Care of patients with inborn errors of immunity in thirty J Project countries between 2004 and 2021

Introduction

The J Project (JP) physician education and clinical research collaboration program was started in 2004 and includes by now 32 countries mostly in Eastern and Central Europe (ECE). Until the end of 2021, 344 inborn errors of immunity (IEI)-focused meetings were organized by the JP to raise awareness and facilitate the diagnosis and treatment of patients with IEI.

Results

In this study, meeting profiles and major diagnostic and treatment parameters were studied. JP center leaders reported patients' data from 30 countries representing a total population of 506 567 565. Two countries reported patients from JP centers (Konya, Turkey and Cairo University, Egypt). Diagnostic criteria were based on the 2020 update of classification by the IUIS Expert Committee on IEI. The number of JP meetings increased from 6 per year in 2004 and 2005 to 44 and 63 in 2020 and 2021, respectively. The cumulative number of meetings per country varied from 1 to 59 in various countries reflecting partly but not entirely the population of the respective countries. Altogether, 24,879 patients were reported giving an average prevalence of 4.9. Most of the patients had predominantly antibody deficiency (46,32%) followed by patients with combined immunodeficiencies (14.3%). The percentages of patients with bone marrow failure and phenocopies of IEI were less than 1 each. The number of patients was remarkably higher that those reported to the ESID Registry in 13 countries. Immunoglobulin (IgG) substitution was provided to 7,572 patients (5,693 intravenously) and 1,480 patients received hematopoietic stem cell therapy (HSCT). Searching for basic diagnostic parameters revealed the availability of immunochemistry and flow cytometry in 27 and 28 countries, respectively, and targeted gene sequencing and new generation sequencing was available in 21 and 18 countries. The number of IEI centers and experts in the field were 260 and 690, respectively. We found high correlation between the number of IEI centers and patients treated with intravenous IgG (IVIG) (correlation coefficient, cc, 0,916) and with those who were treated with HSCT (cc, 0,905). Similar correlation was found when the number of experts was compared with those treated with HSCT. However, the number of patients treated with subcutaneous Ig (SCIG) only slightly correlated with the number of experts (cc, 0,489) and no correlation was found between the number of centers and patients on SCIG (cc, 0,174).

Conclusions

1) this is the first study describing major diagnostic and treatment parameters of IEI care in countries of the JP; 2) the data suggest that the JP had tremendous impact on the development of IEI care in ECE; 3) our data help to define major future targets of JP activity in various countries; 4) we suggest that the number of IEI centers and IEI experts closely correlate to the most important treatment parameters; 5) we propose that specialist education among medical professionals plays pivotal role in increasing levels of diagnostics and adequate care of this vulnerable and still highly neglected patient population; 6) this study also provides the basis for further analysis of more specific aspects of IEI care including genetic diagnostics, disease specific prevalence, newborn screening and professional collaboration in JP countries.

ALPHA- AND BETA-GLOBIN GENE MUTATIONS IN GEORGIA AND ARMENIA

Georgia and Armenia are situated at the northern rim of the thalassemia belt and bordering to countries with a known high prevalence of thalassemias. In this study we assessed the carrier frequency and potential spectrum of alpha- and beta-globin mutations among 202 and 190 unselected Georgian and Armenian subjects, respectively. We found four alpha-globin mutations (-3.7del, -4.2del, anti-3.7 triplication, poly-A2) in 9 Armenians (4.74%) and 4 Georgians (1.78%). The heterozygous beta-globin codon 8 [-AA] mutation was detected in one individual from Armenia only. Overall, carrier frequencies seem to be low in both countries, supporting the notion that thalassemias are not a major health problem there.

PECULIARITIES OF NUTRITION AMONG MEDICAL UNIVERSITY STUDENTS

Healthy nutrition helps to prevent development of chronic diseases and contributes to optimal functioning of the body. Dietary habits mainly are being established during the late adolescence and young adulthood. Aim - to study nutritional habits of the medical university students in Georgia. A questionnaire containing 73 questions was developed in English and Georgian. Sampling frame consisted of students of the 1st and 4th years of the Tbilisi State Medical University (TSMU). Random cluster sampling was used and total number of participants was 427 (34.4% male and 65.6% female). Mean age 20.6±1.9. Cross-sectional study was performed. The survey was anonymous and self-administered. Principles of Declaration of Helsinki were followed. Data analysis was done in Stata 14.0. Majority of the respondents have 3-4 meals a day and have hot meals several times or once a day. 193 (45.20%) refuse drinking alcohol at all. 112 (26.23%) almost never eat breakfast. 196 (45.67%) of the students get up at nights to eat. 233 (54.57%) do not consume meals at regular times. 183 (42.86%) do snack between the meals. 326 (76.35%) read or watch TV while eating. 190 (44.5%) eat white bread once a day or few times a day; 102 (23.89%) never eat buckwheat, oats. 326 (76.35%) add sugar to tea or coffee; 231 (54.10%) add salt to the already cooked food. 97 (22.71%) never eat fish. 166 (39.11%) and 172 (40.28%) correspondingly eat red meat and white meat 1-3 times per month or once a week. Only 159 (37.24%) eat fruits once a day or few times a day. 61 (14.29%) and 69 (16.16%) never eat correspondingly raw and cooked vegetables. Our findings are more or less in line with available international data. We think that the situation is similar in the non-medical students and the youth, in general. It might be advisable to perform additional investigations in this direction.

