Sublingual immunotherapy for the treatment of peanut allergy is safe and effective, even in children as young as age 1 year.

In a double-blind, placebo-controlled, food challenge (DBPCFC) of some 36 peanut-allergic children (mean age 2.2 years, range 1-4 years), those who were randomly assigned to receive peanut sublingual immunotherapy (PNSLIT) showed significant desensitization compared with those who received placebo.

In addition, there was a “strong potential” for sustained unresponsiveness at 3 months for the toddlers who received the active treatment.

The findings were presented in a late breaking oral abstract session at the 2021 American Academy of Allergy, Asthma & Immunology virtual annual meeting (Abstract L2).

“A year ago, the Food and Drug Administration approved the oral agent Palforzia (peanut allergen powder) for the treatment of peanut allergy in children 4 and older, and it is a great option, but I think what we have learned over time is that this approach is not for everybody,” Edwin H. Kim, MD, director of the UNC Food Allergy Initiative, University of North Carolina at Chapel Hill, said in an interview.

Palforzia is a powder that is mixed in food like yogurt or pudding which the child then eats daily, according to a rigorous schedule. But Palforzia treatment presents some difficulties.

“Palforzia requires getting the powder dose, mixing it with food, like pudding or apple sauce, then eating it, which can take up to 30 minutes depending on age and kids’ cooperation. It tastes and smells like peanut which can cause aversion. Kids have to refrain from exercise or strenuous activity for at least 30 minutes before and after dosing and have to be observed for up to 2 hours post dose for symptoms,” Dr. Kim said.

“It’s a great drug, but the treatment could be overly difficult for certain families to be able to do, and in some cases the side effects may be more than certain patients are able or willing to handle, so there is a real urgent need for alternative approaches,” Dr. Kim said. “SLIT is several drops under the tongue, held for 2 minutes, swallowed and done.”

In the current placebo-controlled study, he and his group tested the feasibility, efficacy, and safety of the sublingual approach to peanut allergy in children age 4 years and younger.

Both groups were similar with regard to gender, race, ethnicity, atopic history, peanut skin prick test, and qualifying DBPCFC, and all children were previously allergic with positive blood and skin tests, with a positive reaction during baseline food challenge, thus proving the allergy and establishing the baseline threshold.

“We have learned from some studies, for instance the DEVIL and LEAP studies, that strongly suggest that the immune systems in younger patients may be more amenable to change, and there may be some justification for early intervention,” he said.

“Based on both of those ideas, we wanted to take our sublingual approach, which we have shown to have a pretty good efficacy in older children, and bring it down to this younger group and see if it still could have the same efficacy and also maintain what seems to be a very good safety signal.”

The researchers randomly assigned the children to receive PNSLIT at a daily maintenance dose of 4 mg peanut protein (n = 19) or to receive placebo (n = 17) for 36 months.

“There was a 5- to 6-month buildup period where the SLIT dose was increased every 1-2 weeks up to the target dose of 4 mg, and then the final dose of 4 mg was continued through to the end of the study,” Dr. Kim noted.

Over a total of 20,593 potential dosing days, the children took 91.2% of SLIT doses and 93.5% of placebo doses.

At the end of the 3-year study period, the children were challenged by DBPCFC with up to 4,333 mg of peanut protein.

Sustained unresponsiveness was assessed by an identical DBPCFC after discontinuation of the immunotherapy for 3 months.

Cumulative tolerated dose increased from a median of 143 mg to 4,443 mg in the PNSLIT group, compared with a median of 43 mg to 143 mg in the placebo group (P < .0001).

Fourteen of the children receiving PNSLIT, and none of the children receiving placebo, passed the desensitization food challenge. Twelve of the children receiving PNSLIT and two of the children receiving placebo passed the sustained unresponsiveness challenge.

Children who underwent the immunotherapy saw a decrease in their peanut skin prick test from 10 mm to 3.25 mm, compared to an increase from 11.5 mm to 12 mm with placebo (P < .0001).

The most common side effect reported was itching or irritation in the mouth. Most side effects resolved on their own, although some patients used an antihistamine. Getting children as young as 1 to hold the dose under their tongue was a challenge in some instances, but it eventually worked out, Dr. Kim said.

“It took a lot of work from the parents as well as from our research coordinators in trying to train these young kids to, first of all, allow us to put the peanut medication in the mouth and then to try as best as possible to keep it in their mouth for up to 2 minutes, but the families involved in our study were very dedicated and so we were able to get through that,” he said.
 

Study merits larger numbers

“Among the 36 who completed the 3 years of therapy, the authors report significant rates of desensitization among treated children compared with those receiving placebo. Furthermore, this effect was persistent for at least 3 months after stopping therapy in a subgroup of the children,” said Leonard B. Bacharier, MD, director of the Center for Pediatric Asthma, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn.

“Overall, these findings suggest the promise of peanut SLIT, which should be studied in larger numbers of preschool children,” Dr. Bacharier, who was not part of the study, said in an interview.

Jonathan A. Bernstein, MD, professor of medicine, University of Cincinnati, agreed.

“It’s a well-designed study, it’s small, but it’s promising,” Dr. Bernstein, who was not involved with the study, said in an interview.

“They did show that most of the patients who got the sublingual therapy were able to get to the target dose and develop tolerance, so I think it’s promising. We know that this stuff works. This is just more data from a well-controlled study in a younger population,” he said.

“We do OIT [oral immunotherapy] and sublingual but we don’t do it in such young children in our practice. The youngest is 3 years old, because they have to understand what is going on and cooperate. If they don’t cooperate it’s not possible.”

Dr. Kim reported financial relationships with DBV Technologies, Kenota Health, Ukko, Aimmune Therapeutics, ALK, AllerGenis, Belhaven Pharma, Duke Clinical Research Institute, Nutricia, NIH/NIAID, NIH/NCCIH, NIH/Immune Tolerance Network, FARE, and the Wallace Foundation. Dr. Bacharier and Dr. Bernstein have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Sublingual immunotherapy for the treatment of peanut allergy is safe and effective, even in children as young as age 1 year.

In a double-blind, placebo-controlled, food challenge (DBPCFC) of some 36 peanut-allergic children (mean age 2.2 years, range 1-4 years), those who were randomly assigned to receive peanut sublingual immunotherapy (PNSLIT) showed significant desensitization compared with those who received placebo.

In addition, there was a “strong potential” for sustained unresponsiveness at 3 months for the toddlers who received the active treatment.

The findings were presented in a late breaking oral abstract session at the 2021 American Academy of Allergy, Asthma & Immunology virtual annual meeting (Abstract L2).

“A year ago, the Food and Drug Administration approved the oral agent Palforzia (peanut allergen powder) for the treatment of peanut allergy in children 4 and older, and it is a great option, but I think what we have learned over time is that this approach is not for everybody,” Edwin H. Kim, MD, director of the UNC Food Allergy Initiative, University of North Carolina at Chapel Hill, said in an interview.

Palforzia is a powder that is mixed in food like yogurt or pudding which the child then eats daily, according to a rigorous schedule. But Palforzia treatment presents some difficulties.

“Palforzia requires getting the powder dose, mixing it with food, like pudding or apple sauce, then eating it, which can take up to 30 minutes depending on age and kids’ cooperation. It tastes and smells like peanut which can cause aversion. Kids have to refrain from exercise or strenuous activity for at least 30 minutes before and after dosing and have to be observed for up to 2 hours post dose for symptoms,” Dr. Kim said.

“It’s a great drug, but the treatment could be overly difficult for certain families to be able to do, and in some cases the side effects may be more than certain patients are able or willing to handle, so there is a real urgent need for alternative approaches,” Dr. Kim said. “SLIT is several drops under the tongue, held for 2 minutes, swallowed and done.”

In the current placebo-controlled study, he and his group tested the feasibility, efficacy, and safety of the sublingual approach to peanut allergy in children age 4 years and younger.

Both groups were similar with regard to gender, race, ethnicity, atopic history, peanut skin prick test, and qualifying DBPCFC, and all children were previously allergic with positive blood and skin tests, with a positive reaction during baseline food challenge, thus proving the allergy and establishing the baseline threshold.

“We have learned from some studies, for instance the DEVIL and LEAP studies, that strongly suggest that the immune systems in younger patients may be more amenable to change, and there may be some justification for early intervention,” he said.

“Based on both of those ideas, we wanted to take our sublingual approach, which we have shown to have a pretty good efficacy in older children, and bring it down to this younger group and see if it still could have the same efficacy and also maintain what seems to be a very good safety signal.”

The researchers randomly assigned the children to receive PNSLIT at a daily maintenance dose of 4 mg peanut protein (n = 19) or to receive placebo (n = 17) for 36 months.

“There was a 5- to 6-month buildup period where the SLIT dose was increased every 1-2 weeks up to the target dose of 4 mg, and then the final dose of 4 mg was continued through to the end of the study,” Dr. Kim noted.

Over a total of 20,593 potential dosing days, the children took 91.2% of SLIT doses and 93.5% of placebo doses.

At the end of the 3-year study period, the children were challenged by DBPCFC with up to 4,333 mg of peanut protein.

Sustained unresponsiveness was assessed by an identical DBPCFC after discontinuation of the immunotherapy for 3 months.

Cumulative tolerated dose increased from a median of 143 mg to 4,443 mg in the PNSLIT group, compared with a median of 43 mg to 143 mg in the placebo group (P < .0001).

Fourteen of the children receiving PNSLIT, and none of the children receiving placebo, passed the desensitization food challenge. Twelve of the children receiving PNSLIT and two of the children receiving placebo passed the sustained unresponsiveness challenge.

Children who underwent the immunotherapy saw a decrease in their peanut skin prick test from 10 mm to 3.25 mm, compared to an increase from 11.5 mm to 12 mm with placebo (P < .0001).

The most common side effect reported was itching or irritation in the mouth. Most side effects resolved on their own, although some patients used an antihistamine. Getting children as young as 1 to hold the dose under their tongue was a challenge in some instances, but it eventually worked out, Dr. Kim said.

“It took a lot of work from the parents as well as from our research coordinators in trying to train these young kids to, first of all, allow us to put the peanut medication in the mouth and then to try as best as possible to keep it in their mouth for up to 2 minutes, but the families involved in our study were very dedicated and so we were able to get through that,” he said.
 

Study merits larger numbers

“Among the 36 who completed the 3 years of therapy, the authors report significant rates of desensitization among treated children compared with those receiving placebo. Furthermore, this effect was persistent for at least 3 months after stopping therapy in a subgroup of the children,” said Leonard B. Bacharier, MD, director of the Center for Pediatric Asthma, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn.

“Overall, these findings suggest the promise of peanut SLIT, which should be studied in larger numbers of preschool children,” Dr. Bacharier, who was not part of the study, said in an interview.

Jonathan A. Bernstein, MD, professor of medicine, University of Cincinnati, agreed.

“It’s a well-designed study, it’s small, but it’s promising,” Dr. Bernstein, who was not involved with the study, said in an interview.

“They did show that most of the patients who got the sublingual therapy were able to get to the target dose and develop tolerance, so I think it’s promising. We know that this stuff works. This is just more data from a well-controlled study in a younger population,” he said.

“We do OIT [oral immunotherapy] and sublingual but we don’t do it in such young children in our practice. The youngest is 3 years old, because they have to understand what is going on and cooperate. If they don’t cooperate it’s not possible.”

Dr. Kim reported financial relationships with DBV Technologies, Kenota Health, Ukko, Aimmune Therapeutics, ALK, AllerGenis, Belhaven Pharma, Duke Clinical Research Institute, Nutricia, NIH/NIAID, NIH/NCCIH, NIH/Immune Tolerance Network, FARE, and the Wallace Foundation. Dr. Bacharier and Dr. Bernstein have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Sublingual immunotherapy for the treatment of peanut allergy is safe and effective, even in children as young as age 1 year.

In a double-blind, placebo-controlled, food challenge (DBPCFC) of some 36 peanut-allergic children (mean age 2.2 years, range 1-4 years), those who were randomly assigned to receive peanut sublingual immunotherapy (PNSLIT) showed significant desensitization compared with those who received placebo.

In addition, there was a “strong potential” for sustained unresponsiveness at 3 months for the toddlers who received the active treatment.

The findings were presented in a late breaking oral abstract session at the 2021 American Academy of Allergy, Asthma & Immunology virtual annual meeting (Abstract L2).

“A year ago, the Food and Drug Administration approved the oral agent Palforzia (peanut allergen powder) for the treatment of peanut allergy in children 4 and older, and it is a great option, but I think what we have learned over time is that this approach is not for everybody,” Edwin H. Kim, MD, director of the UNC Food Allergy Initiative, University of North Carolina at Chapel Hill, said in an interview.

Palforzia is a powder that is mixed in food like yogurt or pudding which the child then eats daily, according to a rigorous schedule. But Palforzia treatment presents some difficulties.

“Palforzia requires getting the powder dose, mixing it with food, like pudding or apple sauce, then eating it, which can take up to 30 minutes depending on age and kids’ cooperation. It tastes and smells like peanut which can cause aversion. Kids have to refrain from exercise or strenuous activity for at least 30 minutes before and after dosing and have to be observed for up to 2 hours post dose for symptoms,” Dr. Kim said.

“It’s a great drug, but the treatment could be overly difficult for certain families to be able to do, and in some cases the side effects may be more than certain patients are able or willing to handle, so there is a real urgent need for alternative approaches,” Dr. Kim said. “SLIT is several drops under the tongue, held for 2 minutes, swallowed and done.”

