Association among income loss, financial strain and depressive symptoms during COVID-19: evidence from two longitudinal studies.

BACKGROUND: The COVID-19 pandemic has major ramifications for global health and the economy, with growing concerns about economic recession and implications for mental health. Here we investigated the associations between COVID-19 pandemic-related income loss with financial strain and mental health trajectories over a 1-month course. METHODS: Two independent studies were conducted in the U.S and in Israel at the beginning of the outbreak (March-April 2020, T1; N = 4 171) and at a 1-month follow-up (T2; N = 1 559). Mixed-effects models were applied to assess associations among COVID-19-related income loss, financial strain, and pandemic-related worries about health, with anxiety and depression, controlling for multiple covariates including pre-COVID-19 income. FINDINGS: In both studies, income loss and financial strain were associated with greater depressive symptoms at T1, above and beyond T1 anxiety, worries about health, and pre-COVID-19 income. Worsening of income loss was associated with exacerbation of depression at T2 in both studies. Worsening of subjective financial strain was associated with exacerbation of depression at T2 in one study (US). INTERPRETATION: Income loss and financial strain were uniquely associated with depressive symptoms and the exacerbation of symptoms over time, above and beyond pandemic-related anxiety. Considering the painful dilemma of lockdown versus reopening, with the tradeoff between public health and economic wellbeing, our findings provide evidence that the economic impact of COVID-19 has negative implications for mental health. FUNDING: This study was supported by grants from the National Institute of Mental Health, the US-Israel Binational Science Foundation, Foundation Dora and Kirsh Foundation.

Methemoglobinemia induced by refrigerated vegetable puree in conjunction with supraventricular tachycardia.

UNLABELLED: We report on a case of methemoglobinemia in conjunction with supraventricular tachycardia. A 6-mo-old infant was admitted to hospital with perioral cyanosis three hours after eating a refrigerated mixed-vegetable puree. The patient developed supraventricular tachycardia (SVT) and had a heart rate of 230 beats/min. The arrhythmia resolved spontaneously. A chemical analysis showed oxygen saturation of 85% and a methemoglobin level of 25%. The infant was treated with oxygen and referred to the Pediatric Intensive Care Unit. The patient had two additional short episodes of SVT, which were resolved spontaneously without treatment. She received oxygen for 8 h until the methemoglobin level dropped to 1%. CONCLUSION: Long-term storage of refrigerated vegetables can cause methemoglobinemia in infants. Methemoglobinemia can appear in conjunction with SVT, but it is also possible that in a child with a tendency to develop SVT, methemoglobinemia involved hypoxemia, which then triggers SVT.

Pantoea agglomerans as a cause of septic arthritis after palm tree thorn injury; case report and literature review.

We report the case of a 14 year old healthy boy, who was admitted six weeks after being injured by a palm tree thorn, with limping caused by pain and swelling in his right knee. An ultrasound examination revealed a foreign body in the posterior lateral aspect of the right knee. Pantoea agglomerans was identified in the synovial fluid. The patient underwent two arthrotomies and was treated with amoxicillin-clavulanate intravenously for three weeks. The postoperative course was uneventful, and joint function returned to normal. A review of the literature between 1953 and 2002 revealed that bacterial growth after plant thorn injuries is reported infrequently. Yet when reported, Pantoea agglomearns is the most common organism found. Therefore, it must be considered and suspected in "aseptic" cases of arthritis, when there is a history of a plant thorn injury. We also emphasise the efficacy of ultrasound examination in these cases to identify the presence and location of a plant thorn.

A four year survey of neonatal narcotic withdrawal: evaluation and treatment.

BACKGROUND: Narcotic abuse has steadily become more prevalent in Israel and may result in an increasing number of children exposed prenatally to narcotics, with a consequent increase in the number of infants born with neonatal abstinence syndrome. OBJECTIVE: To report our experience with infants born to narcotic-addicted women between the years 1995 and 1998 at the Soroka University Medical Center. METHODS: The medical records of 24 newborns and their drug-addicted mothers admitted to our Medical Center for parturition were analyzed retrospectively. A diagnosis of NAS was established on the basis of the clinical presentation and anamnesis. The Finnegan Neonatal Abstinence Scoring System was used to assess drug withdrawal. Urine toxicological analysis for narcotics was done only for the year 1998. RESULTS: Of the 24 newborn infants exposed prenatally to narcotics 23 (96%) developed NAS, and 78% (18 of the 23) had a Finnegan score of 8 or more. These 18 infants were treated pharmacologically (tincture of opium and/or phenobarbital) until the score was reduced to less than 8, after which they received supportive treatment. In one child who became lethargic after the first dose of tincture of opium, the medication was stopped and supportive treatment alone was given. Four of the five neonates with scores of 7 and less were given supportive treatment. One of five infants who had a low Finnegan score at birth nevertheless received pharmacological therapy to prevent further deterioration of his physical state since he was born with severe dyspnea. Ten of the 24 children (42%) were followed for lengths of time ranging from 6 to 22 months after discharge, all of whom showed normal development. CONCLUSIONS: About three-quarters of newborns exhibiting withdrawal syndrome required pharmacological therapy. Previous information on maternal drug abuse is a crucial criterion for early detection and treatment.

