Biomedical subjects
J V Hirschmann
Publications and source records attributed to J V Hirschmann.
Dermatologic features of the superior vena cava syndrome.
BACKGROUND: The superior vena cava syndrome occurs when extrinsic compression or intraluminal occlusion impedes blood flow through this vessel. The most common underlying cause is a malignant neoplasm, especially a bronchogenic carcinoma. This article describes the cutaneous findings of this disorder. OBSERVATIONS: Among the earliest and most prominent features are numerous, dilated, vertically oriented, and tortuous cutaneous venules or veins above the rib cage margin. Recognition of this cutaneous sign allowed us to make a diagnosis of lung cancer in several patients. Other features include upper body edema and ruddiness or cyanosis, distended neck veins, proptosis, and conjunctival suffusion. CONCLUSIONS: Detecting the characteristic cutaneous features can lead to an early diagnosis of the superior vena cava syndrome. These skin changes usually represent indirect dermatologic signs of an underlying malignant neoplasm; for most patients, this syndrome is the initial manifestation of their cancer. The most common cause is a bronchogenic carcinoma, especially the small-cell variety, but others include lymphomas, primary mediastinal tumors, and metastases to the mediastinal lymph nodes from extrathoracic primary tumors, especially breast cancer. Treatment of the underlying malignant neoplasm and relief of the obstruction produce prompt improvement in the dermatologic findings.
Bacterial infections of the skin.
This report reflects the best data available at the time the report was prepared, but caution should be exercised in interpreting the data; the results of future studies may require alteration of the conclusions or recommendations set forth in this report.
Topical antibiotics in dermatology.
Topical antibiotics are safe and effective in certain conditions, primarily acne, rosacea, and nasal carriage of Staphylococcus aureus. They are useful in impetigo only when it is of limited extent. Their efficacy in other pyodermas is unclear, although mupirocin is probably effective in many cases. In "infected eczema" that does not require systemic therapy they seem to add little to what topical corticosteroids alone achieve. They are ineffective in reducing the incidence of significant infection with indwelling intravenous catheters. They are safe preparations, but extensive use, especially in closed populations, may encourage the emergence of resistant bacteria.
Skin lesions with disseminated toxoplasmosis in a patient with the acquired immunodeficiency syndrome.
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Cholinergic urticaria. A clinical and histologic study.
We studied the natural history, the prevalence of atopy, and the frequency of systemic symptoms during attacks in 35 patients with cholinergic urticaria, the histologic condition of the eruption in seven patients (20%), and the response to intradermal injections of acetylcholine, histamine, and methacholine in 18 patients (51%). In most patients symptoms began between the ages of 10 and 30 years, persisted for many years, and caused them to modify their activities to avoid the provoking factors of exercise, emotion, and heat. The condition usually improved with time, and five patients (14%) had a spontaneous remission. Atopy, present in about 12 (34%) of the patients, was more frequent than in the general population. Systemic symptoms were uncommon during attacks, and patients had no greater responses than controls to the intradermal tests. The histologic study revealed neutrophils in and around the walls of superficial subpapillary dermal vessels.
Antibiotic therapy and chronic obstructive lung disease.
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Ischemic forms of acute venous thrombosis.
Venous thrombosis in an extremity, when extensive, can cause reversible tissue ischemia or frank gangrene even without arterial or capillary occlusion. Patients gradually or abruptly develop severe pain, extensive edema, and cyanosis of the extremity, nearly always in the legs. Gangrene can occur unless the venous obstruction is relieved. Such ischemic venous thrombosis can complicate surgery, trauma, childbirth, or prolonged immobility, but malignant neoplasms, either obvious or occult, are a major predisposing factor. The optimal therapy is anticoagulation and thrombectomy. Patients with venous gangrene may require amputation if extensive, deep-tissue destruction occurs. The mortality rate for ischemic venous thrombosis is about 40%, the cause of death usually being the underlying disease or pulmonary emboli.
Controversies in antimicrobial prophylaxis.
This paper examines four controversies in antimicrobial prophylaxis. Duration of prophylaxis: Antimicrobial agents must be present in the tissues throughout the operation. Usually, a single preoperative or intraoperative dose will suffice; postoperative doses are unnecessary. Third-generation cephalosporins: no clinical evidence supports their use for surgical prophylaxis. Optimal prophylaxis for colorectal surgery: the information is conflicting, but oral agents combined with a parenteral antibiotic may be optimal. Prophylaxis for patients with indwelling prosthetic joints or vascular grafts: prophylaxis is unnecessary for procedures like dental work that cause transient bacteremia, but established infections should receive prompt, vigorous antimicrobial therapy.
