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Biomedical subjects

M A Ricci

Publications and source records attributed to M A Ricci.

At least 19 recordsLinked to original sources

Eigen versus Zundel complexes in HCl-water mixtures.

There is an ongoing debate on the nature of hydration of the hydrogen ion, H+ in solution, and the extent to which Eigen or Zundel complexes occur. Here, our previous neutron diffraction data on a solution of 1:9 HCl in water are reanalyzed using a new starting hypothesis for the Monte Carlo simulation of the data. Either bare H+ ions, all H3O+ ions, or all H5O2 + ions are allowed in the simulation box together with the water and chlorine ions. All three simulations give a satisfactory fit to the experimental data. From the simulation with simple H+ ions, it is found that all H+ ions form one strong and very short hydrogen bond with water molecules and that on average 75% of them also engage in a second, slightly longer hydrogen bond. This result can be interpreted alternatively either in terms of the formation of a high percentage of asymmetric Zundel complexes or in terms of the formation of distorted H3O+ ions, which in turn form two or three hydrogen bonds, respectively, with neighboring molecules opposite their unbonded hydrogen sites (thus forming Eigen complexes). Therefore the new analysis is not inconsistent with our previous conclusion that the solution consists primarily of Eigen complexes, but does highlight the difficulty of making a clear distinction between Eigen and Zundel complexes due to the continuous random network of hydrogen bonds formed between water and hydrated protons. The role of hydrogen ion to chloride counterion contacts is also discussed in these solutions.

Journal Article↗

Ions in water: the microscopic structure of concentrated hydroxide solutions.

Neutron-diffraction data on aqueous solutions of hydroxides, at solute concentrations ranging from 1 solute per 12 water molecules to 1 solute per 3 water molecules, are analyzed by means of a Monte Carlo simulation (empirical potential structure refinement), in order to determine the hydration shell of the OH- in the presence of the smaller alkali metal ions. It is demonstrated that the symmetry argument between H+ and OH- cannot be used, at least in the liquid phase at such high concentrations, for determining the hydroxide hydration shell. Water molecules in the hydration shell of K+ orient their dipole moment at about 45 degrees from the K+-water oxygen director, instead of radially as in the case of the Li+ and Na+ hydration shells. The K+-water oxygen radial distribution function shows a shallower first minimum compared to the other cation-water oxygen functions. The influence of the solutes on the water-water radial distribution functions is shown to have an effect on the water structure equivalent to an increase in the pressure of the water, depending on both ion concentration and ionic radius. The changes of the water structure in the presence of charged solutes and the differences among the hydration shells of the different cations are used to present a qualitative explanation of the observed cation mobility.

Journal Article↗

Ions in water: the microscopic structure of a concentrated HCl solution.

A neutron diffraction experiment with isotopic H/D substitution on a concentrated HCl/H2O solution is presented. The full set of partial structure factors is extracted, by combining the diffraction data with a Monte Carlo simulation. This allows us to investigate both the changes of the water structure in the presence of ions and their solvation shell, overcoming the limitations of standard diffraction experiments. It is found that the interaction with the solutes affects the tetrahedral network of hydrogen bonded water molecules, in a manner similar to the application of an external pressure to pure water, although HCl seems less effective than other solutes, such as NaOH, at the same concentration. Consistent with experimental and theoretical data, the number of water molecules in the solution is not sufficient to completely dissociate the acid molecule. As a consequence, both dissociated H+ and Cl- ions and undissociated HCl molecules coexist in the sample, and this mixture is correctly reproduced in the simulation box. In particular, the hydrated H+ ions, forming a H3O+ complex, participate in three strong and short hydrogen bonds, while a well-defined hydration shell is found around the chlorine ion. These results are not consistent with the findings of early diffraction experiments on the same system and could only be obtained by combining high quality experimental data with a proper computer simulation.

Journal Article↗

Ions in water: the microscopic structure of concentrated NaOH solutions.

