Activation of the coagulation cascade after infusion of a factor XI concentrate in congenitally deficient patients

Virally inactivated, high-purity factor XI concentrates are available for treatment of patients with factor XI deficiency. However, preliminary experience indicates that some preparations may be thrombogenic. We evaluated whether a highly purified concentrate produced signs of activation of the coagulation cascade in two patients with severe factor XI deficiency infused before and after surgery. Signs of heightened enzymatic activity of the common pathway of coagulation (elevated plasma levels of prothrombin fragment 1 + 2 and fibrinopeptide A) developed in the early post-infusion period, accompanied by more delayed signs of fibrin formation with secondary hyperfibrinolysis (elevated D-dimer and plasmin-antiplasmin complex). These changes occurred in both patients, but were more severe in the older patient with breast cancer when she underwent surgery, being accompanied by fibrinogen and platelet consumption. There were no concomitant signs of heightened activity of the factor VII-tissue factor mechanism on the factor Xase complex (plasma levels of activated factor VII and of factor IX and X activation peptides did not increase). The observed changes in biochemical markers of coagulation activation indicate that concentrate infusions increased thrombin generation and activity and that such changes were magnified by malignancy and surgery. Because some factor XI concentrates may be thrombogenic, they should be used with caution, especially in patients with other risk factors for thrombosis.     

Transluminal extraction catheter atherectomy for the treatment of acute occlusion of an ectatic coronary artery

Thrombotic occlusion of an ectatic coronary artery may not respond to thrombolytic therapy or balloon angioplasty, since the infarct-related vessel contains a significant amount of thrombus. A patient with acute myocardial infarction of an ectatic right coronary artery that was occluded by a heavy clot burden is described. The patient was treated successfully with transluminal extraction catheter atherectomy and results were confirmed by intravascular ultrasound.     

Training and Education in Clinical Psychology in the Context of the Patient Protection and Affordable Care Act

The Patient Protection and Affordable Care Act of 2010 (ACA) is revamping the access, quality, and financing of the health and mental health systems. However, its impact on training and education in clinical psychology is unclear. This article aims to identify specific components of the ACA, in particular the Mental and Behavioral Health Education and Training Grants, that are expected to affect training and education in the field. The article further connects the ACA with four paradigm shifts in clinical psychology that have broad implications for training and education—evidence‐based practices, research methodology, interprofessionalism, and the quality indicator movement. The overarching goal of this article is to begin timely discussions on the future directions of the field under the current healthcare reform.