Publications by authors named "Avichai Weissbach"

17 Publications

  • Page 1 of 1

Transient Cardiac Injury in Adolescents Receiving the BNT162b2 mRNA COVID-19 Vaccine.

Pediatr Infect Dis J 2021 Jun 2. Epub 2021 Jun 2.

From the Department of Pediatrics C Department of Pediatrics B Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Cardiology Department, Schneider Children's Medical Center of Israel, Petah Tikva, Israel Pediatric Intensive Care Unit, Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv, Israel Pediatric Intensive Care Unit, Meir Medical Center, Kfar Saba, Israel Department of Pediatrics A, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.

Background: Vaccines are paramount in the effort to end the coronavirus disease 2019 global epidemic. BNT162b2 is approved for the vaccination of adolescents over 16 years of age. Systemic adverse events were scarce though the pretested cohort of this age group was relatively small. The aim of the current study is to raise awareness for potential adverse reactions.

Methods: This is a case series of patients diagnosed with perimyocarditis following vaccination. Patients were compiled from 3 pediatric medical centers in Israel through a network of pediatricians and data regarding those cases was collected. In addition, incidence of perimyocarditis during the vaccination period was compared with previous years.

Results: All patients were males 16-18 years old, of Jewish descent, who presented with chest pain that began 1-3 days following vaccination (mean, 2.1 days). In 6 of the 7 patients, symptoms began following the 2nd dose and in 1 patient following the 1st dose. All cases were mild and none required cardiovascular or respiratory support. The incidence of perimyocarditis during the vaccination period was elevated in comparison to previous years.

Conclusions: This case series describes a time association between coronavirus disease 2019 vaccine and perimyocarditis in adolescents. All cases were mild, although only long-term follow-up can reveal the true impact of this cardiac injury. While it seems that the incidence of perimyocarditis during the vaccination campaign period is increased, a more comprehensive data collection on a wider scale should be done. We hope this report will serve as a reminder to report events and allow for analysis of potential adverse reactions.
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http://dx.doi.org/10.1097/INF.0000000000003235DOI Listing
June 2021

Persistent pulmonary air leak in the pediatric intensive care unit: Characteristics and outcomes.

Pediatr Pulmonol 2021 Aug 28;56(8):2729-2735. Epub 2021 May 28.

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Persistent air leak (PAL) complicates various lung pathologies in children. The clinical characteristics and outcomes of children hospitalized in the pediatric intensive care unit (PICU) with PAL are not well described. We aimed to elucidate the course of disease among PICU hospitalized children with PAL.

Methods: A retrospective cohort study of all PICU-admitted children aged 0-18 years diagnosed with pneumothorax complicated by PAL, between January 2005 and February 2020 was conducted at a tertiary center. PAL was defined as a continuous air leak of more than 48 h.

Results: PAL complicated the course of 4.8% (38/788) of children hospitalized in the PICU with pneumothorax. Two were excluded due to missing data. Of 36 children included, PAL was secondary to bacterial pneumonia in 56%, acute respiratory distress syndrome (ARDS) in 31%, lung surgery in 11%, and spontaneous pneumothorax in 3%. Compared to non-ARDS causes, children with ARDS required more drains (median, range: 4, 3-11 vs. 2, 1-7; p < .001) and mechanical ventilation (100% vs. 12%; p < .001), and had a higher mortality (64% vs. 0%; p < .001). All children with bacterial pneumonia survived to discharge, with a median air leak duration of 14 days (range 3-72 days). Most of which (90%) were managed conservatively, by continuous chest drainage.

Conclusion: Bacterial pneumonia was the leading cause of PAL in this cohort. PAL secondary to ARDS was associated with a worse outcome. In contrast, non-ARDS PAL was successfully managed conservatively, in most cases.
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http://dx.doi.org/10.1002/ppul.25509DOI Listing
August 2021

Authors' Response to a Letter to the Editor.