SURVEY OF PRACTICES, KNOWLEDGE AND ATTITUDE CONCERNING ANTIBIOTICS AND ANTIMICROBIAL RESISTANCE AMONG MEDICAL UNIVERSITY STUDENTS

Antimicrobial resistance (AMR) has become a global problem and is considered an emerging threat to public health worldwide. Aim - to assess knowledge, attitude and practice (KAP) regarding antimicrobial resistance and antibiotics among medical students in Georgia. KAP questionnaire containing 50 questions was developed in English and Georgian. Sampling frame consisted of students of the 4th year of the Tbilisi State Medical University (TSMU). Random cluster sampling was used and total number of participants was 212 (31.13% - International Faculty of Medicine, 45.75% - Faculty of Medicine, 23.11% - Faculty of Public Health). Mean age 22.95 (sd=0.52) with almost equal gender distribution. Cross-sectional study was performed. The survey was anonymous and self-administered. Principles of Declaration of Helsinki were followed. Data analysis was done in Stata 14.0. 79.25% think that antibiotics can cure bacterial infections, 57.08% think that antibiotics can not cure viral infections (statistically significant difference by faculties p<0.0001). 34.43% think that bacteria cause common cold and influenza (by gender p=0.01 and by faculties p=0.03). 83.02% have heard of antibiotic resistance (by faculties p<0.0001). 83.96% agree that antibiotics resistance has become a problem. 75.00% agree that the abuse of antibiotics has become the main cause leading to bacterial resistance. 60.38% consider that antibiotic resistance affects them and their family's health. 93.40% agree that it is necessary to get more education about antibiotics. 31.61% of the students in Georgia always and often stop taking antibiotics if they start feeling better. 43.40% never keep the remaining antibiotics. Obtained results are in line with the international findings. There was seen a statistically significant difference between public health and medical faculties (both English and Georgian) in responses on knowledge. In the attitude and practical behaviour sections all three groups provided similar results, only some questions were provided significantly different responses by faculties.

THE GLOBAL POINT PREVALENCE SURVEY (PPS) OF ANTIMICROBIAL USE AND ANTIMICROBIAL RESISTANCE AMONG HOSPITALIZED CHILDREN IN GEORGIA

The aims of our study were to determine antibiotic prescribing rates for prevention and treatment of infections in pediatric units, to evaluate the number and type of antimicrobial agents and administration route, reveal commonly used antibiotic subgroups and identify targets for improving the quality of antimicrobial prescribing. A 1-day PPS (Point Prevalence Study) on antibiotic use in hospitalized children was performed in Georgia from 2015 to 2019. 18 clinics in different regions of Georgia were included in the survey. Antimicrobial prevalence rates increased over the years from 60.1% in 2015 to 92.6% in 2018. The most commonly, antibiotics were prescribed for lower respiratory tract infections (LRTI). In 2015 25.1% of LRTI were treated by ampicillin-sulbactam but the next year it replaced with ceftriaxone (37.1% in 2017 and 38.2% in 2018). In pediatric surgical ward, the antibiotics were commonly prescribed for surgical prevention (54.1% in 2015, 32.3% in 2018). The most common conditions treated with antibiotics in neonates were sepsis (30.1%) and LRTI (45.3%). The most used antibiotic was ceftriaxone (33.3% in 2015). Ampicilin-sulbactam was prescribed in 28.1% of pneumonia case in neonates in 2018. In 2015 antibiotics were mainly prescribed empirically (98.0%). In 2018 resistance of MRSA was 8.1%, and resistance to the third-generation cephalosporin 17.3%. Prevalence rate of antibiotics for prevention and treatment of infection disease in pediatric units increased in 2018. Main feasible targets for optimization of antibiotic prescribing have been identified: high use of broad-spectrum antibiotics in hospitals, high frequency of empirical treatment, rarely performed culture tests, prolonged antibiotic prophylaxis in surgery patients and an alarming raise of resistant strains. The implementation of disease-specific clinical pathways associated with annual PPSs could be a good way to monitor and improve antibiotic prescription patterns in neonatal and pediatric inpatients over time.

The antibiotic knowledge, attitudes and behaviors of patients, doctors and pharmacists in the WHO Eastern European region - a qualitative, comparative analysis of the culture of antibiotic use in Armenia, Georgia, Kazakhstan, Moldova, Russia and Tajikistan

BACKGROUND

To reduce antimicrobial resistance (AMR), initiatives such as surveillance activities and activities to increase knowledge about how and why antibiotics (ABs) are (mis)used are needed. More surveillance systems are in place in the WHO Western European region than in the Eastern region, and only sparse knowledge exists about the current culture of AB use in the Eastern European countries.

