Whitney McKnight

Military suicide rates for never-deployed service members now surpass rates for those who have been in-country. Is one of the reasons because veterans who’ve served don’t make the time to help welcome new recruits into the fold, leaving them to feel isolated and not a part of the mission?

"The Army itself has been on a very high operations tempo. Troops are deploying all the time. They’re tired," says Col. Elspeth Cameron Ritchie, U.S. Army retired, and a former Army psychiatrist. "When a new solder joins a unit, [he or she] may not be welcomed in the same way as [a soldier] might have been in the past."

But, does the military attract people who are already predisposed to mental health issues, including suicidal ideation? And while most servicemen and -women are sound of mind and body when they start out, if they do encounter mental health issues, many don’t seek the help that is available to them.

In this audio interview, Dr. Ritchie explains why this may be the case, and examines the role stigma does – or doesn’t – play in addressing mental health issues in the military. She also defines what is only now beginning to receive recognition as a factor in posttraumatic stress disorder: moral injury, or the effects of having to kill on order.

Dr. Ritchie also discussed how PTSD entered our lexicon and what utility the diagnosis has for nonservice members.

[email protected]

On Twitter @whitneymcknight

Military suicide rates for never-deployed service members now surpass rates for those who have been in-country. Is one of the reasons because veterans who’ve served don’t make the time to help welcome new recruits into the fold, leaving them to feel isolated and not a part of the mission?

"The Army itself has been on a very high operations tempo. Troops are deploying all the time. They’re tired," says Col. Elspeth Cameron Ritchie, U.S. Army retired, and a former Army psychiatrist. "When a new solder joins a unit, [he or she] may not be welcomed in the same way as [a soldier] might have been in the past."

But, does the military attract people who are already predisposed to mental health issues, including suicidal ideation? And while most servicemen and -women are sound of mind and body when they start out, if they do encounter mental health issues, many don’t seek the help that is available to them.

In this audio interview, Dr. Ritchie explains why this may be the case, and examines the role stigma does – or doesn’t – play in addressing mental health issues in the military. She also defines what is only now beginning to receive recognition as a factor in posttraumatic stress disorder: moral injury, or the effects of having to kill on order.

Dr. Ritchie also discussed how PTSD entered our lexicon and what utility the diagnosis has for nonservice members.

[email protected]

On Twitter @whitneymcknight

Military suicide rates for never-deployed service members now surpass rates for those who have been in-country. Is one of the reasons because veterans who’ve served don’t make the time to help welcome new recruits into the fold, leaving them to feel isolated and not a part of the mission?

"The Army itself has been on a very high operations tempo. Troops are deploying all the time. They’re tired," says Col. Elspeth Cameron Ritchie, U.S. Army retired, and a former Army psychiatrist. "When a new solder joins a unit, [he or she] may not be welcomed in the same way as [a soldier] might have been in the past."

But, does the military attract people who are already predisposed to mental health issues, including suicidal ideation? And while most servicemen and -women are sound of mind and body when they start out, if they do encounter mental health issues, many don’t seek the help that is available to them.

In this audio interview, Dr. Ritchie explains why this may be the case, and examines the role stigma does – or doesn’t – play in addressing mental health issues in the military. She also defines what is only now beginning to receive recognition as a factor in posttraumatic stress disorder: moral injury, or the effects of having to kill on order.

Dr. Ritchie also discussed how PTSD entered our lexicon and what utility the diagnosis has for nonservice members.

[email protected]

On Twitter @whitneymcknight

CHICAGO – The Food and Drug Administration’s letter rating scale is "unreliable" when it comes to prescribing antidepressants for pregnant women, according to Dr. Marlene P. Freeman, director of clinical services for the perinatal and reproductive psychiatry clinical research program at Massachusetts General Hospital in Boston.

"It’s actually very important to disregard those letters and turn to actual data when making clinical decisions, which can be very difficult for the individual practitioner who doesn’t specialize in this area," Dr. Freeman said in an interview during Psychiatry Update 2014, sponsored by Current Psychiatry and the American Academy of Clinical Psychiatrists.