Pediatr Cardiol 2021 Apr 9;42(4):983-984. Epub 2021 Apr 9.

Pediatric Intensive Care Unit, Schneider Children's Medical Centre of Israel, 4920235, Petach Tikva, Israel.

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http://dx.doi.org/10.1007/s00246-021-02605-1DOI Listing
April 2021

Fluid overload and renal function in children after living-donor renal transplantation: a single-center retrospective analysis.

Pediatr Res 2021 Jan 11. Epub 2021 Jan 11.

Pediatric Intensive Care Unit, Tel Aviv University, Tel Aviv, Israel.

Background: We aimed to compare renal function after kidney transplantation in children who were treated with higher vs. lower fluid volumes.

Methods: A retrospective analysis of 81 living-donor renal transplantation pediatric patients was performed between the years 2007 and 2018. We analyzed associations of the decrease in serum creatinine (delta creatinine) with fluid balance, central venous pressure (CVP), pulmonary congestion, mean arterial pressure (MAP), and MAP-CVP percentiles in the first 3 postoperative days. After correcting creatinine for fluid overload, we also assessed associations of these variables with the above parameters. Finally, we evaluated the association between delta creatinine and estimated glomerular filtration rate (eGFR) at 3 months follow-up.

Results: Both delta creatinine and delta-corrected creatinine were found to be associated with pulmonary congestion on the second and third postoperative days (p < 0.02). In addition, trends for positive correlations were found of delta creatinine with fluid balance/kg (p = 0.07), and of delta-corrected creatinine with fluid balance/kg and CVP (p = 0.06-0.07) on the second postoperative day. An association was also demonstrated between the accumulated fluid balance of the first 2 days and eGFR at 3 months after transplantation (p = 0.03).

Conclusions: An association was demonstrated between indices of fluid overload, >80 ml/kg, and greater improvement in renal function.

Impact: There is no consensus regarding the optimal fluid treatment after pediatric renal transplantation. In our cohort, indices of fluid overload were associated with better renal function immediately after the transplantation and 3 months thereafter. Fluid overload after living-donor renal transplantation in children may have short- and long-term benefits on renal function.
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http://dx.doi.org/10.1038/s41390-020-01330-4DOI Listing
January 2021

Ultrasound Cardiac Output Monitor (USCOM™) Measurements Prove Unreliable Compared to Cardiac Magnetic Resonance Imaging in Adolescents with Cardiac Disease.

Pediatr Cardiol 2021 Mar 4;42(3):692-699. Epub 2021 Jan 4.

Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, 4920235, Petach Tikva, Israel.

The purpose of this stuy is to prospectively assess the reliability of the ultrasound cardiac output monitor (USCOM™) for measuring stroke volume index and predicting left ventricular outflow tract diameter in adolescents with heart disease. Sixty consecutive adolescents with heart disease attending a tertiary medical center underwent USCOM™ assessment immediately after cardiac magnetic resonance imaging. USCOM™ measured stroke volume index and predicted left ventricular outflow tract diameter were compared to cardiac magnetic resonance imaging-derived values using Bland-Altman analysis. Ten patients with an abnormal left ventricular outflow tract were excluded from the analysis. An adequate USCOM™ signal was obtained in 49/50 patients. Mean stroke volume index was 46.1 ml/m by the USCOM™ (range 22-66.9 ml/m) and 42.9 ml/m by cardiac magnetic resonance imaging (range 24.7-59.9 ml/m). The bias (mean difference) was 3.2 ml/m; precision (± 2SD of differences), 17 ml/m; and mean percentage error, 38%. The mean (± 2SD) left ventricular outflow tract diameter was 0.445 ± 0.536 cm smaller by the USCOM™ algorithm prediction than by cardiac magnetic resonance imaging. Attempted adjustment of USCOM™ stroke volume index using cardiac magnetic resonance imaging left ventricular outflow tract diameter failed to improve agreement between the two modalities (bias 28.4 ml/m, precision 44.1 ml/m, percentage error 77.3%). Our study raises concerns regarding the reliability of USCOM™ for stroke volume index measurement in adolescents with cardiac disease, which did not improve even after adjusting for its inaccurate left ventricular outflow tract diameter prediction.
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http://dx.doi.org/10.1007/s00246-020-02531-8DOI Listing
March 2021

Routine chest X-ray following ultrasound-guided internal jugular vein catheterization in critically ill children: A prospective observational Study.

