Biomedical subjects

Michael A Ricci

Publications and source records attributed to Michael A Ricci.

11 recordsLinked to original sources

PubMed2007

Toward optimal recording of surgical complications: concurrent tracking compared to the discharge data set.

BACKGROUND: Information extracted from the hospital discharge data set is used increasingly for outcomes research and for benchmarking hospital and provider performance. The accuracy of these data in detecting vascular complications has never been validated. METHODS: We compared morbidity and mortality data derived from the hospital discharge data set to similar data recorded concurrently by our Surgical Activity Tracking System (SATS) for 1 year on the vascular surgery service. RESULTS: Of 798 total admissions, no complications were detected by either system in 598 admissions (75%). In 200 admissions (25%), there were 335 complications, including 24 deaths (3.0%), that occurred either in-hospital or within 30 days of the date of operation or the date of discharge for nonoperative admissions. Of the 335 complications, 180 (53.7%) were recorded by both systems; the SATS missed 59 complications recorded in the hospital discharge data set (17.6%), whereas the hospital discharge data set missed 96 complications recorded in the SATS (28.7%, P = .003). Of the 289 in-hospital complications, the SATS recorded 230 (79.5%), whereas the hospital discharge data set recorded 229 (79.2%). Of the 24 deaths, the hospital discharge data set missed 6 that occurred after discharge but within the 30-day reporting period CONCLUSIONS: Both systems are not completely accurate for tracking inpatient complications. The SATS was more representative than the hospital discharge data set in capturing 30-day morbidity and mortality. An amalgamation of the 2 systems would provide more optimal tracking of complications.

Databases, Factual↗

PubMed2005

Pressure-induced cellular senescence: a mechanism linking venous hypertension to venous ulcers.

INTRODUCTION: Slow healing of ulcers in chronic venous insufficiency (CVI) has long been thought secondary to venous hypertension. Dermal fibroblasts isolated from venous ulcers have morphologies and protein production suggestive of premature aging. In this study, we hypothesized that neonatal fibroblasts (NNF) cultured under elevated pressure will demonstrate premature aging and that this effect will be augmented by an inflammatory mediator, transforming growth factor beta (TGF-beta). MATERIALS AND METHODS: A unique pressure incubator was used to culture NNF at atmospheric pressure (ATM), ATM + 30 mmHg, ATM + 60 mmHg, and ATM +120 mmHg. Some pressure-exposed NNF were also cultured with TGF- beta (1 ng/ml). Growth rates were determined by flow cytometry. Senescent cells were identified by staining with a marker for cellular senescence, beta-galactosidase (SA-beta-Gal). Light microscopy and digital imaging were used to evaluate cell morphology. Paired linear models and comparison of the slopes were used for statistical analysis of growth. chi2 analysis was used to compare senescence rates. RESULTS: NNF cultured at ATM + 60 mmHg and ATM + 120 mmHg showed increased SA-beta-Gal activity (P <0.05), and reduced growth rates (P <0.05) at 11 days. These effects were not seen at ATM + 30 mmHg. NNF grown with TGF-beta did not show augmented SA-beta-Gal staining. CONCLUSIONS: Pressure-exposed NNF demonstrated an accelerated aging phenomenon similar to fibroblasts isolated from venous ulcers. This aging effect was directly related to the level of pressure. TGF-beta did not augment the aging effect. This study suggests that pressure elevations result in altered cell function and accelerated aging that may contribute to the slowed healing seen in patients with venous insufficiency.

Cell Culture Techniques↗

PubMed2005

Pressure elevation slows the fibroblast response to wound healing.