Other concerns Dr. Freeman thinks clinicians treating pregnant women with depression need to be aware of include which SSRIs can lead to cardiovascular malformations in the child, as well as which ones have been associated with spontaneous abortions. Dr. Freeman also discusses what supplementation offers promise for preventing autism, and when omega-3 fatty acid supplementation is appropriate for first-line therapy in depression.

Current Psychiatry and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

CHICAGO – The Food and Drug Administration’s letter rating scale is "unreliable" when it comes to prescribing antidepressants for pregnant women, according to Dr. Marlene P. Freeman, director of clinical services for the perinatal and reproductive psychiatry clinical research program at Massachusetts General Hospital in Boston.

"It’s actually very important to disregard those letters and turn to actual data when making clinical decisions, which can be very difficult for the individual practitioner who doesn’t specialize in this area," Dr. Freeman said in an interview during Psychiatry Update 2014, sponsored by Current Psychiatry and the American Academy of Clinical Psychiatrists.

Other concerns Dr. Freeman thinks clinicians treating pregnant women with depression need to be aware of include which SSRIs can lead to cardiovascular malformations in the child, as well as which ones have been associated with spontaneous abortions. Dr. Freeman also discusses what supplementation offers promise for preventing autism, and when omega-3 fatty acid supplementation is appropriate for first-line therapy in depression.

Current Psychiatry and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

CHICAGO – The Food and Drug Administration’s letter rating scale is "unreliable" when it comes to prescribing antidepressants for pregnant women, according to Dr. Marlene P. Freeman, director of clinical services for the perinatal and reproductive psychiatry clinical research program at Massachusetts General Hospital in Boston.

"It’s actually very important to disregard those letters and turn to actual data when making clinical decisions, which can be very difficult for the individual practitioner who doesn’t specialize in this area," Dr. Freeman said in an interview during Psychiatry Update 2014, sponsored by Current Psychiatry and the American Academy of Clinical Psychiatrists.

Other concerns Dr. Freeman thinks clinicians treating pregnant women with depression need to be aware of include which SSRIs can lead to cardiovascular malformations in the child, as well as which ones have been associated with spontaneous abortions. Dr. Freeman also discusses what supplementation offers promise for preventing autism, and when omega-3 fatty acid supplementation is appropriate for first-line therapy in depression.

Current Psychiatry and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

How does killing another person because you’ve been commanded to affect one’s mental health? Does it bring on an existential crisis, and does that contribute to posttraumatic stress disorder?

Col. Elspeth Ritchie, U.S. Army retired and an Army psychiatrist, explains how participating in "vast amounts of death and destruction" affects a person’s ability to cope afterward.

[email protected]

On Twitter @whitneymcknight

How does killing another person because you’ve been commanded to affect one’s mental health? Does it bring on an existential crisis, and does that contribute to posttraumatic stress disorder?

Col. Elspeth Ritchie, U.S. Army retired and an Army psychiatrist, explains how participating in "vast amounts of death and destruction" affects a person’s ability to cope afterward.

[email protected]

On Twitter @whitneymcknight

How does killing another person because you’ve been commanded to affect one’s mental health? Does it bring on an existential crisis, and does that contribute to posttraumatic stress disorder?

Col. Elspeth Ritchie, U.S. Army retired and an Army psychiatrist, explains how participating in "vast amounts of death and destruction" affects a person’s ability to cope afterward.

[email protected]

On Twitter @whitneymcknight

CHICAGO – The driving force behind anxiety is avoidance, according to Barbara Rothbaum, Ph.D., an expert in exposure therapy and a presenter at this year’s annual conference of the Anxiety and Depression Association of America.

"What we think maintains [a person’s] anxiety is avoidance of what they’re scared of," says Dr. Rothbaum in this video. "We help people confront what they’re scared of, in a therapeutic manner."