Paediatr Anaesth 2020 12 15;30(12):1378-1383. Epub 2020 Oct 15.

Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.

Background: Recent studies in adults have shown that routine chest X-ray following ultrasound-guided central venous catheter insertion through the internal jugular vein is unnecessary due to a low rate of complications.

Aims: To assess the usefulness of routine chest X-ray following ultrasound-guided central venous catheter insertion through the internal jugular veins in critically ill children.

Methods: A prospective observational study was conducted at a pediatric intensive care unit of a tertiary, university-affiliated pediatric medical center. All children under the age of 18 who underwent ultrasound-guided central venous catheter insertion through the right or left internal jugular vein between May 2018 and November 2019 were evaluated for eligibility. Procedures were prospectively documented, and chest X-ray was screened for pneumothorax, hemothorax, central venous catheter tip position, and resultant corrective interventions.

Results: Of 105 central venous catheter insertion attempts, 99 central venous catheters (94.3%) were inserted. All were located within the venous system. None were diagnosed with pneumo/hemothorax on chest X-ray. Twenty (20.2%; 95% CI 12.8%-29.5%) were defined as malpositioned by strict criteria; however, only one (1%) was judged significantly misplaced by the clinical team leading to its repositioning.

Conclusions: In this critically ill pediatric cohort, all central venous catheters inserted under ultrasound guidance could have been used with safety prior to acquiring chest X-ray. Overall chest X-ray impacted patient management in only 1% of cases. Our results do not support delaying urgent central venous catheter use pending chest X-ray completion in critically ill children.
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http://dx.doi.org/10.1111/pan.14030DOI Listing
December 2020

Hemodynamic effects of intravenous paracetamol in critically ill children with septic shock on inotropic support.

J Intensive Care 2020 29;8:14. Epub 2020 Jan 29.

1Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, 14 Kaplan St., 4920235 Petach Tikva, Israel.

Background: Treatment with intravenous paracetamol may impair hemodynamics in critically ill adults. Few data are available in children. The aim of this study was to investigate the frequency, extent, and risk factors of hypotension following intravenous paracetamol administration in children with septic shock on inotropic support.

Methods: We retrospectively reviewed the electronic medical charts of all children aged 1 month to 18 years with septic shock who were treated with intravenous paracetamol while on inotropic support at the critical care unit of a tertiary pediatric medical center in 2013-2018. Data were collected on patient demographics, underlying disease, Pediatric Logistic Organ Dysfunction (PELOD) score, hemodynamic parameters before and up to 120 min after paracetamol administration, and need for inotropic support or intravenous fluid bolus. The main outcome measures were a change in blood pressure, hypotension, and hypotension requiring intervention.

Results: The cohort included 45 children of mean age 8.9 ± 5.1 years. The mean inotropic support score was 12.1 ± 9.5. A total of 105 doses of paracetamol were administered. The lowest mean systolic pressure (108 ± 15 mmHg) was recorded at 60 min ( = 0.002). Systolic blood pressure decreased at 30, 60, 90, and 120 min after delivery of 50, 67, 61, and 59 drug doses, respectively. There were 5 events of systolic hypotension (decrease of 1 to 16 mmHg below systolic blood pressure hypotensive value). Mean arterial pressure decreased by ≥ 15% in 8 drug doses at 30 min (7.6%, mean - 19 ± 4 mmHg), 18 doses at 60 min (17.1%, mean - 20 ± 7 mmHg), 16 doses at 90 min (15.2%, mean - 20 ± 5 mmHg), and 17 doses at 120 min (16.2%, mean - 19 ± 5 mmHg). Mean arterial hypotension occurred at the respective time points in 2, 13, 10, and 9 drug doses. After 12 drug doses (11.4%), patients required an inotropic dose increment or fluid bolus.

