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Biomedical subjects

R S Kirsner

Publications and source records attributed to R S Kirsner.

At least 73 records · Page 4Linked to original sources
PubMed1997

Cutaneous disseminated histoplasmosis in AIDS patients in south Florida.

BACKGROUND: Histoplasma capsulatum is a dimorphic pathogenic fungus endemic to the Mississippi and Ohio river valleys. In the immunocompetent it causes a self-limited disease, but in the immunocompromised may lead to disseminated disease (disseminated histoplasmosis (DH)). It is one of the opportunistic infections which defines the acquired immunodeficiency syndrome (AIDS) and is rarely encountered outside endemic regions. METHODS: Clinical, laboratory, and histologic information concerning seven patients with DH and AIDS in South Florida was recorded. RESULTS: We report seven cases of DH with mucocutaneous lesions in patients infected with the human immunodeficiency virus (HIV). All patients had markedly depressed CD4 counts of less than 40 cells/mm3, and only two had traveled to endemic areas. Two out of the seven patients were diagnosed with HIV/AIDS at the time DH was identified. All of our patients had mucocutaneous lesions at the time of diagnosis, which clinically presented as a generalized papular eruption, ulcers, and erythematous scaly plaques. CONCLUSIONS: Even in non-endemic regions, HIV-positive patients presenting with fever, chills, weight loss, hepatosplenomegaly, anemia, cough, lymphadenopathy, and mucocutaneous lesions should have an early skin biopsy specimen taken for mycologic tissue culture and histopathologic evaluation for disseminated fungal infections.

AIDS-Related Opportunistic Infections↗
PubMed1997

Split-thickness skin grafting for lower extremity ulcerations.

BACKGROUND: Leg ulcers are often refractory to conservative treatment, often mandating the use of skin grafting. OBJECTIVES: This review article discusses skin grafts, with special emphasis on split-thickness grafts for lower extremity ulcerations. METHODS: Historical background, proposed mechanisms of action, biology of skin grafts, techniques for skin grafting, and results after grafting are discussed separately. RESULTS: Skin grafting has been performed for centuries. However, how skin grafts work, whether solely as tissue replacement or, additionally, as a stimulus for healing, is still not fully known. After placement, the grafted skin proceeds through a series of phases by which nutrients are supplied and neovascularization occurs. Adherence to the ulcer bed through interactions between the graft and the ulcer bed appear critical. When meshed split-thickness skin grafts are properly performed, success rates from 50% to 75% have been reported for refractory venous ulcers. CONCLUSIONS: Better understanding of the biologic and clinical aspects of skin grafting should lead to improved patient care. LEARNING OBJECTIVES: After studying this article, participant should be able: 1. To understand the various types of skin grafts. 2. To learn the potential mechanisms of action of how skin grafts work. 3. To appreciate the benefit of skin grafts for lower extremity ulcerations.

Follow-Up Studies↗
PubMed1997

Cutaneous clues to systemic disease.

Scleroderma, psoriasis, lichen planus, and other skin disorders may signal a more serious internal disease. Physicians who recognize such clues can initiate early treatment while disease is in its early stages. The authors of this article describe several of the more common dermatologic conditions linked to systemic disease, including connective tissue, inflammatory, immunobullous, and infectious diseases.

Acute Disease↗
PubMed1997

The abilities of primary care physicians in dermatology: implications for quality of care.

Quality of care in medicine has become an increasingly important issue as the nature of healthcare delivery has changed. Many managed care systems rely on the primary care physician to serve as a gatekeeper, thereby limiting access to specialist care. Controversy has arisen regarding the abilities of primary care physicians in one such specialty: dermatology. We reviewed the many studies conducted in the United States evaluating primary care physicians' abilities in dermatology. Despite inherent flaws in many of the studies, one can conclude that primary care providers are inferior to dermatologists in the diagnosis and treatment of skin disease. Whether these process-based data predict outcome is not known.

Clinical Competence↗
PubMed1997

Pica: are you hungry for the facts?

Pica, the persistent and compulsive ingestion of particular food items or nonnutritive substances, has been associated with iron deficiency, zinc deficiency, geophagia, mental deficiency, developmental delay, and a family history of pica. Nutritional, sensory physiologic, psychosocial, and cultural theories have been advanced to explain this phenomenon, but the etiology of pica is poorly understood. Pica, secondary to iron deficiency, is relatively common and remits after iron therapy. Complications of pica include abdominal problems (sometimes necessitating surgery), lead poisoning, hypokalemia, hyperkalemia, mercury poisoning, phosphorus intoxication, and dental injury. Pica is an underdiagnosed problem that can be caused by a variety of disorders and can lead to serious complications.