Particularly in posttraumatic stress disorder, there are two drivers holding anxiety in place, which when addressed by repeatedly immersing a patient in a virtual re-creation of the traumatic event, are relieved so the person can find peace. Many patients say, "It doesn’t haunt me anymore," according to Dr. Rothbaum, professor in the department of psychiatry and behavioral sciences and director of the trauma and anxiety recovery program at Emory University, Atlanta.

In this video, Dr. Rothbaum explores what drives anxiety and how the therapeutic, virtual re-creations of painful memories is helping patients with PTSD accept that although certain things will always be "sad," they need not negate joy and pleasure in life.

[email protected]

On Twitter @whitneymcknight

CHICAGO – The driving force behind anxiety is avoidance, according to Barbara Rothbaum, Ph.D., an expert in exposure therapy and a presenter at this year’s annual conference of the Anxiety and Depression Association of America.

"What we think maintains [a person’s] anxiety is avoidance of what they’re scared of," says Dr. Rothbaum in this video. "We help people confront what they’re scared of, in a therapeutic manner."

Particularly in posttraumatic stress disorder, there are two drivers holding anxiety in place, which when addressed by repeatedly immersing a patient in a virtual re-creation of the traumatic event, are relieved so the person can find peace. Many patients say, "It doesn’t haunt me anymore," according to Dr. Rothbaum, professor in the department of psychiatry and behavioral sciences and director of the trauma and anxiety recovery program at Emory University, Atlanta.

In this video, Dr. Rothbaum explores what drives anxiety and how the therapeutic, virtual re-creations of painful memories is helping patients with PTSD accept that although certain things will always be "sad," they need not negate joy and pleasure in life.

[email protected]

On Twitter @whitneymcknight

CHICAGO – The driving force behind anxiety is avoidance, according to Barbara Rothbaum, Ph.D., an expert in exposure therapy and a presenter at this year’s annual conference of the Anxiety and Depression Association of America.

"What we think maintains [a person’s] anxiety is avoidance of what they’re scared of," says Dr. Rothbaum in this video. "We help people confront what they’re scared of, in a therapeutic manner."

Particularly in posttraumatic stress disorder, there are two drivers holding anxiety in place, which when addressed by repeatedly immersing a patient in a virtual re-creation of the traumatic event, are relieved so the person can find peace. Many patients say, "It doesn’t haunt me anymore," according to Dr. Rothbaum, professor in the department of psychiatry and behavioral sciences and director of the trauma and anxiety recovery program at Emory University, Atlanta.

In this video, Dr. Rothbaum explores what drives anxiety and how the therapeutic, virtual re-creations of painful memories is helping patients with PTSD accept that although certain things will always be "sad," they need not negate joy and pleasure in life.

[email protected]

On Twitter @whitneymcknight

CHICAGO – Because not everyone has immediate access to treatment for suicidal depression, Thomas Joiner, Ph.D., codirector of the Military Suicide Research Consortium in Tallahassee, Fla., is helping develop virtual adjunct psychotherapies to help de-escalate acute suicide until first-line therapy can be administered.

"We are trying to locate really simple but effective interventions for suicide in service members – but we think it’s going to be generalizable beyond the military – take those risk factors from a level that is worrisome and in some cases catastrophic and make them more manageable so that other treatments have a chance to take hold and to do their work," Dr. Joiner said in an interview after his presentation given at the scientific session of the annual conference of the Anxiety and Depression Association of America.

The technology for these interventions is basic and "available to most people," according to Dr. Joiner, and includes at least one smartphone app that reminds people experiencing suicidal ideation that they matter to others and that their death would adversely affect people they love.

[email protected]

On Twitter @whitneymcknight

CHICAGO – Because not everyone has immediate access to treatment for suicidal depression, Thomas Joiner, Ph.D., codirector of the Military Suicide Research Consortium in Tallahassee, Fla., is helping develop virtual adjunct psychotherapies to help de-escalate acute suicide until first-line therapy can be administered.