Off-label and unlicensed use of antidotes in paediatric patients.

OBJECTIVE: To determine the extent of unlicensed and off-label antidotes among medicines recommended by the International Programme on Chemical Safety (IPCS) for children. MATERIALS AND METHODS: We considered 77 antidotes from the "IPCS List of antidotes and other useful agents in the treatment of human poisoning" (1996 version). Primary reference sources used were the Physicians' Desk Reference (PDR) and package inserts. Antidotes were assessed for off-label (outside of the term of product license) and unlicensed use in children. RESULTS: Our data show that only 31 (40.3%) of 77 recommended antidotes correspond to the demands of licensing systems for use in children. The rest (46 or 59.7%) are either off-label (32 or 41.5%) or unlicensed (14 or 18.2%). Five antidotes are off-label for two reasons; thus the total number of off-label use (37) is greater than the number of such drugs (32). Inappropriate age is the main reason for use outside the stipulations of the product license (24 of 77 antidotes or 31.2%), whereas different indication and route occur in 11 (14.3%) and 2 (2.6%) antidotes, respectively. The 14 unlicensed antidotes have been used only in animal experiments or in a small number of patients in certain poison centres. CONCLUSIONS: Sixty percent of antidotes and other useful agents in the poison treatment of children do not correspond to the demands of licensing systems. Drugs used in the treatment of poisoned children, as well as adults, must be evaluated scientifically.

The prescription pattern of oral nitrates in coronary artery disease. Appropriateness and cost considerations.

OBJECTIVES: To evaluate the prescription patterns of oral nitrates in terms of appropriateness and cost in a community setting. METHODS: A period prevalence, descriptive, applied study. Data including age, gender, type of medication, dosage and cost were extracted from the database of the largest health maintenance organisation (HMO) in Israel. The study population included enrollees over 35 years of age who received oral nitrates at least once during the 12-month study period. RESULTS: Oral nitrates were prescribed for 8007 patients (mean age 72.85+/-9.59 years, male:female ratio 1:1). A total of 52,694 prescriptions were issued for 56,553 medications, of these 88.1% for mononitrates, which constituted 95% of the annual cost for patients and the HMO. The mean prescribed daily dose for the various drugs ranged from 30% less than to 50% more than the recommended dose. Combination therapy with at least two nitrates, which is not the recommended treatment, was given to 5% of the patients. The recommended alternative treatment will alleviate the financial burden for providers and patients. CONCLUSIONS: Improved prescription habits can provide enhanced quality as well as cost savings for patients and providers.

Acute poisoning in children.

BACKGROUND: Childhood poisoning continues to challenge the diagnostic and treatment skills of the pediatrician. Generally, childhood poisoning can be attributed to suboptimal parental supervision and accessibility of products with poisoning potential. OBJECTIVE: To evaluate the pattern of acute poisoning in children with relation to different age groupings. METHODS: Pediatric patients hospitalized for acute poisoning at the Soroka Medical Center over a 5 year period (1994-98) were evaluated retrospectively. Special attention was given to poisoning in relation to age groupings. RESULTS: During the years 1994-98 a total of 1,143 children were admitted for acute poisoning to the Soroka Medical Center. The majority of cases occurred in children aged 2-5 and 14-18 years. Males under 14 had a higher frequency of poisoning, the poisoning usually being unintentional, whereas poisoning in females occurred mostly in the 14-18 age group and was intentional. Drugs were the most common agent of poisoning in infants (0-1 year), in older children (10-13 years), and in adolescents (14-18 years), while in children aged 2-5 and 6-9 years either cleaning products or drugs were the usual agents of poisoning. Most poisonings in children aged 2-13 occurred between 4 and 8 p.m., and for most adolescent patients (14-18 years old) between 4 p.m. and midnight. Poisoning in children aged 2-13 were usually due to accessible home products, and to medicinal errors such as overdose and improper drug administration. CONCLUSIONS: This study defines the characteristic pattern of pediatric poisoning with respect to different age groups and gender. Unintentional childhood poisoning predominated in males and occurred mostly because of accessible home products and suboptimal parental supervision during critical hours of the day. Most adolescent poisoning occurred in females and was intentional. Parental education and intensified child supervision are indicated measures of prevention for unintentional poisoning.