OBJECTIVE

To investigate AB knowledge, attitudes and behaviors in countries in the WHO Eastern European region in order to identify overall similarities and differences across the region and how AB knowledge, attitudes and behavior patterns may be influenced by the national health care system.

METHODS

Semi-structured interviews were conducted in Armenia, Georgia, Kazakhstan, Moldova, Russia and Tajikistan with patients, doctors and pharmacists. In total, 80 interviews were carried out. A directed content analysis was applied, followed by a comparative analysis, identifying the similarities and differences in AB attitudes, knowledge and behaviors between the countries and discussing how the national health care systems might influence these patterns.

RESULTS

Cross-national patterns were identified regarding patients seeking ABs over-the-counter (OTC), patient variations in their requests for ABs when consulting doctors, and, finally, doctors and pharmacists appearing knowledgeable about ABs and their uses, with doctors displaying careful attitudes towards AMR. Indications of national differences between the countries included the ability of patients to afford ABs, prescribing practices of doctors and pharmacist attitudes towards selling ABs without prescriptions. Multiple aspects involved in patient and pharmacist AB decision making were detected, such as various rationales involved in buying/selling ABs OTC, implying that these processes are more complex than previously reported in the literature.

CONCLUSIONS

Similarities across the Eastern European region could be seen in patient needs and uses of antibiotics obtained OTC at community pharmacies, whereas doctors appeared more influenced by specific structures of the national healthcare system.

The Georgian version of the Juvenile Arthritis Multidimensional Assessment Report (JAMAR)

The Juvenile Arthritis Multidimensional Assessment Report (JAMAR) is a new parent/patient reported outcome measure that enables a thorough assessment of the disease status in children with juvenile idiopathic arthritis (JIA). We report the results of the cross-cultural adaptation and validation of the parent and patient versions of the JAMAR in the Georgian language. The reading comprehension of the questionnaire was tested in 10 JIA parents and patients. Each participating centre was asked to collect demographic, clinical data and the JAMAR in 100 consecutive JIA patients or all consecutive patients seen in a 6-month period and to administer the JAMAR to 100 healthy children and their parents. The statistical validation phase explored descriptive statistics and the psychometric issues of the JAMAR: the 3 Likert assumptions, floor/ceiling effects, internal consistency, Cronbach's alpha, interscale correlations, test-retest reliability, and construct validity (convergent and discriminant validity). A total of 100 JIA patients (26% systemic, 57% oligoarticular, 16% RF negative polyarthritis, and 1% RF positive polyarthritis) and 100 healthy children, were enrolled at two paediatric rheumatology centre. Notably, none of the enrolled JIA patients is affected with psoriatic arthritis or with enthesitis-related arthritis or with undifferentiated arthritis. The JAMAR components discriminated healthy subjects from JIA patients, except for the school-related problems variable. All JAMAR components revealed good psychometric performances. In conclusion, the Georgian version of the JAMAR is a valid tool for the assessment of children with JIA and is suitable for use both in routine clinical practice and clinical research.

[PHYSICAL DEVELOPMENT OF CHILDREN IN ORPHANAGES]

Aim - to define the parameters of physical development of children in orphanages. 72 children (45 boys, 27 girls) without chronic debilitating diseases and condition aged from 1 to 6 years from Tbilisi and Makhinjauri orphanages (Georgia) were assessed. Height and weight of all subjects were measured and BMI, height SDS (standard deviation score) and weight SDS were calculated. Data were compared to the normal values (national data). The retardation of the physical development were seen along almost all findings. The significant differences regarding age and gender were not revealed. The most expressed tendency to delay was expressed in the height of boys, particularly aged 3-5 years. Our data confirm that institution upbringing has a negative impact on the growth of children of 1-6 years of age. In children aged from 1 to 6 years who are healthy but live in orphanages there is a marked tendency to lag behind in physical development, mainly in height. The above-mentioned confirms the opinion about negative impact of upbringing in orphanages on the physical development of children.

Familial Mediterranean fever in Georgia

Familial Mediterranean Fever (FMF) is a hereditary autoinflammatory disorder caused by mutations in the MEFV gene. Carrier rates are known to be particularly high among Sephardic Jews, Turks, Armenians and Arab populations. Our literature survey regarding FMF and MEFV mutations in Georgia revealed a lack of existing studies. We applied multiplex PCR and reverse-hybridization teststrips (FMF StripAssay) to simultaneously analyze twelve common MEFV mutations in DNA samples from dried blood on filter cards, which had been obtained from 202 unselected newborns at various hospitals in Tbilisi, Georgia. We found 30 samples to be heterozygous and one to be compound heterozygous or carrier of a complex allele (two mutations in cis). The carrier rate of MEFV mutations (15.3%) was remarkable. The most frequently observed variants were E148Q (15x), M680I G/C (5x) and M694V (4x). Five other MEFV mutations were found at lower prevalence (V726A, A744S, R761H: 2x each; P369S, F479L: 1x each). Based on these new findings, the awareness for FMF and the availability of appropriate testing should be further promoted in Georgia.

