task for the clinician is to act as soon as possible in order to stop the violence from escalating and to find the quickest way to keep the patient's agitation and violence under control with the maximum of safety for everybody using the less severe yet effective interventions. Multiple steps of talk down interventions and non-coercive behavioral and environmental treatments have been proposed. If such an approach is not effective, more coercive interventions are needed including involuntary medications and chemical restrain as well as physical restraint or seclusion in some cases.

Management of ischemic stroke in Central and Eastern Europe.

Stroke is one of the leading causes of disability in Europe. Central and Eastern European countries have the highest incidence and mortality rates through Europe. The improvements in stroke prevention and treatment in Central and Eastern European countries did not completely reach the quality parameters present in Western European countries. We present features of current management of stroke in Central and Eastern European countries.

A prototype worldwide survey of diagnostic and treatment modalities for stroke.

Stroke is a global health problem. However, very little is known about stroke care in low- to middle-income countries. Obtaining country-specific information could enable us to develop targeted programs to improve stroke care. We surveyed neurologists from 12 countries (Chile, Georgia, Nigeria, Qatar, India, Lithuania, Kazakhstan, Indonesia, Denmark, Brazil, Belgium, and Bangladesh) using a web-based survey tool. Data were analyzed both for individual countries and by income classification (low income, lower middle income, upper middle income, and high income). Six percent (n = 200) of 3123 targeted physicians completed the survey. There was a significant correlation between income classification and access and affordability of head computed tomography scan (ρ = .215, P = .002), transthoracic echocardiogram (ρ = .181, P = .012), extracranial carotid Doppler ultrasound (ρ = .312, P ≤ .000), cardiac telemetry (ρ = .353, P ≤ .000), and stroke treatments such as intravenous thrombolysis (ρ = .276, P ≤ .001), and carotid endarterectomy (ρ = .214, P ≤ .004); stroke quality measures such as venous thromboembolism prophylaxis during hospital stay (ρ = .163, P ≤ .022), discharge from hospital on antithrombotic therapy (ρ = .266, P ≤ .000), consideration for acute thrombolytic therapy (ρ = .358, P ≤ .000), and antithrombotic therapy prescribed by end of hospital day 2 (ρ = .334, P ≤ .000). However, there was no significant correlation between income classification and the access and affordability of antiplatelet agents, vitamin K antagonists and statins, anticoagulation for atrial fibrillation/flutter, statin medication, stroke education, and assessment for rehabilitation. Our study shows that it is possible to get an overview of stroke treatment measures in different countries by conducting an internet-based survey. The generalizability of the findings may be limited by the low survey response rate.

Correlation between MMP-9 and extracellular cytokine HMGB1 in prediction of human ischemic stroke outcome.

Ischemic stroke (IS) outcome predictors include clinical features, biochemical parameters and some risk factors. The relations between two main players in the ischemic brain, MMPs and HMGB1, were estimated in the plasma of ischemic stroke patients stratified according to the Glasgow Outcome Scale and the Oxfordshire Community Stroke Project classification. IS patients exhibited higher plasma concentration of MMP-9 and the inflammatory cytokine HMGB1 compared with healthy controls. A full-blown correlation between MMP-9 activation and increased plasma MMP-9 concentration was observed in case of IS patients. A similar activity of MMP-2 and MMP-12 was characteristic of healthy volunteers and IS patients. In patients with ischemic stroke increased plasma levels of MMP-9 and HMGB1 are associated with a poor functional outcome and are significantly correlated with each other (P=0.0054). We suggest that diagnostic benefits will be obtained if plasma HMGB1 levels are measured for IS patients in addition to MMP-9.

Incidence rates of the primary brain tumours in Georgia--a population-based study.

BACKGROUND: To determine the incidence rate and to describe other basic epidemiological data of primary brain tumours in a population-based study in Georgia, performed between March 2009 and March 2011. METHODS: Active case ascertainment was used to identify brain tumour cases by searching neuroradiology scan reports and medical records from all participating medical institutions, covering almost 100% of the neurooncology patients in the country. RESULTS: A total of 980 new cases were identified during the two-year period. For a population of almost 4.5 million, the overall annual incidence rate was 10.62 per 100,000 person-years, age-standardized to the year 2000 US population (ASR). Non-malignant tumours constituted about 65.5% of all tumours. Males accounted for 44% and females for 56% of the cases. Among classified tumours, age-standardized incidence rates by histology were highest for meningiomas (2.65/100,000), pituitary adenoma (1.23/100,000) and glioblastomas (0.51/100,000). ASR were higher among females than males for all primary brain tumours (10.35 vs. 9.48/100,000) as well as for main histology groups except for neuroepithelial, lymphomas and germ cell tumours. CONCLUSIONS: The annual incidence rate of all primary brain tumours in Georgia, though comparable with some European registry data, is low in comparison with the 2004-2005 Central Brain Tumor Registry of the United States (CBTRUS) database, which may reflect variations in reporting and methodology. The higher percentage of unclassified tumours (37.8%) probably also affects the discrepancies between our and CBTRUS findings. However, the most frequently reported tumour was meningioma with a significant predominance in females, which is consistent with CBTRUS data.

Primary brain tumour epidemiology in Georgia: first-year results of a population-based study.

A population-based cohort study was initiated in Georgia in March 2009 to collect epidemiologic data of malignant and non-malignant primary brain tumours. During the first year, 473 incident cases were identified. For a population of 4.3 million, the annual incidence rate was 10.25 per 100,000 inhabitants, age-standardized to the year 2000 US population. Non-malignant tumours constituted about 66 % of all tumours. Males accounted for 40 % and females for 60 % of the cases. Crude incidence rates by histology were highest for meningiomas (2.92/100,000), pituitary adenoma (1.16/100,000) and glioblastomas (0.64/100,000), which was in agreement with the frequency of reported histology: meningiomas--45.2 %, pituitary adenoma--18.0 % and glioblastomas--9.9 %. The age-standardized incidence rates were higher among females than males for all primary brain tumours (11.05 vs. 8.44/100,000) as well as for individual histologies except for glioblastoma and several other neuroepithelial tumours. Some differences compared with 2004-2005 Central Brain Tumor Registry of the United States data may be explained by a higher percentage of unclassified tumours (37 %) in our study. We suggest further studies to clarify the nature of this discrepancy.

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.