Unlicensed and off-label medication use in a general pediatrics ambulatory hospital unit in Israel.

BACKGROUND: Many medications used for children have not undergone evaluation to assure acceptable standards for optimal dose, safety and efficacy. As a result, the majority of children admitted to hospital wards receive medications outside the terms of their license (off-label) or medications that are not specifically licensed for use in children (unlicensed). The extent of unlicensed and off-label medication use in ambulatory children is unknown. OBJECTIVE: To determine the extent of unlicensed and off-label medication use in a general pediatrics ambulatory hospital unit in Israel. PATIENTS AND METHODS: We conducted a retrospective analysis of the medical records of 132 outpatient children treated in the General Pediatrics Ambulatory Unit of the Soroka Medical Center, Beer Sheva, in November-December 1998. RESULTS: The children's ages ranged from 1 month to 18 years (mean +/- SD 50 +/- 58 months). Of the 222 prescriptions given to these children, one-third were unlicensed (8%) or unlabeled (26%). Different dose and age were the most common categories of off-label medication use. All 18 cases of unlicensed use were due to modification of licensed drugs (tablets were crushed to prepare suspensions). Altogether, 42% of children received medicines that were off-label and/or unlicensed. CONCLUSIONS: More off-label than unlicensed medications were used. Further investigations are required to establish the extent of unproved drug use in both hospitalized and ambulatory pediatric patients in Israel. Recommendations recently issued by the Ministry of Health's National Council for Child Health and Pediatrics constitute a first step in the Israeli contribution to the international effort demanding testing of medications for children.

Poison exposure in children before Passover.

BACKGROUND: Extensive cleaning of homes in Israel before Passover may result in increased exposure of children to cleaning substances. OBJECTIVES: To evaluate the potential danger of Passover cleaning to children, and to study the risk factors in order to identify areas for prevention. METHODS: All cases of poison exposure in Jewish and Arab children under the age of 15 years reported to the Israel Poison Information Center during 1990-95 (n = 5,583) were analyzed for the 6 weeks before and 6 weeks after Passover. Poison exposures in Jewish children < 15 years old were studied in seven pediatric emergency rooms for the 2 weeks before and 6 weeks after Passover (n = 123). RESULTS: The IPIC data showed a highly significant 38% increase in the average weekly poison exposure rate for the 2 weeks before Passover compared with the remaining 10 weeks. Data recorded by the pediatric emergency rooms showed a twofold increase in cleaning substance poisoning during the 2 weeks before Passover compared with the following 6 weeks. The rise in exposures to cleaning substances was observed among children from secular, religious and ultra-orthodox families. In these exposures, the substance was found in open containers in 70% of cases. CONCLUSIONS: The extensive cleaning of homes among Jewish families in preparation for Passover poses the danger to young children of cleaning substance poisoning. Increasing public awareness, closer observation of children, and keeping these substances in closed containers should increase children's safety during this annual cleaning.

Disseminated intravascular coagulation after cerastes vipera envenomation in a 3-year-old child: a case report.

This study presents a case of severe disseminated intravascular coagulation (DIC) in a 3-year-old child following envenomation by the snake, Cerastes vipera. A literature search revealed very few similar cases. We describe a child who was bitten in his left foot by a snake identified as a C. vipera. Initial symptoms were relatively benign. Local signs included a hemorrhagic vesicle at the site of the bite with marked swelling of the entire leg. Twenty-four hours later, the child developed severe bleeding due to DIC, which lasted 5 days and required repeated administration of blood and blood products and total exchange transfusion. The patient was discharged from the hospital after 7 days in good condition. To the best of our knowledge, severe DIC following envenomation by a C. vipera has not been previously described in the literature. Treatment was essentially supportive. The case report indicates that a specific antivenin against this snake's venom should be made available in our area.

Signs and symptoms of carbamazepine overdose in young children.