Conclusions: Hypotensive events are not uncommon in critically ill children on inotropic support treated with intravenous paracetamol, and physicians should be alert to their occurrence and the need for intervention.
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http://dx.doi.org/10.1186/s40560-020-0430-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6988254PMC
January 2020

Triclofos Sodium for Pediatric Sedation in Non-Painful Neurodiagnostic Studies.

Paediatr Drugs 2019 Oct;21(5):371-378

Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, 4920235, Petach Tikva, Israel.

Aim: Triclofos sodium (TFS) has been used for many years in children as a sedative for painless medical procedures. It is physiologically and pharmacologically similar to chloral hydrate, which has been censured for use in children with neurocognitive disorders. The aim of this study was to investigate the safety and efficacy of TFS sedation in a pediatric population with a high rate of neurocognitive disability.

Methods: The database of the neurodiagnostic institute of a tertiary academic pediatric medical center was retrospectively reviewed for all children who underwent sedation with TFS in 2014. Data were collected on demographics, comorbidities, neurologic symptoms, sedation-related variables, and outcome.

Results: The study population consisted of 869 children (58.2% male) of median age 25 months (range 5-200 months); 364 (41.2%) had neurocognitive diagnoses, mainly seizures/epilepsy, hypotonia, or developmental delay. TFS was used for routine electroencephalography in 486 (53.8%) patients and audiometry in 401 (46.2%). Mean (± SD) dose of TFS was 50.2 ± 4.9 mg/kg. Median time to sedation was 45 min (range 5-245), and median duration of sedation was 35 min (range 5-190). Adequate sedation depth was achieved in 769 cases (88.5%). Rates of sedation-related adverse events were low: apnea, 0; desaturation ≤ 90%, 0.2% (two patients); and emesis, 0.35% (three patients). None of the children had hemodynamic instability or signs of poor perfusion. There was no association between desaturations and the presence of hypotonia or developmental delay.

Conclusion: TFS, when administered in a controlled and monitored environment, may be safe for use in children, including those with underlying neurocognitive disorders.
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http://dx.doi.org/10.1007/s40272-019-00346-6DOI Listing
October 2019

The author replies.

Pediatr Crit Care Med 2019 06;20(6):591

Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.

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http://dx.doi.org/10.1097/PCC.0000000000001952DOI Listing
June 2019

The author replies.

Pediatr Crit Care Med 2019 06;20(6):589-590

Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.

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http://dx.doi.org/10.1097/PCC.0000000000001951DOI Listing
June 2019

The Hemodynamic Effect of Intravenous Paracetamol in Children: A Retrospective Chart Review.

Paediatr Drugs 2019 Jun;21(3):177-183

Pediatric Intensive Care Unit, Schneider Children's Medical Center in Israel, 14 Kaplan Street, 4920235, Petach Tikva, Israel.

Aim: Studies in adults have reported frequent episodes of blood pressure drops following intravenous paracetamol administration. We aimed to investigate the hemodynamic effects of intravenous paracetamol in critically ill children.

Methods: The charts of 100 pediatric intensive care patients (age range 0.1-18 years) who were treated with intravenous paracetamol between March and September 2017 were retrospectively reviewed. A hemodynamic event was defined as a drop of > 15% in systolic or mean arterial blood pressure within 120 min after drug administration. Hypotension was defined as either a drop in systolic blood pressure (SBP) below the 5th percentile for age or a hemodynamic event associated with tachycardia, increased lactate level, or treatment with a fluid bolus or vasopressors.

