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Biomedical subjects

S T Shulman

Publications and source records attributed to S T Shulman.

At least 55 records · Page 3Linked to original sources
PubMed1997

Prevalence of coronary artery abnormalities in Kawasaki disease is highly dependent on gamma globulin dose but independent of salicylate dose.

The efficacy of intravenous gamma globulin (IVGG) for treatment of Kawasaki disease (KD) is clearly established. In a metaanalysis, we reviewed U.S. and Japanese multicenter, randomized controlled studies regarding the effect of various doses of IVGG with aspirin administered within the first 7 to 10 days of illness on the prevalence of coronary artery abnormalities in KD. We studied 1629 patients with acute KD from the six reported studies that included blinded echocardiographic assessments. In 868 Japanese patients treated with moderate-dose aspirin (30 to 50 mg/kg per day), the prevalence of coronary abnormalities at the subacute stage (illness day 30) was 26.8% with aspirin alone, 18.1% with total IVGG dose < 1 gm/kg, 17.3% with total IVGG of 1.0 to 1.2 g/kg, and 5.3% with total IVGG of 2 gm/kg; the corresponding prevalence at the convalescent stage of illness (illness day 60) was 17.5%, 13.5%, 9.8%, and 3.5%, respectively. In 761 U.S. patients treated with high-dose aspirin (80 to 120 mg/kg per day), the prevalence of coronary abnormalities at the subacute stage (2 to 3 weeks after enrollment) was 23.0% with aspirin alone, 9.0% with total IVGG of 1.0 gm/kg, 8.6% with total IVGG of 1.6 gm/kg, and 4.6% with total IVGG of 2.0 gm/kg; corresponding prevalence at the convalescent stage (6 to 8 weeks after enrollment) was 17.7%, 9.0%, 6.3%, and 3.8%, respectively. When all data for the 1629 patients were combined, the prevalence at the subacute stage was 25.8% with aspirin alone, 18.1% with IVGG < 1 gm/kg, 15.7% with IVGG of 1 to 1.2 gm/kg, 8.6% with IVGG of 1.6 gm/kg, and 4.8% with IVGG of 2 gm/kg (adjusted R2 = 0.966, p = 0.0017); corresponding prevalence at the convalescent stage was 17.6%, 13.5%, 9.7%, 6.3%, and 3.8%, respectively (adjusted R2 = 0.993, p = 0.0602). The prevalence of coronary abnormalities was inversely related to the total dose of IVGG and was independent of the aspirin dose. We conclude that 2 gm/kg IVGG combined with at least 30 to 50 mg/kg per day aspirin provides maximum protection against development of coronary abnormalities after KD.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed1997

Prevention of bacterial endocarditis: recommendations by the American Heart Association.

OBJECTIVE: To update recommendations issued by the American Heart Association last published in 1990 for the prevention of bacterial endocarditis in individuals at risk for this disease. PARTICIPANTS: An ad hoc writing group appointed by the American Heart Association for their expertise in endocarditis and treatment with liaison members representing the American Dental Association, the Infectious Diseases Society of America, the American Academy of Pediatrics, and the American Society for Gastrointestinal Endoscopy. EVIDENCE: The recommendations in this article reflect analyses of relevant literature regarding procedure-related endocarditis, in vitro susceptibility data of pathogens causing endocarditis, results of prophylactic studies in animal models of endocarditis, and retrospective analyses of human endocarditis cases in terms of antibiotic prophylaxis usage patterns and apparent prophylaxis failures. MEDLINE database searches from 1936 through 1996 were done using the root words endocarditis, bacteremia, and antibiotic prophylaxis. Recommendations in this document fall into evidence level III of the US Preventive Services Task Force categories of evidence. CONSENSUS PROCESS: The recommendations were formulated by the writing group after specific therapeutic regimens were discussed. The consensus statement was subsequently reviewed by outside experts not affiliated with the writing group and by the Science Advisory and Coordinating Committee of the American Heart Association. These guidelines are meant to aid practitioners but are not intended as the standard of care or as a substitute for clinical judgment. CONCLUSIONS: Major changes in the updated recommendations include the following: (1) emphasis that most cases of endocarditis are not attributable to an invasive procedure; (2) cardiac conditions are stratified into high-, moderate-, and negligible-risk categories based on potential outcome if endocarditis develops; (3) procedures that may cause bacteremia and for which prophylaxis is recommended are more clearly specified; (4) an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse; (5) for oral or dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals, but clindamycin and other alternatives are offered; and (6) for gastrointestinal or genitourinary procedures, the prophylactic regimens have been simplified. These changes were instituted to more clearly define when prophylaxis is or is not recommended, improve practitioner and patient compliance, reduce cost and potential gastrointestinal adverse effects, and approach more uniform worldwide recommendations.