OBJECTIVE: Chronic venous insufficiency and venous ulceration are consequences of elevated pressure within affected limbs. We hypothesized that wounded cells maintained at different atmospheric pressures heal at different rates and that pressure would adversely affect the processes necessary for wound healing. METHODS: We have developed an in vitro model that replicates venous hypertension in a unique pressurized incubator using neonatal fibroblasts. Neonatal fibroblasts grown to confluence were wounded with a standardized linear incision and then placed in a unique pressure incubator at atmospheric pressure, atmospheric pressure plus 30 mm Hg, atmospheric pressure plus 60 mm Hg, and atmospheric pressure plus 120 mm Hg. Cells were observed daily until complete healing of the wound occurred. Twelve to 18 hours after wounding, proliferating cell nuclear antigen analysis was done by immunocytochemistry. RESULTS: Wounds at atmospheric pressure plus 30 mm Hg were healed by day 3, those at atmospheric pressure plus 60 mm Hg by day 4, and those grown at atmospheric pressure plus 120 mm Hg took > or =4 days for complete healing. Significantly less proliferating cell nuclear antigen activity was present in cells grown at atmospheric pressure plus 60 mm Hg (P < .0001) and atmospheric pressure plus 120 mm Hg (P < .02). Wound edge fluorescence analysis demonstrated less fluorescence in each group compared with atmospheric pressure. CONCLUSIONS: In this model of wound healing under pressure, neonatal fibroblasts grown to confluence and given a standardized wound displayed characteristics consistent with delayed healing. Elevated pressure has a role in the delayed migration and proliferation seen in this model. CLINICAL RELEVANCE: The elevated pressure in patients with venous insufficiency causes their wounds to heal less quickly. Understanding and quantifying the physiology and role of elevated tissue pressure due to venous hypertension will lead to a better understanding of wound healing in these patients.

Analysis of Variance↗

PubMed2005

The use of telemedicine for delivering continuing medical education in rural communities.

Physicians in rural communities have limited access to continuing medical education (CME) opportunities. We hypothesized that CME could be delivered via a telemedicine network as effectively as in-person. Our institution delivers CME lectures and grand rounds in Burlington, Vermont, for in-person attendees, and also via a telemedicine network that links 14 hospitals in Vermont and rural northeastern New York. All participants complete an evaluation questionnaire to receive CME credit. We compared the questionnaire responses of those attending in person with those attending via the telemedicine network. From October 1, 2000 to June 30, 2003, there were 4733 CME sessions, 650 of which had both in-person and telemedicine attendees. Responses from these 650 sessions were compared. Most questions relating to lecture quality scored higher for in-person attendees. Compared to having the presenter in the room, telemedicine attendance was judged to be "more effective" in 19% (n = 334), "as effective" in 60%, (n = 1074), and "less effective" in 21% (n = 367). Eighteen percent of telemedicine attendees said they would have traveled to attend the session. Telemedicine-delivered CME was considered at least as effective as in-person CME 79% of the time. Travel was avoided for 18% of the remote attendees. CME was delivered where it would not have been obtained for 82% of the remote attendees. Telemedicine systems can be used to deliver CME, in spite of lower overall ratings compared to in-person attendance.

Analysis of Variance↗

PubMed2004

Relation of augmented platelet reactivity to the magnitude of distribution of atherosclerosis.

The extent of luminal involvement of atherosclerotic vascular disease and platelet reactivity portend subsequent cardiovascular events. This study was designed to determine whether platelet reactivity correlates with the extent of the territorial distribution of vascular disease. Blood was obtained from 130 patients who had known atherosclerotic vascular disease categorized as being in > or =1 of the following territories: coronary artery disease (CAD; n = 89), cerebrovascular disease (n = 36), and peripheral arterial disease (n = 61). Platelet reactivity, i.e., the activation of platelets in response to a low concentration of adenosine diphosphate (0.2 micromol/L), was measured using flow cytometry. Patients with vascular disease in >1 territory compared with those with disease in only 1 territory had greater platelet reactivity with respect to P-selectin expression (p = 0.01). The percentages of platelets expressing P-selectin (mean +/- SD) were 6.4 +/- 4.2 in patients who had involvement of 1 territory (n = 88), 10.0 +/- 6.8 in those who had involvement of 2 territories (n = 28), and 10.1 +/- 9.9 in those who had involvement of 3 territories (n = 14). Patients who had CAD and diabetes mellitus had greater P-selectin expression than did those who had CAD without diabetes (p <0.02 for interaction). Thus, platelet reactivity is greater in patients who have more extensive territorial distribution of atherosclerotic vascular disease and in those who have CAD and diabetes mellitus. Accordingly, patients who have more widely distributed vascular disease are likely to derive particular benefit from antiplatelet regimens that suppress platelet function to a greater extent.

Aged↗

PubMed2004

Medical student evaluations of lectures attended in person or from rural sites via interactive videoconferencing.