OBJECTIVE: To examine common signs and symptoms of mild to moderate carbamazepine (CBZ) overdose in young children. METHODS: The medical records of previously healthy children admitted to the pediatric departments for acute accidental CBZ poisoning during the years 1993-1998 were evaluated retrospectively. Information was retrieved on serum CBZ levels, signs and symptoms on admission and during hospitalization, ECG findings, and chemical laboratory test. RESULTS: There were 14 exposed children all under the age of 5 years. These children accidentally took CBZ prescribed for a family member. The diagnosis of CBZ poisoning in seven children was unknown on admission because of inadequate history and was revealed only on toxicology screen. Nystagmus and drowsiness occurred in 8 of the 14 children, nystagmus and ataxia in 4 children, and drowsiness and tachycardia in another 2 children. The peak CBZ serum levels in these children ranged from 18 microg/ml to 32 microg/ml, mean + SD; 25 microg/ml + 4.64 microg/ml (therapeutic range: 5-10 microg/ml). CONCLUSION: Based on a certain group of young pediatric patients with mild to moderate CBZ poisoning, it is concluded that, nystagmus is the most common sign of this overdose. Other common signs are drowsiness and ataxia. The presence of nystagmus and CNS depression of unknown etiology, in a young child should suggest the possibility of CBZ toxicity.

Central nervous system toxicity and early peripheral neuropathy following dermal exposure to methyl bromide.

CASE REPORT: We describe a case of early peripheral neuropathy and central nervous system toxicity as a result of acute predominantly dermal exposure to methyl bromide. A 32-year-old male was admitted after an accidental predominantly dermal exposure to methyl bromide while fumigating soil for pest control. The patient suffered dermal burns and vesicles on the upper and lower limbs. One week following exposure, he developed progressive weakness of the lower limbs, ataxia, paresthesiae of both legs and the left arm, hyperactive tendon reflexes in the lower limbs, and left Babinski sign. Nerve conduction velocity testing was compatible with axonal neuropathy. The patient recovered gradually from his burns. Three months postexposure he showed no signs of central nervous system toxicity, but the peripheral neuropathy was still present. DISCUSSION: Neurological effects primarily referable to the central nervous system following severe inhalation of methyl bromide have frequently been reported. The patient described in this study developed an unusual early peripheral neuropathy following dermal exposure. Peripheral neuropathy can be an outcome of methyl bromide intoxication, but is usually a late sequela of acute central nervous system toxicity or an aftereffect of repetitively inhaled chronic exposure. In this case, exposure to methyl bromide through abraded skin caused early peripheral neuropathy and central nervous system toxicity.

Methanol Intoxication Victims are Suitable Donors for Corneal Transplantation.

Purpose. To evaluate the outcome of corneal transplantation and the feasibility of tissue donation from donors with methanol intoxication.Methods. Four corneas from two methanol intoxication victims were procured and transplanted in four patients at our medical center. The outcome and graft survival were evaluated.Results. The recipients were between 12 and 49 years of age. Indications for transplantation were keratoconus (two patients), post-traumatic corneal perforation (one patient) and alkaline burn (one patient). The follow-up period ranged between 12 and 60 months. All grafts remained clear, and the postoperative visual acuity was 20/30 in keratoconus patients and 20/60 in others.Conclusions. The methanol intoxication victims appear to be suitable donors for corneal transplantation. To the best of our knowledge, this is the first study to report successful corneal transplantation from donors with methanol intoxication.

Acetaminophen (paracetamol) levels in human tears.

This study was designed to measure acetaminophen (paracetamol) levels in tears, and to compare it to serum levels. Paracetamol levels were measured in 20 paired tears and serum samples from 10 healthy volunteers, 1 and 2 hours after ingesting 1.5 g paracetamol. Tears were collected using glass microcapillary tubes while stimulating the conjunctiva with a small sponge placed in the lower fornix. Blood samples were taken simultaneously. The samples were analyzed for paracetamol levels using homogeneous enzyme immunoassay. Tears and serum paracetamol levels 1 hour after ingestion were 16.3 microg/mL +/- 7.2 (mean +/- SD), and 21.4 microg/mL +/- 7.7 (mean +/- SD) respectively. Tears and serum levels 2 hours after ingestion were 14.4 microg/mL +/- 7.8 (mean +/- SD), and 17 microg/mL +/- 7.6 (mean +/- SD) respectively. Tears and serum paracetamol levels of all the 20 paired samples (1 h and 2 h after ingestion) were 15.35 microg/mL +/- 7.4, and 19.25 microg/mL +/- 7.8, respectively (mean +/- SD). There was a strong and highly significant correlation between paracetamol levels in serum and in tears 1 and 2 hours after ingestion (r = 0.8, p = 0.005, r = 0.85, p = 0.002 respectively). Mean +/- SD ratio of tears/serum paracetamol levels 1 hour and 2 hours after ingestion were 0.77 +/- 0.21 and 0.81 +/- 0.25 respectively. Delta tears (difference in mean levels at 1 and 2 hours) paracetamol levels is significantly correlated with delta serum levels (r = 0.7, p = 0.025). A reliable, convenient, and feasible noninvasive method is described for measuring paracetamol in tears. There is no information in the literature about tears paracetamol secretion, and little information of tears drugs concentration.

