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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Pneumococcal vaccine.
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Fever and pulmonary infiltrates in a patient with a renal transplant.
This discussion was selected from the weekly Grand Rounds in the Department of Medicine, University of Washington, Seattle. Taken from a transcription, it has been edited by Drs Paul G. Ramsey, Assistant Professor of Medicine, and Philip J. Fialkow, Professor and Chairman of the Department of Medicine.
Systemic antimicrobial prophylaxis in surgery.
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Pneumococcal vaccine in the United States. A critical analysis.
The capsular polysaccharide pneumococcal vaccine approved by the Food and Drug Administration in November 1977 has been recommended for persons older than 2 years believed to be at high risk for pneumococcal disease, including those aged 50 years and older, those with chronic systemic illnesses, and those living in certain institutions. A critical review of the available evidence shows little documentation of an increased incidence of, or mortality from, pneumococcal disease for many of these suggested categories. Moreover, except for children with sickle cell disease, there is no convincing evidence that the vaccine is effective for the chronically ill, and unpublished controlled studies have demonstrated no benefit for ambulatory, elderly, or institutionalized patients. Thus, there is currently no information to support widespread pneumococcal vaccination in this country, and further investigations are needed to determine in what situations this vaccine is worthwhile.
Drug fever.
Most medications can cause fever, with or without concomitant clinical manifestations. The fever may arise from the drug's pharmacologic action, its effects on thermoregulation, a local complication following parenteral administration, or an idiosyncratic response. The most common mechanism is probably an immunologic reaction mediated by drug-induced antibodies. Drug fever may have any pattern; it typically occurs after seven to ten days of treatment and usually resolves within 48 hours of discontinuing the administration. Failure to diagnose drug fever may lead to inappropriate and potentially harmful diagnostic and therapeutic interventions. In suspected cases, it is necessary to discontinue administration of all potentially causative medicines, together or sequentially. Rechallenge with the offending agent will usually cause recurrence of fever within a few hours, confirming the diagnosis.
Rational antibiotic prophylaxis.
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Fournier's syndrome: necrotizing subcutaneous infection of the male genitalia.
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