ASH News Daily - Sunday, December 11, 2011 - (Page A-6)
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THROMBOSIS
Clinically Complex Clotting Questions
By david gaRcia, Md, and
ShaRi ghanny, Md
most challenging consultations faced
by hematologists. The stakes are
high because the complications of either
the disease (e.g., pulmonary embolism)
or the treatment (e.g., anticoagulant-associated
major bleeding)
can be devastating. In recent years,
important research has improved
our understanding of how to care
C
linical questions about
thrombosis or anticoagulation
represent some of the
for patients with thrombotic disorders.
During yesterday’s Education
Program session “Consultative Hematology
I: Common Questions in
Thrombosis Consults,” attendees
heard the latest practice-changing
evidence related to three important
(and often confusing) topics:
heparin-induced thrombocytopenia
(HIT), thrombophilia testing, and
the role of endovascular procedures
in the management of deep-vein
thrombosis (DVT).
In the first presentation, Dr. Ted
Dr. Theodore Warkentin discusses diagnosis and treatment
during the “Consultative Hematology I: Common Questions
in Thrombosis Consults” session.
Warkentin of McMaster University,
Hamilton,
ON, discussed
the diagnosis
and treatment
of HIT. This
rare but highly
feared complication
of heparin-based
anticoagulation
has
been the subject
of much basic
and clinical
research in recent
years. Dr.
Warkentin provided
attendees
with important
insights about how to interpret the
often confusing diagnostic testing
for HIT. For example, he showed
convincing evidence that patients
who are positive for anti-heparin/
PF4 antibodies (by ELISA) but have
a negative serotonin release assay
do not have HIT. Dr. Warkentin also
described the advantages and disadvantages
of various therapies (direct
thrombin inhibitors versus indirect
factor Xa inhibitors) for HIT.
Next, Dr. Saskia Middeldorp
of the Academic Medical Center,
Amsterdam, The Netherlands, answered
the question “Is Thrombophilia
Testing Useful?” Although
several inherited and acquired conditions
that predispose to venous
thrombosis have now been identified,
many clinicians are uncertain
about when to test for thrombophilias
like protein C deficiency or
how to interpret the results of such
testing when it is done. Dr. Middeldorp’s
presentation not only
provided an overview of the latest
epidemiology but also included the
evidence pertinent to thrombophilia
testing in specific groups: patients
with a personal or family history of
VTE, patients with a history of pregnancy
loss, patients considering oral
contraceptive use, and patients with
arterial thrombosis.
The final presentation, given by
Dr. Suresh Vedantham of Washington
University School of Medicine
in St. Louis focused on the
role of endovascular approaches
for the acute management of DVT.
We know that for patients with
proximal DVT, anticoagulation
alone is highly effective at preventing
both clot extension and embolization
to the lungs. Unfortunately,
some patients with proximal DVT
will go on to experience postthrombotic
syndrome – an often irreversible
condition associated with
edema, pain, and other symptoms.
Dr. Vedantham described the latest
options for more aggressive, upfront
treatment of proximal DVT,
including systemic thrombolysis
as well as endovascular (pharmacomechanical)
interventions. He
discussed existing evidence as well
as ongoing research designed to determine
whether more aggressive
approaches to the management of
proximal DVT can reduce the risk
of long-term sequelae.
Drs. Garcia and Ghanny indicated
no relevant conflicts of interest.
David G. Nathan Awarded Society’s Highest Honor
RED CELLS
D
espite all that David G.
Nathan, MD, of the DanaFarber
Institute and Chil-
dren’s Hospital Boston has contributed
to the field, he will be the
first to tell you that this career move
was not quite of his own choosing.
“Frankly, I was ordered into hematology,”
he said. In 1957 when Dr.
Nathan arrived in the lab of the late
Dr. Nathaniel I. Berlin at the National
Cancer Institute, Dr. Berlin
asked his student what he wanted
to study. “I told him I wanted
to study ammonia metabolism in
liver disease.” Dr. Berlin then told
Dr. Nathan that he wanted him to
study red cell lifespan in leukemia.
Dr. Nathan once again reiterated
his research interests. Then, Dr. Nathan
remembers his mentor pulling
rank. “He asked me to tell him how
many stripes he would have on his
sleeve if we were both in uniform. I
said four. He asked me how many I
would have, and I said two. ‘That,’
he said, ‘is why you are going to
do hematology now and not ammonia
metabolism in liver disease.’”
Dr. Nathan has never regretted
that order.
This afternoon, the American So-
ciety of Hematology will bestow its
highest honor on Dr. Nathan with
the Wallace H. Coulter Award for
Lifetime Achievement in Hematology.
The award commemorates the
innovative spirit, visionary leadership,
and entrepreneurship of Mr.
Coulter, who was best known for
his development of the Coulter
Principle — a proven theory that
provided a methodology for counting,
measuring, and evaluating cells
and microscopic particles suspended
in fluid. Further, his invention
of the Coulter Counter made possible
today’s most common medical
diagnostic test: the complete blood
count. The award in his name is conferred
upon an individual who has
exhibited a lifetime commitment to
hematology, making outstanding
contributions and leaving a significant
impact on education, research,
and/or practice.
Dr. Nathan has made outstand-
ing contributions throughout the
course of his more than 50-year career.
He and his team developed the
first prenatal diagnostic test for thalassemia
and sickle cell anemia, were
the first to introduce hydroxyurea to
prevent certain sickle cell complica-
tions, and were the first
to develop a successful
treatment for patients
who produce an excessive
amount of iron,
subcutaneous deferoxamine,
while undergoing
chronic transfusion
therapy. These accomplishments
have had
a profound impact on
the field of hematology,
especially as it
relates to inherited red
cell disorders.
Having mentored
more than 100 hematologists
during his career,
Dr. Nathan surely understands
the mutual benefits of tutelage. His
most cherished work-related memories
have been witnessing the development
of his many trainees and
some of his younger colleagues into
highly distinguished hematologists,
“several of whom,” he says, “are or
will be Coulter candidates.”
Over the last 50-plus years one
can imagine the profound nuggets
of wisdom Dr. Nathan has obtained
and dispensed. As for the best advice
he has received, Dr. Nathan
David G. Nathan, MD
recalls the words of
the late clinical cardiologist
Dr. Samuel
A. Levine of the then
Peter Brent Brigham
Hospital: “Worry
about your patients.
Think about the complex
ones all the time.
A great idea will
come to you if you
worry about them.”
Dr. Nathan says he
has tried to follow
that advice and admits
that many of his
ideas have seemingly
come out of nowhere.
Despite all of his success, Dr. Na-
than recognizes the need to achieve
a healthy balance between professional
and family life and credits his
wife Jean for making it possible for
him to enjoy his career and his family.
When away from the office, he
enjoys sailing and swimming with
his family in Nantucket, and while
striking this balance has been his
biggest challenge, time spent with
them brings him his greatest joy.
Dr. Nathan will receive his award
today at 1:30 p.m. in Hall AB.
ASH NEWS DAILY
Sunday, December 11, 2011
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