Adult↗
PubMed1997

Screening for skin cancer in primary care settings.

OBJECTIVE: To estimate the frequency of recorded screening for skin cancer in primary care settings. DESIGN: Retrospective observational cohort study. SETTING: Two academically affiliated Department of Veterans Affairs Medical Centers. SUBJECTS: Two hundred randomly selected patients at least 50 years old and receiving care at outpatient medical clinics. MAIN OUTCOME MEASURE: Frequency of documented skin examinations, in comparison with other tests routinely done as screening, during a 2-year period. METHODS: Medical record review to identify how often selected components of the physical examination and specific procedures were documented during ambulatory visits. RESULTS: Among the 200 subjects, the frequency of documented examinations and procedures included fecal occult blood testing in 120 (60%), rectal examination in 128 (64%), and sigmoidoscopy in 93 (47%), prostate examination was performed in 114 (59%) of 193 men. In contrast, skin examination was documented in only 56 (28%) of 200 subjects (P < .001 for each comparison with other tests). As an estimate of the "true" frequency of screening for skin cancer, 35 (18%) of 165 patients without skin-related complaints had a documented skin examination. CONCLUSION: Skin cancer screening is infrequently documented and therefore possibly omitted in the context of primary care visits.

Aged↗
PubMed1996

Squamous cell carcinoma arising in osteomyelitis and chronic wounds. Treatment with Mohs micrographic surgery vs amputation.

BACKGROUND: Squamous cell carcinoma (SCC) is a rare, but well-documented complication of osteomyelitis and chronic wounds. Treatment of choice for these tumors commonly occurring on the legs has been amputation. Two recent articles have suggested the utility of Mohs micrographic surgery (MMS) as a limb saving procedure. OBJECTIVE: To discuss the process of decision analysis in patients with SCC arising in osteomyelitis and chronic wounds. METHODS: Four patients with SCC (three developing in association with chronic osteomyelitis, one after a burn wound) are presented. RESULTS: Two patients underwent MMS as a limb-saving procedure, while the other two underwent amputation. Only two of our patients were able to have MMS since we were confronted with factors that precluded the use of this technique. These factors included the presence of metastatic disease and the potential for the loss of a functional limb after surgery. CONCLUSIONS: Our series confirms the utility of MMS as a potentially limb-saving procedure in patients with SCC arising in either chronic wounds or in association with osteomyelitis. Despite this, patients with distant spread of their disease or extensive local disease leading to the potential loss of functional stability of the leg postoperatively may not be candidates for MMS and may require amputation.

Aged↗
PubMed1996

Lack of correlation between internists' ability in dermatology and their patterns of treating patients with skin disease.

BACKGROUND AND DESIGN: We determine whether a subset of internists exist who are better at diagnosing skin disease and therefore select themselves to treat the majority of patients with dermatologic disorders. A survey was conducted in which internists reported their self-perception regarding their abilities in dermatology, the amount of dermatology training they had received, and the percentage of patients they encounter with and treat for skin diseases. This was correlated with results from an objective photographic (Kodachrome) examination assessing their diagnostic abilities in dermatology. The setting was university and private practices in Miami, Fla, and New Haven, Conn. The participants were general internists, medical subspecialists, and medical residents. After completing a self-administered questionnaire, each physician then participated in an examination where they were shown 20 color photographs of common skin disorders. We correlate the relationship between the survey variables and the results of the photographic examination. RESULTS: Eighty-four internists diagnosed 50.5% of the diseases correctly. Internists perceive themselves as mediocre in dermatology (2.6, on a scale of 1-5, 5 being the best), which correlated with their poor performance on the photographic evaluation (P = .04). Internists reported having limited education or training in dermatology (> 85% having < 1 month of training in or after medical school). There was a trend toward a correlation between the amount of training internists received and their ability in dermatology (P = .07). Notably , there was no correlation between internists' ability in dermatology and the percentage of patients they encounter with and treat for skin disease. CONCLUSIONS: Internists receive limited training and have resultant poor performance in diagnosing skin disease. Internists are aware of their limited ability in dermatology as demonstrated by their mediocre self-perceived ability. Notably, no correlation was found between internists' abilities in dermatology and the percentage of patients they encounter and treat for skin disease. Therefore, we did not demonstrate a subset of internists, superior at dermatology, who treat the majority of patients with skin disease. This suggests patients with skin disease may be better served by dermatologists.