In the current placebo-controlled study, he and his group tested the feasibility, efficacy, and safety of the sublingual approach to peanut allergy in children age 4 years and younger.

Both groups were similar with regard to gender, race, ethnicity, atopic history, peanut skin prick test, and qualifying DBPCFC, and all children were previously allergic with positive blood and skin tests, with a positive reaction during baseline food challenge, thus proving the allergy and establishing the baseline threshold.

“We have learned from some studies, for instance the DEVIL and LEAP studies, that strongly suggest that the immune systems in younger patients may be more amenable to change, and there may be some justification for early intervention,” he said.

“Based on both of those ideas, we wanted to take our sublingual approach, which we have shown to have a pretty good efficacy in older children, and bring it down to this younger group and see if it still could have the same efficacy and also maintain what seems to be a very good safety signal.”

The researchers randomly assigned the children to receive PNSLIT at a daily maintenance dose of 4 mg peanut protein (n = 19) or to receive placebo (n = 17) for 36 months.

“There was a 5- to 6-month buildup period where the SLIT dose was increased every 1-2 weeks up to the target dose of 4 mg, and then the final dose of 4 mg was continued through to the end of the study,” Dr. Kim noted.

Over a total of 20,593 potential dosing days, the children took 91.2% of SLIT doses and 93.5% of placebo doses.

At the end of the 3-year study period, the children were challenged by DBPCFC with up to 4,333 mg of peanut protein.

Sustained unresponsiveness was assessed by an identical DBPCFC after discontinuation of the immunotherapy for 3 months.

Cumulative tolerated dose increased from a median of 143 mg to 4,443 mg in the PNSLIT group, compared with a median of 43 mg to 143 mg in the placebo group (P < .0001).

Fourteen of the children receiving PNSLIT, and none of the children receiving placebo, passed the desensitization food challenge. Twelve of the children receiving PNSLIT and two of the children receiving placebo passed the sustained unresponsiveness challenge.

Children who underwent the immunotherapy saw a decrease in their peanut skin prick test from 10 mm to 3.25 mm, compared to an increase from 11.5 mm to 12 mm with placebo (P < .0001).

The most common side effect reported was itching or irritation in the mouth. Most side effects resolved on their own, although some patients used an antihistamine. Getting children as young as 1 to hold the dose under their tongue was a challenge in some instances, but it eventually worked out, Dr. Kim said.

“It took a lot of work from the parents as well as from our research coordinators in trying to train these young kids to, first of all, allow us to put the peanut medication in the mouth and then to try as best as possible to keep it in their mouth for up to 2 minutes, but the families involved in our study were very dedicated and so we were able to get through that,” he said.
 

Study merits larger numbers

“Among the 36 who completed the 3 years of therapy, the authors report significant rates of desensitization among treated children compared with those receiving placebo. Furthermore, this effect was persistent for at least 3 months after stopping therapy in a subgroup of the children,” said Leonard B. Bacharier, MD, director of the Center for Pediatric Asthma, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn.

“Overall, these findings suggest the promise of peanut SLIT, which should be studied in larger numbers of preschool children,” Dr. Bacharier, who was not part of the study, said in an interview.

Jonathan A. Bernstein, MD, professor of medicine, University of Cincinnati, agreed.

“It’s a well-designed study, it’s small, but it’s promising,” Dr. Bernstein, who was not involved with the study, said in an interview.

“They did show that most of the patients who got the sublingual therapy were able to get to the target dose and develop tolerance, so I think it’s promising. We know that this stuff works. This is just more data from a well-controlled study in a younger population,” he said.

“We do OIT [oral immunotherapy] and sublingual but we don’t do it in such young children in our practice. The youngest is 3 years old, because they have to understand what is going on and cooperate. If they don’t cooperate it’s not possible.”

Dr. Kim reported financial relationships with DBV Technologies, Kenota Health, Ukko, Aimmune Therapeutics, ALK, AllerGenis, Belhaven Pharma, Duke Clinical Research Institute, Nutricia, NIH/NIAID, NIH/NCCIH, NIH/Immune Tolerance Network, FARE, and the Wallace Foundation. Dr. Bacharier and Dr. Bernstein have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

As Jade Myers set out to help create the virtual platform for SHM Converge, she was aware, through surveys and other communication, that the top wish of members of the Society of Hospital Medicine was an extensive and interactive educational experience.

“People really wanted to get back to the in-person conference,” said Ms. Myers, SHM’s director of meetings. “While we couldn’t do that, we can provide the same caliber and as robust an experience from an educational perspective as we would for an in-person activity.”

That has required significant revamping of the virtual platform compared to the platform for last year’s annual conference. In 2020, there was only one session running live at a time. This year, there will be 12 sessions running at the same time. There will also be more opportunities for networking, as well as other features for enjoyment and a sense of calm.

Here are some features of the SHM Converge platform:

• A host segment to kick-start each day, with an introduction of the day’s sessions and events.
• Nine didactic educational sessions at any given time. These sessions will include a live chat for peer-to-peer engagement, as well as questions and answers throughout the session to continue the discussion between speakers and participants.
• Three workshops at any given time. These sessions – on topics such as communication, gender equity, and clinical guidelines – will provide an opportunity for dynamic small-group discussion.
• A scientific abstract poster competition and reception, with an e-gallery of about 700 posters, providing a networking opportunity and highlighting emerging scientific and clinical cases.
• Special Interest Forums, in the form of live, interactive Zoom conferences. There will be 25 forums, which are designed to build community and facilitate collaboration.
• A variety of games, including trivia and a word scramble.
• Personalized profiles with information such as “Hospitalist in Training,” or “Committee Member.” These will be visible to other attendees to make it easier for people to connect when they have something in common.
• Early- and Mid-Career Speed Mentorship, in which a mentor and mentee can interact one-on-one, with each mentee able to meet with two mentors, with pairings designed for the best mentorship experience.
• Sessions on wellness and resilience.

“People are kind of Zoom fatigued,” Ms. Myers said, “so we’re trying to meet their needs while also offering an opportunity for respite, because our attendees are on the front lines right now, and they’re dealing with all types of fatigue and challenging times.”

The annual conference was on target for a banner year in 2020 before the COVID-19 pandemic forced the cancellation of the in-person conference in San Diego, and SHM Converge is a product of planning that began then, as organizers started considering a virtual event.

“In 2020, we were slated to have the largest conference in person that we have ever had,” said Hayleigh Scott, SHM’s meeting projects manager. “San Diego was going to be our really big year.”

But attendance at last year’s virtual conference was a fraction of what was expected at the in-person conference. This year, that seems poised to improve. There will be many more offerings, with more than 125 AMA PRA Category 1 Credits™ and 45 Maintenance of Certification points possible, Ms. Myers said. Because attendees won’t have to worry about being in two places at once, it will be possible to secure more CME credits at SHM Converge than at any previous SHM annual conference, she said.

The volume of content will be a heavy load on SHM personnel. Last year, three society staff members were on hand at each session to make sure it ran smoothly and to answer questions. With 12 sessions running simultaneously this year, many more staff members will need to be involved. But that is not unfamiliar for the society during meeting week, Ms. Myers said.

“We’re going to need to pull from pretty much our entire staff in order to make this conference happen, which is exciting and daunting,” she said. “It’s always been an all-hands-on-deck program and this is going to be more similar to an in-person conference in that way.”

As Jade Myers set out to help create the virtual platform for SHM Converge, she was aware, through surveys and other communication, that the top wish of members of the Society of Hospital Medicine was an extensive and interactive educational experience.

“People really wanted to get back to the in-person conference,” said Ms. Myers, SHM’s director of meetings. “While we couldn’t do that, we can provide the same caliber and as robust an experience from an educational perspective as we would for an in-person activity.”

That has required significant revamping of the virtual platform compared to the platform for last year’s annual conference. In 2020, there was only one session running live at a time. This year, there will be 12 sessions running at the same time. There will also be more opportunities for networking, as well as other features for enjoyment and a sense of calm.

Here are some features of the SHM Converge platform:

• A host segment to kick-start each day, with an introduction of the day’s sessions and events.
• Nine didactic educational sessions at any given time. These sessions will include a live chat for peer-to-peer engagement, as well as questions and answers throughout the session to continue the discussion between speakers and participants.
• Three workshops at any given time. These sessions – on topics such as communication, gender equity, and clinical guidelines – will provide an opportunity for dynamic small-group discussion.
• A scientific abstract poster competition and reception, with an e-gallery of about 700 posters, providing a networking opportunity and highlighting emerging scientific and clinical cases.
• Special Interest Forums, in the form of live, interactive Zoom conferences. There will be 25 forums, which are designed to build community and facilitate collaboration.
• A variety of games, including trivia and a word scramble.
• Personalized profiles with information such as “Hospitalist in Training,” or “Committee Member.” These will be visible to other attendees to make it easier for people to connect when they have something in common.
• Early- and Mid-Career Speed Mentorship, in which a mentor and mentee can interact one-on-one, with each mentee able to meet with two mentors, with pairings designed for the best mentorship experience.
• Sessions on wellness and resilience.

“People are kind of Zoom fatigued,” Ms. Myers said, “so we’re trying to meet their needs while also offering an opportunity for respite, because our attendees are on the front lines right now, and they’re dealing with all types of fatigue and challenging times.”

The annual conference was on target for a banner year in 2020 before the COVID-19 pandemic forced the cancellation of the in-person conference in San Diego, and SHM Converge is a product of planning that began then, as organizers started considering a virtual event.

“In 2020, we were slated to have the largest conference in person that we have ever had,” said Hayleigh Scott, SHM’s meeting projects manager. “San Diego was going to be our really big year.”

But attendance at last year’s virtual conference was a fraction of what was expected at the in-person conference. This year, that seems poised to improve. There will be many more offerings, with more than 125 AMA PRA Category 1 Credits™ and 45 Maintenance of Certification points possible, Ms. Myers said. Because attendees won’t have to worry about being in two places at once, it will be possible to secure more CME credits at SHM Converge than at any previous SHM annual conference, she said.

The volume of content will be a heavy load on SHM personnel. Last year, three society staff members were on hand at each session to make sure it ran smoothly and to answer questions. With 12 sessions running simultaneously this year, many more staff members will need to be involved. But that is not unfamiliar for the society during meeting week, Ms. Myers said.

“We’re going to need to pull from pretty much our entire staff in order to make this conference happen, which is exciting and daunting,” she said. “It’s always been an all-hands-on-deck program and this is going to be more similar to an in-person conference in that way.”

As Jade Myers set out to help create the virtual platform for SHM Converge, she was aware, through surveys and other communication, that the top wish of members of the Society of Hospital Medicine was an extensive and interactive educational experience.

“People really wanted to get back to the in-person conference,” said Ms. Myers, SHM’s director of meetings. “While we couldn’t do that, we can provide the same caliber and as robust an experience from an educational perspective as we would for an in-person activity.”

That has required significant revamping of the virtual platform compared to the platform for last year’s annual conference. In 2020, there was only one session running live at a time. This year, there will be 12 sessions running at the same time. There will also be more opportunities for networking, as well as other features for enjoyment and a sense of calm.

Here are some features of the SHM Converge platform:

• A host segment to kick-start each day, with an introduction of the day’s sessions and events.
• Nine didactic educational sessions at any given time. These sessions will include a live chat for peer-to-peer engagement, as well as questions and answers throughout the session to continue the discussion between speakers and participants.
• Three workshops at any given time. These sessions – on topics such as communication, gender equity, and clinical guidelines – will provide an opportunity for dynamic small-group discussion.
• A scientific abstract poster competition and reception, with an e-gallery of about 700 posters, providing a networking opportunity and highlighting emerging scientific and clinical cases.
• Special Interest Forums, in the form of live, interactive Zoom conferences. There will be 25 forums, which are designed to build community and facilitate collaboration.
• A variety of games, including trivia and a word scramble.
• Personalized profiles with information such as “Hospitalist in Training,” or “Committee Member.” These will be visible to other attendees to make it easier for people to connect when they have something in common.
• Early- and Mid-Career Speed Mentorship, in which a mentor and mentee can interact one-on-one, with each mentee able to meet with two mentors, with pairings designed for the best mentorship experience.
• Sessions on wellness and resilience.

“People are kind of Zoom fatigued,” Ms. Myers said, “so we’re trying to meet their needs while also offering an opportunity for respite, because our attendees are on the front lines right now, and they’re dealing with all types of fatigue and challenging times.”

The annual conference was on target for a banner year in 2020 before the COVID-19 pandemic forced the cancellation of the in-person conference in San Diego, and SHM Converge is a product of planning that began then, as organizers started considering a virtual event.

“In 2020, we were slated to have the largest conference in person that we have ever had,” said Hayleigh Scott, SHM’s meeting projects manager. “San Diego was going to be our really big year.”

But attendance at last year’s virtual conference was a fraction of what was expected at the in-person conference. This year, that seems poised to improve. There will be many more offerings, with more than 125 AMA PRA Category 1 Credits™ and 45 Maintenance of Certification points possible, Ms. Myers said. Because attendees won’t have to worry about being in two places at once, it will be possible to secure more CME credits at SHM Converge than at any previous SHM annual conference, she said.

The volume of content will be a heavy load on SHM personnel. Last year, three society staff members were on hand at each session to make sure it ran smoothly and to answer questions. With 12 sessions running simultaneously this year, many more staff members will need to be involved. But that is not unfamiliar for the society during meeting week, Ms. Myers said.