"We are trying to locate really simple but effective interventions for suicide in service members – but we think it’s going to be generalizable beyond the military – take those risk factors from a level that is worrisome and in some cases catastrophic and make them more manageable so that other treatments have a chance to take hold and to do their work," Dr. Joiner said in an interview after his presentation given at the scientific session of the annual conference of the Anxiety and Depression Association of America.

The technology for these interventions is basic and "available to most people," according to Dr. Joiner, and includes at least one smartphone app that reminds people experiencing suicidal ideation that they matter to others and that their death would adversely affect people they love.

[email protected]

On Twitter @whitneymcknight

CHICAGO – Because not everyone has immediate access to treatment for suicidal depression, Thomas Joiner, Ph.D., codirector of the Military Suicide Research Consortium in Tallahassee, Fla., is helping develop virtual adjunct psychotherapies to help de-escalate acute suicide until first-line therapy can be administered.

"We are trying to locate really simple but effective interventions for suicide in service members – but we think it’s going to be generalizable beyond the military – take those risk factors from a level that is worrisome and in some cases catastrophic and make them more manageable so that other treatments have a chance to take hold and to do their work," Dr. Joiner said in an interview after his presentation given at the scientific session of the annual conference of the Anxiety and Depression Association of America.

The technology for these interventions is basic and "available to most people," according to Dr. Joiner, and includes at least one smartphone app that reminds people experiencing suicidal ideation that they matter to others and that their death would adversely affect people they love.

[email protected]

On Twitter @whitneymcknight

ARUBA – Patients with actinic keratoses are a fixture in most dermatology practices, but is your practice up to date on the full range of treatments available?

At the Caribbean Dermatology Symposium, Dr. David Pariser presented a quick run-down of current, new, and up-and-coming treatments for AKs, including, but not limited to, cryosurgery and imiquimod.

Also, he discusses his experience with field therapy to treat AKs.

"The damage that occurred that caused the actinic keratosis in one specific spot has also occurred in adjacent areas," that can’t be detected visually, he said.

Dr. Pariser is a professor of clinical dermatology at Eastern Virginia Medical School in Norfolk, and a physician in a private group practice in Virginia.

[email protected]

On Twitter @whitneymcknight

ARUBA – Patients with actinic keratoses are a fixture in most dermatology practices, but is your practice up to date on the full range of treatments available?

At the Caribbean Dermatology Symposium, Dr. David Pariser presented a quick run-down of current, new, and up-and-coming treatments for AKs, including, but not limited to, cryosurgery and imiquimod.

Also, he discusses his experience with field therapy to treat AKs.

"The damage that occurred that caused the actinic keratosis in one specific spot has also occurred in adjacent areas," that can’t be detected visually, he said.

Dr. Pariser is a professor of clinical dermatology at Eastern Virginia Medical School in Norfolk, and a physician in a private group practice in Virginia.

[email protected]

On Twitter @whitneymcknight

ARUBA – Patients with actinic keratoses are a fixture in most dermatology practices, but is your practice up to date on the full range of treatments available?

At the Caribbean Dermatology Symposium, Dr. David Pariser presented a quick run-down of current, new, and up-and-coming treatments for AKs, including, but not limited to, cryosurgery and imiquimod.

Also, he discusses his experience with field therapy to treat AKs.

"The damage that occurred that caused the actinic keratosis in one specific spot has also occurred in adjacent areas," that can’t be detected visually, he said.

Dr. Pariser is a professor of clinical dermatology at Eastern Virginia Medical School in Norfolk, and a physician in a private group practice in Virginia.

[email protected]

On Twitter @whitneymcknight

ARUBA – Patients with actinic keratoses are a fixture in most dermatology practices, but is your practice up to date on the full range of treatments available?

At the Caribbean Dermatology Symposium, Dr. David Pariser presented a quick run-down of current, new, and up-and-coming treatments for AKs, including, but not limited to, cryosurgery and imiquimod.