Fuzzy approaches in pediatrics

In this paper we present a review of applications of fuzzy methods in children and adolescence health care. Based on the several examples, available from journal papers, conference proceedings and book chapters we have concentrate ourselves on problems in the pediatrics that have been or can be solved with the help of fuzzy methodology. The paper is organised as follows. In section I we consider the general considerations about fuzzy logic and medicine. Section II considers the basics of fuzzy sets and fuzzy logic, the main methodological approaches for medical practical applications. Section III describes problems and the way of their solving using fuzzy approaches in pediatrics. Conclusions summarise the review in Section IV.

Some personal views on pediatrics and not only

In the paper there are presented author's personal views on youth education, medical education, child and adolescent physiology, some other common medical and pediatric issues. The role of the physician as an educator of the child is underlined. The pediatrician must be the main advisor to the society, school and family in the matter of youth education, contribute to their optimal self-realization. The importance of moral values, gender peculiarities and cultural codes are emphasized. The imprinting of cultural codes should be considered as a biological basis of patriotism. The effectiveness of the implementation of healthy life style is discussed. The opinion regarding the protection of youth from potentially negative effects on their development and behavior is expressed. It would be purposeful to give more consideration to the fundamental research, particularly to the problem of age-related morphological and functional peculiarities of the growing organism in the conditions of norm and pathology. One should have in mind the importance of research of the combination of harmful factors for the organism. The elaboration of empathic and optimistic attitudes should be considered as the very important goals of medical education. The differential usage of clinical guidelines is discussed. It is mentioned the purposefulness of more wide application of fuzzy logic approaches in medicine. The items of rare diseases, individualized medicine, alternative medicine and bacteriophage therapy are discussed as well.

Capillaroscopy and ECG parameters in children and adolescents with diabetes mellitus type I

Evaluate ECG parameters and detect changes in capillaroscopy parameters in children and adolescents with Diabetes mellitus type 1 (DMT1). ECG and capillaroscopy were performed in 32 children and adolescents (6-15 years old, 17 boys,15 girls) with DMT1. Disease duration - less than 2 years -13, 2-4 years - 10, 5-10 years - 9 cases. The patients were divided into two groups: I group - 12 patients with no complications of DMT1 (in all them duration of disease was less than 2 years), II group - 20 patients with diagnosed cardiac complications of DMT1 (diabetic cardiomyopathy, angiopathy). Additionally 6 of them had diabetic encephalopathy , 4 - diabetic encephalopathy and peripheral neuropathy, 4 - nephropathy and retinal antipathy. Level of glycosides hemoglobin was 8-11%, level of glucose 4 to 15 mmole/L. Control group included 20 healthy children of the same age. In group I ECG is less informative. Hypertrophies of left ventricle and atrium and disorders of repolarization were mainly found in group II. In 62.5% of cases rhythm and conduction disorders were revealed, which were more often in group II. Capillaroscopy changes (pale and cyanotic background, decreasing of the number of capillaries in sight, dilated and contracted diameter, pathological shape and order of capillaries, slow blood flow) were seen both in I and II groups with more prevalence and intensity in the latter one. In children and adolescents with Diabetes mellitus type 1 ECG and capillaroscopy should be performed on the regular basis in order to reveal early changes and start the appropriate treatment in time.

Objectified body consciousness and mental health in female adolescents: cross-cultural evidence from Georgian and Swiss national samples

PURPOSE

The current study tested both descriptive and explanatory similarities and differences in a latent objectified body consciousness (OBC) construct and its relationship to three mental health indicators among Georgian and Swiss adolescents. Few studies have been conducted on adolescents; similarly, most work has been completed on U.S. college-age women.

METHODS

School-based questionnaire data were collected from a total of 18,239 adolescents in Georgia (n = 9,499) and Switzerland (n = 8,740), following the same protocol. Participants rated three measures of OBC (body shame, body surveillance, and appearance control beliefs) and three mental health indicators (depressive symptoms, somatic complaints, and suicidal ideation). Final study samples included 2,657 (mean age = 16.4 years) and 3,803 female youth (mean age = 17.8 years), respectively. Data analyses included mean level comparisons, confirmatory factor analysis, path analysis, and multigroup invariance tests.

RESULTS

Findings provide support for a latent OBC construct across cultures, with partial evidence of cultural differences (one of two manifest indicators). By contrast, multigroup invariance tests provide consistent evidence of no differences in the relationships between the OBC latent construct and three mental health indicators between Georgian and Swiss samples.

CONCLUSION

Despite mean level differences, findings support a latent OBC construct in both cultures, perhaps slightly more so among Swiss youth. The links between OBC and mental health indicators were also invariant across the two cultures, providing greater support for a global or universal (vs. "cultured") framework of adolescent development related to the constructs and relationships studied.

