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Biomedical subjects

S T Shulman

Publications and source records attributed to S T Shulman.

At least 127 records · Page 7Linked to original sources
PubMed1987

Incomplete Kawasaki disease with coronary artery involvement.

We report four patients with Kawasaki disease in whom characteristic coronary artery abnormalities developed after illnesses that did not meet diagnostic criteria. An additional patient lacked a history of acute manifestations of Kawasaki disease, but severe Kawasaki-like arterial changes were noted at autopsy. Fever was present in four of the five patients, in three lasting from 7 to 14 days. Despite manifestation of few classic acute clinical features of Kawasaki disease, three of four patients had desquamation of the fingers and toes 10 to 14 days after onset of illness, and the fifth had desquamation several months prior to death. These patients were seen over a 2-year period during which 22 other children were seen with Kawasaki disease with coronary artery abnormalities. Thus, strict adherence to currently accepted criteria for diagnosis of Kawasaki disease may lead to failure to recognize incomplete forms of this illness, with potential sequelae of myocardial infarction or sudden death. This finding suggests that children with prolonged unexplained febrile illnesses, especially those associated with subsequent peripheral desquamation, should undergo echocardiography 3 to 4 weeks after onset of the illness. This practice would help to identify those patients with illnesses characterized by incomplete diagnostic criteria but in whom significant coronary abnormalities develop.

Coronary Aneurysm↗
PubMed1987

Prevention of infective endocarditis: the view from the United States.

The American Heart Association's recommendations for the prevention of infective endocarditis were first published in February, 1955, and the most recent (fifth revision) in December, 1984. The somewhat controversial nature of these recommendations reflects several issues, including the degree to which infective endocarditis in man is preventable and the relative safety of alternative regimens. Nevertheless, it is apparent that a reasonable fraction of cases are preventable and that antibiotics for this purpose are appropriate. It is also clear that certain patient groups, i.e. those with prosthetic valves or surgically constructed systemic-pulmonary shunts, are at greatest risk and warrant more intensive, primarily parenteral antibiotic regimens. Particularly controversial are recommendations related to the very large group of patients with mitral valve prolapse. The latest American Heart Association recommendations are presented in detail.

Endocarditis, Bacterial↗
PubMed1987

Risk factors associated with candidemia in the neonatal intensive care unit: a case-control study.

Systemic candidiasis, especially candidemia, is an increasing problem among high risk neonates. Although possible predisposing factors have been suggested, no case-control study has evaluated potential risk factors. By retrospective chart review we identified 21 infants admitted to the neonatal intensive care unit between 1976 and 1983 (0.9% of all admissions) who had documented nosocomial candidemia before 4 months of age. Twenty patients were matched to a control infant with similar birth weight and date of admission. We found that the median durations of exposure to the following risk factors were significantly longer in patients compared with controls: hyperalimentation; intravenous fat emulsion; endotracheal tubes; and/or tracheostomies and antibiotic therapy. However, by discriminant analysis, duration of antibiotic therapy remained the variable most strongly (and independently) associated with the development of candidemia. Treatment of the 22 episodes of candidemia was variable including catheter removal alone in 12 and a combination of catheter removal, amphotericin, 5-fluorocytosine and/or ketaconazole in the others. Although the overall mortality for the series was 5 of 20 cases (25%), no infant larger than 2000 g died. We conclude that development of candidemia in neonates is associated with, and possibly caused by, prolonged exposure to antibiotics (as documented by multivariate analysis), hyperalimentation, intravenous fat emulsion and tracheal intubation (as documented by univariate analysis). To the greatest extent possible consistent with good clinical care, exposure to these risk factors should be minimized in high risk neonates.

Anti-Bacterial Agents↗
PubMed1987

Ewingella americana: recurrent pseudobacteremia from a persistent environmental reservoir.