Results: A hemodynamic event was observed in 39 patients (39%). In these patients, SBP was in the pre-hypertension or hypertension values in 36/39 patients before paracetamol administration, median (IQR) SBP decreased from the 99th (95-99) percentile for age before to the 50th (50-95) percentile after paracetamol (p < 0.001) and mean heart rate was 137 bpm before treatment and 115 bpm after (p = 0.002). SBP values did not drop below the 5th percentile in any patient. In 15 patients diagnosed with shock on admission, paracetamol treatment did not cause an increase in vasopressor treatment after drug administration.

Conclusions: In the present study of critically ill pediatric patients, intravenous paracetamol administration was associated with a drop in SBP from high to normal values for age, possibly due to pain relief, with no evidence for a negative hemodynamic event.
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http://dx.doi.org/10.1007/s40272-019-00336-8DOI Listing
June 2019

Prevalence of acute kidney injury after liver transplantation in children: Comparison of the pRIFLE, AKIN, and KDIGO criteria using corrected serum creatinine.

J Crit Care 2019 04 14;50:275-279. Epub 2019 Jan 14.

Department of Pediatric Gastroenterology, Schneider Children's Medical Center of Israel, Petach Tikva, Affiliated With Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address:

Purpose: To compare the application of three standardized definitions of acute kidney injury (AKI), using corrected serum creatinine values, in children immediately after liver transplantation.

Methods: Retrospective search of a tertiary pediatric hospital database yielded 77 patients (age < 18 years) who underwent liver transplantation in 2007-2017. Serum creatinine levels during the 24 h before and after surgery were corrected to daily fluid balance, and the prevalence of AKI was calculated using the Pediatric RIFLE (pRIFLE), AKI Network (AKIN), and Kidney Disease Improving Global Outcomes (KDIGO) criteria.

Results: AKI occurred in 44 children (57%) according to the pRIFLE criteria (stage I, 34%; stage II, 10%, stage III, 13%) and 33 children (43%) according to the AKIN and KDIGO criteria (stage I, 20%; stage II, 10%; stage III, 13%). There was a good correlation (kappa = 0.78) among the three criteria. AKI was associated with longer duration of mechanical ventilation (5.5 ± 6.2 vs 3.6 ± 4.0 days, p < .05) and longer ICU stay (15.2 ± 8.8 vs 12.1 ± 7.5 days, p < .05). Serum creatinine normalized in all patients (mean, 0.43 ± 0.17 mg/dl) by one year.

Conclusions: There is a good correlation among the three criteria defining AKI in pediatric liver transplant recipients. AKI is highly prevalent in this patient group and confers a worse ICU course.
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http://dx.doi.org/10.1016/j.jcrc.2019.01.010DOI Listing
April 2019

Acute Kidney Injury in Critically Ill Children Admitted to the PICU for Diabetic Ketoacidosis. A Retrospective Study.

Pediatr Crit Care Med 2019 01;20(1):e10-e14

Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.

Objectives: Acute kidney injury in the critically ill pediatric population is associated with worse outcome. The aim of this study was to assess the prevalence, associated clinical variables, and outcomes of acute kidney injury in children admitted to the PICU with diabetic ketoacidosis.

Design: Retrospective cohort.

Setting: PICU of a tertiary, university affiliated, pediatric medical center.

Patients: All children less than age 18 years with a primary diagnosis of diabetic ketoacidosis admitted to the PICU between November 2004 and October 2017.

Interventions: None.