Assessment of anthropological, physical and functional indices in sportsmen (basketball players) against the background of high physical loading

The goal of the investigation was the estimation of functional condition of anthropometrical, physical and cardiovascular system of sportsmen-basketball players against the background of high physical loading. 100 basketball players at the age from 12 till 18 years underlay the study. Randomized and open controllable research was carried out during 6 months. The following characteristics have been studied: how many days the sportsman is training in a week, how many hours the sportsman is training per day, his mood after training, over fatigue and overtension, frequency of heartbeat, time of breath holding, the general condition, the height in sitting and standing position; circumference of lumbus, chest, arm and limbs, the pulse, pulse, systolic and diastolic arterial pressure before and after physical loading. According to these factors the following sport indices are calculated: Index of Rufe (physical work capacity), the coefficient of endurance (Kvas formula), Shtange test (breath holding at sighing), Genchi test (breath holding at exhalation), average arterial pressure, systolic and cardiac output of blood circulation (the formula of Lilienstrad and Tsander), the coefficient of blood circulation effectiveness, Ketle index (the ratio of height and weight), Minuvre index (the ratio of body and feet length), Pinie index (power of body-build). Statistically authentic increase of breath and pulse in frequency was observed in sportsmen-basketball players after physical loading. The study of amplitude parameters of cardiac cycle among sportsmen-basketball players before and after physical loading has revealed the ability of rather low adaptation of cardiovascular system to physical loading.

A case of DiGeorge syndrome in Georgia

Patient 6 - year- old boy, with history of recurrent otitis, cleft palate, was admitted to the hospital for fever, abdominal pain; He had high ESR,CRP, low T lymphocytes, VSD. Peritoneal fluid was positive for pseudomona aeroginoza. Diagnosis of DiGeorge syndrome was confirmed by further genetical study. Immune deficiencies should be considered when infections are severe, persistent resistant to standard treatment, or caused by opportunistic organisms. Treatments can often correct many of the critical and immediate problems associated with DiGeorge syndrome such as heart defects, calcium defects, poor immune system functions and cleft palate. People who had poor immune function as children due to small or missing thymus, may have an increased risk of autoimmune disorders, such as a rheumatoid arthritis and Graves disease. Because DiGeorge syndrome can result in so many disorders, a number of specialists should be involved in diagnosing specific conditions, recommending treatments and providing care.

Encephalocele and skeletal malformations (case report)

Encephalocele is a herniation of the brain (cranium bifidum, cephalocele, craniocele), formed during embryonic development, because of the incomplete closure of Neural Tube. It is a rare skull defect, with the incidence of 0.8 to 5 per 10,000 live births. The article presents the medical history of a four month old patient, with frontoethmoidal encephalocele and multiple skeletal anomalies, such as amniotic knots on limbs, foot deformity, sindactilia and cleft palate.

Rare tubulopathy - primary hypophosphatemic rickets (case report)

Primary hypophosphatemic rickets is a rare disorder caused by inborn defect of renal tubular reabsorbtion and usually manifested in childhood and infancy with stunted growth and deformities of lower limbs. Patient 12 years old, female, was born to healthy parents, at 41 weeks of gestation by normal delivery and had a normal birth weight and length. She had one healthy sibling (male). Psychomotor development until the age of 2 years was normal. Since the age of 2 years deformation of legs and difficulties with walking have been observed. The Patient was consulted by Pediatric Orthopedist, Nephrologists and Endocrinologist. The blood biochemical findings revealed normal pH, normal calcium (CA), potassium (K), sodium (Na) concentrations, very low phosphate (P) with markedly elevated alkaline phosphatase (AP) and slightly elevated parathyroid hormone (PTH) concentration; urine test indicated impaired tubular function: mild glucosuria, proteinuria, and markedly increased phosphaturia. Phosphate tubular reabsorbtion (PTR) was 52%, phosphate/creatinine clearance 0,52, renal threshold phosphate concentration (TmP/GFR) 0,25 mmol/l. Genetic tests results not available yet.

RESULTS

the diagnosis of phosphate diabetes made on the basis of clinical-laboratory data. The therapy with Inorganic phosphate (50-100mg/kg/d) and 1,25(OH)D3 40-50 ng/kg/d had been started. Childs walking abilities improved with treatment, the deformation of legs decreased, but O-legs and other skeletal deformations are still remarkable. Auxological parameters are not satisfactory. Physical growth is below the normal range (height SDS -3,78); the patient's predicted height less than target height. Biochemical monitoring performed regularly under the treatment, serum phosphate remains below normal, serum ALP is still elevated.

CONCLUSION

This case is in line with other publications and indicates the difficulty to achieve normal phosphate levels and normal growth without an additional treatment with growth hormone. At this stage of the disease, the question of referring to the growth hormone therapy is being considered aimed to improve the growth tendencies. It is possible that orthopedic surgery is also needed in the future.