Anti-Bacterial Agents↗
PubMed1997

Serum amyloid A and high density lipoprotein participate in the acute phase response of Kawasaki disease.

In this study we report changes in HDL concentration and composition in acute and convalescent Kawasaki disease. Notable reductions in plasma HDL-cholesterol (0.54 +/- 0.2 mmol/L, normal level 0.7-1.81 mmol/L) and apolipoprotein A-I (apoA-I) (56 +/- 28 mg/dL, normal level 141 +/- 22 mg/dL) were observed in all 24 patients studied during the acute phase of Kawasaki disease. These changes were accompanied by the marked appearance of serum amyloid A (SAA) protein in the plasma, associated with HDL3-like lipoprotein particles. The distribution of apoA-I was analyzed in five patients and showed a significant increase in lipid-free apoA-I in the bottom fraction (28.8 +/- 4.1%, normal range 10-15%), suggesting displacement of apoA-I from the HDL particles by SAA. Within 2 wk after acute Kawasaki disease, levels of HDL-cholesterol and apoA-I returned to the normal range, and SAA disappeared from the plasma. The HDL of patients with Kawasaki disease was markedly enriched in triglyceride even in the absence of changes in total plasma triglyceride. The core composition of HDL returned to the normal range more slowly than the plasma HDL-cholesterol and apoA-I levels. This suggests that Kawasaki disease has a profound effect on the lipoprotein profile acutely and a more subtle sustained effect on the HDL composition. We interpret these changes as manifestations of the acute phase response in Kawasaki disease.

Acute-Phase Reaction↗
PubMed1997

Prevention of bacterial endocarditis: recommendations by the American Heart Association.

OBJECTIVE: To update recommendations issued by the American Heart Association last published in 1990 for the prevention of bacterial endocarditis in individuals at risk for this disease. PARTICIPANTS: An ad hoc writing group appointed by the American Heart Association for their expertise in endocarditis and treatment with liaison members representing the American Dental Association, the infectious Diseases Society of America, the American Academy of Pediatrics and the American Society for Gastrointestinal Endoscopy. EVIDENCE: The recommendations in this article reflect analyses of relevant literature regarding procedure-related endocarditis, in vitro susceptibility data of pathogens causing endocarditis, results of prophylactic studies in animal models of endocarditis and retrospective analyses of human endocarditis cases in terms of antibiotic prophylaxis usage patterns and apparent prophylaxis failures. MEDLINE database searches from 1936 through 1996 were done using root words endocarditis, bacteremia and antibiotic prophylaxis. Recommendations in this document fall into evidence level III of the U.S. Preventive Services Task Force categories of evidence. CONSENSUS PROCESS: The recommendations were formulated by the writing group after specific therapeutic regimens were discussed. The consensus statement was subsequently reviewed by outside experts not affiliated with the writing group and by the Science Advisory and Coordinating Committee of the American Heart Association. These guidelines are meant to aid practitioners but are not intended as the standard of care or as a substitute for clinical judgment. CONCLUSIONS: Major changes in the updated recommendations include the following: (1) emphasis that most cases of endocarditis are not attributable to an invasive procedure; (2) cardiac conditions are stratified into high-, moderate- and negligible-risk categories based on potential outcome if endocarditis develops; (3) procedures that may cause bacteremia and for which prophylaxis is recommended are more clearly specified; (4) an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse; (5) for oral or dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals, but clindamycin and other alternatives are offered.