From September 1981 through April 1984, 20 patients at one hospital were identified with Ewingella americana pseudobacteremia. Case-control studies demonstrated an association between having a positive blood culture for E. americana and having blood for culture obtained simultaneously with blood obtained for coagulation studies (15 of 19 case patients versus 4 of 38 controls; P = 4.5 X 10(-7)). Review of blood-drawing procedures showed that blood for coagulation studies and culture was drawn with the same syringe, and coagulation tubes were filled before blood culture tubes. Some phlebotomists were not using new sterile needles to inoculate blood culture bottles. Collection tubes for coagulation studies were prepared in the hospital, and E. americana was isolated from all 52 unused coagulation tubes tested. Solutions prepared in the hospital may constitute a persistent inanimate environmental reservoir for this uncommon microorganism. Pseudobacteremia can result in unnecessary antimicrobial therapy for some patients, incurring the risks of adverse drug reactions, selection of drug-resistant bacteria, and increased health care costs.

Adolescent↗
PubMed1987

Plasmids of Ewingella americana: supplementary epidemiologic markers in an outbreak of pseudobacteremia.

During an outbreak of pseudobacteremia in a children's hospital, Ewingella americana was found in blood cultures from 20 patients. E. americana was inoculated into blood culture bottles at the time of specimen collection due to cross contamination from nonsterile, citrated blood collection tubes used for coagulation studies. Antimicrobial susceptibility testing and plasmid profiling were used to assess the association between patient isolates and isolates from unused blood collection tubes. All E. americana isolates had similar antibiograms (i.e., resistance only to cephalothin) when tested at 37 degrees C. However, when the same isolates were tested for antimicrobial susceptibility at 25 degrees C, a different antibiogram (i.e., resistance to chloramphenicol, ampicillin, and cephalothin) was found. The majority of these isolates also demonstrated a unique four-plasmid profile (130, 56, 4.6, and 3.1 megadaltons), and two of these plasmids (130 and 56 megadaltons) were characterized as temperature-sensitive plasmids. An epidemiologic link between outbreak-associated isolates obtained from different time periods in the outbreak was supported by evidence of a significant trend in the ability of the outbreak-associated isolates to reduce nitrate, together with the presence of the resistance antibiogram at 25 degrees C and the demonstration of the unique four-plasmid profile.

Adolescent↗
PubMed1986

Does Kawasaki disease have a retroviral aetiology?

In 18 consecutive children with Kawasaki disease of recent onset, reverse transcriptase (RT) activity was studied in co-cultivated peripheral-blood-mononuclear-cell/lymphoblastoid-cell supernatants. 8 of 18 children, but only 1 of 18 controls, showed RT activity in one or more sample (p = 0.009). RT activity was identified in 14 of 226 samples from patients, but in only 1 of 167 from controls (p less than 0.01). The findings suggest that a retroviral agent may be casually related to Kawasaki disease.

Acute Disease↗
PubMed1986

Combination antibiotic therapy in pediatrics.

Combinations of beta-lactam and aminoglycoside antibiotics are frequently used in the treatment of pediatric infections. At our institution, amikacin has been the sole aminoglycoside utilized for the past five years. Such regimens are used empirically in specific patient populations to treat the pathogens most likely to be responsible for a symptom complex, e.g., sepsis in the immunocompromised host, pneumonitis in patients with cystic fibrosis, neonatal infections such as sepsis or meningitis, and infections in patients with intestinal perforations. Beta-lactam and aminoglycoside combinations are employed as definitive therapy when synergistic interactions can be predicted, such as in systemic Pseudomonas infections, viridans streptococcal endocarditis, or enterococcal infections. In all of these circumstances, we have utilized amikacin extensively as the sole aminoglycoside, with highly satisfactory results. In vitro antibiotic synergy studies, including those employing aminoglycosides such as amikacin, may be used to predict in vivo antibiotic interactions. However, definitions of in vitro synergy vary with the laboratory method used to evaluate synergy. Furthermore, recent data from our laboratory suggest that the absence of demonstrated in vitro synergy between amikacin and imipenem may not correlate with improved survival of neutropenic rats with gram-negative sepsis that are treated with both agents. Thus, in vitro studies of synergy may underestimate the frequency of improved outcomes with combination antibiotics, especially with amikacin and imipenem. There are potential risks associated with the use of multiple, broad-spectrum antibiotics, including fungal or bacterial superinfection and increased drug toxicity. Although the former is common in pediatric patients, aminoglycoside (amikacin) toxicity has rarely been a problem. Combination antibiotic regimens that include an aminoglycoside such as amikacin continue to have an important role in pediatrics and should be used empirically or definitively for the specific indications discussed.