Management options for rare diseases in children and adolescents in Georgia (experience of the country with transitional economy)

We present the results of our research and organizational work aimed at the management optimization for the rare diseases in Georgia (the Country with Transitional Economy). We compiled a list of the rare diseases actual for Georgia; elaborated algorythms and expert systems supporting the diagnosis making process for various clusters of the rare diseases; translated into Georgian and adapted textual materials regarding the management of various rare disorders; assessed the awareness level for the rare diseases of the pediatricians and general practioners in Georgia and attempted to raise it by organizing seminars and conferences, including international ones, in various regions of Georgia; elaborated a model of the expert system (based on the fuzzy logic principles) for unmasking the cases suspicious for the rare disease; laid the foundation for the national register of the rare diseases in children and adolescents; elaborated the module for post-graduate education regarding rare diseases; organized the center for the rare diseases.

EULAR/PRINTO/PRES criteria for Henoch-Schönlein purpura, childhood polyarteritis nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis: Ankara 2008. Part II: Final classification criteria

OBJECTIVES

To validate the previously proposed classification criteria for Henoch-Schönlein purpura (HSP), childhood polyarteritis nodosa (c-PAN), c-Wegener granulomatosis (c-WG) and c-Takayasu arteritis (c-TA).

METHODS

Step 1: retrospective/prospective web-data collection for children with HSP, c-PAN, c-WG and c-TA with age at diagnosis <or=18 years. Step 2: blinded classification by consensus panel of a representative sample of 280 cases. Step 3: statistical (sensitivity, specificity, area under the curve and kappa-agreement) and nominal group technique consensus evaluations.

RESULTS

827 patients with HSP, 150 with c-PAN, 60 with c-WG, 87 with c-TA and 52 with c-other were compared with each other. A patient was classified as HSP in the presence of purpura or petechiae (mandatory) with lower limb predominance plus one of four criteria: (1) abdominal pain; (2) histopathology (IgA); (3) arthritis or arthralgia; (4) renal involvement. Classification of c-PAN required a systemic inflammatory disease with evidence of necrotising vasculitis OR angiographic abnormalities of medium-/small-sized arteries (mandatory criterion) plus one of five criteria: (1) skin involvement; (2) myalgia/muscle tenderness; (3) hypertension; (4) peripheral neuropathy; (5) renal involvement. Classification of c-WG required three of six criteria: (1) histopathological evidence of granulomatous inflammation; (2) upper airway involvement; (3) laryngo-tracheo-bronchial involvement; (4) pulmonary involvement (x-ray/CT); (5) antineutrophilic cytoplasmic antibody positivity; (6) renal involvement. Classification of c-TA required typical angiographic abnormalities of the aorta or its main branches and pulmonary arteries (mandatory criterion) plus one of five criteria: (1) pulse deficit or claudication; (2) blood pressure discrepancy in any limb; (3) bruits; (4) hypertension; (5) elevated acute phase reactant.

CONCLUSION

European League Against Rheumatism/Paediatric Rheumatology International Trials Organisation/Paediatric Rheumatology European Society propose validated classification criteria for HSP, c-PAN, c-WG and c-TA with high sensitivity/specificity.

A test of Jessor's problem behavior theory in a Eurasian and a Western European developmental context

PURPOSE

The current study tested the applicability of Jessor's problem behavior theory (PBT) in national probability samples from Georgia and Switzerland. Comparisons focused on (1) the applicability of the problem behavior syndrome (PBS) in both developmental contexts, and (2) on the applicability of employing a set of theory-driven risk and protective factors in the prediction of problem behaviors.

METHODS

School-based questionnaire data were collected from n = 18,239 adolescents in Georgia (n = 9499) and Switzerland (n = 8740) following the same protocol. Participants rated five measures of problem behaviors (alcohol and drug use, problems because of alcohol and drug use, and deviance), three risk factors (future uncertainty, depression, and stress), and three protective factors (family, peer, and school attachment). Final study samples included n = 9043 Georgian youth (mean age = 15.57; 58.8% females) and n = 8348 Swiss youth (mean age = 17.95; 48.5% females). Data analyses were completed using structural equation modeling, path analyses, and post hoc z-tests for comparisons of regression coefficients.

RESULTS

Findings indicated that the PBS replicated in both samples, and that theory-driven risk and protective factors accounted for 13% and 10% in Georgian and Swiss samples, respectively in the PBS, net the effects by demographic variables. Follow-up z-tests provided evidence of some differences in the magnitude, but not direction, in five of six individual paths by country.

CONCLUSION

PBT and the PBS find empirical support in these Eurasian and Western European samples; thus, Jessor's theory holds value and promise in understanding the etiology of adolescent problem behaviors outside of the United States.

New approach to estimate different drugs and/or other medical interventions effectiveness based on fuzzy logic principles

A new approach for the evaluation of the efficacy of drugs and/or other medical interventions is proposed. It is based on the principles of fuzzy logic, particularly on fuzzy sets, fuzzy cluster analysis and fuzzy expert system.

Health-related quality of life of patients with juvenile idiopathic arthritis coming from 3 different geographic areas. The PRINTO multinational quality of life cohort study

OBJECTIVES

To compare health-related quality of life (HRQL) and to identify clinical determinants for poor HRQL of patients with juvenile idiopathic arthritis (JIA) coming from three geographic areas.

