A Nearly Missed Case of Mitral Bioprosthetic Paravalvular Leak (PVL)-Related Waring Blender Syndrome Treated With Transcatheter Mitral PVL Closure.

A 72-year-old woman with recently diagnosed non-small cell lung cancer, who underwent cardiac bypass and bioprosthetic mitral valve replacement presented to our cancer center with lightheadedness, severe fatigue, and shortness of breath. Initial blood tests showed mild hemolytic anemia. The patient also complained of occasional bright red bleeding per rectum. Esophagogastroduodenoscopy and colonoscopy did not reveal an acute source of bleeding. An initial transesophageal echocardiogram did not show significant valvular or paravalvular abnormalities. Meanwhile, the patient's hemolytic anemia worsened. She received eight units of packed red blood cell transfusions. Schematic workup for hemolytic anemia revealed negative Coomb's test, positive urine hemosiderin, normal ADAMTS13 activity, and absent splenomegaly. A relook of the patient's transesophageal echocardiogram (TEE) showed a small paravalvular leak of the bioprosthetic mitral valve. The patient was referred to a tertiary center, and repair of the perivalvular leak with glue resolved her hemolytic anemia, subsequently improving the lab values, symptoms, and quality of life. This case highlights the schematic workup of hemolytic anemia and also the importance of recognizing the association between hemolytic anemia and valvular abnormalities.

A Retrospective Chart Review Evaluating the Relationship between Cancer Diagnosis and Residential Water Source on the Lower Eastern Shore of Maryland, USA.

Well water contamination in heavily agricultural regions has previously been linked with increased cancer incidence and mortality. The lower Eastern shore of Maryland is a rural, agricultural region with some of the highest rates of cancer in Maryland and the United States. Our study sought to characterize residential private well water use among cancer patients on the lower Eastern shore of Maryland, and to compare private well water utilization between cancer patients and the general regional population. Retrospective chart review was conducted to identify patients diagnosed with colon, lung, melanoma or breast cancer at a regional hospital from 1 January 2017 through 31 December 2018. Residential water source was determined using residential address and municipal water records. Fisher's exact test was used to compare residential private well water utilization between our study population and the baseline regional population. The majority of cancer patients (57%) lived in homes supplied by private well water (428/746). Cancer patients were more likely to live in homes supplied by private well water compared to individuals in the general regional population (57% vs. 32%, p < 0.001). In conclusion, cancer patients on the lower Eastern shore of Maryland were more likely to live in homes supplied by residential private well water than the regional population. Additional studies are needed to evaluate well water use and cancer risk in this vulnerable region.

Quantitative characterization of T-cell repertoire and biomarkers in kidney transplant rejection.

BACKGROUND: T-cell-mediated rejection (TCMR) remains a major cause of kidney allograft failure. The characterization of T-cell repertoire in different immunological disorders has emerged recently as a novel tool with significant implications. We herein sought to characterize T-cell repertoire using next generation sequencing to diagnose TCMR. METHODS: In this prospective study, we analyzed samples from 50 kidney transplant recipients. We collected blood and kidney transplant biopsy samples at sequential time points before and post transplant. We used next generation sequencing to characterize T-cell receptor (TCR) repertoire by using illumina miSeq on cDNA synthesized from RNA extracted from six patients' samples. We also measured RNA expression levels of FOXP3, CD8, CD4, granzyme and perforin in blood samples from all 50 patients. RESULTS: Seven patients developed TCMR during the first three months of the study. Out of six patients who had complete sets of blood and biopsy samples two had TCMR. We found an expansion of the TCR repertoire in blood at time of rejection when compared to that at pre-transplant or one-month post transplant. Patients with TCMR (n = 7) had significantly higher RNA expression levels of FOXP3, Perforin, Granzyme, CD4 and CD8 in blood samples than those with no TCMR (n = 43) (P = 0.02, P = 0.003, P = 0.002, P = 0.017, and P = 0.01, respectively). CONCLUSIONS: Our study provides a potential utilization of TCR clone kinetics analysis in the diagnosis of TCMR. This approach may allow for the identification of the expanded T-cell clones associated with the rejection and lead to potential noninvasive diagnosis and targeted therapies of TCMR.