Also, he discusses his experience with field therapy to treat AKs.

"The damage that occurred that caused the actinic keratosis in one specific spot has also occurred in adjacent areas," that can’t be detected visually, he said.

Dr. Pariser is a professor of clinical dermatology at Eastern Virginia Medical School in Norfolk, and a physician in a private group practice in Virginia.

[email protected]

On Twitter @whitneymcknight

ARUBA – Patients with actinic keratoses are a fixture in most dermatology practices, but is your practice up to date on the full range of treatments available?

At the Caribbean Dermatology Symposium, Dr. David Pariser presented a quick run-down of current, new, and up-and-coming treatments for AKs, including, but not limited to, cryosurgery and imiquimod.

Also, he discusses his experience with field therapy to treat AKs.

"The damage that occurred that caused the actinic keratosis in one specific spot has also occurred in adjacent areas," that can’t be detected visually, he said.

Dr. Pariser is a professor of clinical dermatology at Eastern Virginia Medical School in Norfolk, and a physician in a private group practice in Virginia.

[email protected]

On Twitter @whitneymcknight

ARUBA – Patients with actinic keratoses are a fixture in most dermatology practices, but is your practice up to date on the full range of treatments available?

At the Caribbean Dermatology Symposium, Dr. David Pariser presented a quick run-down of current, new, and up-and-coming treatments for AKs, including, but not limited to, cryosurgery and imiquimod.

Also, he discusses his experience with field therapy to treat AKs.

"The damage that occurred that caused the actinic keratosis in one specific spot has also occurred in adjacent areas," that can’t be detected visually, he said.

Dr. Pariser is a professor of clinical dermatology at Eastern Virginia Medical School in Norfolk, and a physician in a private group practice in Virginia.

[email protected]

On Twitter @whitneymcknight

CHICAGO – In a study of 100 people who attempted suicide, researchers found the persons all had elevated levels of proinflammatory cytokines in their blood, according to a presentation made at this year’s annual conference of the Anxiety and Depression Association of America.

Now the study’s lead investigator, Dr. Lena C. Brundin of the department of translational science & molecular medicine at Michigan State University, Grand Rapids, seeks to replicate her findings across a larger population with varying degrees of suicidal ideation, to see whether specific biomarkers can be identified to determine which patients are at elevated risk and develop targeted therapies for inflammation to reduce that risk.

In an interview, Dr. Brundin explains her hypothesis for the mechanisms of this neuroinflammatory response: that metabolites in the kynurenine pathway adversely affect glutamate neurotransmission (kynurenic acid is an antagonist of the glutamatergic N-methyl-D-aspartate [NMDA] receptor), creating "very profound and strong effects" on the brain, and possibly contributing to suicidal ideation.

[email protected]On Twitter @whitneymcknight

CHICAGO – In a study of 100 people who attempted suicide, researchers found the persons all had elevated levels of proinflammatory cytokines in their blood, according to a presentation made at this year’s annual conference of the Anxiety and Depression Association of America.

Now the study’s lead investigator, Dr. Lena C. Brundin of the department of translational science & molecular medicine at Michigan State University, Grand Rapids, seeks to replicate her findings across a larger population with varying degrees of suicidal ideation, to see whether specific biomarkers can be identified to determine which patients are at elevated risk and develop targeted therapies for inflammation to reduce that risk.

In an interview, Dr. Brundin explains her hypothesis for the mechanisms of this neuroinflammatory response: that metabolites in the kynurenine pathway adversely affect glutamate neurotransmission (kynurenic acid is an antagonist of the glutamatergic N-methyl-D-aspartate [NMDA] receptor), creating "very profound and strong effects" on the brain, and possibly contributing to suicidal ideation.

[email protected]On Twitter @whitneymcknight

CHICAGO – In a study of 100 people who attempted suicide, researchers found the persons all had elevated levels of proinflammatory cytokines in their blood, according to a presentation made at this year’s annual conference of the Anxiety and Depression Association of America.