Algorithms↗
PubMed1997

Cardiac transplantation for Kawasaki disease.

OBJECTIVE: Severe cardiac sequelae from Kawasaki disease include coronary ischemia and have been treated with a variety of coronary artery bypass procedures. There is only one published report of a child who underwent cardiac transplantation for severe Kawasaki disease-related cardiac complications. The purpose of this study was to gather the worldwide experience with cardiac transplantation for Kawasaki disease. METHODS: Data were obtained from the United Network for Organ Sharing Registry, the European transplant experience, and a phone survey of many Kawasaki disease investigators. Diagnostic and surgical reports as well as clinical records were reviewed. Results. We identified 13 Kawasaki disease patients who underwent cardiac transplantation and obtained data on 10. In these 10 patients, the timing of transplantation was within 6 months after diagnosis of Kawasaki disease (4 patients), 1 to 5 years after diagnosis (3 patients), and 9 to 12 years after diagnosis (3 patients). Indications for transplantation included severe myocardial dysfunction, severe ventricular arrhythmias including cardiac arrest, and severe distal multivessel occlusive coronary artery disease. Nine of the 10 patients remain alive and healthy, with up to 6 years' posttransplant follow-up. One patient died 10 months posttransplant after severe refractory rejection. In addition, 1 patient required retransplantation at 4 years for severe rejection. CONCLUSIONS: Cardiac transplantation for severe ischemic heart disease as a sequela of Kawasaki disease is feasible and can benefit the small subgroup of patients who are not candidates for revascularization because of distal coronary stenosis or aneurysms and/or those with severe irreversible myocardial dysfunction.

Adolescent↗
PubMed1996

Risk factors for pertussis in young infants during an outbreak in Chicago in 1993.

Because young infants are at highest risk for severe pertussis and death and are also too young to have received the minimal protective series of three doses of diphtheria-tetanus-pertussis (DTP) vaccine, we conducted a matched case-control study to assess risk factors for pertussis among young infants during a pertussis outbreak in Chicago in 1993. We enrolled 39 cases < 7 months of age from a single teaching hospital and 96 controls, individually matched for age, from the well-child clinic at the same hospital. Demographic characteristics, immunization status, and opportunities for disease exposure were analyzed by means of conditional logistic regression. Cases and controls were similarly up to date with their DTP vaccinations (87% and 89%, respectively). Infants of adolescent mothers (matched odds ratio [OR], 6.4; 95% confidence interval [CI], 1.3-41.4) and infants of mothers who suffered > or = 7 days of cough during the child's incubation period (matched OR, 12.0; 95% CI, 1.4 to infinity) were significantly more likely to have pertussis. Young mothers and mothers with a cough lasting > or = 7 days may be an important source of pertussis infection for their young infants.

Adolescent↗
PubMed1996

Neurocysticercosis among children in Chicago.

Neurocysticercosis has been diagnosed increasingly in the United States as a consequence of increased immigration from and travel to areas of endemic cysticercosis. We report a retrospective series of 47 pediatric cases of neurocysticercosis in our large children's hospital in Chicago, which has a large immigrant population. Neurocysticercosis was diagnosed on the basis of any of the following three criteria: (1) surgical biopsy findings, (2) radiographic findings consistent with neurocysticercosis as well as diagnostic serum and/or cerebrospinal fluid titers, or (3) consistent radiographic findings and a compatible epidemiologic history (without diagnostic serological findings). Epidemiologic, clinical, laboratory, and radiographic data were analyzed. Neurocysticercosis is a relatively common cause of afebrile seizures in children who present to our emergency department in Chicago. Computed tomography and magnetic resonance imaging are both important modalities in evaluation of children with neurocysticercosis. Laboratory studies are neither sensitive for nor predictive of the diagnosis of neurocysticercosis. Therapy is well tolerated. The long-term prognosis for treated patients appears to be excellent.

