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Leaflet escape from mechanical heart valves is a rare but potentially fatal complication of prosthetic valve replacement. Historically, the incompetent valve is replaced emergently and the escaped leaflet is subsequently retrieved from its settlement in a distal vessel. If it is not retrieved, the fragment can increase the risk of infection, thrombosis, and migration. We report a case of a mechanical aortic valve leaflet that embolized during valve reoperation and caused occlusive aortic disease found 2 years later. This case emphasizes the importance of locating leaflet fragments after they are noticed missing.

Objective: To describe patient preparation for routine outpatient blood work and examine the implications of surreptitious fasting on interpretation of glucose results. Patients and Methods: We designed a survey and administered it between September 1, 2016, and April 30, 2017, to assess fasting behaviors in a convenience sample of 526 adults presenting for outpatient blood work in 2 health systems between 7 am and 12 pm. We reviewed the electronic health records to extract glucose results. We describe the frequency of clinician-directed fasting and surreptitious fasting. In those surreptitiously fasting, we describe the frequency of missed diagnoses of prediabetes and diabetes. Results: Of 526 participants, 330 (62.7%) self-identified as fasting, and 304 (92.1%) of those fasting met American Diabetes Association fasting criteria. Only 131 (24.9%) of those fasting were told to fast by their health care team. Almost 50% (257 of 526) believed it was important to fast for every blood test. Of the 64 patients with diabetes who were taking insulin, 37 (57.8%) fasted and took their insulin as prescribed. Among the 89 patients without diabetes who fasted without knowledge of their health care team and had glucose tested, 2 (2.2%) had a missed diagnosis of diabetes and 18 (20.2%) had a missed diagnosis of prediabetes. Conclusion: Fasting for outpatient blood work is common, and patients frequently fast without awareness of their health care team. Failure to capture fasting status at the time of glucose testing is a missed opportunity to identify undiagnosed cases of diabetes and prediabetes.

Background: In 2017, an academic health sciences library in Utah developed a multimedia studio for students, faculty, and academic staff. Educational projects needing video, audio, and lecture capture could utilize a one-button studio for recording video sessions, microphones for audio, and various screen capture software for lectures. Since the pandemic, this service has seen rapid growth due to academic lectures going exclusively online. In response, the library launched a dedicated podcasting suite to accommodate the increase in students and faculty needing to record lectures or podcasts for others in the medical profession. Description: This article will outline the process of creating the podcasting suite and provide equipment rosters and methods other libraries may consider for establishing their own studio. Administrating duties of the studio will also be included, such as handling reservations and user assessment. An instructional guide for users is also included to assist patrons in accomplishing their podcast creations. Conclusion: Podcasts created in the space range from topics about teaching strategies in medicine to diagnoses and treatments of skin disorders. A podcasting suite is another way libraries can provide valuable services for asynchronous learning and student projects. Students, staff, and faculty have appreciated the ease of the service and the support behind it. A feedback loop was developed to further improve the space to meet the needs of users.

Abstract Visible and near‐infrared spectroscopy (Vis‐NIRS) is a promising tool for increasing phenotyping throughput in plant‐breeding programs, but existing analysis software packages are not optimized for a breeding context. Additionally, commercial software options are often outside of budget constraints for some breeding and research programs. To that end, we developed an open‐source R package, waves, for the streamlined analysis of spectral data with several cross‐validation schemes to assess prediction accuracy. waves is compatible with a wide range of spectrometer models and performs visualization, filtering, aggregation, cross‐validation set formation, model training, and prediction functions for the association of Vis‐NIR spectra with reference measurements. Furthermore, we have integrated this package into the Breedbase family of open‐source databases, expanding the analysis capabilities of this growing digital ecosystem to a number of crop species. Taken together, the standalone and Breedbase versions of waves enhance the accessibility of tools for the analysis of spectral data during the plant breeding process.

