Alternative anticoagulation during cardiovascular procedures in pediatric patients with heparin-induced thrombocytopenia.

Patients with heparin-induced thrombocytopenia (HIT) that require anticoagulation for cardiovascular procedures represent a challenging and high-risk group. Bivalirudin and argatroban have been successfully used as alternative anticoagulants in adult patients with HIT. There have been few experiences published involving the pediatric population and controversy exists regarding the properties and optimal dosing of these drugs. This report describes the experience of managing two pediatric patients with HIT that underwent cardiovascular procedures requiring anticoagulation. Bivalirudin was used in both cases for anticoagulation during cardiopulmonary bypass, while argatroban was used without complications during cardiac catheterization. A description of perfusion and anticoagulation protocols is included.

Immune defects in breast cancer patients after radiotherapy.

The purpose of this study was to evaluate the immune status of women with stage I-III breast cancer after receiving external beam radiotherapy (RT). Fourteen stage I-III, estrogen or progesterone receptor-positive or-negative (FER/PR +\-), postsurgical breast cancer patients undergoing a standard course of chemotherapy and radiation were studied. Complete blood counts (CBC) with differential, phagocytic activity, natural killer (NK) cell functional activity, and tumor necrosis factor-alpha (TNF-alpha) and interferon-gamma cytokine activity were measured immediately before and for the six weeks following the completion of radiation therapy. Fatigue levels after completion of RT were measured using the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue scale. Nonparametric statistical methods (Wilcoxon rank and Spearman correlations) were used to analyze the data. Compared with postchemotherapy, following the completion of RT, these breast cancer patients showed lymphopenia, low functional activity of natural killer lymphocytes, decreased monocyte phagocytic activity, and decreased TNF-alpha production but no neutropenia, no anemia, and no change in interferon-gamma production. Lymphocyte count did not return to normal by the end of the 6-week post-RT observation period. The severity of lymphopenia and low natural killer cell activity was related to RT area but not radiation dose. Patients did not report significant fatigue levels for the 6 weeks after completing RT. Significant decreases in the numbers and functions of cells from both the innate and adaptive immune system were detected following a standard course of radiation therapy for the treatment of breast cancer. Immune deficits in lymphocyte populations and TNF-alpha production, should they persist, may have consequences for immune response to residual or recurrent malignancy following completion of conventional treatment. The use of adjunctive immune therapies which target these specific defects may be warranted in the post-treatment period.