A neutron diffraction experiment with isotopic H/D substitution on four concentrated NaOH/H(2)O solutions is presented. The full set of partial structure factors is extracted, by combining the diffraction data with a Monte Carlo simulation. These allow to investigate both the changes of the water structure in the presence of ions and their solvation shells. It is found that the interaction with the solute affects the tetrahedral network of hydrogen bonded water molecules in a manner similar to the application of high pressure to pure water. The solvation shell of the OH(-) ions has an almost concentration independent structure, although with concentration dependent coordination numbers. The hydrogen site coordinates a water molecule through a weak bond, while the oxygen site forms strong hydrogen bonds with a number of molecules that is on the average very close to four at the higher water concentrations and decreases to about three at the lowest one. The competition between hydrogen bond interaction and Coulomb forces in determining the orientation of water molecules within the cation solvation shell is visible in the behavior of the g(NaHw)(r) function

Journal Article↗

Improved rural provider access to continuing medical education through interactive videoconferencing.

We sought to describe use patterns and user evaluation of remotely-attended continuing medical education (CME) programs in Vermont and upstate New York. Remote attendees were required to return an evaluation form to receive CME credit. The form included name and date of the program; name, location, and specialty of the respondent; and questions regarding program quality, value, effectiveness, and attendee plans if the program had not been available via telemedicine. From April, 1996, through December, 1998, health care providers from 14 remote sites used the network 927 times to attend 394 CME programs at Fletcher Allen Health Care in Burlington, Vermont. After the start-up period, an average of over three programs per week was attended, with an average of 2.4 remote attendees per program. Seventy-seven percent of remote attendees stated that they would not have attended the program if it had not been available over telemedicine, while the remaining 23% said that they avoided traveling due to videoconferencing. When asked the effectiveness of telemedicine technology for attending, 73% said it was as effective as having the presenter in the room, 23% said it was less effective, and 4% said it was more effective. Major technical problems, such as having the call disconnect during the presentation, decreased over time. There were continuing minor logistical problems common to large group videoconferencing. The telemedicine system has increased availability of CME programs for rural providers in Vermont and upstate New York. Most attendees have found the programs to be worthwhile, and technological advancements have improved the quality of the system.

Attitude of Health Personnel↗

Five-year follow-up of prophylactic vena cava filters in high-risk trauma patients.

OBJECTIVE: To assess the short- and long-term outcomes of vena cava filter (VCF) placement for prophylaxis against pulmonary embolism in patients at high risk due to trauma. DESIGN AND SETTING: Case series at a level I trauma center. PATIENTS: Patients were considered for prophylactic VCF placement if they met 1 of the injury criteria--spinal cord injuries with neurologic deficit, severe fractures of the pelvis or long bone (or both), and severe head injury--and had a contraindication to anticoagulation. INTERVENTION: Vena cava filters were placed percutaneously by the interventional radiologists when the acute trauma condition was stabilized following admission. MAIN OUTCOME MEASURES: Filter tilt of 14 degrees or more, strut malposition, insertion-related deep vein thrombosis, pulmonary embolism, or inferior vena cava patency. RESULTS: There were 132 prophylactic VCFs placed. A 3.1% rate of insertion-related deep vein thrombosis occurred, all of which were asymptomatic. Filter tilt occurred in 5.5% of patients and strut malposition in 38%. Three cases of pulmonary embolism (1 fatal) occurred in a prophylactic VCF, and all patients had either filter tilt or strut malposition. The risk of pulmonary embolism developing was higher in those patients with filter tilt or strut malposition than in those who did not have these complications (6.3% vs 0%; P=.05; Fisher exact test). The 1-, 2-, and 3-year inferior vena cava patency rates (+/-SD) were 97%+/-3%. CONCLUSIONS: Prophylactic VCF can be placed safely with an acceptable rate of insertion-related deep vein thrombosis and long-term inferior vena cava patency. Patients with prophylactic VCF remain at risk for pulmonary embolism if the filter is tilted 14 degrees or more or has strut malposition. In such patients, consideration should be given to placing a second filter.

Adult↗

Prevalence of abdominal aortic aneurysms in patients undergoing coronary artery bypass.