Objectives Previous studies have implicated therapeutic drug monitoring (TDM), by measuring serum or urine drug levels, as a highly reliable technique for detecting medication non-adherence but the attitudes of patients and physicians toward TDM have not been evaluated previously. Accordingly, we solicited input from patients with uncontrolled hypertension and their physicians about their views on TDM.Design Prospective analysis of responses to a set of questions during semistructured interviews.Setting Outpatient clinics in an integrated health system which provides care for a low-income, uninsured population.Participants Patients with uncontrolled hypertension with either systolic blood pressure of at least 130 mm Hg or diastolic blood pressure of at least 80 mm Hg despite antihypertensive drugs and providers in the general cardiology and internal medicine clinics.Primary and secondary outcome measures Attitudes towards TDM and the potential impact on physician–patient relationship.Results We interviewed 11 patients and 10 providers and discussed the findings with 13 community advisory panel (CAP) members. Of the patients interviewed, 91% (10 of 11) and all 10 providers thought TDM was a good idea and should be used regularly to better understand the reasons for poorly controlled hypertension. However, 63% (7 of 11) of patients and 20% of providers expressed reservations that TDM could negatively impact the physician–patient relationship. Despite some concerns, the majority of patients, providers and CAP members believed that if test results are communicated without blaming patients, the potential benefits of TDM in identifying suboptimal adherence and eliciting barriers to adherence outweighed the risks.Conclusion The idea of TDM is well accepted by patients and their providers. TDM information if delivered in a non-judgmental manner, to encourage an honest conversation between patients and physicians, has the potential to reduce patient–physician communication obstacles and to identify barriers to adherence which, when overcome, can improve health outcomes.

This case study will explain steps in creating a multimedia studio inside a health sciences library with existing software and a minimal budget. From ideation to creation to assessment, the process will be outlined in development phases and include examples of documentation, user feedback, lessons learned, and future considerations. We’ll explore multimedia software like One Button Studio, GameCapture, Kaltura, Adobe Creative Cloud, Garage Band, and others and compare their effectiveness when working on audio and visual projects in the library.

Human pluripotent stem cells have the capacity for directed differentiation into a wide variety of neuronal subtypes that may be useful for brain repair. While a substantial body of research has lead to a detailed understanding of the ability of neurons in fetal tissue grafts to structurally and functionally integrate after intra-cerebral transplantation, we are only just beginning to understand the in vivo properties of neurons derived from human pluripotent stem cells. Here we have utilised the human embryonic stem (ES) cell line Envy, which constitutively expresses green fluorescent protein (GFP), in order to study the in vivo properties of neurons derived from human ES cells. Rapid and efficient neural induction, followed by differentiation as neurospheres resulted in a GFP+ neural precursor population with traits of neuroepithelial and dorsal forebrain identity. Ten weeks after transplantation into neonatal rats, GFP+ fibre patterns revealed extensive axonal growth in the host brain, particularly along host white matter tracts, although innervation of adjacent nuclei was limited. The grafts were composed of a mix of neural cell types including differentiated neurons and glia, but also dividing neural progenitors and migrating neuroblasts, indicating an incomplete state of maturation at 10 weeks. This was reflected in patch-clamp recordings showing stereotypical properties appropriate for mature functional neurons, including the ability to generate action potentials, as well profiles consistent for more immature neurons. These findings illustrate the intrinsic capacity for neurons derived from human ES cells to integrate at a structural and functional level following transplantation.

Deep brain stimulation (DBS) of the ventral capsule/ventral striatum (VC/VS) is a novel therapy for neuropsychiatric disorders. Hypomania is a known complication of VC/VS DBS, but who is at risk is less understood. Factors such as family history, combined with details of DBS programming, might quantify that risk. The authors performed an iterative modeling procedure on a VC/VS DBS patient registry to identify key predictors. Hypomania was less common for men and for patients stimulated on the ventral right contact. It was more common with right monopolar stimulation. These findings may help to establish decision rules to reduce complications of VC/VS DBS.

Background: Major variations in medical practice have been documented internationally. Variations raise questions about the quality, equity, and efficiency of resource allocation and use, and have important implications for health care and health policy., Objective: To perform a systematic review of the peer-reviewed literature on medical practice variations in OECD countries., Methods: We searched MEDLINE to find publications on medical practice variations in OECD countries published between 2000 and 2011. We present an overview of the characteristics of published studies as well as the magnitude of variations for select high impact conditions., Results: A total of 836 studies were included. Consistent with the gray literature, there were large variations across regions, hospitals and physician practices for almost every condition and procedure studied. Many studies focused on high-impact conditions, but very few looked at the causes or outcomes of medical practice variations., Conclusion: While there were an overwhelming number of publications on medical practice variations the coverage was broad and not often based on a theoretical construct. Future studies should focus on conditions and procedures that are clinically important, policy relevant, resource intensive, and have high levels of public awareness. Further study of the causes and consequences of variations is important., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: Roughly half of people with severe mental disorders also experience a co-occurring substance use disorder, and recovery from both is a critical objective for health care services. While understanding of abstinence initiation has grown, the strategies people with co-occurring disorders use to maintain sobriety are largely unknown. This article reports strategies for relapse prevention as described by men with co-occurring disorders who achieved one or more years of sobriety., Methods: We analyzed semi-structured interviews conducted with a sample of 12 men with co-occurring psychosis and substance use disorder who achieved and maintained sobriety for at least one year, supplemented with demographic and diagnostic clinical record data. These men were participating in residential or outpatient treatment at a private, nonprofit integrated treatment clinic., Results: The 12 men were primarily Caucasian (91.7%) and unmarried (100%), and their ages ranged from 23 to 42 years. The two most common psychiatric disorders were schizoaffective disorder (n = 4, 33.3%) and bipolar disorder (n = 4, 33.3%), while the two most commonly misused substances were alcohol and cannabis. Qualitative analyses showed that participants maintained sobriety for at least one year by building a supportive community, engaging in productive activities, and carefully monitoring their own attitudes toward substances, mental health, and responsibility. Alcoholics Anonymous might act as a catalyst for building skills., Conclusions: People with co-occurring disorders who achieve sobriety use a variety of self-management strategies to prevent relapse-seeking support, activities, and a healthy mindset. The findings suggest a relapse prevention model that focuses on social networks, role functioning, and self-monitoring and conceptualizes self-care as critical to extending periods of wellness.

