Ariel Tenenbaum

Morbidity and hospitalizations of adults with Down syndrome

Over the last decade a significant increase in the life expectancy of people with Down syndrome (DS) has been observed, which has caused a higher incidence of morbidity as they age. However, there is a lack of literature regarding morbidity and hospitalization of adults with DS. Analysis of 297 hospitalizations of 120 adults with DS aged 18-73 years hospitalized at Hadassah Medical Centers during the years 1988-2007 compared with data of the general population, hospitalized at the same period. At the age range 18-66 years, mean number of hospitalizations was significantly higher than the general population (P = 0.000001) with hospitalization also significantly longer (P = 0.0009). Exceptionally long hospitalizations were seen at the departments of internal medicine, dermatology and intensive care units. There was no significant difference in mortality between DS and the general population (P = 0.221). More than a fourth of the hospitalizations were caused by infectious diseases, mostly respiratory infections. Hypothyroidism was more prevalent compared with the estimated number reported by the literature (30.8% vs. 15%). Convulsive disorder was prevalent as well (15.8%). However, the prevalence of congenital heart disease, dementia, osteoporosis and obesity was found less than expected. Adults with DS are hospitalized more than the general population and for longer duration. The results of this study emphasize the need for preventive community-based medicine, awareness of co-morbidities and possible deterioration and to prepare the medical staff for a complex course of illness, expecting longer hospitalizations, arising from the complexity of this population.

Antibiotic effects on mitochondrial translation and in patients with mitochondrial translational defects

The infantile presentation of mitochondrial respiratory chain defects frequently simulates acute bacterial infection and sepsis. Consequently, broad spectrum antibiotic therapy is often initiated before definitive diagnosis is reached and without taking into consideration the potential harm of antibiotics affecting mitochondrial translation. Here, we demonstrate that some commonly used translation-targeted antibiotics adversely affect the growth of fibroblasts from patients with defective mitochondrial translation systems. In addition, we show that these antibiotics inhibit mitochondrial translation in vitro. Our results suggest that patients with mitochondrial translation defects may be more vulnerable to toxic-side-effects following the administration of certain translation-targeted antibiotics.

Unintentional organophosphate intoxication in children

Objectives: To describe the demographic characteristics, clinical course, and outcome of children with acute organophosphate (OP) poisoning admitted to a regional medical center. Methods: The clinical charts of all children admitted to the pediatric wards in Hadassah University Hospital with a diagnosis of acute OP intoxication were reviewed. Results: During the study period (1989-2003), 31 children, mean age 5.6 ± 3.9 years, presented with manifestations of acute OP poisoning. In 71% of the patients, it was possible to identify the toxin, most commonly parathion and diazinone. The most common route of exposure was ingestion of agricultural products treated with OPs (71%). The major clinical manifestation was neurological, with most of the patients presenting with coma and/or seizures (71%). The classic muscarinic and nicotinic signs of intoxication including increased secretions, bradycardia, fasciculations, and miosis were less common in our patient population. Treatment included decontamination, administration of antidote, and supportive care. Most patients responded well to treatment, but 2 patients (6.4%) died. Conclusions: The manifestations of OP poisoning in children are different from those of adults. Pediatricians should be aware of these differences because in some cases, a history of OP exposure is not obtained.

Increased Extent of and Risk Factors for Pandemic (H1N1) 2009 and Seasonal Influenza among Children, Israel

During the pandemic (H1N1) 2009 outbreak in Israel, incidence rates among children were 2× higher than that of the previous 4 influenza seasons; hospitalization rates were 5× higher. Children hospitalized for pandemic (H1N1) 2009 were older and had more underlying chronic diseases than those hospitalized for seasonal influenza.

Factors associated with bacteremia in young infants with urinary tract infection.

Background: Urinary tract infection (UTI) is the most frequent severe bacterial infection in infants. Up to 31% of infants with UTI have bacteremia. Methods: We retrospectively identified all infants aged 0–2 months who were managed in our hospital with UTI during a 1-year period. Those with bacteremia were compared with those without bacteremia, according to the following variables: ethnicity, age, gender, white blood cell and polymorphonuclear counts, C-reactive protein, urinalysis and blood creatinine values as related to age-appropriate norms, imaging and outcome. Results: We identified 81 infants with 82 episodes of UTI. Most occurred in males (72.8%) and 35 (42.7%) were in infants of non-Jewish origin. In 14/81 (17.3%) of episodes, Escherichia coli was cultured from blood. In multivariate analysis, increased blood creatinine levels (P = 0.004) and non-Jewish origin (P = 0.006) were associated with bacteremia. Time to defervescence was significantly longer in bacteremic versus nonbacteremic children (P = 0.018). Duration of hospitalization was longer in bacteremic infants—10 (7–17) days in bacteremic versus 7 (1–14) days in nonbacteremic children (P < 0.001). Conclusions: In infants aged 0–2 months with UTI, increased blood creatinine value at admission was associated with bacteremia. This value provides an additional clue on admission, independent of personal judgment, to help identify infants at higher risk for bacteremia, prolonged hospitalization and possible complications.

