Urinary and reproductive tract infection symptoms and menstrual hygiene practices in refugee camps in Jordan: A cross-sectional study.

BACKGROUND: Urinary tract infections and reproductive tract infections pose significant health risks, particularly among women living in challenging conditions. Unhygienic menstrual practices can exacerbate these risks, impacting physical and psychological well-being. OBJECTIVES: This study assessed the association between unhygienic menstrual care and self-reported urinary tract infection/reproductive tract infection symptoms among refugee women. In addition, it explored the association between these symptoms and mental health, specifically depressive symptoms. DESIGN: This study adopted a cross-sectional observational design. METHODS: This study was conducted between January and March 2023, involving 387 reproductive-age refugee women. Data collected included sociodemographic information and urinary tract infection/reproductive tract infection symptoms. In addition, we used the Menstrual Practice Needs Scale to evaluate menstrual hygiene practices and the Patient Health Questionnaire-9 for depressive symptoms. Statistical analysis was performed using Python version 3.9.12. RESULTS: Of 387 refugee women, 92.25% reported having urinary or reproductive tract infection symptoms in the previous 3 months. Factors like older age (odds ratio = 1.764, 95% confidence interval = 1.083-2.873, p-value = 0.023), lower family income (odds ratio = 0.327, 95% confidence interval = 0.138-0.775, p-value = 0.011), lower educational level (odds ratio = 0.222, 95% confidence interval = 0.068-0.718, p-value = 0.012), and being married (odds ratio = 0.328, 95% confidence interval = 0.188-0.574, p-value < 0.001) were significantly associated with urinary or reproductive tract infection risk. Difficulties obtaining menstrual products and thus reusing them increased the odds of urinary or reproductive tract infection diagnosis (odds ratio = 2.452, 95% confidence interval = 1.497-4.015, p-value < 0.001). Women with urinary or reproductive tract infection symptoms exhibited higher Patient Health Questionnaire-9 scores than those without (12.14 ± 5.87 vs 9.99 ± 5.86, p-value < 0.001, respectively). CONCLUSION: This study highlights a high prevalence of urinary or reproductive tract infection symptoms among refugee women residing in camps in Jordan, which was associated with poor menstrual hygiene practices and depressive symptoms. To reduce the urinary tract infection/reproductive tract infection burden in marginalized communities, public health initiatives should enhance healthcare accessibility, provide reproductive education, and promote holistic well-being practices for refugee women.

Percutaneous Intracardiac Mass Extraction in High Surgical-Risk Patients.

Large intracardiac masses including tumors, thrombi, and vegetations result in detrimental embolic or obstructive sequelae and present a management dilemma. Open heart surgery, the traditional approach, may not be an option for many patients with a prohibitive surgical risk due to multiple comorbidities. Recently, percutaneous options have emerged with reported success in extracting such intracardiac masses. A 42-year-old female with history of advanced primary sclerosing cholangitis with decompensated liver cirrhosis causing ascites and variceal bleed presented to the emergency department with fatigue, subjective fevers, chills and melena. Laboratory results revealed neutrophil-predominant leukocytosis and normocytic anemia, and blood cultures were positive for Candida albicans. Electrocardiography showed sinus tachycardia. Chest X-ray was unremarkable. She underwent packed red blood cell transfusion and esophageal banding for variceal bleeding. Transthoracic echocardiogram revealed normal left ventricular ejection fraction and no wall motion abnormalities. A right atrial mobile mass measuring approximately 1.0 × 3.0 cm was noted. Multidisciplinary heart team discussion concluded that while the mass posed a high embolic risk, the patient had a prohibitive risk for surgical intervention. Successful percutaneous removal of the mass using Penumbra system device (Penumbra Incorporated, Alameda, CA) was accomplished. This case report details the procedure and outcomes, as well as presents a literature review.