Although several studies describe the prevalence of coronary artery disease in patients with abdominal aortic aneurysms (AAA), the opposite relationship is virtually unexplored. It is the purpose of this study to determine the prevalence of AAA in patients with severe coronary artery disease undergoing bypass grafting (CABG). Patients scheduled for elective CABG underwent aortic ultrasound (US) preoperatively. A control group of patients without cardiovascular disease also underwent US. An AAA was defined as a maximal diameter > or =3.0 cm. US was performed on 192 CABG patients and 140 controls. The overall prevalence (previously repaired AAA and new cases) of AAA in CABG patients was 18.2%. The prevalence of new cases of AAA was 13.0% compared to 1.4% in controls (p = 0.0001). Ten patients had an AAA greater than 5.0 cm in size (5.2%). Logistic regression identified age > or =65 years and smoking as significant risk factors for AAA in the CABG population. The higher prevalence of AAA in CABG patients was confirmed by a case-control analysis of 73 age-matched patients. This study provides the first convincing evidence that the prevalence of AAA is higher in patients undergoing CABG than in the control population in Vermont. Consideration should be given to screening patients for AAA who are undergoing CABG, particularly older, smoking males.

Aged↗

Vascular ultrasound.

Surgeon-interpreted diagnostic ultrasound has become the preferred screening test and often the definitive test for the diagnosis of arterial stenosis, aneurysm, and venous thrombosis. As a modality for surveillance, its noninvasive quality makes it particularly appealing as the test of choice to screen patients for abdominal aortic aneurysms or to perform follow-up examinations on those patients with a carotid endartectomy or in situ bypass grafts. The increasing reliance on intraoperative duplex imaging of vascular procedures demands that the surgeon learn the skills to perform the studies without a technologist or radiologist to interpret the examination.

Aortic Aneurysm↗

Desktop telemedicine in vascular surgery: some preliminary findings.

OBJECTIVE: Surgical specialists have generally underutilized telemedicine technologies. This report describes the use of real-time interactive-video telemedicine to augment the care of vascular surgical patients in underserved rural areas within our region. MATERIALS AND METHODS: The telemedicine system at Fletcher-Allen Health Care (FAHC) and the University of Vermont in Burlington utilizes desktop video conferencing technology with terrestrial transmission at 384 kbps. The current system was initiated in January 1996, and there are at present 18 external sites and multiple locations at FAHC, including the vascular laboratory, angiography suites, operating rooms, and the home of one vascular surgeon. During the first 12 months of operation, the vascular surgeons were asked to complete a questionnaire to evaluate the technology and its usefulness in clinical care. The use of the telemedicine system by the vascular surgeons was monitored by the questionnaires, phone bills, and a special "no charge" billing code. Telemedicine events were classified as clinical or educational. RESULTS: In the 26 months since implementation, 107 events have taken place, including both clinical and educational uses. There were 103 clinical uses by three vascular surgeons, including five emergency uses. A joint Vermont-Maine vascular educational conference has taken place four times. Overall, use by vascular surgery represented 14.2% of all telemedicine events in the first year or 30.9% of all clinical events during that time period. Use of telemedicine was reported to have improved patient care in 96% of the cases. Eighty percent of the telemedicine uses in the first year saved patient travel. There were no diagnostic errors, as determined by in-person clinical follow-up, attributable to the telemedicine system use. CONCLUSIONS: Use of a real-time video telemedicine has great potential for vascular surgeons, but cost-effectiveness studies may be needed prior to its widespread adoption.

Angiography↗

The changing role of duplex scan in the management of carotid bifurcation disease and endarterectomy.

The development of carotid duplex scanning revolutionized the diagnosis of carotid artery disease. Continued advances in the technology as well as widespread experience with cartoid ultrasound have redefined the role this technology plays in the care of patients with carotid atherosclerosis. Recent clinical trials have shown the efficacy of carotid endarterectomy for both symptomatic and asymptomatic carotid artery stenosis, but benefit was shown at different degrees of stenosis from commonly used duplex diagnostic criteria. Investigators have therefore refined duplex diagnostic criteria to conform with the randomized trials while also redefining the effect of contralateral occlusions. These refined criteria have not only facilitated surgeons' clinical recommendations but allowed the performance of carotid surgery without the risks and expenses of arteriography. In addition, a better understanding of the significance of intraoperative duplex findings and the implications for restenosis has increased the utility of duplex scanning during surgery while decreasing the frequency of postoperative follow-up. Finally, this review discusses a few developing applications of carotid duplex scanning.

