Background: Argatroban, a synthetic, parenteral, nonheparin anticoagulant, is a direct thrombin inhibitor indicated for the prophylaxis or treatment of venous thromboembolism (VTE) in patients with heparin-induced thrombocytopenia with thrombosis (HITT) and for use during percutaneous coronary intervention (PCI) in patients who have or are at risk for developing HITT. Although heparin resistance occurs in approximately 0.5% to 5% of heparin-treated patients and is well documented in the literature, argatroban resistance is limited to a single case report. The objective of this case is to describe a case in which argatroban resistance was suspected in a patient with critical limb ischemia. Methods: This is a case report of a single patient. Results: A 68-year-old female admitted for critical limb ischemia requiring vascular intervention was treated for presumed HITT with argatroban. A therapeutic activated partial thromboplastin time (aPTT) was not attained (31 seconds) despite multiple uptitrations of the dose to 2.8 μg/kg/min (adjusted based on the institutional protocol and with consideration of organ dysfunction). A coagulopathy workup revealed a high level of factor VIII (265%). Conclusion: This case supports early assessment of factor VIII levels and the consideration of argatroban resistance and in patients who have a subtherapeutic aPTT, despite multiple increases in dose with an elevated factor VIII level. Early identification should prompt the use of an alternative anticoagulant to ensure efficacy.

Background Radiological assessment is an important skill to develop in general surgery training. Therefore, we aimed to determine general surgery residents' points of view on receiving formal radiology didactics. Methods We performed an anonymous survey of general surgery residents throughout the USA. The survey queried the residents' postgraduate year, training program type, diagnostic radiology education in their training program, as well as the residents' comfort level in interpreting various imaging modalities, followed by a series of images to assess the residents' ability to interpret images showing various surgical disease processes. Results A total of 365 residents responded to the survey. In total, 76.6% of the respondent states that there is no structured didactic session in their program on radiological studies. However, 66.3% felt that interpretation of radiological images should be used to determine surgical competency and promotion to the next academic year. In terms of accurately reading images-68.7% of the residents were able to read an X-ray showing cecal volvulus correctly, 51.9% were able to read a cholangiogram correctly, and 95.3% were correctly read an X-ray showing free under the diaphragm. Conclusion Most residents favored having radiological assessments as part of the competency evaluation. Furthermore, a curriculum and inbuilt training structure that aims to ensure residents develop competent clinical image interpretation abilities may enhance the development and retention of such skills, ultimately influencing patient outcomes.

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