BACKGROUND: Interactive videoconferencing may be an effective way for medical students on remote rotations to attend teaching sessions at the main campus. PURPOSE: To compare medical student evaluations of lectures for those attending in person and those attending through interactive videoconferencing. METHODS: Lecture evaluations were completed by medical students on University of Vermont College of Medicine clinical clerkship rotations. Students on clerkships at rural sites attended lectures using our telemedicine network. Responses from in-person and remote attendees were compared. RESULTS: Evaluation forms for 110 lectures were received from 648 in-person and 255 remote attendees. All evaluation items were rated "good" or "excellent" by at least 95% of in-person attendees. Over 90% of remote attendees rated nontelemedicine evaluation items, such as appropriateness of lecture topic for students, as good or excellent. Ratings of telemedicine-specific questions, such as ability to hear the lecturer, were lower. CONCLUSIONS: Level of satisfaction was high for most aspects of remote lecture attendance, although not quite as high as for in-person attendance. Improved technical reliability would likely increase remote attendee satisfaction. Overall, lecture attendance using videoconferencing was found to be an acceptable alternative to travel for medical students in rural clerkships.

Computer-Assisted Instruction↗

PubMed2003

A new in vitro model of venous hypertension: the effect of pressure on dermal fibroblasts.

PURPOSE: Venous hypertension leads to venous stasis ulcers. White cell activation, protein leakage from pressurized capillaries, and cytokine imbalances have all been implicated as indirect effects of venous hypertension that contribute to dermal changes seen in chronic venous insufficiency. The direct effect of increased tissue pressures on dermal elements has not been investigated. Prior studies have shown that fibroblasts isolated from venous ulcers have altered growth rates, morphologies, and protein production similar to senescent or aged fibroblasts. We hypothesize that neonatal fibroblasts (NNFs) cultured in conditions of increased atmospheric pressure will demonstrate altered cell function when compared with those grown at normal atmospheric pressure (ATM). METHODS: A pressure incubator was used to culture populations of NNFs at ATM, 60 mm Hg over ATM (ATM + 60 mm Hg), and 120 mm Hg over ATM (ATM + 120 mm Hg). NNF population growth rates were determined by periodic flow cytometry analysis over a 2-week period. Light microscopy and digital imaging were used to evaluate cell morphology. Senescence-associated B-galactosidase (SA-beta-Gal) activity was determined using the X-Gal stain. Fibronectin production was assessed by exposing cells sequentially to anti-fibronectin antibodies and Oregon Green-conjugated goat anti-mouse secondary antibodies. Flow cytometry then was used to determine relative proportions of cells staining positively for fibronectin. Statistical analysis was accomplished with analysis of variance. RESULTS: Populations of cells grown under increased pressures (both ATM + 60 and ATM + 120) showed reduced growth rates (P <.001). Similarly, morphologies of cells grown under pressure had increased cytoplasm to nuclear ratios with abnormal nuclear shapes. Populations of cells grown under pressure had higher percentages of cells staining positive for fibronectin (ATM = 45%, ATM + 60 = 59%, ATM + 120 = 79%). After 14 days of growth under pressure, fibroblast populations did not demonstrate augmented productions of the senescence marker SA-beta-Gal (ATM =.5%, ATM + 60 =.25%, ATM + 120 =.75%). CONCLUSIONS: This study demonstrated that NNFs grown in culture under increased pressures undergo a transformation not seen in cells grown at atmospheric pressure. Cells grown under pressure demonstrated reduced growth rates, increased fibronectin production, and abnormal morphologies similar to fibroblasts isolated from venous ulcers. This study suggests that pressure elevations (like venous hypertension) can directly result in altered cell function and morphology that may contribute to the delayed wound healing seen in patients with venous ulcers. This model uses a pressurized incubator that may prove to be a valuable adjunct in studying the effects of venous hypertension.

Atmospheric Pressure↗

PubMed2003

Evaluating chronic venous disease with a new venous severity scoring system.