Carotid Artery Injuries↗

Dependence of augmentation of arterial endothelial cell expression of plasminogen activator inhibitor type 1 by insulin on soluble factors released from vascular smooth muscle cells.

BACKGROUND: Insulin-resistant states are characterized by accelerated atherosclerosis and are associated with increased plasma concentrations of insulin and plasminogen activator inhibitor type 1 (PAI-1). To determine whether arterial expression of PAI-1 in response to insulin contributes to the increased PAI-1 observed, human and porcine arteries in culture were exposed to insulin, and results were compared with responses of specific arterial cellular constituents maintained in culture and coculture. METHODS AND RESULTS: Human and porcine arterial segments and cells obtained from arteries were maintained in culture. Insulin increased accumulation of PAI-1 in conditioned medium from arterial segments (ng PAI-1 [1 nmol/L insulin minus control]: human arteries 47+/-17, porcine arteries 3.1+/-1.2, P<.05 for each) and from endothelial cells (ECs) cocultured with smooth muscle cells (SMCs, ng PAI-1 [1 nmol/L insulin minus control]: human cells 43+/-8, porcine cells 0.5+/-0.1, P<.05 for each). Insulin had no effect on EC expression of PAI-1 when not cocultured with SMCs. Increased accumulation of PAI-1 was seen when ECs, in coculture chambers without SMCs, were cultured with medium previously conditioned by SMCs in the presence of insulin. The increased accumulation of PAI-1 in conditioned medium was secondary to both an increased transport of PAI-1 from the basal to the apical surface of ECs as well as an increased production of PAI-1 by ECs. CONCLUSIONS: Insulin augments arterial expression of PAI-1 by stimulating release of a soluble factor(s) from SMCs. Accordingly, increased arterial elaboration of PAI-1 in response to insulin is likely to account, in part, for the elevated PAI-1 observed in the blood of subjects with insulin-resistant states.

Arteries↗

Hemodynamic evaluation of foot venous compression devices.

PURPOSE: Venous compression devices effectively prevent deep venous thrombosis. Recently, because traumatic injury of the limb often precludes application of calf devices, newer methods have been developed that are only applied to the foot. This study was designed to evaluate the venous hemodynamic effects produced by four different compressive devices compared with calf-only intermittent pneumatic compression (IPC). METHODS: Twenty-seven healthy volunteers had application of each device followed by duplex scanning determination of the venous hemodynamics at the popliteal vein (PV) and the common femoral vein (CFV). Endpoints included (1) resting (peak) systolic velocity (RSV); (2) maximum venous velocity (MVV) during device activation; (3) acceleration, the slope of the line from RSV to MVV; and (4) return time (RT) from MVV back to RSV. The devices evaluated included two commercially available mechanical foot devices, (1) foot compressive device (FCD1), and (2) FCD2; (3) an experimental mechanical foot device (FCD3); (4) an experimental pneumatic foot device (FCD4); and (5) a calf-only IPC device (IPC). RESULTS: The RSV was higher in the CFV than the PV. The initial RSV was not statistically significant between the five experimental groups (p = 0.37) at either the PV or CFV, although the RSV was higher in the CFV than in the calf (CFV, 24.3 +/- 6.7 cm/sec; PV, 12.5 +/- 3.7 cm/sec; p < 0.0001). MVV was significantly higher with FCD2 and the IPC (p = 0.0002) at the PV level, but this difference decreased at the CFV. Acceleration was greatest with the two available foot devices, FCD1 and FCD2, compared with the other three devices (p < 0.0001) at both levels. On the other hand, the RT was significantly longer only with the IPC; RT was four to 10 times slower at the PV and three to five times slower at the CFV compared with the other four devices. CONCLUSIONS: The two commercially available foot devices, FCD1 and FCD2, and the IPC produced significant alterations in venous hemodynamics. Changes produced at the PV level by both foot and calf devices were seen proximally at the CFV, although the changes were usually less. The mechanical devices produced rapid acceleration of venous flow to an elevated MVV, whereas the IPC produced an elevated peak with a sustained period of flow above baseline (RT). Further clinical comparison should be completed before widespread adaptation of these devices as an equivalent to existing IPC devices.