“We’re going to need to pull from pretty much our entire staff in order to make this conference happen, which is exciting and daunting,” she said. “It’s always been an all-hands-on-deck program and this is going to be more similar to an in-person conference in that way.”

With dozens and dozens of sessions on the SHM Converge program, picking what to go to can feel virtually impossible.

The editorial board of The Hospitalist is here to help. With knowledge in an array of subspecialties – and experience in attending many SHM annual conferences, they have pointed out sessions they consider “must see,” whether based on the importance of the topic, the entertainment aspect, or the dynamic qualities of the speakers.

Here are their selections:
 

Ilaria Gadalla, DMSc, PA-C, physician assistant department chair, South University, West Palm Beach, Fla.

What You Say, What They Hear: Conversations with Your Hospital C-suite (Tuesday, May 4, 1:40 p.m. to 2:40 p.m.)

“As a department leader, developing my communication skills is always an area I seek to improve,” Dr. Gadalla said. “Tips to help with interpreting the audience and tailoring presentations for receptive feedback are invaluable tools.”

Hiring the Right Hospitalist: The Other Kind of Choosing Wisely (Wednesday, May 5, 2 p.m. to 3 p.m.)

“[This] is also an interesting session – selection criteria in the age of virtual interviewing is challenging,” she said. “I look forward to benefiting from my colleagues’ experience to enhance my leadership style.”

Shyam Odeti, MD, SFHM, FAAFP, MBA, hospitalist at Ballad Health, Johnson City, Tenn.

Understanding High-Value Care: Cost, Rationing, Overuse, and Underuse: Workshop (Tuesday May 4, 1:40 p.m. to 2:40 p.m.)

“Health care in the U.S. is expensive, and we have to pay utmost attention to the cost while providing the highest-quality medical care and service to sustain the health care,” Dr. Odeti said. “I am excited about this workshop organized by Dr. Justin Glasgow, Dr. Sarah Baron, Dr. Mona Krouss, and Dr. Harry Cho. I have known these leaders in the health care quality and patient safety arena over several years and their immense contributions to their organizations and the quality improvement special interest group of SHM. This workshop will help us understand how to define value in health care, implement high-value care, and eliminate low-value care.”

Hospitalists Piloting the Twin Engines of the Mid-Revenue Cycle Ship: A Primer on Utilization Management and Clinical Documentation Improvement (Thursday, May 6, 2:30 p.m. to 3:30 p.m.)

“The business of running hospitals carries with it many financial challenges,” Dr. Odeti said. “The intersection of tremendous fixed overhead and the vagaries of payer behavior is the cause. The COVID-19 pandemic and its devastating impact have compounded the problem. Hospitalists are natural institution leaders who are fundamental in overcoming this impasse through taking command and piloting the twin-engine ship of utilization management and clinical documentation improvement. These two domains working in synergy with experienced pilots are critical to attaining both high-quality care and the long-term viability of our health care systems. Dr. Aziz Ansari has been an expert in this domain and a highly sought-after speaker at SHM annual conferences. His sessions are incredibly captivating and educational.”

Harry Cho, MD, FACP, SFHM, chief value officer at NYC Health+ Hospitals

Medical Jeopardy (Thursday, May 6, 2:30 p.m. to 3:10 p.m.)

“[I am] always looking forward to a fun-filled session for medical learning with this fantastic group of facilitators,” Dr. Cho said.

Back to the Future - Things I Wish I Knew Earlier in my Career (Wednesday, May 5, 3:50 p.m. to 4:30 p.m.)

“Listening to Brad Sharpe brings me back to the days in training, eagerly absorbing every pearl of wisdom from mentors,” he said.

Marina Farah, MD, MHA, performance improvement consultant, FarahMD Consulting, Corvallis, Ore.

James Kim, MD, associate professor of medicine, Emory University, Atlanta

Health Equity and Disparities in Hospitalized Patients (Tuesday, May 4, 3:30 p.m. to 4:10 p.m. )

“[Kimberly Manning, MD] is an amazing speaker, and I know that this is a topic that she can speak about both eloquently and passionately,” Dr. Kim said. “She has been advocating for her patients at Grady for years and so this is something that she has first-hand experience about.”

Top 5 Clinical Practice Guidelines Every Hospitalist Needs to Know: Workshop (Wednesday, May 5, 3:50 p.m. to 4:50 p.m. )

“This sounds like a high-yield session,” he said. “For busy clinicians, being able to know what guidelines should affect your daily practice is extremely important.”

Lonika Sood, MD, MHPE, FACP, FHM, clinical education director of internal medicine, Washington State University, Spokane

Anika Kumar, MD, FAAP, FHM, assistant professor of pediatrics, Cleveland Clinic Lerner College of Medicine

Fireside Chat: Story-telling and the Nocturnist in Pediatrics (Tuesday, May 4, 3:30 p.m. to 4:50 p.m.)

“I look forward to their discussion about storytelling and the role narrative medicine plays in patient care, especially pediatrics,” Dr. Kumar said.

Febrile Infant Update (Thursday, May 6, 3:10 p.m. to 3:50 p.m.)

“This clinical update session with Dr. Russell McCulloh will be exciting, as caring for febrile infants is bread-and-butter pediatric hospital medicine,” she said. “And this update will help review new research in this diagnosis.”

Kranthi Sitammagari, MD, FACP, CHCQM-PHYADV, director of clinical operations, quality, and patient experience, Atrium Health Hospitalist Group, Monroe, N.C.

Any session in the “Clinical Updates” and “Quality” tracks

“I would recommend ‘Clinical Updates’ and ‘Quality’ sessions, as they are so close to my practice and I look forward to those sessions,” Dr. Sitammagari said. “Clinical Updates provide the latest updates in clinical practice which is very useful for everyday patient management for hospitalists. Quality sessions discuss innovative ways to improve the quality of hospitalist practice.”

Raman Palabindala, MD, SFHM, medical director of utilization management, University of Mississippi Medical Center, Jackson

Medical Jeopardy (Thursday, May 6, 2:30 p.m. to 3:10 p.m.)

“I will always promote my fun event, Medical Jeopardy (Dr. Palabindala is a moderator). It is going to be a challenge between three great attendings from three great organizations across the country to win the national Jeopardy competition. Not only will you learn a lot, but you also will have a lot of fun. I am sure it is going to be more entertaining this time, given virtual play.”

LAMA’s DRAMA: Left AMA – Documentation & Rules of AMA (Friday, May 7, 3:30 p.m. to 4:30 p.m.)

“I also recommend the talk by Dr. Medarametla not just for the title LAMA DRAMA (for ‘left against medical advice’),” he said. “We all need to learn this one to the core and I am sure he will deliver the most engaging presentation.”

With dozens and dozens of sessions on the SHM Converge program, picking what to go to can feel virtually impossible.

The editorial board of The Hospitalist is here to help. With knowledge in an array of subspecialties – and experience in attending many SHM annual conferences, they have pointed out sessions they consider “must see,” whether based on the importance of the topic, the entertainment aspect, or the dynamic qualities of the speakers.

Here are their selections:
 

Ilaria Gadalla, DMSc, PA-C, physician assistant department chair, South University, West Palm Beach, Fla.

What You Say, What They Hear: Conversations with Your Hospital C-suite (Tuesday, May 4, 1:40 p.m. to 2:40 p.m.)

“As a department leader, developing my communication skills is always an area I seek to improve,” Dr. Gadalla said. “Tips to help with interpreting the audience and tailoring presentations for receptive feedback are invaluable tools.”

Hiring the Right Hospitalist: The Other Kind of Choosing Wisely (Wednesday, May 5, 2 p.m. to 3 p.m.)

“[This] is also an interesting session – selection criteria in the age of virtual interviewing is challenging,” she said. “I look forward to benefiting from my colleagues’ experience to enhance my leadership style.”

Shyam Odeti, MD, SFHM, FAAFP, MBA, hospitalist at Ballad Health, Johnson City, Tenn.

Understanding High-Value Care: Cost, Rationing, Overuse, and Underuse: Workshop (Tuesday May 4, 1:40 p.m. to 2:40 p.m.)

“Health care in the U.S. is expensive, and we have to pay utmost attention to the cost while providing the highest-quality medical care and service to sustain the health care,” Dr. Odeti said. “I am excited about this workshop organized by Dr. Justin Glasgow, Dr. Sarah Baron, Dr. Mona Krouss, and Dr. Harry Cho. I have known these leaders in the health care quality and patient safety arena over several years and their immense contributions to their organizations and the quality improvement special interest group of SHM. This workshop will help us understand how to define value in health care, implement high-value care, and eliminate low-value care.”

Hospitalists Piloting the Twin Engines of the Mid-Revenue Cycle Ship: A Primer on Utilization Management and Clinical Documentation Improvement (Thursday, May 6, 2:30 p.m. to 3:30 p.m.)

“The business of running hospitals carries with it many financial challenges,” Dr. Odeti said. “The intersection of tremendous fixed overhead and the vagaries of payer behavior is the cause. The COVID-19 pandemic and its devastating impact have compounded the problem. Hospitalists are natural institution leaders who are fundamental in overcoming this impasse through taking command and piloting the twin-engine ship of utilization management and clinical documentation improvement. These two domains working in synergy with experienced pilots are critical to attaining both high-quality care and the long-term viability of our health care systems. Dr. Aziz Ansari has been an expert in this domain and a highly sought-after speaker at SHM annual conferences. His sessions are incredibly captivating and educational.”

Harry Cho, MD, FACP, SFHM, chief value officer at NYC Health+ Hospitals

Medical Jeopardy (Thursday, May 6, 2:30 p.m. to 3:10 p.m.)

“[I am] always looking forward to a fun-filled session for medical learning with this fantastic group of facilitators,” Dr. Cho said.

Back to the Future - Things I Wish I Knew Earlier in my Career (Wednesday, May 5, 3:50 p.m. to 4:30 p.m.)

“Listening to Brad Sharpe brings me back to the days in training, eagerly absorbing every pearl of wisdom from mentors,” he said.

Marina Farah, MD, MHA, performance improvement consultant, FarahMD Consulting, Corvallis, Ore.

James Kim, MD, associate professor of medicine, Emory University, Atlanta

Health Equity and Disparities in Hospitalized Patients (Tuesday, May 4, 3:30 p.m. to 4:10 p.m. )

“[Kimberly Manning, MD] is an amazing speaker, and I know that this is a topic that she can speak about both eloquently and passionately,” Dr. Kim said. “She has been advocating for her patients at Grady for years and so this is something that she has first-hand experience about.”

Top 5 Clinical Practice Guidelines Every Hospitalist Needs to Know: Workshop (Wednesday, May 5, 3:50 p.m. to 4:50 p.m. )

“This sounds like a high-yield session,” he said. “For busy clinicians, being able to know what guidelines should affect your daily practice is extremely important.”

Lonika Sood, MD, MHPE, FACP, FHM, clinical education director of internal medicine, Washington State University, Spokane

Anika Kumar, MD, FAAP, FHM, assistant professor of pediatrics, Cleveland Clinic Lerner College of Medicine

Fireside Chat: Story-telling and the Nocturnist in Pediatrics (Tuesday, May 4, 3:30 p.m. to 4:50 p.m.)

“I look forward to their discussion about storytelling and the role narrative medicine plays in patient care, especially pediatrics,” Dr. Kumar said.

Febrile Infant Update (Thursday, May 6, 3:10 p.m. to 3:50 p.m.)

“This clinical update session with Dr. Russell McCulloh will be exciting, as caring for febrile infants is bread-and-butter pediatric hospital medicine,” she said. “And this update will help review new research in this diagnosis.”

Kranthi Sitammagari, MD, FACP, CHCQM-PHYADV, director of clinical operations, quality, and patient experience, Atrium Health Hospitalist Group, Monroe, N.C.

Any session in the “Clinical Updates” and “Quality” tracks

“I would recommend ‘Clinical Updates’ and ‘Quality’ sessions, as they are so close to my practice and I look forward to those sessions,” Dr. Sitammagari said. “Clinical Updates provide the latest updates in clinical practice which is very useful for everyday patient management for hospitalists. Quality sessions discuss innovative ways to improve the quality of hospitalist practice.”

Raman Palabindala, MD, SFHM, medical director of utilization management, University of Mississippi Medical Center, Jackson

Medical Jeopardy (Thursday, May 6, 2:30 p.m. to 3:10 p.m.)

“I will always promote my fun event, Medical Jeopardy (Dr. Palabindala is a moderator). It is going to be a challenge between three great attendings from three great organizations across the country to win the national Jeopardy competition. Not only will you learn a lot, but you also will have a lot of fun. I am sure it is going to be more entertaining this time, given virtual play.”

LAMA’s DRAMA: Left AMA – Documentation & Rules of AMA (Friday, May 7, 3:30 p.m. to 4:30 p.m.)

“I also recommend the talk by Dr. Medarametla not just for the title LAMA DRAMA (for ‘left against medical advice’),” he said. “We all need to learn this one to the core and I am sure he will deliver the most engaging presentation.”

With dozens and dozens of sessions on the SHM Converge program, picking what to go to can feel virtually impossible.

The editorial board of The Hospitalist is here to help. With knowledge in an array of subspecialties – and experience in attending many SHM annual conferences, they have pointed out sessions they consider “must see,” whether based on the importance of the topic, the entertainment aspect, or the dynamic qualities of the speakers.