The Role of Non-coding RNAs in Alzheimer's Disease: Pathogenesis, Novel Biomarkers, and Potential Therapeutic Targets

OBJECTIVE: Long non-coding RNAs (IncRNAs) are regulatory RNA transcripts that have recently been associated with the onset of many neurodegenerative illnesses, including Alzheimer's disease (AD). Several IncRNAs have been found to be associated with AD pathophysiology, each with a distinct mechanism. In this review, we focused on the role of IncRNAs in the pathogenesis of AD and their potential as novel biomarkers and therapeutic targets. METHODS: Searching for relevant articles was done using the PubMed and Cochrane library databases. Studies had to be published in full text in English in order to be considered. RESULTS: Some IncRNAs were found to be upregulated, while others were downregulated. Dysregulation of IncRNAs expression may contribute to AD pathogenesis. Their effects manifest as the synthesis of beta-amyloid (Aß) plaques increases, thereby altering neuronal plasticity, inducing inflammation, and promoting apoptosis. CONCLUSION: Despite the need for more investigations, IncRNAs could potentially increase the sensitivity of early detection of AD. Until now, there has been no effective treatment for AD. Hence, InRNAs are promising molecules and may serve as potential therapeutic targets. Although several dysregulated AD-associated lncRNAs have been discovered, the functional characterization of most lncRNAs is still lacking.

All-cause unplanned readmissions in the United States: insights from the Nationwide Readmission Database.

BACKGROUND: There are few studies looking into adult, all-cause and age-group-specific unplanned readmissions. The predictors of such unplanned readmissions for all inpatient encounters remain obscure. AIMS: To describe the incidence and factors associated with unplanned readmissions in all inpatient encounters in the United States. METHODS: The US Nationwide Readmission Database (NRD) is a representative sample of hospitalisations in the United States (from approximately 28 states) accounting for approximately 60% of the US population. All inpatient encounters during January-November 2017 in the NRD were evaluated for the rates, predictors and costs of unplanned 30 days readmissions for age groups 18-44 years, 45-64 years, 65-75 years and ≥75 years. Elective readmissions and those patients who died on their index hospitalisations were excluded. Weighted analysis was performed to obtain nationally representative data. RESULTS: We identified 28 942 224 inpatient encounters with a total of 3 051 189 (10.5%) unplanned readmissions within 30 days. The age groups 18-44 years, 45-64 years, 65-74 years and ≥75 years had 7.0%, 12.0%, 11.7% and 12.3% readmissions respectively. Female gender, private insurance and elective admissions were negative predictors for readmissions. For the group aged 18-44 years, schizophrenia and diabetes mellitus complications were the most frequent primary diagnosis for readmissions, while in all older age groups septicaemia and heart failure were the most frequent primary diagnosis for readmissions. CONCLUSIONS: Thirty-day unplanned readmissions are common in patients over age 45 years, leading to significant morbidity. Effective strategies for reducing unplanned readmission may help to improve quality of care, outcomes and higher value care.

Reverse Takotsubo Cardiomyopathy in a Patient With Commotio Cordis.

Takotsubo cardiomyopathy (TCM), also known as stress cardiomyopathy or "broken heart syndrome", is characterized by acute transient regional left ventricular systolic dysfunction in the absence of obstructive coronary artery disease or acute plaque rupture. Atypical forms and rare anatomical variants can have different presentations; hence, recognition becomes more important. Prognosis is much more favorable if managed appropriately. An equally infrequent cause of cardiac arrest is commotio cordis (CC). This is defined as sudden cardiac death secondary to a blunt chest wall impact leading to ventricular arrhythmias. We report a case with findings of TCM and/or CC in a patient with a blunt chest trauma in the setting of motor vehicle accident.

Treatment of Inferior Vena Cava Thrombosis by Endovascular Stenting: A Case Report.

Optimal treatment of inferior vena cava (IVC) thrombosis remains unclear, especially given the contraindications to anticoagulation use and because interventional options remain limited. We present a case of a 62-year-old man with advanced liver cirrhosis who developed IVC thrombosis with symptoms of severe abdominal pain and leg swelling. IVC flow was restored via successful recanalization with a transjugular and common femoral approach after deploying a 22 × 70 mm Wallstent. On follow-up, the patient had a resolution of his symptoms.