Now the study’s lead investigator, Dr. Lena C. Brundin of the department of translational science & molecular medicine at Michigan State University, Grand Rapids, seeks to replicate her findings across a larger population with varying degrees of suicidal ideation, to see whether specific biomarkers can be identified to determine which patients are at elevated risk and develop targeted therapies for inflammation to reduce that risk.

In an interview, Dr. Brundin explains her hypothesis for the mechanisms of this neuroinflammatory response: that metabolites in the kynurenine pathway adversely affect glutamate neurotransmission (kynurenic acid is an antagonist of the glutamatergic N-methyl-D-aspartate [NMDA] receptor), creating "very profound and strong effects" on the brain, and possibly contributing to suicidal ideation.

[email protected]On Twitter @whitneymcknight

Throughout history the diagnosis "posttraumatic stress disorder" has been called many things and been defined by a variety of presentations.

In this interview, Col. Elspeth Cameron Ritchie, U.S. Army retired, and an Army psychiatrist, examines how the term PTSD came to be and the elements of existentialism that are inherent within it.

[email protected]

On Twitter @whitneymcknight

Throughout history the diagnosis "posttraumatic stress disorder" has been called many things and been defined by a variety of presentations.

In this interview, Col. Elspeth Cameron Ritchie, U.S. Army retired, and an Army psychiatrist, examines how the term PTSD came to be and the elements of existentialism that are inherent within it.

[email protected]

On Twitter @whitneymcknight

Throughout history the diagnosis "posttraumatic stress disorder" has been called many things and been defined by a variety of presentations.

In this interview, Col. Elspeth Cameron Ritchie, U.S. Army retired, and an Army psychiatrist, examines how the term PTSD came to be and the elements of existentialism that are inherent within it.

[email protected]

On Twitter @whitneymcknight

The first treatment guidelines developed for pulmonary hypertension in sickle cell disease are now available from the American Thoracic Society.

Because more effective treatments have extended the lives of patients with the disease, their risk of mortality from pulmonary hypertension and elevated tricuspid regurgitant jet velocity has increased. Until now, however, there has been no standardized approach for identifying and managing these conditions.

The guidelines are published in the March 15 issue of the American Journal of Respiratory Critical Care Medicine (doi: 10.1164/rccm.201401-0065ST).

The multidisciplinary committee that wrote the guidelines defined mortality risk as a tricuspid regurgitant velocity (TRV) of at least 2.5 m/second; an N-terminal pro-brain natriuretic peptide (NT-pro-BNP) level of at least 160 pg/mL; or pulmonary hypertension (PH) confirmed by a right heart catheterization (RHC).

Patients with elevated mortality risk should be treated with hydroxyurea as first-line therapy. Chronic transfusion therapy for patients who are not candidates for or responsive to hydroxyurea is noted as a "weak recommendation."

For those with RHC-confirmed pulmonary hypertension, venous thromboembolism, and no additional risk factors for hemorrhage, indefinite – not limited – anticoagulant therapy is recommended.

For patients with either an elevated TRV or an elevated NT-pro-BNP level, the guidelines strongly recommend against pulmonary hypertensive–specific therapies such as prostanoid, endothelin-receptor antagonist, and phosphodiesterase-5 inhibitor therapy.

The same guidance was given for patients who have RHC-confirmed PH.

While the guidelines recommend against targeted therapies for RHC-confirmed pulmonary hypertension, a trial of either a prostanoid or an endothelin-receptor antagonist is recommended for patients with confirmed PH and elevated pulmonary vascular resistance, normal pulmonary capillary wedge pressure, and related symptoms. These patients should not be given phosphodiesterase-5 inhibitor therapy as first-line treatment.

The lack of both large-scale clinical trials in this population and integrated standards of care limit the guidelines’ effect, Dr. Elizabeth S. Klings, who chaired the guidelines committee, noted in a written statement.