Here are their selections:
 

Ilaria Gadalla, DMSc, PA-C, physician assistant department chair, South University, West Palm Beach, Fla.

What You Say, What They Hear: Conversations with Your Hospital C-suite (Tuesday, May 4, 1:40 p.m. to 2:40 p.m.)

“As a department leader, developing my communication skills is always an area I seek to improve,” Dr. Gadalla said. “Tips to help with interpreting the audience and tailoring presentations for receptive feedback are invaluable tools.”

Hiring the Right Hospitalist: The Other Kind of Choosing Wisely (Wednesday, May 5, 2 p.m. to 3 p.m.)

“[This] is also an interesting session – selection criteria in the age of virtual interviewing is challenging,” she said. “I look forward to benefiting from my colleagues’ experience to enhance my leadership style.”

Shyam Odeti, MD, SFHM, FAAFP, MBA, hospitalist at Ballad Health, Johnson City, Tenn.

Understanding High-Value Care: Cost, Rationing, Overuse, and Underuse: Workshop (Tuesday May 4, 1:40 p.m. to 2:40 p.m.)

“Health care in the U.S. is expensive, and we have to pay utmost attention to the cost while providing the highest-quality medical care and service to sustain the health care,” Dr. Odeti said. “I am excited about this workshop organized by Dr. Justin Glasgow, Dr. Sarah Baron, Dr. Mona Krouss, and Dr. Harry Cho. I have known these leaders in the health care quality and patient safety arena over several years and their immense contributions to their organizations and the quality improvement special interest group of SHM. This workshop will help us understand how to define value in health care, implement high-value care, and eliminate low-value care.”

Hospitalists Piloting the Twin Engines of the Mid-Revenue Cycle Ship: A Primer on Utilization Management and Clinical Documentation Improvement (Thursday, May 6, 2:30 p.m. to 3:30 p.m.)

“The business of running hospitals carries with it many financial challenges,” Dr. Odeti said. “The intersection of tremendous fixed overhead and the vagaries of payer behavior is the cause. The COVID-19 pandemic and its devastating impact have compounded the problem. Hospitalists are natural institution leaders who are fundamental in overcoming this impasse through taking command and piloting the twin-engine ship of utilization management and clinical documentation improvement. These two domains working in synergy with experienced pilots are critical to attaining both high-quality care and the long-term viability of our health care systems. Dr. Aziz Ansari has been an expert in this domain and a highly sought-after speaker at SHM annual conferences. His sessions are incredibly captivating and educational.”

Harry Cho, MD, FACP, SFHM, chief value officer at NYC Health+ Hospitals

Medical Jeopardy (Thursday, May 6, 2:30 p.m. to 3:10 p.m.)

“[I am] always looking forward to a fun-filled session for medical learning with this fantastic group of facilitators,” Dr. Cho said.

Back to the Future - Things I Wish I Knew Earlier in my Career (Wednesday, May 5, 3:50 p.m. to 4:30 p.m.)

“Listening to Brad Sharpe brings me back to the days in training, eagerly absorbing every pearl of wisdom from mentors,” he said.

Marina Farah, MD, MHA, performance improvement consultant, FarahMD Consulting, Corvallis, Ore.

James Kim, MD, associate professor of medicine, Emory University, Atlanta

Health Equity and Disparities in Hospitalized Patients (Tuesday, May 4, 3:30 p.m. to 4:10 p.m. )

“[Kimberly Manning, MD] is an amazing speaker, and I know that this is a topic that she can speak about both eloquently and passionately,” Dr. Kim said. “She has been advocating for her patients at Grady for years and so this is something that she has first-hand experience about.”

Top 5 Clinical Practice Guidelines Every Hospitalist Needs to Know: Workshop (Wednesday, May 5, 3:50 p.m. to 4:50 p.m. )

“This sounds like a high-yield session,” he said. “For busy clinicians, being able to know what guidelines should affect your daily practice is extremely important.”

Lonika Sood, MD, MHPE, FACP, FHM, clinical education director of internal medicine, Washington State University, Spokane

Anika Kumar, MD, FAAP, FHM, assistant professor of pediatrics, Cleveland Clinic Lerner College of Medicine

Fireside Chat: Story-telling and the Nocturnist in Pediatrics (Tuesday, May 4, 3:30 p.m. to 4:50 p.m.)

“I look forward to their discussion about storytelling and the role narrative medicine plays in patient care, especially pediatrics,” Dr. Kumar said.

Febrile Infant Update (Thursday, May 6, 3:10 p.m. to 3:50 p.m.)

“This clinical update session with Dr. Russell McCulloh will be exciting, as caring for febrile infants is bread-and-butter pediatric hospital medicine,” she said. “And this update will help review new research in this diagnosis.”

Kranthi Sitammagari, MD, FACP, CHCQM-PHYADV, director of clinical operations, quality, and patient experience, Atrium Health Hospitalist Group, Monroe, N.C.

Any session in the “Clinical Updates” and “Quality” tracks

“I would recommend ‘Clinical Updates’ and ‘Quality’ sessions, as they are so close to my practice and I look forward to those sessions,” Dr. Sitammagari said. “Clinical Updates provide the latest updates in clinical practice which is very useful for everyday patient management for hospitalists. Quality sessions discuss innovative ways to improve the quality of hospitalist practice.”

Raman Palabindala, MD, SFHM, medical director of utilization management, University of Mississippi Medical Center, Jackson

Medical Jeopardy (Thursday, May 6, 2:30 p.m. to 3:10 p.m.)

“I will always promote my fun event, Medical Jeopardy (Dr. Palabindala is a moderator). It is going to be a challenge between three great attendings from three great organizations across the country to win the national Jeopardy competition. Not only will you learn a lot, but you also will have a lot of fun. I am sure it is going to be more entertaining this time, given virtual play.”

LAMA’s DRAMA: Left AMA – Documentation & Rules of AMA (Friday, May 7, 3:30 p.m. to 4:30 p.m.)

“I also recommend the talk by Dr. Medarametla not just for the title LAMA DRAMA (for ‘left against medical advice’),” he said. “We all need to learn this one to the core and I am sure he will deliver the most engaging presentation.”

Ingrid Pinzon, MD, FACP, was working as a medical assistant to a physician a decade ago when she heard the doctor prescribe ibuprofen to a woman who was in the latter stages of pregnancy. Dr. Pinzon was a doctor, having received her education and training in Colombia, but because she had emigrated to the United States and hadn’t yet completed her certification and training here, she was not recognized yet as an American physician.

But she knew that ibuprofen was not recommended during late-term pregnancy, and she was alarmed. She informed the physician of the mistake. The doctor headed to Google, Dr. Pinzon said, and called the patient to rescind the ibuprofen prescription. But she soon fired Dr. Pinzon, seemingly for having had the courage to speak up.

Dr. Pinzon, now medical director of care coordination at Emory Johns Creek Hospital in Atlanta, will describe her experience as an immigrant physician in the Society of Hospital Medicine Converge session: “A Walk in Our Shoes: Immigrant Physicians Sharing Their Stories.” She will be joined by Patricia O’Brien, MD, PhD, FAAP, a pediatric hospitalist in Tampa; Manpreet Malik, MD, a hospitalist at Emory University; and Benji Mathews, MD, SFHM, FACP, chief of hospital medicine at HealthPartners and associate professor at the University of Minnesota.

They will describe their struggles to find their way in the United States, along with the satisfaction of having hard work pay off with better lives for themselves and their families. And together, they’ll provide a variety of narratives that will show, contrary to how many Americans view immigrants, how the experiences of immigrants don’t follow the same path, but each one carves out a path of his or her own.

“The thrust of this is really storytelling, along with putting into context what we can do to help our hospitalist brothers and sisters who are immigrants, and shining the light on it,” Dr. O’Brien said.

Dr. Pinzon was working as a doctor for the Colombian government when she began receiving threats from soldiers in a guerrilla army, which didn’t agree with her alignment with the government. One day, a guerrilla soldier threatened her and her two daughters – aged 5 and 11 at the time – and accurately described her daughters’ whereabouts.

Less than a week later, she and her daughters flew from Bogota to the United States, never to return to Colombia.

“I dropped everything I had when I came here,” she said. An immigration attorney initially recommended that she marry an American man in order to stay in the United States. When Dr. Pinzon declined, they pursued political asylum, and she received it less than a year later.

For 3 years, she worked jobs as assistants in medical offices and in other jobs, well below her education level, as she guided her daughters through school and went through the U.S. medical certification process. She was besieged by doubt constantly, she said.

“I cried for 3 years in a row,” she said. “I wanted to go back to my country. I didn’t want to stay here.”

Finally, she did her medical residency between 2011 and 2014, and got a job with Emory. Her daughters are grown, and one is a doctor in general surgery residency. Dr. Pinzon said she is happy to care for patients, particularly those who are Spanish-speaking and struggle as she did. But she often encounters patients who don’t hide that they dislike her accent.

“I will mute the TV and I will say: ‘I have a strong accent and so I want to make sure communication is clear,’ ” she said. “We have to prove ourselves all of the time. I feel like I have to prove myself to my patients that I’m a good doctor all of the time.” American-born doctors, she added, “shouldn’t take for granted what they already have.”

Dr. O’Brien grew up in Ireland, but in the late 1980s, the country was in a serious recession, with unemployment close to 20%, and her father applied for residency in Canada and the United States. They were accepted in Canada first, and moved there in 1988. A few years later, her parents moved them to Florida.

“They knew in order for us to do well, we had to go abroad,” she said. Dr. O’Brien went to college, medical school and graduate school in Florida, and completed residency in Cincinnati. Feeling the tug of her birthplace, she moved back to Ireland and worked there for a couple years.

“I never really wanted to leave because it was my home,” she said. While there, she came to a new-found appreciation for the U.S. health care system. It’s true that, in Ireland, everyone is insured, but there long wait times – for example, up to 2 years for a sedated nonurgent MRI for a child. She once had to send a patient to Dublin in a taxi with a nurse because an ambulance was unavailable.

“After going back to Ireland, where – I honestly thought I was going to go back and settle there – I realized how visionary my parents were in moving us,” Dr. O’Brien said. “This system in the U.S., there are lot of things broken about it, but we have all the resources.”

She moved back to the United States in August 2016, during a period of anti-immigrant rhetoric.

Nonetheless, Dr. O’Brien said she is happy to be here despite the lack of tolerance she sees in a minority of the U.S. population.

“Have a bit of sensitivity toward your provider. Maybe they speak with an accent. Maybe they don’t speak English perfectly. Maybe they have a different skin color. But their intention is good and it’s to help you and improve your health,” she said.

Ingrid Pinzon, MD, FACP, was working as a medical assistant to a physician a decade ago when she heard the doctor prescribe ibuprofen to a woman who was in the latter stages of pregnancy. Dr. Pinzon was a doctor, having received her education and training in Colombia, but because she had emigrated to the United States and hadn’t yet completed her certification and training here, she was not recognized yet as an American physician.

But she knew that ibuprofen was not recommended during late-term pregnancy, and she was alarmed. She informed the physician of the mistake. The doctor headed to Google, Dr. Pinzon said, and called the patient to rescind the ibuprofen prescription. But she soon fired Dr. Pinzon, seemingly for having had the courage to speak up.

Dr. Pinzon, now medical director of care coordination at Emory Johns Creek Hospital in Atlanta, will describe her experience as an immigrant physician in the Society of Hospital Medicine Converge session: “A Walk in Our Shoes: Immigrant Physicians Sharing Their Stories.” She will be joined by Patricia O’Brien, MD, PhD, FAAP, a pediatric hospitalist in Tampa; Manpreet Malik, MD, a hospitalist at Emory University; and Benji Mathews, MD, SFHM, FACP, chief of hospital medicine at HealthPartners and associate professor at the University of Minnesota.

They will describe their struggles to find their way in the United States, along with the satisfaction of having hard work pay off with better lives for themselves and their families. And together, they’ll provide a variety of narratives that will show, contrary to how many Americans view immigrants, how the experiences of immigrants don’t follow the same path, but each one carves out a path of his or her own.

“The thrust of this is really storytelling, along with putting into context what we can do to help our hospitalist brothers and sisters who are immigrants, and shining the light on it,” Dr. O’Brien said.

Dr. Pinzon was working as a doctor for the Colombian government when she began receiving threats from soldiers in a guerrilla army, which didn’t agree with her alignment with the government. One day, a guerrilla soldier threatened her and her two daughters – aged 5 and 11 at the time – and accurately described her daughters’ whereabouts.

Less than a week later, she and her daughters flew from Bogota to the United States, never to return to Colombia.

“I dropped everything I had when I came here,” she said. An immigration attorney initially recommended that she marry an American man in order to stay in the United States. When Dr. Pinzon declined, they pursued political asylum, and she received it less than a year later.

For 3 years, she worked jobs as assistants in medical offices and in other jobs, well below her education level, as she guided her daughters through school and went through the U.S. medical certification process. She was besieged by doubt constantly, she said.

“I cried for 3 years in a row,” she said. “I wanted to go back to my country. I didn’t want to stay here.”

Finally, she did her medical residency between 2011 and 2014, and got a job with Emory. Her daughters are grown, and one is a doctor in general surgery residency. Dr. Pinzon said she is happy to care for patients, particularly those who are Spanish-speaking and struggle as she did. But she often encounters patients who don’t hide that they dislike her accent.