Adolescent↗
PubMed1996

Large outbreak of pertussis among young children in Chicago, 1993: investigation of potential contributing factors and estimation of vaccine effectiveness.

BACKGROUND: An outbreak of pertussis from July, 1993, to April, 1994, in Chicago was investigated to identify potential contributing factors. METHODS: Surveillance was enhanced to identify cases. Information from a vaccination coverage survey was used to define a retrospective cohort to estimate vaccine effectiveness of three or more doses of pertussis vaccine. RESULTS: The median age of 218 reported cases was 8 months, 46% had Hispanic surnames and cases were clustered geographically. Vaccination status was known for 173 of 191 (91%) children younger than 6 years of age. Of these 173, 90 (52%) were younger than 7 months, and 35 (20%) children at least 7 months of age had received fewer than 3 doses of pertussis vaccine. Pertussis vaccine effectiveness was 76% (95% confidence interval, 29 to 92). CONCLUSIONS: The limited ability of the current pertussis vaccination schedule to protect young infants accounted for 52% of cases, primary vaccine failure accounted for 28% of cases and failure to vaccinate children on time accounted for 20% of cases in young children. Low vaccine effectiveness did not appear to be a contributing factor.

Causality↗
PubMed1996

Evaluation of penicillins, cephalosporins, and macrolides for therapy of streptococcal pharyngitis.

OBJECTIVE: To review recent clinical experience with treatment of acute streptococcal pharyngitis with penicillins, cephalosporins, and macrolide antibiotics. METHODS: Literature review and analysis. RESULTS AND CONCLUSIONS: Oral penicillin V administered two to three times daily for 10 days is the treatment of choice for acute streptococcal pharyngitis and is the oral standard against which other treatments should be measured. A single intramuscular dose of benzathine penicillin also remains highly effective. Recent studies evaluating alternative oral agents given for less than 10 days or in once-daily regimens have yielded promising results. Studies should make efforts to exclude chronic streptococcal carriers with intercurrent viral pharyngitis because their inclusion in treatment trials substantially confounds the data. As issues of health care costs assume increasing importance, the cost of newer antimicrobial agents will deter their usage for acute streptococcal pharyngitis.

Anti-Bacterial Agents↗
PubMed1995

Antibiotic treatment of adults with infective endocarditis due to streptococci, enterococci, staphylococci, and HACEK microorganisms. American Heart Association.

OBJECTIVE: To provide guidelines for the treatment of endocarditis in adults caused by the following microorganisms: viridans streptococci and other streptococci, enterococci, staphylococci, and fastidious gram-negative bacilli of the HACEK group. PARTICIPANTS: An ad hoc writing group appointed by the American Heart Association under the auspices of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young. EVIDENCE: Published studies of the treatment of patients with endocarditis and the collective clinical experience of this group of experts. CONSENSUS PROCESS: The recommendations were formulated during meetings of the working group and were prepared by a writing committee after the group had agreed on the specific therapeutic regimens. The consensus statement was subsequently reviewed by standing committees of the American Heart Association and by a group of experts not affiliated with the working group. CONCLUSIONS: Sufficient evidence has been published that recommendations regarding treatment of the most common microbiological causes of endocarditis (viridans streptococci, enterococci, Streptococcus bovis, staphylococci, and the HACEK organisms) are justified. There are insufficient published data to make a strong statement regarding the efficacy of specific therapeutic regimens for cases of endocarditis due to microorganisms that uncommonly cause endocarditis. As a useful aid to the practicing clinician, the writing group developed a consensus opinion regarding management of endocarditis caused by the most commonly encountered microorganisms and regarding those cases due to infrequent causes of endocarditis.