Anemia and Iron Deficiency in Children: Association With Red Meat and Poultry Consumption

Objective: The aim of this study was to study the relative contribution of dietary sources of iron in children with high prevalence of anemia and iron deficiency (ID). Methods: A cross-sectional study in 263 healthy, 1.5- to 6-year-old children in the Jewish sector of Jerusalem, Israel. Venous blood samples and a qualitative Food Frequency Questionnaire on iron-rich foods were obtained. Anemia was defined as hemoglobin <11 g/dL for children younger than 4 years and <11.5 g/dL for children older than 4 years; ID was defined as ferritin <12 &mgr;g/L. Results: Anemia was found in 11.2%, ID in 22%, and iron-deficiency anemia in 3.7%. The prevalence of anemia was higher in toddlers ages 1.5 to 3 years compared with children ages 3 to 6 years (17.7% vs 7.3%, P = 0.01). Children with extremely low red meat consumption (seldom) had 4-fold higher rates of ID than those who consumed ≥2 times per week (odds ratio 3.98; 95% confidence interval 1.21–13.03; P = 0.023), whereas poultry consumption was not associated with ID. Soy consumption was inversely associated with ferritin (marginally significant, r = −0.134, P = 0.057). Conclusions: The high prevalence of anemia and ID found in this study, mainly in children 1.5 to 3 years old, is related to low red meat consumption. The characteristically high poultry consumption in the Israeli population was not protective. The shift toward reduced red meat consumption and higher poultry consumption in developed countries may result in increasing the risk of ID.

Lamotrigine Overdose in a Child

The purpose of this article is to describe an unusual presentation of lamotrigine toxicity in an epileptic child treated on a lower than previously reported dosage. This is a case description of a 5-year-old epileptic girl on lamotrigine monotherapy, which caused toxicity. The child presented with ataxia, drowsiness, and acute confusion after ingesting 500 mg (25 mg/kg/d) in two 250-mg doses 12 hours apart. This was followed by vomiting and seizure exacerbation. Discontinuing lamotrigine, intravenous fluids and observation were the mainstays of therapy. Until now, the reported minimum dose of lamotrigine causing toxicity was 800 mg. In this patient, toxic manifestation occurred after the initial 250 mg. This case report demonstrates the low safety margin in children treated with lamotrigine.

Eradication failure of newly acquired Pseudomonas aeruginosa isolates in cystic fibrosis

Eradication of Pseudomonas aeruginosa (PA) is critical in cystic fibrosis (CF) patients. OBJECTIVES To determine eradication success rate of newly acquired PA and to identify characteristics associated with eradication failure. METHODS In an observational study, data from patients with newly acquired PA infection from 2007 to 2013 were collected. Clinical variables were compared in patients with and without successful eradication for ≥1year. RESULTS Of 183 patients out of 740 (25%) from 7 CF Centers that had newly acquired PA, eradication succeeded in 72%. Patients with the highest risk of failure had multi-resistant PA, fewer sputum cultures taken, were older, and were diagnosed at a later age. The risk of eradication failure increased by 1.3% with each year of delayed CF diagnosis; successful eradication increased by 17% with each additional sputum culture taken. CONCLUSIONS Delayed detection of PA infection leading to delayed treatment and growth of multi-resistant organisms is associated with eradication failure.

Antibiotic treatment of children with community-acquired pneumonia: Comparison of penicillin or ampicillin versus cefuroxime†

Adherence to current guidelines for treatment of non‐complicated community‐acquired pneumonia (CAP) in children, recommending penicillin or ampicillin as first‐line treatment, has been poor. Our objective was to examine whether cefuroxime confers an advantage over penicillin or ampicillin for the treatment of children hospitalized with non‐complicated CAP.

Hospitalization of Children with Down Syndrome

Introduction: Children with Down syndrome present with multiple medical problems in a higher prevalence compared with the general population, which may lead to hospitalizations. Methods: Analysis of 560 hospitalizations of 162 children aged 0–16 years with Down syndrome at Hadassah Medical Center during the years 1988–2007 compared with data on children in the general population, hospitalized at the same period. Data was collected from patient files and statistical data from the Ministry of Health. Results: Respiratory infections were the leading cause for hospitalization of children with Down syndrome. The number of hospitalizations of children with Down syndrome compared to the number of all children, who were hospitalized was surprisingly similar to their proportion in the general population. Eleven children died during their hospitalization (five heart failure, three sepsis, one respiratory tract infection, and one due to complication after surgery). Nine of the 11 had a congenital heart anomaly. Conclusion: Children with Down syndrome can present with complex medical issues and we support the concept of a multidisciplinary team that has experience and knowledge to serve as a “one stop shop” for these individuals and their families, with timely visits in which a comprehensive evaluation is performed, problems attended to and prevention plans applied. In this way, we may prevent morbidity, hospitalizations, and mortality.