“I will mute the TV and I will say: ‘I have a strong accent and so I want to make sure communication is clear,’ ” she said. “We have to prove ourselves all of the time. I feel like I have to prove myself to my patients that I’m a good doctor all of the time.” American-born doctors, she added, “shouldn’t take for granted what they already have.”

Dr. O’Brien grew up in Ireland, but in the late 1980s, the country was in a serious recession, with unemployment close to 20%, and her father applied for residency in Canada and the United States. They were accepted in Canada first, and moved there in 1988. A few years later, her parents moved them to Florida.

“They knew in order for us to do well, we had to go abroad,” she said. Dr. O’Brien went to college, medical school and graduate school in Florida, and completed residency in Cincinnati. Feeling the tug of her birthplace, she moved back to Ireland and worked there for a couple years.

“I never really wanted to leave because it was my home,” she said. While there, she came to a new-found appreciation for the U.S. health care system. It’s true that, in Ireland, everyone is insured, but there long wait times – for example, up to 2 years for a sedated nonurgent MRI for a child. She once had to send a patient to Dublin in a taxi with a nurse because an ambulance was unavailable.

“After going back to Ireland, where – I honestly thought I was going to go back and settle there – I realized how visionary my parents were in moving us,” Dr. O’Brien said. “This system in the U.S., there are lot of things broken about it, but we have all the resources.”

She moved back to the United States in August 2016, during a period of anti-immigrant rhetoric.

Nonetheless, Dr. O’Brien said she is happy to be here despite the lack of tolerance she sees in a minority of the U.S. population.

“Have a bit of sensitivity toward your provider. Maybe they speak with an accent. Maybe they don’t speak English perfectly. Maybe they have a different skin color. But their intention is good and it’s to help you and improve your health,” she said.

Ingrid Pinzon, MD, FACP, was working as a medical assistant to a physician a decade ago when she heard the doctor prescribe ibuprofen to a woman who was in the latter stages of pregnancy. Dr. Pinzon was a doctor, having received her education and training in Colombia, but because she had emigrated to the United States and hadn’t yet completed her certification and training here, she was not recognized yet as an American physician.

But she knew that ibuprofen was not recommended during late-term pregnancy, and she was alarmed. She informed the physician of the mistake. The doctor headed to Google, Dr. Pinzon said, and called the patient to rescind the ibuprofen prescription. But she soon fired Dr. Pinzon, seemingly for having had the courage to speak up.

Dr. Pinzon, now medical director of care coordination at Emory Johns Creek Hospital in Atlanta, will describe her experience as an immigrant physician in the Society of Hospital Medicine Converge session: “A Walk in Our Shoes: Immigrant Physicians Sharing Their Stories.” She will be joined by Patricia O’Brien, MD, PhD, FAAP, a pediatric hospitalist in Tampa; Manpreet Malik, MD, a hospitalist at Emory University; and Benji Mathews, MD, SFHM, FACP, chief of hospital medicine at HealthPartners and associate professor at the University of Minnesota.

They will describe their struggles to find their way in the United States, along with the satisfaction of having hard work pay off with better lives for themselves and their families. And together, they’ll provide a variety of narratives that will show, contrary to how many Americans view immigrants, how the experiences of immigrants don’t follow the same path, but each one carves out a path of his or her own.

“The thrust of this is really storytelling, along with putting into context what we can do to help our hospitalist brothers and sisters who are immigrants, and shining the light on it,” Dr. O’Brien said.

Dr. Pinzon was working as a doctor for the Colombian government when she began receiving threats from soldiers in a guerrilla army, which didn’t agree with her alignment with the government. One day, a guerrilla soldier threatened her and her two daughters – aged 5 and 11 at the time – and accurately described her daughters’ whereabouts.

Less than a week later, she and her daughters flew from Bogota to the United States, never to return to Colombia.

“I dropped everything I had when I came here,” she said. An immigration attorney initially recommended that she marry an American man in order to stay in the United States. When Dr. Pinzon declined, they pursued political asylum, and she received it less than a year later.

For 3 years, she worked jobs as assistants in medical offices and in other jobs, well below her education level, as she guided her daughters through school and went through the U.S. medical certification process. She was besieged by doubt constantly, she said.

“I cried for 3 years in a row,” she said. “I wanted to go back to my country. I didn’t want to stay here.”

Finally, she did her medical residency between 2011 and 2014, and got a job with Emory. Her daughters are grown, and one is a doctor in general surgery residency. Dr. Pinzon said she is happy to care for patients, particularly those who are Spanish-speaking and struggle as she did. But she often encounters patients who don’t hide that they dislike her accent.

“I will mute the TV and I will say: ‘I have a strong accent and so I want to make sure communication is clear,’ ” she said. “We have to prove ourselves all of the time. I feel like I have to prove myself to my patients that I’m a good doctor all of the time.” American-born doctors, she added, “shouldn’t take for granted what they already have.”

Dr. O’Brien grew up in Ireland, but in the late 1980s, the country was in a serious recession, with unemployment close to 20%, and her father applied for residency in Canada and the United States. They were accepted in Canada first, and moved there in 1988. A few years later, her parents moved them to Florida.

“They knew in order for us to do well, we had to go abroad,” she said. Dr. O’Brien went to college, medical school and graduate school in Florida, and completed residency in Cincinnati. Feeling the tug of her birthplace, she moved back to Ireland and worked there for a couple years.

“I never really wanted to leave because it was my home,” she said. While there, she came to a new-found appreciation for the U.S. health care system. It’s true that, in Ireland, everyone is insured, but there long wait times – for example, up to 2 years for a sedated nonurgent MRI for a child. She once had to send a patient to Dublin in a taxi with a nurse because an ambulance was unavailable.

“After going back to Ireland, where – I honestly thought I was going to go back and settle there – I realized how visionary my parents were in moving us,” Dr. O’Brien said. “This system in the U.S., there are lot of things broken about it, but we have all the resources.”

She moved back to the United States in August 2016, during a period of anti-immigrant rhetoric.

Nonetheless, Dr. O’Brien said she is happy to be here despite the lack of tolerance she sees in a minority of the U.S. population.

“Have a bit of sensitivity toward your provider. Maybe they speak with an accent. Maybe they don’t speak English perfectly. Maybe they have a different skin color. But their intention is good and it’s to help you and improve your health,” she said.

An overview of five important advances in pulmonary and critical care medicine are on the agenda for the “Update in Pulmonary and Critical Care” session on Tuesday, May 4, at the virtual 2021 SHM Converge conference.

“I hope this session gives attendees a nice, broad look at advances both in the intensive care unit and in general pulmonary medicine,” said James Walter, MD, of Northwestern Medicine in Chicago, who serves as director of the session.

On the critical care medicine side, Dr. Walter will review the latest research on the efficacy of ascorbic acid in treating patients with severe sepsis and septic shock. “There was a lot of excitement and some skepticism about early results promising a really large treatment effect in giving critically ill patients with sepsis large doses of vitamin C,” Dr. Walter said. The last year has produced some high-quality randomized trials that have contributed to a better understanding of the potential effects ascorbic acid in sepsis can have, he noted.

Dr. Walter, who is also medical director of the Northwestern Lung Rescue Program, intends to discuss what he believes is a definitive trial regarding the benefit of preemptively starting critically ill patients with acute kidney injury on renal replacement therapy instead of waiting until there are specific clinical signs. “This has been another area of uncertainty in critical care and I think we finally have a very definitive answer with this high quality, randomized, controlled trial that I plan to review,” he said.

Though he said there have been a number of important advances in pulmonary medicine over the past year, Dr. Walter will highlight just two.

Up until recently, the antifibrotics nintedanib and pirfenidone have mostly been used in patients with idiopathic pulmonary fibrosis. However, recent research suggests there may be a potential benefit to using these drugs in patients with fibrotic lung disease outside of idiopathic pulmonary fibrosis. “I think this is an important advance for hospital medicine providers to be aware of,” said Dr. Walter.

He will also go over some large randomized controlled trials of the use of triple therapy – a combination of a long-acting beta agonist (LABA), a long-acting muscarinic antagonist (LAMA), and an inhaled corticosteroid in one inhaler – in chronic obstructive pulmonary disease. The trials looked at whether triple inhaler therapy was beneficial compared to the typical therapies used for COPD.

The session wouldn’t be complete without a nod to COVID-19, which Dr. Walter said has significantly changed the landscape for hospital medicine providers. He plans to discuss what he considers the most impactful study – the RECOVERY trial. This study looked at the role of dexamethasone in patients with more severe manifestations of SARS-CoV-2.

“From the incredible amount of data that’s come out in the last year about COVID, I think this is probably the trial that’s changed practice the most and shown the largest therapeutic benefit of all the pharmacotherapies,” Dr. Walter said. “It’s an important one for providers to be aware of in terms of what the trial shows and how it informs which patients are most likely to benefit from dexamethasone therapy.”

Dr. Walter hopes clinicians who participate in the session will leave with these takeaways:

• Be able to summarize recent trials of ascorbic acid in sepsis and think about how to incorporate – or not – the use of vitamin C in critically ill sepsis patients.
• A thorough understanding of when renal replacement therapy should be offered to critically ill patients with acute kidney dysfunction.
• Be able to discuss the impact of antifibrotic therapy in interstitial lung diseases outside of idiopathic pulmonary fibrosis.
• An understanding of the role of triple inhaler combinations in COPD.
• Be able to explain when dexamethasone is most likely to benefit hypoxemic patients with COVID-19.

An overview of five important advances in pulmonary and critical care medicine are on the agenda for the “Update in Pulmonary and Critical Care” session on Tuesday, May 4, at the virtual 2021 SHM Converge conference.

“I hope this session gives attendees a nice, broad look at advances both in the intensive care unit and in general pulmonary medicine,” said James Walter, MD, of Northwestern Medicine in Chicago, who serves as director of the session.

On the critical care medicine side, Dr. Walter will review the latest research on the efficacy of ascorbic acid in treating patients with severe sepsis and septic shock. “There was a lot of excitement and some skepticism about early results promising a really large treatment effect in giving critically ill patients with sepsis large doses of vitamin C,” Dr. Walter said. The last year has produced some high-quality randomized trials that have contributed to a better understanding of the potential effects ascorbic acid in sepsis can have, he noted.

Dr. Walter, who is also medical director of the Northwestern Lung Rescue Program, intends to discuss what he believes is a definitive trial regarding the benefit of preemptively starting critically ill patients with acute kidney injury on renal replacement therapy instead of waiting until there are specific clinical signs. “This has been another area of uncertainty in critical care and I think we finally have a very definitive answer with this high quality, randomized, controlled trial that I plan to review,” he said.

Though he said there have been a number of important advances in pulmonary medicine over the past year, Dr. Walter will highlight just two.

Up until recently, the antifibrotics nintedanib and pirfenidone have mostly been used in patients with idiopathic pulmonary fibrosis. However, recent research suggests there may be a potential benefit to using these drugs in patients with fibrotic lung disease outside of idiopathic pulmonary fibrosis. “I think this is an important advance for hospital medicine providers to be aware of,” said Dr. Walter.

He will also go over some large randomized controlled trials of the use of triple therapy – a combination of a long-acting beta agonist (LABA), a long-acting muscarinic antagonist (LAMA), and an inhaled corticosteroid in one inhaler – in chronic obstructive pulmonary disease. The trials looked at whether triple inhaler therapy was beneficial compared to the typical therapies used for COPD.

The session wouldn’t be complete without a nod to COVID-19, which Dr. Walter said has significantly changed the landscape for hospital medicine providers. He plans to discuss what he considers the most impactful study – the RECOVERY trial. This study looked at the role of dexamethasone in patients with more severe manifestations of SARS-CoV-2.

“From the incredible amount of data that’s come out in the last year about COVID, I think this is probably the trial that’s changed practice the most and shown the largest therapeutic benefit of all the pharmacotherapies,” Dr. Walter said. “It’s an important one for providers to be aware of in terms of what the trial shows and how it informs which patients are most likely to benefit from dexamethasone therapy.”

Dr. Walter hopes clinicians who participate in the session will leave with these takeaways:

• Be able to summarize recent trials of ascorbic acid in sepsis and think about how to incorporate – or not – the use of vitamin C in critically ill sepsis patients.
• A thorough understanding of when renal replacement therapy should be offered to critically ill patients with acute kidney dysfunction.
• Be able to discuss the impact of antifibrotic therapy in interstitial lung diseases outside of idiopathic pulmonary fibrosis.
• An understanding of the role of triple inhaler combinations in COPD.
• Be able to explain when dexamethasone is most likely to benefit hypoxemic patients with COVID-19.

An overview of five important advances in pulmonary and critical care medicine are on the agenda for the “Update in Pulmonary and Critical Care” session on Tuesday, May 4, at the virtual 2021 SHM Converge conference.

“I hope this session gives attendees a nice, broad look at advances both in the intensive care unit and in general pulmonary medicine,” said James Walter, MD, of Northwestern Medicine in Chicago, who serves as director of the session.

On the critical care medicine side, Dr. Walter will review the latest research on the efficacy of ascorbic acid in treating patients with severe sepsis and septic shock. “There was a lot of excitement and some skepticism about early results promising a really large treatment effect in giving critically ill patients with sepsis large doses of vitamin C,” Dr. Walter said. The last year has produced some high-quality randomized trials that have contributed to a better understanding of the potential effects ascorbic acid in sepsis can have, he noted.