Measurements And Main Results: Acute kidney injury was categorized into three stages using the Kidney Disease Improving Global Outcomes scale. Of the 82 children who met the inclusion criteria, 24 (30%) had acute kidney injury: 18 (75%) stage 1, five (21%) stage 2, and one (4%) stage 3. None needed renal replacement therapy. Compared with the patients without acute kidney injury, the acute kidney injury group was characterized by higher mean admission serum levels of sodium (143.25 ± 9 vs 138.6 ± 4.9 mmol/L; p = 0.0035), lactate (29.4 ± 17.1 vs 24.1 ± 10.8 mg/dL; p = 0.005), and glucose (652 ± 223 vs 542 ± 151 mg/dL; p = 0.01). There was no between-group difference in length of PICU stay (1.38 ± 0.7 vs 1.4 ± 0.7 d; p = 0.95) or hospitalization (6.1 ± 2.1 vs 5.8 ± 5.6 d; p = 0.45). Kidney injury was documented at discharge in four patients with acute kidney injury (16.7%), all stage 1; all had normal creatinine levels at the first clinical outpatient follow-up. All 82 patients with diabetic ketoacidosis survived.

Conclusions: In this study, acute kidney injury was not uncommon in children with diabetic ketoacidosis hospitalized in the PICU. However, it was usually mild and not associated with longer hospitalization or residual kidney injury.
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http://dx.doi.org/10.1097/PCC.0000000000001758DOI Listing
January 2019

Case Not Closed: Prescription Errors 12 Years after Computerized Physician Order Entry Implementation.

J Pediatr 2017 11;190:236-240.e2

Pediatric Intensive Care Unit, Schneider Children's Medical Center in Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objective: To assess the prolonged impact of computerized physician order entry (CPOE) on medication prescription errors in pediatric intensive care patients.

Study Design: This observational study was conducted at a pediatric intensive care unit in which a CPOE (Metavision, iMDsoft, Israel) with a limited clinical decision support system was implemented between 2004 and 2007. Since then, no changes were made to the systems. We analyzed 2500 electronic prescriptions (1250 prescriptions from 2015 and 1250 prescriptions from 2016). Prescription errors were identified by a pediatric intensive care physician and classified as potential adverse drug events, medication prescription errors, or rule violations. Their prevalence was compared with the rate in 2007, reported in a previous study from the same unit. A randomly selected 10% of the prescriptions were also analyzed by the pediatric intensive care unit pharmacist, and the level of agreement was determined.

Results: The rate of prescription errors increased from 1.4% in 2007 to 3.2% in 2015 (P = .03). Following revision of the clinical decision support system tools, prescription errors decreased to 1% in 2016 (P < .0001). The potential adverse drug event rate dropped from 2% in 2015 to 0.7% in 2016 (P = .006), and the medication prescription error rate, from 1% to 0.2% (P = .01). The agreement between the 2 reviewers was excellent (k = 0.96).

Conclusions: The rate of prescription errors may increase with time from implementation of a CPOE. Repeated surveillance of prescription errors is highly advised to plan strategies to reduce them. This approach should be considered in quality improvement of computerized information systems in general.
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http://dx.doi.org/10.1016/j.jpeds.2017.08.013DOI Listing
November 2017

Serum Tumor Necrosis Factor-Alpha Levels in Children with Nephrotic Syndrome: A Pilot Study.

Isr Med Assoc J 2017 Jan;19(1):30-33

Department of Pediatric Nephrology Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.

Background: Several studies link the pathogenesis of nephrotic syndrome to tumor necrosis factor-alpha (TNFα). However, data on the serum TNFα level in children with nephrotic syndrome are sparse.

Objectives: To investigate serum TNFα levels and the effect of steroid therapy in children with nephrotic syndrome.

Methods: A prospective cohort pilot study of children with nephrotic syndrome and controls was conducted during a 1 year period. Serum TNFα levels were measured at presentation and at remission, or after a minimum of 80 days if remission was not achieved.

Results: Thirteen patients aged 2-16 years with nephrotic syndrome were compared with 12 control subjects. Seven patients had steroid-sensitive and six had steroid-resistant nephrotic syndrome. Mean baseline serum TNFα level was significantly higher in the steroid-resistant nephrotic syndrome patients than the controls (6.13 pg/ml vs. 4.36 pg/ml, P = 0.0483). Mean post-treatment TNFα level was significantly higher in the steroid-resistant than in the steroid-sensitive nephrotic syndrome patients (5.67 pg/ml vs. 2.14 pg/ml, P = 0.001). In the steroid-resistant nephrotic syndrome patients, mean serum TNFα levels were similar before and after treatment.