Some principles of systemic glucocorticoid therapy.
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Fournier's syndrome: necrotizing subcutaneous infection of the male genitalia.
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Haemophilus influenzae infections in adults: report of nine cases and a review of the literature.
Haemophilus influenzae is an aerobic pleomorphic gram-negative coccobacillus that requires both X and V factors for growth. It grows poorly, if at all, on ordinary blood agar unless streaked with Staph. aureus. It grows well on chocolate agar. Because this medium is often not used in culturing specimens from adults and because the organism may be overgrown by other bacteria, the frequency of H. influenzae infections has undoubtedly been seriously underestimated. This is aggravated by the failure of many physicians to obtain blood cultures in suspected bacterial infections and the failure of many laboratories to subculture them routinely onto chocolate agar. H. influenzae, along with Streptococcus pneumoniae, is a major factor in acute sinusitis. It is probably the most frequent etiologic agent of acute epiglottitis. It is probably a common, but commonly unrecognized, cause of bacterial pneumonia, where it has a distinctive appearance on Gram stain. It is unusual in adult meningitis, but should particularly be considered in alcoholics; in those with recent or remote head trauma, especially with cerebrospinal fluid rhinorrhea; in patients with splenectomies and those with primary or secondary hypogammaglobulinemia. It may rarely cause a wide variety of other infections in adults, including purulent pericarditis, endocarditis, septic arthritis, obstetrical and gynecologic infections, urinary and biliary tract infections, and cellulitis. Antimicrobial susceptibility testing is somewhat capricious in part from the marked effect of inoculum size in some circumstances. In vitro and in vivo results support the use of ampicillin, unless the organism produces beta-lactamase. Alternatives in minor infections include tetracycline, erythromycin, and sulfamethoxazole-trimethoprim. For serious infections chloramphenicol is the best choice if the organism is ampicillin-resistant or the patient is penicillin-allergic.
Sounding board. Medical references.
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Prudent use of the aminoglycosides.
Kanamycin, gentamicin, tobramycin, and amikacin are potent aminoglycoside antibiotics useful in treatment of infections with aerobic Gram-negative bacilli. For many bacteria, no other effective agents exist. These antibiotics must be used prudently. Prescribing physicians have a responsibility to avoid unnecessary therapy with agents that have the potential of causing serious ototoxic and nephrotoxic effects and to avoid indiscriminate use that may encourage the emergence of resistant organisms. These medications are much too valuable to be rendered ineffective by unwise use.
Transient bacteremia and endocarditis prophylaxis. A review.
Transient, usually asymptomatic bacteremia occurs in a wide variety of procedures and manipulations, particularly those associated with mucous membrane trauma. It may also occur with such daily functions as tooth brushing and bowel movements. These brief bacteremias are especially common in tooth extraction and other dental procedures. Although numerical risk is uncertain, these bacteremias can occasionally give rise to infective endocarditis in the susceptible patient. While no proof exists that antibiotics given prior to procedures causing bacteremia prevent endocarditis in humans, experimental evidence in rabbits supports their use. Therefore, in situations where bacteremia is highly predictable, it would seem wise to administer prophylactic antimicrobials. Procedures in the susceptible host where prophylactic antibiotics seem prudent include dental manipulations and urinary tract instrumentation. Whether patients with acquired valvular or congenital heart disease who are to undergo abdominal surgical procedures should routinely receive prophylactic antibiotics is unclear. However, until the incidence of transient bacteremia associated with various abdominal procedures is further defined, endocarditis-prone patients should probably receive prophylaxis. Furthermore, patients with prosthetic valves who are subjected to upper gastrointestinal endoscopy, sigmoidoscopy, liver biopsy, or barium enema should also probably have antibiotic pretreatment. For dental procedures and for upper gastrointestinal endoscopy in patients with prosthetic valves, a combination of penicillin and streptomycin or vancomycin alone is recommended. For urinary tract instrumentation in all patients and for sigmoidoscopy, liver biopsy, or barium enema in patients with prosthetic valves, prophylaxis should be with ampicillin and gentamicin or vancomycin and gentamicin.
Candida vertebral osteomyelitis.
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