Dr. Walter, who is also medical director of the Northwestern Lung Rescue Program, intends to discuss what he believes is a definitive trial regarding the benefit of preemptively starting critically ill patients with acute kidney injury on renal replacement therapy instead of waiting until there are specific clinical signs. “This has been another area of uncertainty in critical care and I think we finally have a very definitive answer with this high quality, randomized, controlled trial that I plan to review,” he said.

Though he said there have been a number of important advances in pulmonary medicine over the past year, Dr. Walter will highlight just two.

Up until recently, the antifibrotics nintedanib and pirfenidone have mostly been used in patients with idiopathic pulmonary fibrosis. However, recent research suggests there may be a potential benefit to using these drugs in patients with fibrotic lung disease outside of idiopathic pulmonary fibrosis. “I think this is an important advance for hospital medicine providers to be aware of,” said Dr. Walter.

He will also go over some large randomized controlled trials of the use of triple therapy – a combination of a long-acting beta agonist (LABA), a long-acting muscarinic antagonist (LAMA), and an inhaled corticosteroid in one inhaler – in chronic obstructive pulmonary disease. The trials looked at whether triple inhaler therapy was beneficial compared to the typical therapies used for COPD.

The session wouldn’t be complete without a nod to COVID-19, which Dr. Walter said has significantly changed the landscape for hospital medicine providers. He plans to discuss what he considers the most impactful study – the RECOVERY trial. This study looked at the role of dexamethasone in patients with more severe manifestations of SARS-CoV-2.

“From the incredible amount of data that’s come out in the last year about COVID, I think this is probably the trial that’s changed practice the most and shown the largest therapeutic benefit of all the pharmacotherapies,” Dr. Walter said. “It’s an important one for providers to be aware of in terms of what the trial shows and how it informs which patients are most likely to benefit from dexamethasone therapy.”

Dr. Walter hopes clinicians who participate in the session will leave with these takeaways:

• Be able to summarize recent trials of ascorbic acid in sepsis and think about how to incorporate – or not – the use of vitamin C in critically ill sepsis patients.
• A thorough understanding of when renal replacement therapy should be offered to critically ill patients with acute kidney dysfunction.
• Be able to discuss the impact of antifibrotic therapy in interstitial lung diseases outside of idiopathic pulmonary fibrosis.
• An understanding of the role of triple inhaler combinations in COPD.
• Be able to explain when dexamethasone is most likely to benefit hypoxemic patients with COVID-19.

The weeks leading up to our Annual Conference always trigger certain rituals for me.

Deciding which sessions to attend feels like planning an intellectual feast mixed with an exercise in compromise, as I realize there is just no way to attend every session that I want to. Scheduling all my plans to connect over dinner and drinks with current and former colleagues is a logistical challenge I undertake with anticipation and some stress, especially when I’m the one tasked with making restaurant reservations. Thinking about how to pay for it all means digging out the rules around my CME faculty allowance, after first figuring out if I still even have a CME allowance, of course.

In the years that I am presenting, there are the last-minute emails with my co-presenters to arrange a time to run through our slides together on site. The prospect of seeing cherished colleagues and friends from SHM mixes with the fact that I know I will miss my wife and young son while I am away. Overall though, I am filled with a tremendous sense of excitement, a feeling that I enjoy in a sustained way for weeks before the meeting.

My excitement for SHM Converge is just as strong, but different in some great and important ways. The availability of on-demand content means I won’t have to choose one session over another this year – I can have my cake and eat it, too. Without the need to travel, expenses will be considerably less, and I won’t need to be away from my family.

But what I am most thrilled about when I think about SHM Converge is the content. A year of planning by our outstanding SHM staff, leadership, and Annual Conference Committee has produced a lineup of world-class speakers. Our virtual platform will offer a rich interactive and networking experience. Perennial favorite sessions, such as the Great Debate, Rapid Fire, and Update sessions will provide attendees the chance to update their core clinical knowledge across the breadth of hospital medicine.

Many aspects of health equity will be explored. Over 15 sessions and four special-interest forums covering topics such as racial and gender inequities, implicit bias, vulnerable populations, and ethics will help attendees not only understand the issues but also will show them how they can take action to make a difference.

Clinical and operational aspects of COVID-19 will also be covered at SHM Converge as speakers share the tremendous innovation, triumphs, and challenges that have taken place over the past year. Wellness and resilience are, of course, as relevant as ever, and sessions on balancing parenthood and work, learning from personal failures, and how to handle uncertainty and be resilient are among the topics that will be covered.

The essence of what we will do at SHM Converge in May is captured in our new meeting logo, an animation of nodes connecting with each other through lines that travel short and long, and intersect along the way. It’s a great representation of the togetherness, community, and mutual support that is at the core of who we are as SHM – now, more than ever. Thank you for joining us!

Dr. Steinberg is chief patient safety officer at Mount Sinai Downtown, and associate dean for quality/patient safety in GME, Mount Sinai Health System, New York. He is professor of medicine and medical education at the Icahn School of Medicine at Mount Sinai, and course director of SHM Converge.

The weeks leading up to our Annual Conference always trigger certain rituals for me.

Deciding which sessions to attend feels like planning an intellectual feast mixed with an exercise in compromise, as I realize there is just no way to attend every session that I want to. Scheduling all my plans to connect over dinner and drinks with current and former colleagues is a logistical challenge I undertake with anticipation and some stress, especially when I’m the one tasked with making restaurant reservations. Thinking about how to pay for it all means digging out the rules around my CME faculty allowance, after first figuring out if I still even have a CME allowance, of course.

In the years that I am presenting, there are the last-minute emails with my co-presenters to arrange a time to run through our slides together on site. The prospect of seeing cherished colleagues and friends from SHM mixes with the fact that I know I will miss my wife and young son while I am away. Overall though, I am filled with a tremendous sense of excitement, a feeling that I enjoy in a sustained way for weeks before the meeting.

My excitement for SHM Converge is just as strong, but different in some great and important ways. The availability of on-demand content means I won’t have to choose one session over another this year – I can have my cake and eat it, too. Without the need to travel, expenses will be considerably less, and I won’t need to be away from my family.

But what I am most thrilled about when I think about SHM Converge is the content. A year of planning by our outstanding SHM staff, leadership, and Annual Conference Committee has produced a lineup of world-class speakers. Our virtual platform will offer a rich interactive and networking experience. Perennial favorite sessions, such as the Great Debate, Rapid Fire, and Update sessions will provide attendees the chance to update their core clinical knowledge across the breadth of hospital medicine.

Many aspects of health equity will be explored. Over 15 sessions and four special-interest forums covering topics such as racial and gender inequities, implicit bias, vulnerable populations, and ethics will help attendees not only understand the issues but also will show them how they can take action to make a difference.

Clinical and operational aspects of COVID-19 will also be covered at SHM Converge as speakers share the tremendous innovation, triumphs, and challenges that have taken place over the past year. Wellness and resilience are, of course, as relevant as ever, and sessions on balancing parenthood and work, learning from personal failures, and how to handle uncertainty and be resilient are among the topics that will be covered.

The essence of what we will do at SHM Converge in May is captured in our new meeting logo, an animation of nodes connecting with each other through lines that travel short and long, and intersect along the way. It’s a great representation of the togetherness, community, and mutual support that is at the core of who we are as SHM – now, more than ever. Thank you for joining us!

Dr. Steinberg is chief patient safety officer at Mount Sinai Downtown, and associate dean for quality/patient safety in GME, Mount Sinai Health System, New York. He is professor of medicine and medical education at the Icahn School of Medicine at Mount Sinai, and course director of SHM Converge.

The weeks leading up to our Annual Conference always trigger certain rituals for me.

Deciding which sessions to attend feels like planning an intellectual feast mixed with an exercise in compromise, as I realize there is just no way to attend every session that I want to. Scheduling all my plans to connect over dinner and drinks with current and former colleagues is a logistical challenge I undertake with anticipation and some stress, especially when I’m the one tasked with making restaurant reservations. Thinking about how to pay for it all means digging out the rules around my CME faculty allowance, after first figuring out if I still even have a CME allowance, of course.

In the years that I am presenting, there are the last-minute emails with my co-presenters to arrange a time to run through our slides together on site. The prospect of seeing cherished colleagues and friends from SHM mixes with the fact that I know I will miss my wife and young son while I am away. Overall though, I am filled with a tremendous sense of excitement, a feeling that I enjoy in a sustained way for weeks before the meeting.

My excitement for SHM Converge is just as strong, but different in some great and important ways. The availability of on-demand content means I won’t have to choose one session over another this year – I can have my cake and eat it, too. Without the need to travel, expenses will be considerably less, and I won’t need to be away from my family.

But what I am most thrilled about when I think about SHM Converge is the content. A year of planning by our outstanding SHM staff, leadership, and Annual Conference Committee has produced a lineup of world-class speakers. Our virtual platform will offer a rich interactive and networking experience. Perennial favorite sessions, such as the Great Debate, Rapid Fire, and Update sessions will provide attendees the chance to update their core clinical knowledge across the breadth of hospital medicine.

Many aspects of health equity will be explored. Over 15 sessions and four special-interest forums covering topics such as racial and gender inequities, implicit bias, vulnerable populations, and ethics will help attendees not only understand the issues but also will show them how they can take action to make a difference.

Clinical and operational aspects of COVID-19 will also be covered at SHM Converge as speakers share the tremendous innovation, triumphs, and challenges that have taken place over the past year. Wellness and resilience are, of course, as relevant as ever, and sessions on balancing parenthood and work, learning from personal failures, and how to handle uncertainty and be resilient are among the topics that will be covered.

The essence of what we will do at SHM Converge in May is captured in our new meeting logo, an animation of nodes connecting with each other through lines that travel short and long, and intersect along the way. It’s a great representation of the togetherness, community, and mutual support that is at the core of who we are as SHM – now, more than ever. Thank you for joining us!

Dr. Steinberg is chief patient safety officer at Mount Sinai Downtown, and associate dean for quality/patient safety in GME, Mount Sinai Health System, New York. He is professor of medicine and medical education at the Icahn School of Medicine at Mount Sinai, and course director of SHM Converge.

The antibody-drug conjugate enfortumab vedotin is superior to chemotherapy in patients with previously treated advanced urothelial carcinoma, primary results of the EV-301 trial show.

Findings were reported at the 2021 Genitourinary Cancers Symposium (Abstract 393).

“Treatment after platinum-based chemotherapy and immune checkpoint inhibitors is challenging. Overall survival is short, and therapeutic options are also limited,” noted first author Thomas Powles, MD, a professor of genitourinary oncology and director of the Barts Cancer Centre, Queen Mary University of London. “Chemotherapy is being used as the global standard of care, but randomized trials supporting these treatment choices are actually lacking. In this setting, new therapeutic agents supported by randomized trials are needed.”

Patients enrolled in EV-301 (NCT03474107), an international open-label, phase 3 trial, had locally advanced or metastatic urothelial carcinoma, had received platinum-based chemotherapy, and had experienced progression during or after immune checkpoint inhibitor therapy (anti–PD1/PD-L1 therapy).

The trial met its primary endpoint, showing that, relative to chemotherapy, enfortumab vedotin reduced the risk of death by 30%, giving patients nearly 4 additional months of life. The toxicity profile was similar to that seen in earlier trials and was manageable.

“Enfortumab vedotin is the first drug, beyond chemotherapy and immunotherapy, to show a significant survival advantage in previously treated urothelial cancer. This is a big step in the right direction for patients with advanced urothelial cancer, where treatment options remain quite limited,” Dr. Powles maintained.

The drug is also showing promising activity when used in the immunotherapy-treated but cisplatin-ineligible patients in the second cohort of the predecessor EV-201 trial, reported at the symposium as well (Abstract 394), he noted. “I hope that, as we move it earlier, we will show better efficacy.”

The Food and Drug Administration granted enfortumab vedotin accelerated approval as third-line therapy in 2019 on the basis of data from the EV-201 trial’s first cohort. With these new data from both trials, the manufacturers have submitted applications to convert the accelerated approval to regular approval, and to expand the current label to include cisplatin-ineligible patients.
 

Trial details

In EV-301, a total of 608 patients were randomized evenly to enfortumab vedotin (an antibody-drug conjugate that targets nectin-4, a cell-adhesion molecule highly expressed in urothelial carcinoma) or the physician’s choice among three standard chemotherapy options having similar efficacy (docetaxel, paclitaxel, or vinflunine).

“None of these chemotherapy drugs have spectacular response rates, and the overall survival is best described as modest,” Dr. Powles said.

He reported results of the trial’s planned interim analysis, which became the primary analysis because the primary endpoint was positive. Specifically, median overall survival was 12.9 months with enfortumab vedotin and 9.0 months with chemotherapy (hazard ratio, 0.70; P = .00142). Benefit was similar across most patient subgroups.

The enfortumab vedotin group also had a better median progression-free survival (5.6 vs. 3.7 months; HR, 0.62; P < .00001) and investigator-assessed overall response rate (40.6% vs. 17.9%; P < .001).

The rate of grade 3 or worse treatment-related adverse events was 51% with enfortumab vedotin and 50% with chemotherapy. The former was associated with a higher rate of grade 3 or worse maculopapular rash (7% vs. 0%), whereas the latter was associated with higher rates of grade 3 or worse decreased neutrophil count (13% vs. 6%), decreased white blood cell count (7% vs. 1%), and febrile neutropenia (6% vs. 1%).

