Ultrasound-assisted catheter-directed thrombolysis versus systemic anticoagulation alone for submassive pulmonary embolism.

Pulmonary embolism (PE) is a significant contributor to morbidity and mortality in the United States. Catheter-directed, ultrasound-assisted thrombolysis (USAT) uses high-frequency, low-energy ultrasound waves to disaggregate uncrosslinked fibrin fibers and increase thrombus penetration of a locally delivered thrombolytic to treat an acute PE. The purpose of this study is to compare the efficacy and safety of catheter-directed USAT versus systemic anticoagulation alone in submassive PE. This was a single-center, retrospective study of patients with a diagnosis of acute submassive PE from April 4, 2014 to May 1, 2019 at a large, academic medical center. Subjects were split into two different groups based on treatment with either USAT with systemic anticoagulation or systemic anticoagulation alone. The primary outcome was the incidence of severe or life-threatening GUSTO bleeding within 72 h or until hospital discharge if sooner. A total of 130 subjects were included (n = 40 in the USAT group and n = 90 in systemic anticoagulation alone group). Significantly fewer subjects in the USAT group had an active diagnosis of cancer at the time of presentation (7.5% vs 28.9%, p = 0.006). There was no difference in severe or life-threatening GUSTO bleeding or any component of the GUSTO bleeding definitions. Administration of USAT with systemic anticoagulation was well-tolerated when compared to systemic anticoagulation alone, but bias may have led to selection of patients for USAT with a lower bleeding risk and higher functional status at baseline.

Assessing Preceptor Use of Cognitive Apprenticeship: Is the Maastricht Clinical Teaching Questionnaire (MCTQ) a Useful Approach?

Construct: The authors investigated the utility of the Maastricht Clinical Teaching Questionnaire (MCTQ) to assess preceptor use of cognitive apprenticeship teaching methods. Background: The MCTQ is an instrument first studied in medical and veterinary education; it was shown to produce valid and reliable data when evaluating how well preceptors engage in cognitive apprenticeship. Additional validity evidence, however, is needed to determine if the MCTQ is useful and applicable in other healthcare professions, such as pharmacy. Approach: Student pharmacists and pharmacy residents at a large academic medical center completed the MCTQ to evaluate pharmacist preceptors. A confirmatory factor analysis (CFA) was used to determine how consistent the data were with the 5-factor structure of the cognitive apprenticeship teaching methods (e.g., modeling, coaching, articulation, exploration, and safe learning environment). A structural equation model (SEM) was used to evaluate the relationship between the 5 factors. Preceptor and student perceptions were also collected to evaluate the response process and potential consequences of using the instrument. Results: Thirty-eight learners (2nd-year and 4th-year student pharmacists and pharmacy residents) submitted 157 evaluations. The CFA showed appreciable fit with the 5-factor structure of the cognitive apprenticeship framework after 2 modifications (removal of 1 item and moving 1 item to a different factor). The SEM had poor model fit compared to previous studies, and an exploratory analysis suggests that there is a complex relationship between the various teaching methods. Preceptors and students highly agreed that the instrument was valuable for providing feedback. Conclusion: The MCTQ has additional validity evidence that supports it as a viable instrument to assess preceptor engagement in teaching methods consistent with the cognitive apprenticeship framework. Additional research is warranted to explore the relationship between components in the cognitive apprenticeship framework to determine how preceptors can best focus their efforts to improve clinical teaching.

Impact of Thrombocytopenia on Postoperative Bleeding Incidence in Patients Receiving Aspirin Following Coronary Artery Bypass Grafting.

BACKGROUND: Early postoperative aspirin following coronary artery bypass graft (CABG) surgery has been shown to maintain bypass graft patency, reduce mortality, and prevent adverse cardiovascular events. Despite this known benefit, aspirin may be delayed due to thrombocytopenia and perceived higher bleeding risk. The purpose of this study was to assess the impact of postoperative platelet count on bleeding in patients receiving aspirin after CABG. METHODS: A retrospective analysis included all patients who underwent CABG surgery at our institution from April 2014 to June 2018 and received aspirin within 24 hours. The primary outcome was International Society on Thrombosis and Hemostasis (ISTH) major bleeding within 7 days (or up to discharge) following CABG surgery compared between patients with and without postoperative thrombocytopenia. RESULTS: This study included 280 patients. Major bleeding occurred in 24.6% of the population, with no difference when stratified by the presence or absence of postoperative thrombocytopenia (27.3% versus 23.8%, p = 0.571). There was no significant difference in hemoglobin fall (13.6% versus 14%, p = 0.948), transfusion requirement (6.1% versus 4.2%, p = 0.531), or critical site bleeding (12.1% versus 7.9%, p = 0.298). CONCLUSION: In this single-center analysis of patients who received aspirin within 24 hours of CABG, postoperative thrombocytopenia was not associated with an increase in bleeding.

Methemoglobinemia Induced By Ingesting Lava Lamp Contents.

A patient presented after ingesting the contents of a lava lamp that he believed to contain alcohol. It was later discovered that this product was comprised of 76% calcium nitrate, leading to his subsequent development of methemoglobinemia. This disease is a medical emergency secondary to poor transportation of oxygen and resultant tissue hypoxic effects. Therefore, having high suspicion for this disease process in patients with toxic ingestions, understanding the proper diagnosis, and promptly starting treatment are all critical actions for emergency physicians.