Assessment of independent clinical predictors of early readmission after percutaneous endoluminal left atrial appendage closure with the Watchman device using National Readmission Database.

BACKGROUND: Percutaneous endoluminal left atrial appendage closure (pLAAC) procedure has been used to prevent strokes in patients who are not eligible for long-term prophylactic anticoagulation. Since its approval, multiple studies have looked at its efficacy with comparable outcomes to anticoagulation, the current standard of care. OBJECTIVES: To assess the readmission rate and determine the factors associated with readmission after the endocardial pLAAC procedure using the Watchman device. METHODS: Data was obtained from the National Readmission Database (NRD), and we used SPSS software to determine statistically significant clinical predictors affecting readmission after implantation of the Watchman device at 30 days. RESULTS: The rate of readmission was found to be 9.2%. The true median cost of index hospitalization for the total population in the study was found to be [median (interquartile range = IQR), p] USD 24594 (USD 18883-31,041), whereas the true median cost of admission for those who were getting readmitted after 30 days was [median (IQR)] USD 7699 (USD 4955-14,243). Multivariate analysis of all clinically relevant predictors showed adjusted ratio for [adjusted odds ratio (OR), 95% confidence interval (95% CI), p-value] female genders (1.288, 1.104-1.503, p = 0.001), discharge to home health care (6.155, 1.509-25.096, p = 0.01), chronic kidney disease (CKD) (1.847,1.511-2.258, p < 0.001), chronic lung disease (1.419, 1.194-1.686, p < 0.001), heart failure (1.280, 1.040-1.574, p = 0.02), pericardial disorders (1.485, 1.011-2.179, p = 0.04), fluid and electrolyte disorders (1.456,1.050-2.018, p = 0.02) in those who were getting readmitted at 30-days compared to those who were not readmitted. The median length of stay for the index hospitalization was found to be one day, whereas the median length of stay at the 30-day readmission was reported to be [Median (IQR)] 4 days (2-6 days). Major cardiac reasons for readmission were heart failure, arrhythmias, and pericardial disorders. CONCLUSION: Our study aims to assess 30-day outcomes in the US population after pLAAC using a Watchman device. Our analysis showed that one in ten patients were getting readmitted. In addition, chronic kidney disease, chronic obstructive pulmonary disease, heart failure, and pericardial disorders were associated with higher readmission rates. These findings will help us assess clinical correlations and predict which patients are more at risk of readmission after a Watchman procedure.

Predictors of 30-Day Unplanned Readmission After Carotid Artery Stenting Using Artificial Intelligence.

INTRODUCTION: This study aimed to describe the rates and causes of unplanned readmissions within 30 days following carotid artery stenting (CAS) and to use artificial intelligence machine learning analysis for creating a prediction model for short-term readmissions. The prediction of unplanned readmissions after index CAS remains challenging. There is a need to leverage deep machine learning algorithms in order to develop robust prediction tools for early readmissions. METHODS: Patients undergoing inpatient CAS during the year 2017 in the US Nationwide Readmission Database (NRD) were evaluated for the rates, predictors, and costs of unplanned 30-day readmission. Logistic regression, support vector machine (SVM), deep neural network (DNN), random forest, and decision tree models were evaluated to generate a robust prediction model. RESULTS: We identified 16,745 patients who underwent CAS, of whom 7.4% were readmitted within 30 days. Depression [p < 0.001, OR 1.461 (95% CI 1.231-1.735)], heart failure [p < 0.001, OR 1.619 (95% CI 1.363-1.922)], cancer [p < 0.001, OR 1.631 (95% CI 1.286-2.068)], in-hospital bleeding [p = 0.039, OR 1.641 (95% CI 1.026-2.626)], and coagulation disorders [p = 0.007, OR 1.412 (95% CI 1.100-1.813)] were the strongest predictors of readmission. The artificial intelligence machine learning DNN prediction model has a C-statistic value of 0.79 (validation 0.73) in predicting the patients who might have all-cause unplanned readmission within 30 days of the index CAS discharge. CONCLUSIONS: Machine learning derived models may effectively identify high-risk patients for intervention strategies that may reduce unplanned readmissions post carotid artery stenting. CENTRAL ILLUSTRATION: Figure 2: ROC and AUPRC analysis of DNN prediction model with other classification models on 30-day readmission data for CAS subjects.