Adult↗
PubMed1995

Feasibility of exercise stress echocardiography for the follow-up of children with coronary involvement secondary to Kawasaki disease.

BACKGROUND: The development of coronary aneurysms as sequelae of Kawasaki disease can result in myocardial ischemia, infarction, and sudden death. Traditionally, these patients have undergone coronary angiography and nuclear stress imaging for risk stratification and follow-up. However, angiography is invasive, and both modalities expose the patient to repeated radiation, which is an important issue in children. The purpose of this study was to determine the feasibility of performing exercise stress echocardiography in children diagnosed with coronary abnormalities secondary to Kawasaki disease. METHODS AND RESULTS: Treadmill exercise stress echocardiographic studies were performed in 28 children ages 6 to 16 years. All had acute Kawasaki disease 1 to 10 years before study, and coronary artery abnormalities were identified during previous echocardiographic imaging. Patients were exercised using a standard Bruce protocol. Transthoracic echocardiographic images, obtained in the parasternal long, short, apical two- and four-chamber views immediately before and after exercise, were digitized for review and analysis. In baseline studies before exercise, wall motion abnormalities were identified in 2 patients; these segments became normal with exercise. Two patients developed new exercise-induced wall motion abnormalities that corresponded to angiographically defined critical stenosis of the left anterior descending coronary artery. No patients had resting or exercise-induced ECG evidence of ischemia. There were no adverse reactions, and 26 of 28 patients had normal exercise tolerance. CONCLUSIONS: Among patients with coronary artery involvement resulting from Kawasaki disease, exercise stress echocardiography is a safe, noninvasive procedure and may identify children with myocardial ischemia that was not detected with ECG stress test alone.

Adolescent↗
PubMed1995

Comparative safety and efficacy of two immune globulin products in Kawasaki disease.

OBJECTIVE: To compare the safety and efficacy of various intravenously administered immune globulin (IVGG) products in patients with Kawasaki disease. METHODS: We performed a retrospective matched-pair study of 45 pairs of patients, matched by age, gender, hospital, and illness day when IVGG therapy was initiated. All patients received aspirin, 80 to 100 mg/kg per day; one of each pair received Venoglobulin, 2 gm/kg (product A), and the other received Iveegam, 2 gm/kg (product B). Safety was assessed during and after IVGG infusion by recording rigors, pruritus, hypotension, urticaria, and nausea. Treatment efficacy was evaluated by posttreatment height and duration of fever, and subsequent echocardiographic changes. RESULTS: Untoward reactions during infusions occurred more often with product A (25%) than with product B (2%) (p < 0.025); most reactions were rigors (18% vs 2%) (p < 0.05). Therapy was completed in all patients. Height of fever and proportion of patients febrile each day after product A or B did not differ significantly. No differences were found in the frequency of coronary artery abnormalities 1 year after illness. CONCLUSIONS: No significant differences in efficacy appeared between the two IVGG products, but they differed significantly in non-life-threatening adverse reactions, especially infusion-related rigors. Other IVGG products should be evaluated in a similar fashion.

Child↗
PubMed1995

Kawasaki disease in infants less than one year of age.