Adult↗

The Vermont Telemedicine Project: initial implementation phases.

OBJECTIVE: A comprehensive rural telemedicine system was implemented between Fletcher-Allen Health Care (FAHC) and a number of community hospitals in three distinct phases. We sought to describe each phase of its implementation to date and evaluate the technology and provider acceptance, as well as overall usage. PHASE I: A room-based video conferencing system with T-1 connections to two rural hospitals was initiated. The primary use of this system was telepathology, which underwent a rigorous evaluation. The system was well accepted by both referring and consulting pathologists, and the diagnostic accuracy was high, 91.2%. PHASE II: A desktop telemedicine system utilizing ISDN transmission at 384 kbps was implemented to six additional hospitals. Continuing medical education as well as consultative services for virtually every medical specialty were offered. Evaluation included tracking usage logs at each site, review of forms filled out for conferences, and (3) review of forms filled out by providers for medical consultations and clinical care delivered over the system. Technology failure represented the most frequent source of problems, particularly with multipoint calls. Usage increased steadily so that by 6 months, there was an average of one documented use per day. The principal use was for care delivered by pathology, surgery, nephrology, and obstetrics and gynecology. Video quality was judged excellent (62%) or satisfactory (15%) in most cases, while audio quality was excellent in 31% of cases and satisfactory in 46%. Overall, referring providers felt that the system improved patient care in 85% of cases, while 100% of the consultants felt this. PHASE III: Because of technology problems encountered in Phase II, a new system was designed and implemented. The network was expanded to additional sites, including physicians' offices. Evaluation is continuing. PHASE IV: Implementation of a regional information system, including video teleconferencing to every to provider's office in the region, is in the initial stages. CONCLUSIONS: Problems with video conferencing technology hamper use, but once providers utilize telemedicine as a clinical tool, use increases steadily. Clinical use across multiple specialties is possible in a manner that most providers feel improves patient care.

Attitude of Health Personnel↗

Prophylactic vena cava filter insertion in selected high-risk orthopaedic trauma patients.

OBJECTIVES: (a) To determine the incidence and risk factors for the development of pulmonary embolism in orthopaedic trauma patients and (b) to determine whether prophylactic vena cava filters are efficacious against pulmonary edema in high-risk patients. DESIGNS: Before and after trial on the incidence of pulmonary embolism in the orthopaedic trauma population before and after the introduction of prophylactic vena cava filters. SETTING: Tertiary care level I trauma center. PATIENTS: Thirty-five patients received prophylactic vena cava filters. These patients had a long bone and pelvic, multiple long bone fractures, or a complex (Kane's III or IV) pelvic fracture with at least one additional risk-factor at an age of > 55 years and an Injury Severity Score of > 16 or requiring prolonged (> 6 weeks) immobilization. INTERVENTION: Thirty-five patients had vena cava filters placed (32 titanium Greenfield filters, Medi-tech/Boston Scientific, Watertown, MA; and three Bird's Nest filters, Cook Bloomington, IN). Most filters (n = 33) were placed percutaneously in radiology. MAIN OUTCOME MEASURES: (a) Morbidity related to filter insertion, (b) incidence of pulmonary embolism in orthopaedic trauma population compared with historical controls who did not receive filters, and (c) patency of filters. RESULTS AND CONCLUSIONS: Minimal morbidity was related to prophylactic vena cava filter insertion. There was a significant (p < 0.04); (Fisher's exact) decrease in the incidence of pulmonary embolism in the orthopaedic trauma population as a whole after the use of prophylactic vena cava filters. Follow-up ultrasound showed a 1 and 2-year inferior vena cava patency rate of 93.6% +/- 6.2% by life table analysis. We conclude that selected use of prophylactic vena cava filters in orthopaedic trauma is safe and decreases the incidence of pulmonary embolism.