We present a novel deep neural network-based artificial intelligence prediction model to help identify a subgroup of patients undergoing carotid artery stenting who are at risk for short-term unplanned readmissions. Prior studies have attempted to develop prediction models but have used mainly logistic regression models and have low prediction ability. The novel model presented in this study boasts 79% capability to accurately predict individuals for unplanned readmissions post carotid artery stenting within 30 days of discharge.

Detection and Phylogenetic Analysis of Viruses Linked with Fig Mosaic Disease in Seventeen Fig Cultivars in Palestine.

Fig mosaic is a viral disease (FMD) that spreads in Palestinian common fig ( Ficus carica L.) orchards. Recognizing the economic value of fig plants and the harmful nature of FMD, the disease poses a significant threat to the economy of the fig production in Palestine. We applied the reverse transcription and amplification (RT-PCR) and PCR technique to leaf samples of 77 trees and 14 seedlings of 17 fig cultivars. The samples were collected from orchards in the main fig-growing provinces of the Palestinian West Bank, to assess the prevalence of viruses associated with FMD, and confirm a possible link of symptoms with viruses detected. Four viruses were detected: Fig mosaic virus (FMV), Fig badnavirus-1 (FBV-1), Fig leaf mottle-associated virus 2 (FLMaV-2), and Fig fleck-associated virus (FFkaV). FMV and FBV-1 were found in all tested fig plants (100%), while FLMaV-2 and FFkaV were detected in 61.5% and 33% of the fig samples, respectively. The high incidence of FBV-1 in the newly propagated symptomatic and symptomless seedlings from different cultivars may be an indication that FBV-1 is integrated into the genome of the fig in a cultivar nondiscriminatory manner. Very weak or no association was detected between FMD symptoms severity in the 17 Palestinian fig cultivars with the various viruses' combinations observed (i.e., number of the viruses infecting the plant). These results support the notion that FMD symptom severity expression is likely to be controlled by a combination of FMV infection, cultivars, and environmental factors, rather than the number of viruses infecting the plant.

Transcatheter Coil Embolization of Iatrogenic Aorto-Right Atrial Fistula.

Coronary artery fistula (CAF) is a rare complication following coronary artery bypass grafting (CABG). True incidence is unknown, as at least 50% are asymptomatic. CAF can be either congenital or acquired. Congenital CAF is either an isolated finding or seen with other congenital cardiac anomalies or structural heart defects. Acquired CAF is seen in relation with trauma, infection, or iatrogenic injury. We report a rare case of a 58-year-old man with iatrogenic aorto-right atrial fistula following inadvertent saphenous vein grafting (SVG) implantation to a right coronary vein with persistent angina following CABG and resolution of symptoms following successful obliteration of large, hemodynamically significant, fistulae by coil embolization when medical management failed.

Trastuzumab-Induced Cardiomyopathy and Intermittent Left Bundle Branch Block.

Trastuzumab-induced cardiomyopathy is a known complication of its use in breast cancer treatment, but it remains mostly asymptomatic and often reversible. Non-myopathic cardiac complications have been rarely reported with trastuzumab. These include left and right bundle branch block, arrhythmias and sinus node dysfunction. We report a case of a 52-year-old female breast cancer patient with trastuzumab-induced asymptomatic intermittent left bundle branch block recurring nearly a year after the initial diagnosis and resolution of trastuzumab-related cardiomyopathy.

