Fellows identify key issues affecting surgery.

All changes in our health care delivery system during the past three years have had an effect on reimbursement rates, net income, and practice satisfaction among surgeons. Implementation of the Medicare fee schedule and increasing penetration of the health care market by managed care firms have clearly had the most profound influence. Sixty percent of practicing surgeons have experienced a decrease in net practice income since 1992.

The PPRC: 1994 update.

The health care debate will continue throughout much of the summer in the legislative committees and subcommittees of Congress. Both the American College of Surgeons and the PPRC will participate in that process through invitations to testify on many of the issues discussed in this article. The author will begin his third three-year term on the PPRC in July 1994, and will continue to express the concerns of the surgical community to that body.

Subeschar tissue fluid: a source of cell-mediated immune suppression in victims of severe thermal injury.

Thermal injury results in pronounced physiologic alterations in microcirculation at the site of tissue damage. The consequence of these changes is an increase in microvascular permeability, leading to the accumulation of tissue edema, or subeschar tissue fluid (STF). One of the adverse properties of edema is its capacity in vitro to inhibit cell-mediated immune function.

Assessing nutritional needs for the burned patient.

Assessment of nutritional needs following thermal injury remains an important adjunct to providing dietary therapy designed to minimize the detrimental effects of hypermetabolism and subsequent catabolism. Most anthropometric measurements, frequently utilized in nonburned patients, have relatively little usefulness in assessing burned individuals. Energy expenditure can be adequately estimated for most patients by direct calorimetry, indirect calorimetry, or formulae.

In vitro effects of complement inactivation upon burn-associated cell-mediated immunosuppression.

Serum of severely burned patients possesses in vitro capacity to suppress cell-mediated immunologic responses. Failure to establish immune competence is predictive of mortality, usually from sepsis. In this investigation, the hypothesis that complement fragments, known to be elevated in the acute phases of burn injury, contribute to this suppression is tested.

Transportation of immunosuppressive substances produced at the site of burn injury into the systemic circulation: the role of lymphatics.

Serum of patients with severe burns has the ability to suppress mitogen-induced lymphocyte proliferation. Edema fluid collected from the site of injury during resuscitation and at the time of fascial excision has also been shown to suppress this response. An animal model was designed to identify the onset time of the formation of suppressive factors, their potential site(s) of origin, and their route of entry into the systemic circulation.

The Physician Payment Review Commission: a 1990 update.

Major changes have been effected in Medicare Part B payment policy during the past year. Many of the objectives of both the PPRC and the ACS have been attained, and implementation of the reform measures will take place over the next five years. Much work remains to be done to polish the technical factors that are necessary for implementation, but current progress is on schedule.

A new technique for sutureless intestinal anastomosis. A prospective, randomized, clinical trial.

A polyglycolic acid device has been designed for the performance of sutureless colonic anastomoses. The use of this biofragmentable anastomosis ring (BAR) was compared with conventional techniques in a prospective, randomized study of 59 patients (x age, 49 years) undergoing ileocolostomy (n = 23) or colocolostomy (n = 36). The anastomotic technique was determined at surgery by randomization (BAR, 27 patients; suture, 16 patients; staple, 16 patients).

Smoke inhalation injury: evaluation of radiographic manifestations and pulmonary dysfunction.

Inhalation injury is a frequent complication in burned patients. Upper airway injury is reliably diagnosed endoscopically, but early diagnosis of pulmonary parenchymal injury is less reliable. Radiographic diagnosis in such cases is inconsistent.

Effects of fibrinogen degradation fragments D and E on cell-mediated immunity.

Serum taken from severely traumatized victims suppresses in vitro the response of normal lymphocytes to the mitogenic stimulant phytohemagglutinin (PHA). In the postburn period, fibrin degradation products (fragments D and E) are elevated in a high percentage. Controversy exists as to whether these fragments contribute to what is clinically evident as cell-mediated immune (CMI) suppression.

The Physician Payment Review Commission and payment reform: a revisit.

The PPRC recommendations for Medicare physician payment reform are comprehensive and, for the most part, are now being evaluated utilizing computer simulation for possible effects upon our health care delivery system. Such simulations, however, require the utilization of assumptions with regard to economic growth, human behavior, and the general health of the population. Obviously, not all alterations in the system with regard to medical access and quality of care will be predicted with certainty.

Inhibition of lymphocyte blastogenesis caused by suppression of interleukin-2 receptor sites after thermal injury.

Burn patients often exhibit prolonged cell-mediated immune suppression. Of the mechanisms proposed to account for this, one invokes an inability on the part of T lymphocytes to undergo blastogenesis, clonal expansion, and differentiation--a process partially mediated by interleukin-2. Triplicate samples of 10% dilutions of burn serum from nine burn patients (three with greater than 60% burn) were analyzed for their ability to suppress mitogen-induced lymphocyte blastogenesis.

The suppressive effect of subeschar tissue fluid upon in vitro cell-mediated immunologic function.

Unlabelled: Fluid administered during resuscitation translocates beneath the burn wound and is considered inert "third space" loss. This study was done to determine whether subeschar tissue fluid (STF) functions as an immunobiologic reservoir. Seven patients with a mean BSA burn of 55% underwent isotonic volume resuscitation and burn treatment with low penetration topical agents.

Complications of Crotalidae antivenin therapy.

Polyvalent antivenin is the mainstay of treatment of serious snake envenomation. Its use, however, has been challenged as being unnecessary in minor envenomations and potentially hazardous due to allergic complications. Our institution routinely uses antivenin, and this report focuses on the allergic complications of this therapy.

Hypothermia prevents increased capillary permeability following ischemia-reperfusion injury.

Unlabelled: Severely injured trauma victims are frequently hypothermic. It is unclear, however, whether hypothermia itself is a detrimental or protective physiologic response to injury. One of the major consequences of fluid resuscitation following ischemic injury is edema formation, characterized by ischemia-reperfusion injury models.

Hypothermia in trauma victims: an ominous predictor of survival.

Hypothermia in trauma patients is generally considered an ominous sign, although the actual temperature at which hypothermia affects survival is ill defined. In this study, the impact of body core hypothermia on outcome in 71 adult trauma patients with Injury Severity Scores (ISS) greater than or equal to 25 was analyzed. Forty-two per cent of the patients had a core temperature (Tc) below 34 degrees C, 23% below 33 degrees C, and 13% below 32 degrees C.

Analysis of altered capillary pressure and permeability after thermal injury.

In order to investigate the effects of thermal injury on microvascular hemodynamics and permeability, hindpaw arterial (PA), venous (PV), and capillary (PC) pressures, blood (QB) and lymph (QL) flows, and lymph (CL) and plasma (CP) total protein concentrations were measured before and for 3 hr after a 10-sec 100 degrees C scald burn in 11 dogs. Prior to injury in eight experiments (Group I--permeability analysis) venous pressure was elevated by outflow restriction until the minimal CL/CP was obtained. In three experiments (Group II--hemodynamic analysis) outflow was not restricted.