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A 39-year-old man presented with chest pain initially attributed to viral pericarditis. He was found to have an embolized inferior vena cava filter strut that perforated the right ventricle. Inferior vena cava filter fracture and embolization should be considered in patients with chest pain and pericardial effusion. (Level of Difficulty: Beginner.), Graphical abstract

Graphical abstract, Highlights • There is a higher incidence of strokes in patients with a PFO. • Right-to-left shunting can be diagnosed on TTE by a “bubble study.” • With cryptogenic stroke and a negative bubble study with agitated NS, consider repeat study with D50.

Transfemoral aortic valve implantation (TAVI) has become a viable alternative to surgical valve implantation, particularly for higher risk patients; however, vascular complications (VCs) remain a concern in transfemoral TAVI. We aimed to determine clinical and computed tomographic angiography-derived risk factors associated with Valve Academic Research Consortium (VARC)-2 criteria VCs in patients who underwent TAVI. From 2011 to 2017, 481 patients underwent percutaneous transfemoral TAVI at the Minneapolis Heart Institute and were screened for procedural and postprocedural access-related VC according to VARC-2 criteria. Clinical and clinical and computed tomographic angiography-derived data were collected to establish risk factors for VC. A total of 99 (21%) patients had VARC-2 VCs. Closure device failure (CDF) occurred in 56 of 99 (57%), minor VCs in 37 of 99 (37%), and major VCs occurred in 6 of 99 (6%). Access site-related VCs were preceded by CDF in 18 of 43 (42%) patients and the risk of major/minor VCs was 14 times greater in patients who experienced closure complications. The incidence of CDF was higher in common femoral artery (CFA) access sites with circumferential vessel wall calcification of more than 90° (p = 0.02) and when skin-surface to CFA access-site distance at an optimal access angle of 45° exceeded 80 mm (p = 0.03). In conclusion, both the degree of circumferential CFA access site calcification and distance to skin surface at an optimal access angle may improve risk stratification of access planning in patients who underwent percutaneous transfemoral TAVI.

Background Point-of-care ultrasound (POCUS) is becoming an important part of internal medicine (IM) residency training. Achieving competency requires performing a large volume of clinical exams which can be difficult within the constraints of residency. Often-cited barriers include insufficient resident time and the interruption of daily workflow. Despite availability of hospital station-based laptop ultrasound machines, we hypothesized that the addition of ward team-based tablet ultrasound devices would lower barriers and increase clinical POCUS volume within an IM residency POCUS curriculum at a 670-bed, quaternary care, teaching hospital. IM resident POCUS volumes and characteristics during an 18-mo. baseline (station-based laptop devices only) period were compared to matched months during the intervention (station-based + tablet). Results Total patients examined with POCUS by 6 inpatient resident teams during the 18-mo. baseline and intervention periods were 1386 and 1853, respectively. Patients examined per month increased during the intervention by 34% (77 vs. 103, p = 0.002). The number of areas (e.g., abdominal, cardiac) and items (e.g., bladder, pericardial effusion) examined per month increased by 27% (p = 0.021) and 23% (p = 0.073), respectively. Conclusions A combined program infrastructure of station-based laptop and “in-the-pocket” tablet ultrasound devices lowered common POCUS barriers of inadequate time and workflow disruption for IM residents and resulted in a meaningful increase of exams within a longitudinal residency-based training program where station-based laptop devices already existed.

Mutationally constrained epitopes of variable pathogens represent promising targets for vaccine design but are not reliably identified by sequence conservation. In this study, we employed structure-based network analysis, which applies network theory to HIV protein structure data to quantitate the topological importance of individual amino acid residues. Mutation of residues at important network positions disproportionately impaired viral replication and occurred with high frequency in epitopes presented by protective human leukocyte antigen (