Anomalous Origin of Left Anterior Descending Artery and Left Circumflex Artery from Right Coronary Sinus with Malignant Left Anterior Descending Artery Course: Role of Coronary CT Angiography Derived Fractional Flow Reserve in Decision Making.

Congenital coronary anomalies are uncommon and are mostly asymptomatic; however, patients may have symptoms depending on the origin and course of anomalous artery. Very rarely, coronary anomalies can also lead to life-threatening complications especially in young athletes. A malignant course of the left main (LM) or left anterior descending (LAD) artery between aorta and pulmonary artery is considered the most significant risk factor for such complications. Various noninvasive tests are available to evaluate myocardial ischemia due to anomalous coronary artery. Coronary computed tomography (CT) angiogram derived fractional flow reserve (CT-FFR) is a noninvasive diagnostic test which has shown promising results in the hemodynamic assessment of obstructive coronary artery disease. However, its role in coronary anomalies has not been studied. We present a case of a 22-year-old male who presented with atypical chest pain and was found to have anomalous origin of left anterior descending (LAD) artery and left circumflex (LCX) artery from right coronary sinus. LAD had a malignant course for which CT-FFR was done which was hemodynamically nonsignificant. The decision was made to manage the patient conservatively.

Myocardial Stunning After Electrocution With Complete Reversibility Within 24 Hours: Role of Repeat Transthoracic Echocardiograms in Potential Cardiac Transplant Donors.

Despite the development of ventricular assist devices, cardiac transplantation remains an important procedure for patients with advanced heart failure. The number of transplants done annually has remained stable because of lack of of donors. Left ventricular systolic dysfunction remains one of the most important reasons for seeking a donor heart. Myocardial stunning is an important cause of reversible systolic dysfunction. Electrical injury is a recognized cause of myocardial stunning with variable duration ranging from days to weeks. Repeating the transthoracic echocardiogram to look for reversibility of left ventricular dysfunction can be a cost-effective method to improve the selection of heart donors. This can significantly help to decrease critical organ shortage. We present a case of myocardial stunning after electrocution which was completely reversible within a few hours, thus meeting cardiac transplant donor criteria.

Left Main Coronary Artery Diverticulum: Case Report and Review of the Literature.

Coronary artery disease is a major cause of morbidity and mortality, and while most commonly is atherosclerotic, it can present with variable manifestations, both congenital and acquired. One such manifestation is coronary aneurysm, which is a localized dilatation of a coronary artery wall segment to greater than 1.5 times the adjacent normal segments. While a dilated outpouching of a coronary artery has been commonly classified as a coronary aneurysm, a non-dilated outpouching is rare and is referred to as a diverticulum, with only one previous case report in the literature. It is conceivable that other cases of coronary artery diverticulum may have been previously reported as an aneurysm, given the overlapping angiographic appearance. We present a case of a 72-year-old female patient with an incidental finding of left main coronary artery diverticulum on diagnostic coronary angiogram done for preoperative liver transplantation evaluation.

Bioprosthetic Valve Thrombosis.

Degenerative valve disease is on the rise with greater than 100,000 valve operations performed in the US alone per year. The majority of those procedures employ tissue bioprostheses to avoid the attendant risk of anticoagulation, especially in the elderly. Though traditionally this approach has been considered a superior option to avoid anticoagulation, more recent analyses have demonstrated a significant incidence of previously unrecognized thrombosis associated with bioprosthetic valves, especially with the more recent advent of the transcatheter aortic valve replacement implantations. Bioprosthetic valve thrombosis is a major cause of either acute or indolent bioprosthetic valve degeneration, and often has an elusive presentation causing delayed recognition and treatment. The literature has extensively addressed the risks and benefits of anticoagulation following bioprosthetic valve replacement to prevent bioprosthetic valve thrombosis (BPVT), without conclusive evidence-based recommendations. The duration of anticoagulation following an episode of BPVT is unclear, and lifelong anticoagulation has been suggested. The increasing use of transcatheter aortic valve replacement as an alternative to surgical aortic valve replacement in various risk groups has introduced new challenges with regards to valve thrombosis, which have been poorly studied with regards to optimal treatment and prevention. The increasing use of valve-in-valve procedures is expected to bring on further uncharted challenges.