METHODS

The HRQL was assessed through the Child Health Questionnaire (CHQ). A total of 30 countries were included grouped in three geographic areas: 16 countries in Western Europe; 10 in Eastern Europe; and four in Latin America. Potential determinants of poor HRQL included demographic data, physician's and parent's global assessments, measures of joint inflammation, disability as measured by Childhood Health Assessment Questionnaire (CHAQ) and erythrocyte sedimentation rate. Poor HRQL was defined as a CHQ physical summary score (PhS) or psychosocial summary score (PsS) <2 S.D. from that of healthy children.

RESULTS

A total of 3167 patients with JIA, younger than 18 yrs, were included in this study. The most affected health concepts (<2 S.D. from healthy children) that differentiate the three geographic areas include physical functioning, bodily pain/discomfort, global health, general health perception, change in health with respect to the previous year, self-esteem and family cohesion. Determinants for poor HRQL were similar across geographic areas with physical well-being mostly affected by the level of disability while the psychosocial well-being by the intensity of pain.

CONCLUSION

We found that patients with JIA have a significant impairment of their HRQL compared with healthy peers, particularly in the physical domain. Disability and pain are the most important determinants of physical and psychosocial well-being irrespective of the geographic area of origin.

Substance abuse among adolescents in Georgia

To estimate the substance abuse and thus assess the basic indicators of health risk behavior of the adolescents in Georgia: frequencies of their tobacco, alcohol and drugs consumption. A self-administered anonymous questionnaire was adapted from the Swiss Survey (SMASH2002), translated into Georgian and other languages mainly used in schools (Russian, Armenian and Azeri). It contained 87 questions. Two-stage cluster sampling was devised. Weight was adjusted. A total of 599 classes were selected. Field work took place in 2004. All questionnaires (n=9499; 56,8% filled out by girls, 39,6% - by boys; the mean age was 15,5+/-1,1 years) before being processed into the Epidata were edited. The final data were analysed by SPSS 11.0. 10,4% of adolescents have reported to smoke. The average age of starting to smoke is 13,4 years. 61,2% girls and 67.8% boys drink vine. 56,7% out of the total number of respondents claimed to have been never drunk, 30,0% - answered positively. 2,3% said that they had intravenous drug injection. The drug of preference is cannabis - 6,8%. 72,2% of those who have had intravenous drug injections answered positively to the question "Have you ever been really drunk?" Performed survey is a first one done among adolescents in Georgia. It gave us basic information for planning and implementation of necessary measures in order to improve the health of adolescents and raise awareness of professionals involved in health care and prevention settings for adolescents.

Adolescents health in Georgia: a national portrait

The aim of the study was to assess the basic indicators of health of adolescents in Georgia. A self-administered anonymous questionnaire was adapted from the Swiss Survey (SMASH2002), translated into Georgian and other languages mainly used in schools (Russian, Armenian and Azeri). It contained 87 questions. Two-stage cluster sampling was devised. Weight was adjusted. A total of 599 classes were selected. All questionnaires before being processed into the Epidata (www.epidata.dk) were edited. The final data were analysed by SPSS 11.0. General health status was considered as excellent and very good by 34.0+/-0.8% of respondents. 21.5% claimed to never miss the school due to the illness. The frequencies of physical disability and chronic diseases were 8.0% and 5.0% correspondingly. Among health-related problems the most frequent are problems with teeth, headache and acne. 5.9% of girls had some kind of gynecological problems quite often and very often. Performed survey is a first one done among adolescents in Georgia. It gave us basic information for planning and implementation of necessary measures in order to improve the health of adolescents and raise awareness of professionals involved in health care and prevention settings for adolescents. The data can be also used for monitoring of health status of adolescents in Georgia.

The Georgian Adolescent Health Survey: methodological and strategic issues

OBJECTIVES

To conduct a national survey on adolescent health and lifestyles in Georgia and to thus set up a database on adolescent.

METHODS

A two-stage cluster sample of around 8000-10000 in-school 15-18 years adolescents are being reached through a random selection of classes in Georgia. The sample has been stratified by age, region, type of school and language. A self-administered questionnaire of 87 questions has been developed and translated into the four main languages used in Georgia.

RESULTS

Up to June 2004, the researchers have reached 511 classes (9306 pupils). In total, 8039 questionnaires have been considered valid. The main concerns encountered for this survey are linked with acceptance of the survey, cross-cultural issues, political and strategic problems as well as inadequate physical environmental support.

CONCLUSION

Despite Georgia's unfavourable economical and political situation, it has been possible to run a national survey on the health of adolescents, according to the usual standards used in the field. This survey should allow for 1) the identification of priorities in the field of health care and health promotion 2) the monitoring of adolescent health in the future.