OBJECTIVE--To assess the completeness of acquired immunodeficiency syndrome (AIDS) case reporting in New York City (NYC), and to determine whether the completeness of reporting differs in various populations. DESIGN--Retrospective record review of hospital laboratory logs, death certificates, hospital discharge records, and patient registries at private physicians' offices and hospital outpatient clinics. SETTING--Public and private hospitals, and private physicians' offices in NYC. PATIENTS--Adults and adolescents with AIDS or with illnesses suggestive of AIDS were identified using both population-based and nonrandom sampling techniques. These persons were matched with the NYC AIDS case registry, and the medical records of nonmatching persons were reviewed to determine whether they met the 1987 Centers for Disease Control and Prevention surveillance case definition for AIDS. MAIN OUTCOME MEASURES--The completeness of reporting was calculated for the five individual projects and for the aggregate database by gender, race/ethnicity, risk, borough of residence, age, first AIDS diagnosis, and year of diagnosis. RESULTS--Of 7015 persons with AIDS identified in the five projects, 5912 (84%) had been previously reported (range, 77% to 89%). The completeness of reporting ranged from 81% to 87% in all major gender, race/ethnicity, risk, borough of residence, and age subgroups. In a multivariate analysis, the odds of being unreported were significantly higher among outpatients in hospital clinics, out-of-state residents, persons with diagnoses other than Pneumocystis carinii pneumonia, and persons recently diagnosed with AIDS. CONCLUSIONS--This study indicates that the NYC AIDS surveillance system functioned effectively during the first decade of the AIDS epidemic. Completeness-of-reporting studies are an integral part of AIDS surveillance, providing data that are critical for assessing the validity of the AIDS surveillance database.

Objectives: To define the spectrum of HIV-1-related disease in New York City (NYC) and to determine how the clinical spectrum of illness differs in various populations., Design and Methods: The medical records of the 2983 HIV-infected individuals who had received care through 1989 at four hospital outpatient clinics and two private physicians' offices were reviewed retrospectively., Results: Sixty-one per cent of the study patients and 48% of patients seen in 1989 had AIDS. HIV-infected women were significantly less likely to have AIDS and CD4 lymphocyte counts less than 200 x 10(6)/l than men. For every 100 AIDS patients seen in 1989, there were 88 non-AIDS patients with CD4 counts less than 500 x 10(6)/l, of whom 41 had CD4 counts less than 200 x 10(6)/l; thus, in addition to an estimated 16,425 individuals living with AIDS in NYC, we estimate that there are at least 14,454 HIV-infected individuals without AIDS with CD4 counts less than 500 x 10(6)/l, of whom 6734 have CD4 counts less than 200 x 10(6)/l. Men who have sex with men were significantly more likely to have Kaposi's sarcoma, cytomegalovirus disease and retinitis, cryptosporidiosis and lymphoma, and significantly less likely to have Pneumocystis carinii pneumonia, esophageal candidiasis, extrapulmonary tuberculosis (TB) and bacterial pneumonia than intravenous drug users. Whites were significantly less likely to have pulmonary TB than Hispanics, non-Haitian and Haitian blacks, toxoplasmosis than Hispanics and Haitian blacks, and salmonella septicemia than non-Haitian blacks. The frequencies of most diagnoses did not differ by sex; gynecologic diseases were recorded infrequently in the medical records of women in this study., Conclusions: These data indicate that there are more than 30,000 HIV-infected adults living in NYC with significant immunosuppression, that an increasing proportion of AIDS cases in NYC will occur among women, and that the spectrum of HIV-related disease varies markedly in different populations.