OBJECTIVE: To identify risk factors for severe sequelae, analyze disease characteristics, and assess efficacy of intravenously administered immune globulin (IVGG) therapy in infants less than 12 months of age with Kawasaki disease. DESIGN: Retrospective chart review of children less than 12 months of age with Kawasaki disease between 1980 and 1993. RESULTS: Of 443 patients with Kawasaki disease, 57 (13%) were less than 1 year of age, including 14 (3%) less than 6 months. Age at onset was a predictor of the development of coronary artery aneurysms (CAA) and of giant (> 8 mm) aneurysms: 11 (79%) of 14 children < 6 months and 17 (44%) of 39 children 6 to 12 months of age acquired CAA (p = 0.06), and 5 (37%) of 14 children < 6 months and 2 (5%) of 39 children 6 to 12 months of age acquired giant CAA (p < 0.01). No specific clinical or laboratory features predicted the development of CAA, which was found in 7 (29%) of 24 patients treated with IVGG by illness day 10 and in 21 (73%) of 29 patients treated after day 10 or never treated with IVGG (p < 0.01). Only 1 (4%) of 24 patients treated by day 10 but 6 (21%) of 29 children treated after day 10 or never treated with IVGG acquired giant CAA (p = 0.01). Persistent (> 1 year) CAA were present in 4 (17%) of 24 IVGG-treated children by day 10 and in 14 (48%) of 29 children not treated by day 10 or never treated with IVGG (p < 0.025). There was no difference in outcome if IVGG was given by illness day 7 or on illness days 8 to 10. CONCLUSIONS: Patients with Kawasaki disease less than 6 months of age are at particularly increased risk of having CAA and giant CAA. Therapy with IVGG, given by illness day 10, is associated with substantial reduction in the frequency of CAA and giant CAA in this high-risk population.

Age of Onset↗
PubMed1995

Kawasaki disease.

This article is an up-to-date review of issues surrounding Kawasaki disease, with particular emphasis on the immunologic aspects. Kawasaki disease is now the leading cause of acquired heart disease in children in most developed countries.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed1995

The absence of evidence of staphylococcal toxin involvement in the pathogenesis of Kawasaki disease.

To detect a causative superantigen and to clarify a possible role for staphylococci in Kawasaki disease (KD), culture supernatants of individual bacterial isolates from 11 acute-stage patients were studied. Toxic shock syndrome toxin-1 (TSST-1) and antibody to TSST-1 and enterotoxins A (SEA), B (SEB), and C (SEC) in acute (mean, day 7) and late convalescent (mean, month 15) sera from 26 patients (12 with coronary artery aneurysms) and 22 age-matched controls were measured. Only 1 of 60 supernatants was mitogenic for human lymphocytes; it was 1 of the 4 Staphylococcus aureus isolates. Mitogenicity was neutralized by sera obtained after administration of intravenous gamma globulin (mean, week 4) but not by late convalescent sera. TSST-1 was detectable in 2 of 26 acute sera and 1 of 22 control sera. No KD but 1 control serum had IgM to TSST-1. IgG seroconversion rates to TSST-1, SEA, SEB, and SEC were 10%, 15%, 21% and 16%, respectively. These data do not support the involvement of toxin-producing staphylococci in KD.

Antibodies, Bacterial↗
PubMed1995

Lung abscess in infants and children.

We retrospectively reviewed 18 cases of primary lung abscess and 10 cases of secondary lung abscess in infants and children during a 6-year period. Among 18 patients with primary abscesses, nine were boys and nine girls, from 9 months to 20 years old, but only two of 18 were less than 5 years old. Each had a solitary abscess. Location of abscesses included the right lower lobe (8), the right upper lobe (3), the left upper lobe (1), and the left lower lobe (6). One patient had Streptococcus pneumoniae bacteremia. Other bacterial isolates were from the upper respiratory tract and of uncertain significance. All patients recovered, although lobectomy was considered necessary in five patients because of failure to respond to intravenous antibiotic therapy. Secondary lung abscesses occurred in six boys and four girls who were from 2 1/2 months to 13 years old. All 10 had solitary, right-sided lesions, seven in the right lower lobe and three in the right upper lobe. Bacteria of unclear significance were recovered from three of 10 patients, while two had documented gram-negative bacteremia. Three secondary abscess patients underwent lobectomy because of perceived inadequate response to medical therapy, including intravenous antibiotics. Based upon the literature and our experience, therapy for pulmonary abscess should include a parenteral antibiotic with gram-positive activity against both penicillinase-producing Staphylococcus aureus and anaerobes for a minimum of 3 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