Health-related interests of Georgian adolescents

The aim of the study was to find out what adolescents in Georgia would like to know about health. Pupils of 6-10 grades (11-17 years old) (n=524) of the focus schools (secondary schools where FRESH program is being implemented) were investigated. A method of participatory research (so called social anthropologic approach) was applied. The study was anonymous. It yielded 3756 questions in total. The questions dedicated to health-related issues made up 36.8% for group I (11-13y.o.), 45,75% for group II (14-17y.o.), 40.5% -- total. The interest in different somatic and psychological problems and diseases was the same in both age groups (14,3%). Interest in sexual items was higher in later adolescents (group I -- 10.58+/-0.66%, group II -- 14.97+/-0.90%, p<0.05). Girls have shown more interest in diseases and common medical problems (M -- 27.3+/-3.2%, F - 45.2+/-2.6%; p<0.05). Boys were more interested in sexual behavior (M -- 40.2+/-3.6%, F -- 25.2+/-2.3%; p<0.05). There was shown a purposefullness of applied research methodology.

Application of narrative method to the study of adolescent sexuality

Sexual life is one of the most important health-related behaviors of adolescents. WHO has proposed the Narrative Research Method, a way to identify adolescents' sexuality as seen by themselves. The aim of the study was to apply the narrative method as a new research method in order to reveal the level of adolescents' knowledge about sexual life and their attitude to it in Georgia. Two groups of adolescents have been investigated. First group (n=69, age 14-16) consisted of students of secondary school in Tkibuli, second group (n=58, age 17-19) -- of students of the Tbilisi State Medical University College. 81.8% of the total number of respondents think that the couple should have some physical intimacy "within the limits"; sexual relationships before marriage were acceptable to 49.6%; in case of unexpected pregnancy or STD almost 50% would have addressed parents; in case of pregnancy 28% would have consider abortion and 55% -- marriage. The study was a pilot one. It has shown the advisability of the narrative research method as an effective approach to the investigation of adolescents sexuality especially in countries where the direct questions are not acceptable because of different reasons.

[Efficacy of to'thema in the treatment of iron deficiency anemia in early childhood with concomitant copper deficiency]

IDA is still the major medico-social problem in pediatric hematology, especially in early childhood. In this correction ferroresistant forms of IDA are interesting. The aim of our investigation was: studying the Efficacy of Tot'hema in the treatment of Iron Deficiency Anemia in Early childhood with concomitant copper deficiency. We observed 42 patients with IDA (age 0,4 - 3 years) in open control investigation. The carried-out investigations revealed that IDA in early childhood is often proceeded by the concomitant copper deficiency and ceruloplasmin, mainly in premature infants and in children with prolonged diarrhea in anamnesis. In such cases it is important to investigate the copper metabolism together with the peripheral blood index and iron metabolism. Tot'hema improves hematologic and biochemical index, completely supplies iron and copper deficiency, prevents of iron resistant form of IDA. Tot'hema has no side effects.

PRINTO/PRES international website for families of children with rheumatic diseases: www.pediatric-rheumatology.printo.it

OBJECTIVE

To prepare a website for families and health professionals containing up to date information about paediatric rheumatic diseases (PRD).

METHODS

Firstly, paediatric rheumatology centres and family self help associations were surveyed to characterise current clinical practice of physicians providing care for children with PRD, research activities, and training facilities of each centre. Secondly, international consensus was reached on the content of the website. Finally, the website was developed and the texts translated.

RESULTS

The web page contains three main sections: (a) description for families of the characteristics of 15 PRD; (b) list of paediatric rheumatology centres; (c) contact information for family self help associations. A version for 45 countries in 52 languages (with another three in progress) is now available on the web. 291 surveys from 171 centres and 102 family associations were received from 42 countries. The median proportion of time spent in paediatric practice in the centres examined was 100%, with 70% of this time dedicated to paediatric rheumatology. 90% of the centres were willing to perform clinical trials in the future.

CONCLUSIONS

The PRINTO/PRES website provides a well defined and competent set of information about PRD, with appropriate multiple translated versions and easy web navigational direction.

The Georgian version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ)

We report herein the results of the cross-cultural adaptation and validation into the Georgian language of the parent's version of two health related quality of life instruments. The Childhood Health Assessment Questionnaire (CHAQ) is a disease specific health instrument that measures functional ability in daily living activities in children with juvenile idiopathic arthritis (JIA). The Child Health Questionnaire (CHQ) is a generic health instrument designed to capture the physical and psychosocial well-being of children independently from the underlying disease. The Georgian CHAQ CHQ were fully validated with 3 forward and 3 backward translation. A total of 115 subjects were enrolled: 54 patients with JIA (44% systemic onset, 28% polyarticular onset, 7.5% extended oligoarticular subtype, and 20.5% persistent oligoarticular subtype) and 61 healthy children. The CHAQ clinically discriminated between healthy subjects and JIA patients, with the systemic, polyarticular and extended oligoarticular subtypes having a higher degree of disability, pain, and a lower overall well-being when compared to their healthy peers. Also the CHQ clinically discriminated between healthy subjects and JIA patients, with the systemic onset, polyarticular onset and extended oligoarticular subtypes having a lower physical and psychosocial well-being when compared to their healthy peers. In conclusion the Georgian version of the CHAQ-CHQ is a reliable, and valid tool for the functional, physical and psychosocial assessment of children with JIA.