Successful Treatment of Iatrogenic External Iliac Artery Perforation With Covered Stent: Case Report and Review of the Literature.

Retroperitoneal hemorrhage from iliac artery injury is a potentially serious complication of vascular interventional procedures leading to hemorrhagic shock and death if not diagnosed early and treated promptly. We report a 70-year-old male admitted to our facility with non-ST-elevation myocardial infarction, whose heart catheterization revealed left anterior descending artery (LAD) with 80% proximal, 95% mid and 100% distal disease. The left circumflex and right coronary arteries were 100% occluded proximally and received collaterals from the LAD. The patient declined coronary artery bypass surgery; therefore, the decision was made to perform high-risk percutaneous coronary intervention (PCI) of the LAD with Impella left ventricular assist device support. Left femoral artery angiogram revealed severely tortuous and calcified aorta, left external iliac and left common iliac arteries, and was accessed with 14-inch Impella sheath. He developed groin pain with mild hypotension thought to be due to sedation, which responded to intravenous fluids and dopamine. He underwent successful rotational atherectomy of the proximal and mid LAD with deployment of drug-eluting stents. Following PCI, he suffered acute profound hypotension necessitating intravenous fluids and vasopressor support with epinephrine. Emergency transthoracic echocardiogram did not reveal any pericardial effusion, and showed normal left ventricle and right ventricle systolic function. The Impella device was removed and selective left common iliac angiogram from the right femoral access revealed a vascular injury site with shift of the bladder to the right indicative of retroperitoneal hematoma. A digital subtraction angiogram revealed extravasation of blood at the vascular injury site. An 8.0 × 59 mm iCAST covered stent was deployed to the left external iliac artery with successful sealing of the perforation. The Impella device site was closed with two Perclose devices. The patient required 4 units of packed red blood cell transfusion. His hospital course was complicated by transient acute kidney injury, with return of his renal function to baseline at discharge 10 days later. This case underscores the importance of prompt recognition and treatment of vascular complications associated with interventional procedures, and highlights some of the risk predictors of such complications, which should be anticipated and planned for prior to intervention.

Thyrotoxic Valvulopathy: Case Report and Review of the Literature.

We report a 42-year-old female who was admitted for abdominal pain, and also endorsed dyspnea, fatigue and chronic palpitations. Past medical history included asthma, patent ductus arteriosus repaired in childhood and ill-defined thyroid disease. Physical examination revealed blood pressure of 136/88 mm Hg and heart rate of 149 beats per minute. Cardiovascular exam revealed an irregularly irregular rhythm, and pulmonary exam revealed mild expiratory wheezing. Abdomen was tender. Electrocardiogram revealed atrial fibrillation with rapid ventricular response which responded to intravenous diltiazem. Labs revealed TSH of < 0.1 mU/L and free T4 of 2.82 ng/dL, a positive TSH-receptor and thyroid peroxidase antibodies suggesting Grave's thyrotoxicosis. A transthoracic echocardiogram reported an ejection fraction of 55-60%, with mild to moderate mitral regurgitation (MR) and moderate to severe tricuspid regurgitation (TR) and dilated right heart chambers. Pulmonary artery systolic pressure was 52 mm Hg. Transesophageal echocardiogram revealed a myxomatous tricuspid valve with thickening and malcoaptation of the leaflets and moderate to severe TR, mild to moderate MR with mild thickening of the mitral valve leaflets. Abdominal ultrasound revealed wall thickening of the gall bladder concerning for acute cholecystitis. She underwent laparoscopic cholecystectomy and was discharged in stable condition on methimazole for her thyroid disease, and on oral diltiazem for rate control and anticoagulation for atrial fibrillation. Follow-up visit with her cardiologist few months later documented absence of cardiac symptoms, and no murmurs were reported on physical examination. This case underscores the importance of maintaining a high index of suspicion for hyperthyroidism when faced with significant newly diagnosed pulmonary hypertension and TR, as treatment of the thyroid abnormalities can reverse these cardiac findings.