Conclusions: Elevated serum TNFα levels are associated with a lack of response to corticosteroids. Further studies are needed to investigate the role of TNFα in the pathogenesis of nephrotic syndrome.
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January 2017

Respiratory alkalosis and metabolic acidosis in a child treated with sulthiame.

Pediatr Emerg Care 2010 Oct;26(10):752-3

Department of Pediatrics B, Schneider Children's Medical Center of Israel, Petah Tiqwa, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objectives: To report on severe acid-base disturbance in a child with symptomatic epilepsy treated with sulthiame.

Results: A 9.5-year-old boy with chronic generalized tonic-clonic seizures was treated with carbamazepine and valproic acid. Because of poor seizure control, sulthiame was added to the treatment. Two months later, he presented at the emergency department with severe weakness, headache, dizziness, dyspnea, anorexia, and confusional state. Arterial blood gas analysis showed mixed respiratory alkalosis with high anion gap metabolic acidosis. Sulthiame-induced acid-base disturbance was suspected. The drug was withheld for the first 24 hours and then restarted at a reduced dosage. The arterial blood gases gradually normalized, the confusion disappeared, and the patient was discharged home.Three months later, 4 weeks after an increase in sulthiame dosage, the patient was once again admitted with the same clinical picture. Improvement was noted after the drug dosage was reduced.

Conclusions: This is the first report of mixed respiratory alkalosis and metabolic acidosis in a child treated with sulthiame. Monitoring of the acid-base status should be considered in patients treated with sulthiame.
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http://dx.doi.org/10.1097/PEC.0b013e3181f39b4bDOI Listing
October 2010

Adenotonsilectomy improves enuresis in children with obstructive sleep apnea syndrome.

Int J Pediatr Otorhinolaryngol 2006 Aug 28;70(8):1351-6. Epub 2006 Feb 28.

Department of Pediatrics B, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Objectives: To evaluate the prevalence of nocturnal enuresis (NE) in children diagnosed with obstructive sleep apnea syndrome (OSAS) and the effect of tonsillectomy and adenoidectomy on enuresis.

Design, Setting, And Participants: All children 4-18 years of age who underwent polysomnography (PSG) between January 2003 and May 2004 were included (n=161). The evaluation was based on a retrospective review of a standard sleep questionnaire and a full overnight PSG, followed by an additional structured telephone questionnaire performed 9 months after adenotonsillectomy (T&A) (range 5-14).

Results: We identified 144 (89%) children with an apnea hypopnea index >1. Of these 144 children, 42 [29.2% (95% CI, 21.8-36.6)] were reported to have enuresis, 27 of these 42 underwent T&A. Among the 27 enuretic children who had undergone adenotonsillectomy, 74.1% had 3 or more wet nights per week before the procedure compared to 37%, 1 month after [n=27 (chi2=3.308, McNemar pv<0.0001)]. Of the 27 children who underwent adenotonsillectomy, any decrease in enuresis severity was reported by 70.4% (95% CI 53.2-87.62), while in 56% of these 27 (95% CI 41.96-70.06) it occurred 1 month postoperatively. In 11/27 children (41%), enuresis totally disappeared within 1 month, while in 3/27 (11%) enuresis disappeared throughout the remaining time of follow-up.

Conclusions: Obstructive sleep apnea in children is frequently associated with nocturnal enuresis. Adenotonsillectomy has a favorable therapeutic effect on enuresis in children with obstructive sleep apnea presenting this symptom.
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http://dx.doi.org/10.1016/j.ijporl.2006.01.011DOI Listing
August 2006
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