A small number of thromboembolic events, including deep venous thrombosis and myocardial infarction, have been reported in patients receiving IVIG. These events have primarily occurred in patients receiving high-dose IVIG and have been attributed to an increase in blood viscosity. To test the hypothesis that a procoagulant might be present in IgG preparations, twenty-nine samples of intravenous immunoglobulin (IVIG) from eight different manufacturers were assayed for procoagulant activity. Twenty-six of these samples shortened the clotting time of factor XI-deficient plasma. Of these, fourteen samples had factor XI activities greater than 0.001 U/ml of normal pooled plasma. The remaining samples possessed less than 0.001 U/ml of normal plasma activity. The procoagulant activity in these samples could be inhibited by an anti-factor XI polyclonal antibody, suggesting that the procoagulant activity was factor XI. The procoagulant activity increased in two samples after storage at 4°C for 4 weeks, likely as a result of factor XIa autoactivation. Additionally, activity in some IVIG samples was able to directly activate factor IX, indicating that activated factor XI was present in these samples. Finally, the degree of factor XI(a) contamination in the samples was correlated with the manufacturer, suggesting that variations in the manufacturing process or source plasma affect the level of factor XI in the IVIG product. Because addition of small amounts of factor XIa to plasma can lead to production of significant amounts of thrombin, we suggest that factor XIa present in some IVIG preparations could contribute to the in vivo risk of thrombosis after IVIG therapy. Am.

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Coaching is a critical tool to guide student development of clinical competency and formation of professional identity in medicine, two inextricably linked concepts. Because progress toward clinical competence is linked to thinking, acting and feeling like a physician, a coach's knowledge about a learner's development of clinical skills is essential to promoting the learner's professional identity formation. A longitudinal coaching program provides a foundation for the formation of coach-learner relationships built on trust. Trusting relationships can moderate the risk and vulnerability inherent in a hierarchical medical education system and allow coaching conversations to focus on the promotion of self-regulated learning and fostering skills for lifelong learning. Herein, we describe a comprehensive, longitudinal clinical coaching program for medical students designed to support learners' professional identify formation and effectively promote their emerging competence.

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