Fractures, Bone↗

Changes in arterial expression of fibrinolytic system proteins in atherogenesis.

Plasminogen activators (PAs) and their inhibitor, plasminogen activator inhibitor type-1 (PAI-1), have been implicated in modulation of luminal fibrinolysis and mural proteolysis contributing to atherogenesis. Expression of PAs/PAI-1 (normalized to extracted tissue protein) was delineated by assays of conditioned media and of extracts from walls of human arterial segments in culture. Arterial specimens (n = 39 from 26 subjects) were divided into four groups: normal (n = 14), fatty streak (n = 6), moderate atherosclerosis (mural thickening with < 70% lumen obstruction, n = 5), and severe atherosclerosis (mural thickening with > 70% lumen obstruction, n = 14). Paired samples from the same individual comprising a normal arterial segment and an atherosclerotic segment were evaluated also. A fourfold molar excess in PAI-1:t-PA was seen in conditioned media from samples with any evidence of atherosclerosis compared with normal specimens (normal 21 +/- 4, diseased 82 +/- 21, P < or = .05). Compared with normal pairs, the tissue content of PAI-1 (ng) was increased in fatty streak lesions (n = 3, normal 35 +/- 12, fatty streak 50 +/- 8, P < or = .05); stable to decreased in moderate atherosclerosis (n = 3, normal 34 +/- 3, moderate 22 +/- 7, P = .16); and increased in severe atherosclerosis (n = 6, normal 48 +/- 9, severe 85 +/- 19, P < or = .05). The tissue content of PAs (ng), though not increased in fatty streak lesions, was elevated in moderately and severely atherosclerotic segments (normal 0.7 +/- 0.2, moderate 1.6 +/- 0.1; normal 0.8 +/- 0.3, severe 2.1 +/- 0.3, P < or = .05 for each comparison). Atherogenesis is associated with decreased luminal fibrinolytic capacity that may exacerbate thrombosis. Decreased mural proteolysis in early atherogenesis may exacerbate matrix accumulation. Increased mural proteolysis later is associated with, and may potentiate, smooth muscle cell migration and proliferation.

Aged↗

Efficacy of tele-endoscopy in a rural capitated market.

PURPOSE: To attempt to quantify the potential for success of tele-endoscopy as a component of the VTMEDNET Plus telemedicine implementation, a multi-part prospective study was undertaken by faculty of the Vermont Initiative for Rural Health Informatics and Telemedicine. METHOD: The study was comprised of three separate parts, evaluation of image quality, cost analysis, and identification of referring providers needs and attitudes regarding tele-endoscopy. FINDINGS: The image quality was satisfactory to support remote diagnosis in most cases; there was significant cost savings in a managed care environment; referring providers were generally positive about the attributes of tele-endoscopy. CONCLUSION: Tele-endoscopy is a viable and cost-effective component within a telemedicine system.

Capitation Fee↗

Desktop teleradiology in support of rural orthopedic trauma care.

UNLABELLED: Research has shown that diagnostic quality images for most teleradiology applications requires a sophisticated telemedicine system and access to a large amount of bandwidth. While the ideal standards have been set by those involved in evaluating teleradiology, these standards are impractical for many small rural health centers which deliver routine trauma care. While there is no disagreement about the ultimate need for this level of teleradiology support, the purpose of this research was to determine whether Orthopedists would be able to read plain radiographs of orthopedic trauma injuries using a desktop teleradiology system in support of rural trauma care. METHOD: Two radiology residents and two orthopedic residents viewed forty radiographs, twenty through a desktop teleradiology system and twenty in person. Diagnostic findings and certainty of diagnosis were recorded. FINDINGS: There was no statistically significant difference between modalities in orthopedic residents' ability to correctly diagnose orthopedic trauma injuries. Further, for those instances when the diagnosis was imprecise, the residents were aware of their inability to make an accurate diagnosis. CONCLUSION: Although the study was relatively limited and further research needs to be done, the use of desktop teleradiology in support of rural orthopedic trauma consultation is a promising alternative to the more expensive forms of telemedicine technology.

Evaluation Studies as Topic↗