Plasma cell dyscrasias are a subset of hematological malignancies involving the production of monoclonal immunoglobulins. This spectrum of disorders includes asymptomatic conditions such as monoclonal gammopathy of unknown significance as well as extremely aggressive malignancies such as plasma cell leukemia. Monoclonal gammopathies are occasionally associated with renal failure, which can occur via many pathophysiological processes. The most common of these is light chain cast nephropathy, but many rare renal complications exist, including thrombotic microangiopathy (TMA) and focal segmental glomerulosclerosis (FSGS). Here, we report a patient with new renal failure with features of TMA and FSGS on biopsy and found to be secondary to plasma cell leukemia.

Introduction/Objective The Direct Antiglobulin Test (DAT) is a useful screening test to determine whether a patient’s red blood cells have been sensitized to immunoglobulin or complement. Like the majority of screening tests, the DAT compromises specificity for sensitivity in order to quickly assess for hemolysis and its dangerous sequelae. Because of the high sensitivity of the DAT, improper ordering of this test can confuse the clinical picture at best and result in misdiagnosis at worst. Pre-tests for ruling-out disease have proven effective in limiting test ordering, such as the Pulmonary Embolism Rule-out Criteria (“PERC rule”) for limiting the use of D-dimers. A similar pre-test could prove useful in DATs. We use “in silico testing” – testing via computer simulation – to predict the likelihood of any DAT being positive, given common patient attributes and laboratory values. Methods A three-layer deep-learning artificial neural network (ANN) was created using Python and the machine learning framework Keras. The ANN was compiled to maximize specificity while retaining 100% sensitivity. Input variables to the model were patient sex and age, along with most recent lab values for hemoglobin, hematocrit, white blood cell count, platelet count, total bilirubin, direct bilirubin, and haptoglobin, where available. The output of the ANN was a binary variable: “ruled-out” versus “further testing necessary”. The ANN was trained on all positive (n=30) and negative (n=63) DATs performed on November 2019 through March 2020, with a final total of ninety-three patients. A 10-fold cross-validation of the entire dataset was used to measure performance. Results The ANN was able to maximize specificity to 83% while retaining 100% sensitivity. A ROC curve of the model shows performance well above that of the no-discrimination line. Conclusion “In-silico testing” can accurately screen the likelihood of a positive result for a labor and time-intensive test, such as the DAT, before the actual test is performed. This has the potential to reduce unnecessary testing if validated in clinical practice. Analogous to their clinical counterpart “the PERC rule,” computer models that maximize specificity while retaining 100% sensitivity could achieve more effective test utilization and more informative results.

Background: Surgical aortic valve replacement (SAVR) carries the known risk of shedding debris into the left ventricle during valve leaflet excision and annulus debridement. Embolization of this debris may have devastating effects for the patient. While surgeons have developed methods to mitigate this risk, no data exists as to their efficacy. Herein, we present the first study that evaluates the efficacy of a technique for capturing debris during SAVR. Methods: Our group conducted a prospective case series of 20 patients who underwent SAVR using the insertion of an intraventricular surgical sponge prior to valve leaflet excision and annulus debridement to capture debris. Surgical sponges were grossly, radiographically, and histologically examined for the presence of cellular and acellular debris to determine the efficacy of this technique. Results: Of the 20 surgical sponges analyzed, 15 (75%) specimens registered positivity for cellular and/or acellular debris. 7 (35%) sponges were grossly positive, 15 (75%) were radiographically positive, and 4 (20%) were histologically positive for calcified debris on examination. Conclusions: This represents the first study that objectively evaluates a method used to capture debris in SAVR procedures. Our results demonstrate a high frequency of debris captured within intraventricular surgical sponges and confirms the efficacy of this technique. While this data is promising, numerous additional approaches exist to capture debris and a best practice standard should exist across the specialty. In addition, this study does not address the clinical outcomes associated with this technique. To these ends, additional data and multicenter collaboration is required.

Objective: Surgical aortic valve replacement (SAVR) carries the known risk of shedding debris into the left ventricle during valve leaflet excision and annulus debridement. Embolization of this debris may have devastating effects for the patient. Although surgeons have developed methods to mitigate this risk, no data exist as to their efficacy. Herein, we present the first study that evaluates the efficacy of a technique for capturing debris during SAVR. Methods: Our group conducted a prospective case series of 20 patients who underwent SAVR using the insertion of an intraventricular surgical sponge prior to valve leaflet excision and annulus debridement to capture debris. Surgical sponges were grossly, radiographically, and histologically examined for the presence of cellular and acellular debris to determine the efficacy of this technique. Results: Of the 20 surgical sponges analyzed, 15 specimens (75%) registered positivity for cellular and/or acellular debris. Seven sponges (35%) were grossly positive, 15 sponges (75%) were radiographically positive, and 4 sponges (20%) were histologically positive for calcified debris on examination. Conclusions: This is one of the few studies to objectively evaluate a method used to capture debris in SAVR procedures. Our results demonstrate a high frequency of debris captured within intraventricular surgical sponges and confirms the efficacy of this technique. While these data are promising, numerous additional approaches exist to capture debris, and a best practice standard should exist across the specialty.  In addition, this study does not address the clinical outcomes associated with this technique. To these ends, additional data and multicenter collaboration are required.

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