"Management of [these patients] will ultimately be a collaborative effort including adult and pediatric pulmonologists, cardiologists, and hematologists," added Dr. Klings of the department of medicine at Boston University.

Dr. Klings receives support from NIH grant R21HL107993.

Dr. Susan Millard, FCCP, comments: The guidelines are a breath of fresh air. I feel they are very well thought out. More research needs to be done on the therapies for pulmonary hypertension, but the authors of these guidelines admit that there is a paucity of data in this area.

In addition, more collaboration is needed between our pulmonary, hematology, oncology, and cardiology specialties. Pulmonologists do not perform right heart catheterizations, but when we ask cardiologists about pulmonary hypertension concerns, we regularly get shot down by the ones who feel that echocardiograms are sufficient to look for this problem. Yet when we want help managing these patients, they don’t want to do that either because it is pulmonary hypertension. You need a dedicated group of people locally to workup these patients.

There are not many experienced pulmonary hypertension centers easily accessible for both adult and pediatric patient referrals. It is difficult, for example, to refer patients out of state and get it approved by insurance companies.

Dr. Susan Millard is a pediatric pulmonologist, Helen DeVos Children’s Hospital, Grand Rapids, Mich.; and CHEST board member.

[email protected]

The first treatment guidelines developed for pulmonary hypertension in sickle cell disease are now available from the American Thoracic Society.

Because more effective treatments have extended the lives of patients with the disease, their risk of mortality from pulmonary hypertension and elevated tricuspid regurgitant jet velocity has increased. Until now, however, there has been no standardized approach for identifying and managing these conditions.

The guidelines are published in the March 15 issue of the American Journal of Respiratory Critical Care Medicine (doi: 10.1164/rccm.201401-0065ST).

The multidisciplinary committee that wrote the guidelines defined mortality risk as a tricuspid regurgitant velocity (TRV) of at least 2.5 m/second; an N-terminal pro-brain natriuretic peptide (NT-pro-BNP) level of at least 160 pg/mL; or pulmonary hypertension (PH) confirmed by a right heart catheterization (RHC).

Patients with elevated mortality risk should be treated with hydroxyurea as first-line therapy. Chronic transfusion therapy for patients who are not candidates for or responsive to hydroxyurea is noted as a "weak recommendation."

For those with RHC-confirmed pulmonary hypertension, venous thromboembolism, and no additional risk factors for hemorrhage, indefinite – not limited – anticoagulant therapy is recommended.

For patients with either an elevated TRV or an elevated NT-pro-BNP level, the guidelines strongly recommend against pulmonary hypertensive–specific therapies such as prostanoid, endothelin-receptor antagonist, and phosphodiesterase-5 inhibitor therapy.

The same guidance was given for patients who have RHC-confirmed PH.

While the guidelines recommend against targeted therapies for RHC-confirmed pulmonary hypertension, a trial of either a prostanoid or an endothelin-receptor antagonist is recommended for patients with confirmed PH and elevated pulmonary vascular resistance, normal pulmonary capillary wedge pressure, and related symptoms. These patients should not be given phosphodiesterase-5 inhibitor therapy as first-line treatment.

The lack of both large-scale clinical trials in this population and integrated standards of care limit the guidelines’ effect, Dr. Elizabeth S. Klings, who chaired the guidelines committee, noted in a written statement.

"Management of [these patients] will ultimately be a collaborative effort including adult and pediatric pulmonologists, cardiologists, and hematologists," added Dr. Klings of the department of medicine at Boston University.

Dr. Klings receives support from NIH grant R21HL107993.

Dr. Susan Millard, FCCP, comments: The guidelines are a breath of fresh air. I feel they are very well thought out. More research needs to be done on the therapies for pulmonary hypertension, but the authors of these guidelines admit that there is a paucity of data in this area.