Regarding events of special interest, enfortumab vedotin led to more grade 3 or worse skin reactions of any type (15% vs. 1%), peripheral neuropathy (5% vs. 2%), and hyperglycemia (4% vs. 0%). However, the majority of all treatment-related adverse events of special interest were mild to moderate in severity and consistent with those previously reported.

“There is a skill associated with the management of toxicity, and there is going to be a learning curve for people who haven’t used the drug before,” Dr. Powles acknowledged. “But my experience is, it’s a manageable drug, and delays and dose interruptions actually make it a relatively straightforward drug to give in the context of the profile that we’ve seen today.”
 

Level 1 evidence

“We now know that enfortumab vedotin is here to stay in the armamentarium for the treatment of urothelial cancer, adding its name to the ranks of others which have shown level 1 evidence, proof of a survival benefit in metastatic urothelial carcinoma,” commented invited discussant Arlene O. Siefker-Radtke, MD, a professor in the department of genitourinary medical oncology, University of Texas MD Anderson Cancer Center, Houston.

“I’ve been impressed not only by the activity of enfortumab vedotin in visceral and liver metastases, but also by the impact in patients with bone metastases as this appears very helpful in controlling bone pain in many patients,” she noted.

Preventing and managing toxicity requires appropriate patient selection, careful monitoring, and dose modifications, with knowledge of the agent’s adverse event profile and of factors conferring elevated risk for events, Dr. Siefker-Radtke said.

“The early evidence for enfortumab vedotin in the postimmunotherapy, platinum-ineligible group suggests that this can help treat patients with an unmet need due to their inability to receive platinum-based therapy,” she concluded. “And while it’s currently approved in the third-line setting, we are all eagerly awaiting the outcomes of the frontline studies of enfortumab vedotin combined with pembrolizumab, which showed such a promising objective response rate, as has been presented at earlier meetings.”

The trial was sponsored by Astellas Pharma and Seagen. Dr. Powles disclosed relationships with Astellas Pharma, AstraZeneca, Bristol-Myers Squibb, and numerous other pharmaceutical and biotechnology companies. Dr. Siefker-Radtke disclosed relationships with AstraZeneca, Bavarian Nordic, Bristol-Myers Squibb, and a variety of other pharmaceutical and biotechnology companies, as well as patents, royalties, and/or other intellectual property pertaining to methods of characterizing and treating molecular subsets of muscle-invasive bladder cancer.

The antibody-drug conjugate enfortumab vedotin is superior to chemotherapy in patients with previously treated advanced urothelial carcinoma, primary results of the EV-301 trial show.

Findings were reported at the 2021 Genitourinary Cancers Symposium (Abstract 393).

“Treatment after platinum-based chemotherapy and immune checkpoint inhibitors is challenging. Overall survival is short, and therapeutic options are also limited,” noted first author Thomas Powles, MD, a professor of genitourinary oncology and director of the Barts Cancer Centre, Queen Mary University of London. “Chemotherapy is being used as the global standard of care, but randomized trials supporting these treatment choices are actually lacking. In this setting, new therapeutic agents supported by randomized trials are needed.”

Patients enrolled in EV-301 (NCT03474107), an international open-label, phase 3 trial, had locally advanced or metastatic urothelial carcinoma, had received platinum-based chemotherapy, and had experienced progression during or after immune checkpoint inhibitor therapy (anti–PD1/PD-L1 therapy).

The trial met its primary endpoint, showing that, relative to chemotherapy, enfortumab vedotin reduced the risk of death by 30%, giving patients nearly 4 additional months of life. The toxicity profile was similar to that seen in earlier trials and was manageable.

“Enfortumab vedotin is the first drug, beyond chemotherapy and immunotherapy, to show a significant survival advantage in previously treated urothelial cancer. This is a big step in the right direction for patients with advanced urothelial cancer, where treatment options remain quite limited,” Dr. Powles maintained.

The drug is also showing promising activity when used in the immunotherapy-treated but cisplatin-ineligible patients in the second cohort of the predecessor EV-201 trial, reported at the symposium as well (Abstract 394), he noted. “I hope that, as we move it earlier, we will show better efficacy.”

The Food and Drug Administration granted enfortumab vedotin accelerated approval as third-line therapy in 2019 on the basis of data from the EV-201 trial’s first cohort. With these new data from both trials, the manufacturers have submitted applications to convert the accelerated approval to regular approval, and to expand the current label to include cisplatin-ineligible patients.
 

Trial details

In EV-301, a total of 608 patients were randomized evenly to enfortumab vedotin (an antibody-drug conjugate that targets nectin-4, a cell-adhesion molecule highly expressed in urothelial carcinoma) or the physician’s choice among three standard chemotherapy options having similar efficacy (docetaxel, paclitaxel, or vinflunine).

“None of these chemotherapy drugs have spectacular response rates, and the overall survival is best described as modest,” Dr. Powles said.

He reported results of the trial’s planned interim analysis, which became the primary analysis because the primary endpoint was positive. Specifically, median overall survival was 12.9 months with enfortumab vedotin and 9.0 months with chemotherapy (hazard ratio, 0.70; P = .00142). Benefit was similar across most patient subgroups.

The enfortumab vedotin group also had a better median progression-free survival (5.6 vs. 3.7 months; HR, 0.62; P < .00001) and investigator-assessed overall response rate (40.6% vs. 17.9%; P < .001).

The rate of grade 3 or worse treatment-related adverse events was 51% with enfortumab vedotin and 50% with chemotherapy. The former was associated with a higher rate of grade 3 or worse maculopapular rash (7% vs. 0%), whereas the latter was associated with higher rates of grade 3 or worse decreased neutrophil count (13% vs. 6%), decreased white blood cell count (7% vs. 1%), and febrile neutropenia (6% vs. 1%).

Regarding events of special interest, enfortumab vedotin led to more grade 3 or worse skin reactions of any type (15% vs. 1%), peripheral neuropathy (5% vs. 2%), and hyperglycemia (4% vs. 0%). However, the majority of all treatment-related adverse events of special interest were mild to moderate in severity and consistent with those previously reported.

“There is a skill associated with the management of toxicity, and there is going to be a learning curve for people who haven’t used the drug before,” Dr. Powles acknowledged. “But my experience is, it’s a manageable drug, and delays and dose interruptions actually make it a relatively straightforward drug to give in the context of the profile that we’ve seen today.”
 

Level 1 evidence

“We now know that enfortumab vedotin is here to stay in the armamentarium for the treatment of urothelial cancer, adding its name to the ranks of others which have shown level 1 evidence, proof of a survival benefit in metastatic urothelial carcinoma,” commented invited discussant Arlene O. Siefker-Radtke, MD, a professor in the department of genitourinary medical oncology, University of Texas MD Anderson Cancer Center, Houston.

“I’ve been impressed not only by the activity of enfortumab vedotin in visceral and liver metastases, but also by the impact in patients with bone metastases as this appears very helpful in controlling bone pain in many patients,” she noted.

Preventing and managing toxicity requires appropriate patient selection, careful monitoring, and dose modifications, with knowledge of the agent’s adverse event profile and of factors conferring elevated risk for events, Dr. Siefker-Radtke said.

“The early evidence for enfortumab vedotin in the postimmunotherapy, platinum-ineligible group suggests that this can help treat patients with an unmet need due to their inability to receive platinum-based therapy,” she concluded. “And while it’s currently approved in the third-line setting, we are all eagerly awaiting the outcomes of the frontline studies of enfortumab vedotin combined with pembrolizumab, which showed such a promising objective response rate, as has been presented at earlier meetings.”

The trial was sponsored by Astellas Pharma and Seagen. Dr. Powles disclosed relationships with Astellas Pharma, AstraZeneca, Bristol-Myers Squibb, and numerous other pharmaceutical and biotechnology companies. Dr. Siefker-Radtke disclosed relationships with AstraZeneca, Bavarian Nordic, Bristol-Myers Squibb, and a variety of other pharmaceutical and biotechnology companies, as well as patents, royalties, and/or other intellectual property pertaining to methods of characterizing and treating molecular subsets of muscle-invasive bladder cancer.

The antibody-drug conjugate enfortumab vedotin is superior to chemotherapy in patients with previously treated advanced urothelial carcinoma, primary results of the EV-301 trial show.

Findings were reported at the 2021 Genitourinary Cancers Symposium (Abstract 393).

“Treatment after platinum-based chemotherapy and immune checkpoint inhibitors is challenging. Overall survival is short, and therapeutic options are also limited,” noted first author Thomas Powles, MD, a professor of genitourinary oncology and director of the Barts Cancer Centre, Queen Mary University of London. “Chemotherapy is being used as the global standard of care, but randomized trials supporting these treatment choices are actually lacking. In this setting, new therapeutic agents supported by randomized trials are needed.”

Patients enrolled in EV-301 (NCT03474107), an international open-label, phase 3 trial, had locally advanced or metastatic urothelial carcinoma, had received platinum-based chemotherapy, and had experienced progression during or after immune checkpoint inhibitor therapy (anti–PD1/PD-L1 therapy).

The trial met its primary endpoint, showing that, relative to chemotherapy, enfortumab vedotin reduced the risk of death by 30%, giving patients nearly 4 additional months of life. The toxicity profile was similar to that seen in earlier trials and was manageable.

“Enfortumab vedotin is the first drug, beyond chemotherapy and immunotherapy, to show a significant survival advantage in previously treated urothelial cancer. This is a big step in the right direction for patients with advanced urothelial cancer, where treatment options remain quite limited,” Dr. Powles maintained.

The drug is also showing promising activity when used in the immunotherapy-treated but cisplatin-ineligible patients in the second cohort of the predecessor EV-201 trial, reported at the symposium as well (Abstract 394), he noted. “I hope that, as we move it earlier, we will show better efficacy.”

The Food and Drug Administration granted enfortumab vedotin accelerated approval as third-line therapy in 2019 on the basis of data from the EV-201 trial’s first cohort. With these new data from both trials, the manufacturers have submitted applications to convert the accelerated approval to regular approval, and to expand the current label to include cisplatin-ineligible patients.
 

Trial details

In EV-301, a total of 608 patients were randomized evenly to enfortumab vedotin (an antibody-drug conjugate that targets nectin-4, a cell-adhesion molecule highly expressed in urothelial carcinoma) or the physician’s choice among three standard chemotherapy options having similar efficacy (docetaxel, paclitaxel, or vinflunine).

“None of these chemotherapy drugs have spectacular response rates, and the overall survival is best described as modest,” Dr. Powles said.

He reported results of the trial’s planned interim analysis, which became the primary analysis because the primary endpoint was positive. Specifically, median overall survival was 12.9 months with enfortumab vedotin and 9.0 months with chemotherapy (hazard ratio, 0.70; P = .00142). Benefit was similar across most patient subgroups.

The enfortumab vedotin group also had a better median progression-free survival (5.6 vs. 3.7 months; HR, 0.62; P < .00001) and investigator-assessed overall response rate (40.6% vs. 17.9%; P < .001).

The rate of grade 3 or worse treatment-related adverse events was 51% with enfortumab vedotin and 50% with chemotherapy. The former was associated with a higher rate of grade 3 or worse maculopapular rash (7% vs. 0%), whereas the latter was associated with higher rates of grade 3 or worse decreased neutrophil count (13% vs. 6%), decreased white blood cell count (7% vs. 1%), and febrile neutropenia (6% vs. 1%).

Regarding events of special interest, enfortumab vedotin led to more grade 3 or worse skin reactions of any type (15% vs. 1%), peripheral neuropathy (5% vs. 2%), and hyperglycemia (4% vs. 0%). However, the majority of all treatment-related adverse events of special interest were mild to moderate in severity and consistent with those previously reported.

“There is a skill associated with the management of toxicity, and there is going to be a learning curve for people who haven’t used the drug before,” Dr. Powles acknowledged. “But my experience is, it’s a manageable drug, and delays and dose interruptions actually make it a relatively straightforward drug to give in the context of the profile that we’ve seen today.”
 

Level 1 evidence

“We now know that enfortumab vedotin is here to stay in the armamentarium for the treatment of urothelial cancer, adding its name to the ranks of others which have shown level 1 evidence, proof of a survival benefit in metastatic urothelial carcinoma,” commented invited discussant Arlene O. Siefker-Radtke, MD, a professor in the department of genitourinary medical oncology, University of Texas MD Anderson Cancer Center, Houston.

“I’ve been impressed not only by the activity of enfortumab vedotin in visceral and liver metastases, but also by the impact in patients with bone metastases as this appears very helpful in controlling bone pain in many patients,” she noted.

Preventing and managing toxicity requires appropriate patient selection, careful monitoring, and dose modifications, with knowledge of the agent’s adverse event profile and of factors conferring elevated risk for events, Dr. Siefker-Radtke said.

“The early evidence for enfortumab vedotin in the postimmunotherapy, platinum-ineligible group suggests that this can help treat patients with an unmet need due to their inability to receive platinum-based therapy,” she concluded. “And while it’s currently approved in the third-line setting, we are all eagerly awaiting the outcomes of the frontline studies of enfortumab vedotin combined with pembrolizumab, which showed such a promising objective response rate, as has been presented at earlier meetings.”

The trial was sponsored by Astellas Pharma and Seagen. Dr. Powles disclosed relationships with Astellas Pharma, AstraZeneca, Bristol-Myers Squibb, and numerous other pharmaceutical and biotechnology companies. Dr. Siefker-Radtke disclosed relationships with AstraZeneca, Bavarian Nordic, Bristol-Myers Squibb, and a variety of other pharmaceutical and biotechnology companies, as well as patents, royalties, and/or other intellectual property pertaining to methods of characterizing and treating molecular subsets of muscle-invasive bladder cancer.