Amikacin↗
PubMed1986

Mucocutaneous lymph node syndrome (Kawasaki disease): delayed aortic and mitral insufficiency secondary to active valvulitis.

A 2 8/12 year old girl with acute mucocutaneous lymph node syndrome (Kawasaki disease), presented 17 months later with a new onset of mitral and aortic insufficiency. Congestive heart failure rapidly developed and double valve replacement was performed. Pathologic study of the excised valve tissue disclosed active valvulitis. This is the first report of late onset aortic and mitral valvulitis associated with Kawasaki disease.

Aortic Valve↗
PubMed1986

Correlation of antibiotic synergy in vitro and in vivo: use of an animal model of neutropenic gram-negative sepsis.

The predictive value of in vitro studies of antibiotic interaction for clinical drug interactions is unclear. Five clinical isolates (two Klebsiella, two Pseudomonas aeruginosa, and one Serratia marcescens) were evaluated by the time-kill curve method for in vitro synergy between amikacin and imipenem. When we used the stringent definition of synergy of Hallander et al., no synergy was present for any study strain; however, when we used a more-conventional definition of synergy, these drugs interacted synergistically against all study strains. The results of these in vitro studies were correlated with in vivo interactions by using neutropenic infant rats injected ip with study organisms and given various treatment regimens. For 80% of the study strains, treatment of rats with amikacin and imipenem resulted in significantly greater survival than did therapy with either drug alone or than could be predicted by addition of survival rates achieved with either agent alone (P less than .005). In vitro studies predicted this in vivo synergy in 80% of the cases when the more-conventional definition of synergy was used, whereas they were not predictive when the more-stringent definition of synergy was used. This rat model of neutropenia and gram-negative sepsis may provide more insight into in vivo drug interactions than do current methods.

Agranulocytosis↗
PubMed1986

In vitro activity of antibiotics alone and in combination against Actinobacillus actinomycetemcomitans.

The MICs for 90% of the organisms tested (MIC90S) of 11 antibiotics against 24 clinical isolates of Actinobacillus actinomycetemcomitans were determined by the MIC 2000 system. The lowest MIC90S (16 micrograms/ml) were observed with ceftriaxone and rifampin. The next lowest MIC90S were found with cephapirin, tetracycline, and chloramphenicol (3.12 micrograms/ml). The MIC90S of penicillin, ampicillin, ticarcillin, piperacillin, and amikacin were each greater than or equal to 12.5 micrograms/ml. Antibiotic synergy was studied by the killing curve method and was defined as a greater than or equal to 2 log10 reduction in CFU when two antibiotics were used in combination at one-fourth the MBC for each compared with the effect of each antibiotic alone at one-half the MBC. Synergism between rifampin and penicillin, cephapirin, or ceftriaxone was tested for with 12 A. actinomycetemcomitans strains. In 7 of 37 instances, synergism was demonstrated for the combinations rifampin plus ceftriaxone (n = 3) or rifampin plus penicillin (n = 4); in 9 instances, an additive effect was noted, and impaired killing with drug combinations compared with the effect of a single antibiotic was suggested in 4 strains. The majority of strains were indifferent to the combinations. Similarly, variable results were observed when the combination of trimethoprim and cephapirin was tested against eight A. actinomycetemcomitans strains. Our data suggest that rifampin and cephapirin are the most active of the 11 antibiotics studied against A. actinomycetemcomitans. In addition, in vitro synergism between rifampin and other antibiotics or between trimethoprim and cephapirin was not consistently demonstrable.

Actinobacillus↗