In addition, more collaboration is needed between our pulmonary, hematology, oncology, and cardiology specialties. Pulmonologists do not perform right heart catheterizations, but when we ask cardiologists about pulmonary hypertension concerns, we regularly get shot down by the ones who feel that echocardiograms are sufficient to look for this problem. Yet when we want help managing these patients, they don’t want to do that either because it is pulmonary hypertension. You need a dedicated group of people locally to workup these patients.

There are not many experienced pulmonary hypertension centers easily accessible for both adult and pediatric patient referrals. It is difficult, for example, to refer patients out of state and get it approved by insurance companies.

Dr. Susan Millard is a pediatric pulmonologist, Helen DeVos Children’s Hospital, Grand Rapids, Mich.; and CHEST board member.

[email protected]

The first treatment guidelines developed for pulmonary hypertension in sickle cell disease are now available from the American Thoracic Society.

Because more effective treatments have extended the lives of patients with the disease, their risk of mortality from pulmonary hypertension and elevated tricuspid regurgitant jet velocity has increased. Until now, however, there has been no standardized approach for identifying and managing these conditions.

The guidelines are published in the March 15 issue of the American Journal of Respiratory Critical Care Medicine (doi: 10.1164/rccm.201401-0065ST).

The multidisciplinary committee that wrote the guidelines defined mortality risk as a tricuspid regurgitant velocity (TRV) of at least 2.5 m/second; an N-terminal pro-brain natriuretic peptide (NT-pro-BNP) level of at least 160 pg/mL; or pulmonary hypertension (PH) confirmed by a right heart catheterization (RHC).

Patients with elevated mortality risk should be treated with hydroxyurea as first-line therapy. Chronic transfusion therapy for patients who are not candidates for or responsive to hydroxyurea is noted as a "weak recommendation."

For those with RHC-confirmed pulmonary hypertension, venous thromboembolism, and no additional risk factors for hemorrhage, indefinite – not limited – anticoagulant therapy is recommended.

For patients with either an elevated TRV or an elevated NT-pro-BNP level, the guidelines strongly recommend against pulmonary hypertensive–specific therapies such as prostanoid, endothelin-receptor antagonist, and phosphodiesterase-5 inhibitor therapy.

The same guidance was given for patients who have RHC-confirmed PH.

While the guidelines recommend against targeted therapies for RHC-confirmed pulmonary hypertension, a trial of either a prostanoid or an endothelin-receptor antagonist is recommended for patients with confirmed PH and elevated pulmonary vascular resistance, normal pulmonary capillary wedge pressure, and related symptoms. These patients should not be given phosphodiesterase-5 inhibitor therapy as first-line treatment.

The lack of both large-scale clinical trials in this population and integrated standards of care limit the guidelines’ effect, Dr. Elizabeth S. Klings, who chaired the guidelines committee, noted in a written statement.

"Management of [these patients] will ultimately be a collaborative effort including adult and pediatric pulmonologists, cardiologists, and hematologists," added Dr. Klings of the department of medicine at Boston University.

Dr. Klings receives support from NIH grant R21HL107993.

Dr. Susan Millard, FCCP, comments: The guidelines are a breath of fresh air. I feel they are very well thought out. More research needs to be done on the therapies for pulmonary hypertension, but the authors of these guidelines admit that there is a paucity of data in this area.

In addition, more collaboration is needed between our pulmonary, hematology, oncology, and cardiology specialties. Pulmonologists do not perform right heart catheterizations, but when we ask cardiologists about pulmonary hypertension concerns, we regularly get shot down by the ones who feel that echocardiograms are sufficient to look for this problem. Yet when we want help managing these patients, they don’t want to do that either because it is pulmonary hypertension. You need a dedicated group of people locally to workup these patients.

There are not many experienced pulmonary hypertension centers easily accessible for both adult and pediatric patient referrals. It is difficult, for example, to refer patients out of state and get it approved by insurance companies.

Dr. Susan Millard is a pediatric pulmonologist, Helen DeVos Children’s Hospital, Grand Rapids, Mich.; and CHEST board member.

[email protected]