Late Presentation of Aortic Aneurysm and Dissection Following Cardiac Catheterization.

We report a 63-year-old female with hypertension, hyperlipidemia, and prior pacemaker insertion for atrial fibrillation with symptomatic bradycardia, who was admitted with substernal chest pressure and diaphoresis. Her electrocardiogram revealed atrial fibrillation with demand ventricular pacing and her cardiac biomarkers were negative for acute coronary syndrome. Echocardiogram revealed normal left ventricular systolic function and normal aortic root diameter. Coronary angiography revealed 60-70% obtuse marginal lesion, otherwise mild disease. She was treated medically and discharged in stable condition. She was readmitted 1 month later with recurring chest pain, and shortness of breath which started shortly after her most recent discharge. Blood pressure was 152/93 mm Hg, and heart rate was 105 bpm. BNP was elevated at 1,400 pg/mL, and other cardiac biomarkers were negative. She was treated with diuretics, which resulted in decrease of her blood pressure to 81/51 mm Hg. Repeat echocardiogram revealed severely dilated aortic root, measuring 6.7 cm, with aortic dissection flap and moderate to severe aortic regurgitation. CT angiogram revealed aortic dissection extending proximally to the aortic root above the coronary ostia and distally to the left subclavian artery takeoff. She underwent surgery; she, however, could not be weaned off from cardiopulmonary bypass and died in the operating room. This case illustrates the importance of having a high index of suspicion for iatrogenic aortic dissection following cardiac catheterization as a cause of recurrence of cardiac symptoms, as early detection may help avert a catastrophic outcome, as we report in our patient.

Iatrogenic aortic insufficiency following mitral valve replacement: case report and review of the literature.

We report a 28-year-old white female who suffered significant aortic insufficiency (AI) following mitral valve (MV) replacement for endocarditis. The patient had history of rheumatoid arthritis and presented to our emergency department with a 3-month history of dyspnea, orthopnea, fevers and weight loss, worsening over 2 weeks, for which she took intermittent acetaminophen. On admission, vital signs revealed blood pressure of 99/70 mm Hg, heart rate of 120 beats/minute, and temperature of 98.8 °F; her weight was 100 lbs. Physical exam revealed a thin and pale female. Cardiac auscultation revealed regular tachycardic rhythm with a third heart sound, and a short early systolic murmur at the left lower sternal border without radiation. Lungs revealed right lower lobe rhonchi. Initial pertinent laboratory evaluation revealed hemoglobin 9.6 g/dL and white blood cell count 17,500/µL. Renal function was normal, and hepatic enzymes were mildly elevated. Chest radiogram revealed right lower lobe infiltrate. Blood cultures revealed Enterococcus faecalis. Two-dimensional echocardiogram revealed large multilobed vegetation attached to the anterior MV leaflet with severe mitral regurgitation (MR), otherwise normal left ventricular systolic function. She was started on appropriate antibiotics and underwent MV replacement with 25-mm On-X prosthesis. She was noted post-operatively to have prominent systolic and diastolic murmurs. Repeat echocardiogram revealed normal mitral prosthesis function, with new moderately severe AI. Transesophageal echocardiogram revealed AI originating from a tethered non-coronary cusp, due to a suture preventing proper cusp mobility. The patient declined further surgery. She recovered slowly and was discharged to inpatient rehabilitation 4 weeks later. This case highlights the importance of vigilance to this potential serious complication of valve surgery with regard to diagnosis and treatment to prevent long-term adverse consequences.