Acute dilated cardiomyopathy and central nervous system toxicity following propranolol intoxication.

OBJECTIVE: We report a case of a 16-year-old boy who developed central nervous system (CNS) depression and acute dilated cardiomyopathy following ingestion of 3200 mg of propranolol in a suicide attempt. Early echocardiographic findings were the only sign of cardiac toxicity. DESIGN: A case report. SETTING: Pediatric intensive care unit of a teaching hospital. RESULTS: This child developed significant acute dilated cardiomyopathy and severe CNS depression 2 hours after ingesting 3200 mg of propranolol. The child was treated with gastric lavage, activated charcoal, and mechanical ventilation. Following the echocardiographic findings, treatment with isoprenaline hydrochloride and glucagon were given intravenously. Echocardiographic examination 12 hours following treatment showed normal left ventricular size and function. No change in pulse rate or blood pressure was reported on admission and during his hospitalization. DISCUSSION: In the early stages of propranolol and other lipophilic beta-blocker intoxication, severe CNS depression can develop in the absence of clinical signs of cardiac toxicity. Early echocardiographic evaluation is important and may prevent delay in diagnosis and treatment of cardiac toxicity.

Carbamate and organophosphate poisoning in young children.

OBJECTIVE: Retrospective evaluation of the clinical course of carbamate and organophosphate poisoning in young children. DESIGN: The records of 36 children intoxicated with carbamate and 16 children intoxicated with organophosphate (age range: 2 to 8 years, median: 2.8 years) were examined retrospectively. The carbamate agents were identified as methomyl or aldicarb, and the organophosphate as parathion, fenthion, malathion, and diazinon. The causes of poisoning were accidental ingestion in 46 children and inhalation in six children. CLINICAL SETTING: Pediatric Intensive Care Unit of a teaching hospital. INTERVENTIONS: Gastric lavage was performed, and activated charcoal was administered to all children who had ingested poisonous pesticides. Atropine sulphate was administered intravenously in repeated doses to all children with bradycardia, diarrhea, salivation, and miosis. Obidoxime chloride was administered to patients with organophosphate poisoning and to those in whom the ingested material was unidentified on admission. RESULTS: Predominant symptoms were related to central nervous system depression and severe hypotonia. Other clinical signs such as miosis, diarrhea, salivation, bradycardia, and fasciculation were less frequent, while tearing and diaphoresis were not observed. Pulmonary edema developed in six patients with organophosphte poisoning. Three children required mechanical ventilation for several hours. One child (organophosphate poisoning) died shortly after arrival at the emergency department. All other children recovered completely. CONCLUSION: Based on a relatively large group of young pediatric patients with carbamate and organophosphate poisoning, it is concluded that the clinical presentation differed from those described in adults. Absence of classic muscarinic effects does not exclude the possibility of cholinesterase inhibitor agents poisoning in young children with central nervous system depression.

[Use of unlicensed and off-label drugs in hospitalized children].

Many drugs used in children are based on pharmacological data obtained in adults. Therefore, many drugs are either unlicensed for use in children or are prescribed outside the terms of the product license (off-label). This pilot study assessed use of unlicensed or off-label drugs in hospitalized children. Drug orders of patients admitted to a general pediatric ward were reviewed retrospectively in a random sample. Assessment was based on the data of the Physicians' Desk Reference and the Israel Drug Compendium. 80 different drugs and 278 drug orders were written for 92 patients (0.5 months-11 years old, mean 26.9 months) in 97 admissions. Of these 52.9% were either off-label or unlicensed. Patients received 1 or more unlicensed or off-label drugs in 64.9% of admissions. They were more often off-label than unlicensed. The main reasons for use of off-label drugs were unusual doses and inappropriate age. The main reason for unlicensed drugs was modification of a particular formulation of a licensed drug. This pilot study indicates that use of drugs in an off-label or unlicensed manner in children is probably quite frequent in Israel. Our data emphasize the need for licensing a large number of drugs for use in children, based on the same scientific principles as in adults. Further collaborative studies in different pediatric centers in Israel, involving different types of pediatric settings (ambulatory and in-hospital), is required to evaluate comprehensively the magnitude of this preliminary finding.