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Biomedical subjects

P W Curreri

Publications and source records attributed to P W Curreri.

At least 19 recordsLinked to original sources
PubMed1995

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. Of referrals from required gatekeeper physicians, 15 percent of such episodes are viewed by surgeons to result in decreased quality of care. Finally, there was a surprisingly high (40%) enthusiasm for implementation of a federalized single-payor health care system.

Attitude of Health Personnel↗
PubMed1994

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. Thus, your comments and opinions are always appreciated.

Health Care Reform↗
PubMed1990

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. Direct calorimetry is the most expensive and complicated method, while use of a formula is the most inexpensive and least complicated. All yield good results in the clinical setting. Differences in estimated energy expenditure by the multiple formulae may be statistically significant, but rarely are clinically significant. Therefore selection of a formula should be based on simplicity. Estimations by formula require readjustment at intervals of 1 to 2 weeks. In general, enteral feedings remain superior to parenteral delivery of nutrients. Finally, current animal research suggests significant differences in metabolic and immunologic effects of the diet depending on qualitative make-up of dietary fat sources.

Animals↗
PubMed1990

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. The single major difference of opinion between the PPRC and the ACS is related to the provision for a separate MVPS for surgical procedures. Clearly, better data are required before this issue can be resolved, and continued cooperation will be necessary to satisfy the congressional mandate for separate surgical and nonsurgical MVPSs. Payment for Medicaid services frequently is woefully inadequate, and the PPRC feels a strong obligation to make appropriate recommendations to Congress in order to correct these inequities. Finally, the PPRC and the ACS are on record as strongly opposing the administration's budget proposals for 1991 and instead as having supported congressional counterproposals that would result in much less severe reductions in Part B outlays.

Health Expenditures↗
PubMed1990

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). Performance of an anastomosis with the BAR required an average of 22 minutes, a stapled anastomosis required 33 minutes, and the suture technique required 37 minutes. Learning curve error contributed to the six intraoperative complications that occurred with performance of the anastomosis (BAR, three; end-to-end anastomosis [EEA] instrument, three). The two postoperative deaths were unrelated to the anastomosis. Length of hospitalization in uncomplicated patients was the same among the three groups. The 17 patients with prolonged hospitalization had complications unrelated to anastomotic technique. All patients were followed for a minimum of 6 weeks; no additional complications were identified. We concluded that 1) the BAR is a rapid, safe method for performance of sutureless anastomoses; 2) perioperative mortality and morbidity rates of the BAR are comparable to conventional techniques of suture and staple; and 3) long-term follow-up of BAR patients is warranted to determine the incidence of complications, such as structure and/or stenosis.

Anastomosis, Surgical↗
PubMed1990

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. Serum taken from patients with massive (greater than 60%) and major (less than or equal to 60%) burn injury was analyzed for the ability to suppress mitogen-induced lymphocyte blastogenesis before and after exposure of the burn serum to (complement inactivating) temperatures. All patients in this study had immune suppressive serum. Heat inactivation partially restored immune competence in the serum of all patients, though significantly more so in patients with major burns compared with those with massive burns. Complement appears to play a contributory role in the acute stages of burn-induced, cell-mediated immunosuppression, though its role in patients with massive burn injury is overshadowed by the presence of serologic suppressive factors not present (or present in lower concentration) in patients with major burns.

Adult↗
PubMed1989

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. Purified fragments D and E were isolated over an ion exchange cellulose column after activating, with streptokinase, a solution containing fibrinogen and plasminogen. Lymphocytes from six volunteers were cultured with PHA and serial dilutions of fragments D and E; each was analyzed for ability to incorporate radiolabeled thymidine. Fragment E possessed in vitro CMI suppression at pharmacologic doses. Fragment D demonstrated immune suppressive capabilities at doses approximating those estimated to occur in the acute postburn phases of injury.

Fibrin Fibrinogen Degradation Products↗
PubMed1989

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. This study correlated degree of chest X-ray (CXR) change with pulmonary function in 29 adult patients during the first 5 days after inhalation injury. Daily CXRs were graded: 0 (normal), 1+ (peribronchial cuffing or perivascular edema), 2+ (edema involving one third of the lung field), 3+ (edema involving two thirds of the lung field), and 4+ (edema involving the entire lung field). Extravascular lung water volume (EVLW) was measured in vivo with the thermal/green dye double indicator technique. Twenty-five of the 29 patients were intubated on admission. Of these patients with serious inhalation injury, 84% showed some abnormality on CXR within 48 hours after injury. When abnormalities were present on CXR, pulmonary dysfunction (increases EVLW, increases Qs/Qt, decreases compliance) was clinically important. These data suggest that this grading scale may have utility in reports of CXR findings in inhalation injury.

Adult↗
PubMed1989

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. Thus, the PPRC will need to monitor such factors extensively and to make appropriate adjustments on a regular basis. Whether or not the Congress will implement all, some, or none of the PPRC proposals is unknown at this time. An alternative, but less satisfactory approach, would be to continue the present policy of reducing payments for arbitrarily selected "over-priced" procedures and services. The ACS will continue to play a significant role as an advisor to the PPRC as it defines and "fine tunes" medical policy recommendations for the Administration and Congress.

Fee Schedules↗
PubMed1988

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. The purpose of this study was to examine the effect of regional hypothermia on a feline intestinal model of ischemia-reperfusion injury. An autoperfused segment of cat ileum was isolated and arterial, venous, and lymphatic vessels were cannulated. Lymph flow (Q1), lymph (C1), and plasma (Cp) protein concentrations and segmental blood flow (Qb) were measured. Permeability changes were characterized by the minimal C1/Cp ratio obtained by elevating venous outflow pressure. Animals were divided into the following groups: Group I: 1 hr of intestinal ischemia (30 mm Hg) with autoreperfusion; Group II: 1 hr of intestinal hypothermia (28 degrees C) with subsequent rewarming; Group III: 1 hr of combined ischemia and hypothermia. Group III animals were either kept hypothermic (IIIA) or rewarmed (IIIB) during autoreperfusion. Minimal C1/Cp ratios (mean +/- SEM) were as follows: CONTROL: 0.15 +/- 0.02; Group I*: 0.32 +/- 0.03; Group II: 0.15 +/- 0.01; Group IIIA: 0.18 +/- 0.02; Group IIIB*: 0.42 +/- 0.02; (* = P less than 0.01 vs control). Reperfusion flow rates were no different between Group IIIA and Group IIIB animals. Ischemia-reperfusion, but not hypothermia alone, caused a marked increase in intestinal capillary permeability. Permeability increased after combined ischemia and hypothermia only if reperfusion was accompanied by rewarming. Hypothermic reperfusion protected against the increased permeability following ischemia.

Animals↗
PubMed1988

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. Forty patients with Crotalidae snake bites were evaluated and treated over a 7-year period. Twenty-six patients received a total of 507 vials of antivenin, the dose correlating with the clinical severity of envenomation. All patients were skin tested. Immediate hypersensitivity reactions occurred in six patients (23%). Cutaneous manifestations alone occurred in three of these patients, while systemic anaphylaxis occurred in three. Twenty patients were available for followup, and ten (50%) developed serum sickness. Skin testing was not reliable in predicting the development of immediate (anaphylaxis) or delayed (serum sickness) hypersensitivity reactions. Treatment of antivenin allergic reactions was uniformly effective, with no mortality, minimal morbidity, and no chronic sequelae.

Adolescent↗