Clinical Medicine↗
PubMed1996

Skin grafts as pharmacological agents: pre-wounding of the donor site.

Initially thought to act as tissue replacement, cultured epithelial allografts are now known to work by providing a potent stimulus for healing. In a similar fashion, we believe that traditional autografts may also provide a stimulus to help heal chronic wounds, thus acting as pharmacological agents for healing. We attempted to assess the possibility of augmenting the stimulatory properties of donor skin by initiating the healing process in the donor region prior to grafting. This was accomplished by pre-wounding the donor area 3 days prior to harvesting the donor skin. We compared these 'pre-wounded' grafts to those harvested immediately. Two patients underwent punch grafting for chronic leg ulceration. Half of the ulcer was grafted with donor skin harvested from an area that was pre-wounded and the other half from freshly harvested skin. We evaluated each for improvement of granulation tissue and degree of edge effect (migration of the previously dormant wound edges). All the grafts did well. There was marked improvement in granulation tissue in the ulcer bed after grafting, and the obvious presence of an edge effect. The edge effect was increased on the site where the pre-wounded grafts were placed. It may be possible to augment the growth stimulatory properties of donor skin. This may offer therapeutic options in patients with chronic wounds.

Adult↗
PubMed1995

A comparison of diagnosis, evaluation, and treatment of patients with dermatologic disorders.

BACKGROUND: Managed care in the American health care system may limit access to health care specialists. OBJECTIVE: We assessed primary care providers' abilities at diagnosing and treating patients with a previously undiagnosed skin disorder. METHODS: Patients with previously undiagnosed skin disorders were seen and examined sequentially by three groups of physicians: (1) internal medicine residents, (2) board-certified internal medicine attending physicians and (3) dermatology faculty. The internal medicine residents and attending physicians' diagnoses were compared with the dermatologists'. Appropriateness of therapy ordered by the internal medicine residents and attending physicians was assessed. RESULTS: Medical residents' diagnoses were correct in 43% of the patients whereas the attending physicians diagnosed 52% of cases correctly. Attending physicians and residents frequently ordered therapy inappropriate for the patient's diagnosis. Internal medicine residents and attending physicians were more likely to order skin biopsies than dermatologists. CONCLUSIONS: Our results confirm earlier studies that nondermatologists perform poorly in the diagnosis and treatment of skin disease. Primary care providers should receive more training in dermatology, or dermatologists should be permitted to act as primary caregivers to patients with skin disease.

Adult↗
PubMed1995

Treatment with alpha interferon associated with the development of paraneoplastic pemphigus.

The use of interferon (INF) is usually considered safe, the major side-effect being a flu-like syndrome. However, with its ability to alter immune responsiveness, INF has been associated with the induction of autoimmune diseases. We report a patient with Waldenström's macroglobulinaemia who developed a generalized blistering eruption after treatment with systemic INF-alpha 2A (INF) for multiple skin cancers. The patient's skin showed histological features, immunofluorescence findings, and immunoprecipitation diagnostic of paraneoplastic pemphigus. Despite aggressive treatment the patient died. In our patient, the use of INF was temporally related to the development of paraneoplastic pemphigus. Although interferon has been shown to induce other autoimmune diseases, to our knowledge this is only the second report of a patient treated with an interferon who subsequently developed a fatal autoimmune blistering disorder. Paraneoplastic pemphigus is a recently described autoimmune bullous disorder with a poor prognosis. The mechanism by which INF triggered the paraneoplastic pemphigus is not known.

Aged↗
PubMed1995

Split-thickness skin grafting of leg ulcers. The University of Miami Department of Dermatology's experience (1990-1993).

BACKGROUND: Skin grafting for large and recalcitrant lower extremity ulcers is a commonly used therapy. However, the success rate for grafts performed by dermatologists is largely unknown. OBJECTIVE: To analyze our experience with meshed split-thickness skin grafts for leg ulcers. METHODS: We retrospectively analyzed all hospitalized dermatology patients who underwent meshed split-thickness skin grafting for lower extremity ulceration due to a variety of causes performed by the Department of Dermatology at the University of Miami over a 3-year period (1990-1993). RESULTS: Twenty-nine patients with 36 ulcers were grafted. Greater than 90% of ulcers had initial graft take. At long-term follow-up, 52% of ulcers were healed, 26% were partially healed, and 22% recurred. CONCLUSION: We conclude that meshed split-thickness skin grafting is a safe and effective therapy for recalcitrant lower extremity ulcers.

Adolescent↗