BACKGROUND: The Venous Clinical Severity Score (VCSS) has been proposed by the American Venous Forum as an objective means to clinically assess venous disease more completely than with the clinical CEAP classification. However, validation of the VCSS against an objective test is lacking. The purpose of this study was to test the VCSS against abnormalities found on venous ultrasound (US) scans. METHODS: As part of a screening project in a large kindred population with protein C deficiency, VCSS and venous US scanning were performed in 210 patients (420 limbs). A single examiner scored the VCSS (0-3) clinically for pain, varicose veins, edema, skin pigmentation, inflammation, induration, ulcer duration and size, and compressive therapy. Another experienced examiner, blinded to the subject's medical history, performed a US examination of the deep and superficial venous system, with a hand-carried US system. The relationship between US and VCSS scores was analyzed by calculating an odds ratio (OR) and its 95% confidence interval (CI). RESULTS: Of the 420 limbs screened, VCSS was 0 in 283 limbs, and VCSS was 1 or greater in the following categories: pain, 63 limbs; varicose veins, 70 limbs; edema, 51 limbs; skin pigmentation, 17 limbs; inflammation, 2 limbs; induration, 8 limbs; and compressive therapy, 9 limbs. The highest total score in any limb was 8. A clear association was seen with the VCSS and abnormalities found on US scans. When the score was dichotomized (0 = normal, 1 = any abnormality), it was a strong predictor of US scan abnormalities; limbs with VCSS greater than 0 had a 26-fold greater chance of US scan abnormalities than did limbs with VCSS = 0 (OR, 26.5; 95% CI, 11-64). With ultrasonography as the standard, sensitivity of VCSS compared with US scans was 89.3%, and specificity was 76.1%. Negative predictive value of VCSS = 0 was 97.9%, and positive predictive value for any positive score was 36.5% CONCLUSIONS: The results of this study are based on a large kindred population with a higher risk for venous disease than found in the general population. Though the VCSS was devised to quantify the severity of chronic venous disease, this study found it a useful screening tool. The VCSS showed good association with abnormalities on US scans, and when VCSS = 0 there is a high likelihood that the patient does not have venous disease. This simple test may prove valuable in clinical practice.

Adolescent↗

PubMed2003

Telemedicine reduces discrepancies in rural trauma care.

Patients injured in rural areas die at roughly twice the rate of those patients with similar injuries in urban areas. A multitude of explanations have been suggested for higher mortality rates from trauma in the rural areas of the United States. Since rural emergency room (ER) staff see far fewer traumas than ER staff at large metropolitan trauma centers, their lack of exposure to this low-volume problem certainly contributes to the problem. To address discrepancies in trauma education and the delivery of care in our rural region, a telemedicine system was utilized to provide rapid consultation from surgeons at the level 1 trauma center and to provide enhanced educational opportunities for rural ambulance emergency first responders. Clinical outcome measures and evaluation questionnaires were designed in advance of implementation. Forty-one "tele-trauma consults" were performed over the first 30 months of the project, all for major, multi-system trauma. Though many clinical recommendations were made, the system was judged to be life saving in three instances, and both rural and trauma center providers felt the system enhanced clinical care. In addition, educational sessions for rural first responders were well attended and favorably reviewed. Early results of a telemedicine system provide encouragement as a means to address discrepancies in the outcomes after major trauma in rural areas, although more work needs to be completed and evaluated.

Ambulances↗

PubMed2002

Successful endovascular treatment of a ruptured internal iliac aneurysm.

Internal iliac artery aneurysms (IIAs) are rare but can be the source of considerable morbidity when rupture occurs. IIAs have traditionally been treated with direct surgical exclusion or ligation. More recently, the advent of endovascular techniques have been adapted to treat isolated common and IIAs in lieu of elective surgical correction. This case report describes an 81-year-old patient with multiple medical problems and a symptomatic IIA, initially diagnosed with computed tomographic scan. Arteriography results showed extravasation of contrast from a left IIA. The aneurysm was treated with endovascular exclusion, with multiple coils in the IIA followed by placement of a covered stent within the common and external iliacs to exclude the orifice of the IIA. The patient tolerated the procedure well, and at 2 months after the procedure, no endoleak was present on follow-up computed tomographic scan results. At 12 months postprocedure, the patient has remained well. This case shows that endovascular therapies may offer a good treatment option in symptomatic or ruptured IIA, particularly in a patient who is at poor operative risk.

Aged↗

PubMed2002

Documentation of competency: Maintaining an outcomes database.

Medical practice in the 21st century will include increased scrutiny of the competency of vascular surgeons measured in large part by treatment outcomes. At least part of the drive behind this is that the public demand for clinical competency of its doctors is greater than ever as the unassailable position of the "all-knowing physician" is (appropriately) vanishing. Two general types of variables need to be considered in the assessment of treatment outcomes: key outcome variables and key process variables. Key outcome variables are the critical results from a treatment plan, whereas key process variables affect these results. Ideal tracking methods do not exist in most hospital systems, and many variables are out of the control of the individual surgeon. Difficulties recording and reporting outcomes and determining competencies are numerous, but vascular surgeons must accept and overcome these difficulties. Standardized definitions for preoperative, surgical, and postoperative variables as well as treatment results must be decided before attempting to determine competency. Once the variables and definitions to define competency are determined, commercially available computer software can make the task of data recording and data output realistic. Eventually, systemwide "enterprise" solutions from computer companies will make this task even more uncomplicated.

Clinical Competence↗