Girls with more body fat experienced earlier menarche and hormone changes, but later full breast development, compared with those with normal weight, according to longitudinal data from 90 girls aged 8-15 years.

A link between obesity and early puberty has been observed among U.S. girls for decades, but more recent studies suggest that “girls with greater childhood adiposity have earlier thelarche and progress through puberty at a faster rate than normal weight girls,” wrote Madison T. Ortega, MD, of the National Institute of Environmental Health Sciences, Durham, N.C., and colleagues. However, studies involving hormone levels have yielded mixed results, they said.

In a study published in the Journal of Clinical Endocrinology & Metabolism , the researchers followed 36 girls with overweight or obesity and 54 girls with normal weight for 4 years; normal weight was defined as body mass index in the 5th to 85th percentile, overweight was defined as BMI in the 85th to 95th percentile, and obese was defined as greater than 95th percentile. Overweight and obese were combined into one category for comparison with normal weight girls.

Participants had an average of 2.8 study visits during this period and provided additional information by phone and online. Visits included measurement of total body fat using dual-energy x-ray absorptiometry (DXA), Tanner staging, breast ultrasound for morphological staging (BMORPH; A-E), pelvic ultrasound, hormone tests, and menarchal status assessment.

Overall, girls with overweight/obesity (OW/OB) had significantly more advanced breast development at baseline than did those with normal weight (NW), but these girls progressed through BMORPH stage D later than did NW girls. Early-stage breast development was not affected by total body fat. However, “an increase of 5 percentage points in mean total body fat, for example, was associated with a 26% decrease in the transition rate out of stage D,” the researchers noted.

Hormone levels were similar at baseline for follicle-stimulating hormone, inhibin B, estrone (E1), total and free testosterone, and androstenedione. However, these levels increased more quickly after 1 year for girls with OW/OB, while they plateaued in girls with NW and dropped among girls with lower total body fat. Total body fat had no apparent effect on other reproductive hormones including luteinizing hormone, modified vaginal maturation index, and estradiol 2.

The average age of menarche was 12.4 years across all participants, but girls with higher total body fat at baseline were more likely to reach menarche at a younger age. “For every 1-unit increase in visit one total body fat, the chance of achieving menarche at any given time point was 3% higher,” the researchers said. No interaction appeared between race and total body fat with regard to menarche.


 

Several surprising findings

The study is important because “there have been no longitudinal studies in U.S. girls to examine how total body fat affects serum reproductive hormones or the development of the breast and ovaries using ultrasound imaging,” corresponding author Natalie Shaw, MD, of the National Institute of Environmental Health Sciences, said in an interview.

Dr. Shaw said she was surprised by several of the study findings. “Others have reported increased male-like hormones (androgens) in overweight/obese girls in cross-sectional studies; however, we were surprised to find that FSH and inhibin B were also elevated in girls with excess body fat,” she said. “We also found, unexpectedly, that even though the breast bud appears earlier in overweight/obese girls (thelarche), which signals the onset of puberty, the breast matured more slowly during the course of puberty in overweight/obese girls compared with normal weight girls,” she noted.

“The main take-home message is that puberty looks different in girls with excess body fat; they develop breast tissue earlier, yet take longer to achieve a fully mature breast, and they undergo menarche earlier,” Dr. Shaw said. Clinicians should be aware of the hormonal differences based on body fat, Dr. Shaw emphasized. “Girls with greater body fat had higher levels of FSH (a pituitary hormone), inhibin B (an ovarian hormone), and male-like reproductive hormones (e.g., testosterone) that are made by the adrenal glands and the ovaries in the late stages of puberty,” she said.
 

Potential implications for adulthood

“The findings in this study contribute to better understanding how total body fat impacts hormonal findings of puberty,” M. Susan Jay, MD, of the Medical College of Wisconsin and Children’s Hospital of Wisconsin, Milwaukee, said in an interview. “Prior studies have linked weight gain as a factor that contributes to pubertal development, but this study is attempting to longitudinally investigate how body weight may affect clinical and biochemical pubertal markers in girls,” she noted.

“The take-home message is that this study and other earlier studies have illustrated that puberty is not a fixed pattern in all individual girls,” Dr. Jay emphasized. “Rather, there are environmental factors which can impact pubertal course,” she said. “In effect, there are pathways through puberty in individual adolescents that require greater ongoing studies to further identify the arc of puberty and the impact of how the length in various stages may affect exposure to estrogen and other neurohormonal factors,” she explained. These factors impact not only adolescence but also future health in adulthood, she said.

“Ongoing prospective studies are needed to identify how factors such as body weight can affect adolescent pubertal development and the possible impact long after adolescence for health issues such as breast cancer,” Dr. Jay added.

The study findings were limited by several factors including the available data from only two completed study visits for most participants, as well as the racial differences among body weight groups and lack of standardized timing for blood draws, the researchers noted.

The study was supported in part by the National Institute of Environmental Health Sciences, and corresponding author Dr. Shaw disclosed support as a Lasker Clinical Research Scholar. The other researchers, as well as Dr. Jay, had no disclosures.

Girls with more body fat experienced earlier menarche and hormone changes, but later full breast development, compared with those with normal weight, according to longitudinal data from 90 girls aged 8-15 years.

A link between obesity and early puberty has been observed among U.S. girls for decades, but more recent studies suggest that “girls with greater childhood adiposity have earlier thelarche and progress through puberty at a faster rate than normal weight girls,” wrote Madison T. Ortega, MD, of the National Institute of Environmental Health Sciences, Durham, N.C., and colleagues. However, studies involving hormone levels have yielded mixed results, they said.

In a study published in the Journal of Clinical Endocrinology & Metabolism , the researchers followed 36 girls with overweight or obesity and 54 girls with normal weight for 4 years; normal weight was defined as body mass index in the 5th to 85th percentile, overweight was defined as BMI in the 85th to 95th percentile, and obese was defined as greater than 95th percentile. Overweight and obese were combined into one category for comparison with normal weight girls.

Participants had an average of 2.8 study visits during this period and provided additional information by phone and online. Visits included measurement of total body fat using dual-energy x-ray absorptiometry (DXA), Tanner staging, breast ultrasound for morphological staging (BMORPH; A-E), pelvic ultrasound, hormone tests, and menarchal status assessment.

Overall, girls with overweight/obesity (OW/OB) had significantly more advanced breast development at baseline than did those with normal weight (NW), but these girls progressed through BMORPH stage D later than did NW girls. Early-stage breast development was not affected by total body fat. However, “an increase of 5 percentage points in mean total body fat, for example, was associated with a 26% decrease in the transition rate out of stage D,” the researchers noted.

Hormone levels were similar at baseline for follicle-stimulating hormone, inhibin B, estrone (E1), total and free testosterone, and androstenedione. However, these levels increased more quickly after 1 year for girls with OW/OB, while they plateaued in girls with NW and dropped among girls with lower total body fat. Total body fat had no apparent effect on other reproductive hormones including luteinizing hormone, modified vaginal maturation index, and estradiol 2.

The average age of menarche was 12.4 years across all participants, but girls with higher total body fat at baseline were more likely to reach menarche at a younger age. “For every 1-unit increase in visit one total body fat, the chance of achieving menarche at any given time point was 3% higher,” the researchers said. No interaction appeared between race and total body fat with regard to menarche.


 

Several surprising findings

The study is important because “there have been no longitudinal studies in U.S. girls to examine how total body fat affects serum reproductive hormones or the development of the breast and ovaries using ultrasound imaging,” corresponding author Natalie Shaw, MD, of the National Institute of Environmental Health Sciences, said in an interview.

Dr. Shaw said she was surprised by several of the study findings. “Others have reported increased male-like hormones (androgens) in overweight/obese girls in cross-sectional studies; however, we were surprised to find that FSH and inhibin B were also elevated in girls with excess body fat,” she said. “We also found, unexpectedly, that even though the breast bud appears earlier in overweight/obese girls (thelarche), which signals the onset of puberty, the breast matured more slowly during the course of puberty in overweight/obese girls compared with normal weight girls,” she noted.

“The main take-home message is that puberty looks different in girls with excess body fat; they develop breast tissue earlier, yet take longer to achieve a fully mature breast, and they undergo menarche earlier,” Dr. Shaw said. Clinicians should be aware of the hormonal differences based on body fat, Dr. Shaw emphasized. “Girls with greater body fat had higher levels of FSH (a pituitary hormone), inhibin B (an ovarian hormone), and male-like reproductive hormones (e.g., testosterone) that are made by the adrenal glands and the ovaries in the late stages of puberty,” she said.
 

Potential implications for adulthood

“The findings in this study contribute to better understanding how total body fat impacts hormonal findings of puberty,” M. Susan Jay, MD, of the Medical College of Wisconsin and Children’s Hospital of Wisconsin, Milwaukee, said in an interview. “Prior studies have linked weight gain as a factor that contributes to pubertal development, but this study is attempting to longitudinally investigate how body weight may affect clinical and biochemical pubertal markers in girls,” she noted.

“The take-home message is that this study and other earlier studies have illustrated that puberty is not a fixed pattern in all individual girls,” Dr. Jay emphasized. “Rather, there are environmental factors which can impact pubertal course,” she said. “In effect, there are pathways through puberty in individual adolescents that require greater ongoing studies to further identify the arc of puberty and the impact of how the length in various stages may affect exposure to estrogen and other neurohormonal factors,” she explained. These factors impact not only adolescence but also future health in adulthood, she said.

“Ongoing prospective studies are needed to identify how factors such as body weight can affect adolescent pubertal development and the possible impact long after adolescence for health issues such as breast cancer,” Dr. Jay added.

The study findings were limited by several factors including the available data from only two completed study visits for most participants, as well as the racial differences among body weight groups and lack of standardized timing for blood draws, the researchers noted.

The study was supported in part by the National Institute of Environmental Health Sciences, and corresponding author Dr. Shaw disclosed support as a Lasker Clinical Research Scholar. The other researchers, as well as Dr. Jay, had no disclosures.

Girls with more body fat experienced earlier menarche and hormone changes, but later full breast development, compared with those with normal weight, according to longitudinal data from 90 girls aged 8-15 years.

A link between obesity and early puberty has been observed among U.S. girls for decades, but more recent studies suggest that “girls with greater childhood adiposity have earlier thelarche and progress through puberty at a faster rate than normal weight girls,” wrote Madison T. Ortega, MD, of the National Institute of Environmental Health Sciences, Durham, N.C., and colleagues. However, studies involving hormone levels have yielded mixed results, they said.

In a study published in the Journal of Clinical Endocrinology & Metabolism , the researchers followed 36 girls with overweight or obesity and 54 girls with normal weight for 4 years; normal weight was defined as body mass index in the 5th to 85th percentile, overweight was defined as BMI in the 85th to 95th percentile, and obese was defined as greater than 95th percentile. Overweight and obese were combined into one category for comparison with normal weight girls.

Participants had an average of 2.8 study visits during this period and provided additional information by phone and online. Visits included measurement of total body fat using dual-energy x-ray absorptiometry (DXA), Tanner staging, breast ultrasound for morphological staging (BMORPH; A-E), pelvic ultrasound, hormone tests, and menarchal status assessment.

Overall, girls with overweight/obesity (OW/OB) had significantly more advanced breast development at baseline than did those with normal weight (NW), but these girls progressed through BMORPH stage D later than did NW girls. Early-stage breast development was not affected by total body fat. However, “an increase of 5 percentage points in mean total body fat, for example, was associated with a 26% decrease in the transition rate out of stage D,” the researchers noted.

Hormone levels were similar at baseline for follicle-stimulating hormone, inhibin B, estrone (E1), total and free testosterone, and androstenedione. However, these levels increased more quickly after 1 year for girls with OW/OB, while they plateaued in girls with NW and dropped among girls with lower total body fat. Total body fat had no apparent effect on other reproductive hormones including luteinizing hormone, modified vaginal maturation index, and estradiol 2.

The average age of menarche was 12.4 years across all participants, but girls with higher total body fat at baseline were more likely to reach menarche at a younger age. “For every 1-unit increase in visit one total body fat, the chance of achieving menarche at any given time point was 3% higher,” the researchers said. No interaction appeared between race and total body fat with regard to menarche.


 

Several surprising findings

The study is important because “there have been no longitudinal studies in U.S. girls to examine how total body fat affects serum reproductive hormones or the development of the breast and ovaries using ultrasound imaging,” corresponding author Natalie Shaw, MD, of the National Institute of Environmental Health Sciences, said in an interview.

Dr. Shaw said she was surprised by several of the study findings. “Others have reported increased male-like hormones (androgens) in overweight/obese girls in cross-sectional studies; however, we were surprised to find that FSH and inhibin B were also elevated in girls with excess body fat,” she said. “We also found, unexpectedly, that even though the breast bud appears earlier in overweight/obese girls (thelarche), which signals the onset of puberty, the breast matured more slowly during the course of puberty in overweight/obese girls compared with normal weight girls,” she noted.

“The main take-home message is that puberty looks different in girls with excess body fat; they develop breast tissue earlier, yet take longer to achieve a fully mature breast, and they undergo menarche earlier,” Dr. Shaw said. Clinicians should be aware of the hormonal differences based on body fat, Dr. Shaw emphasized. “Girls with greater body fat had higher levels of FSH (a pituitary hormone), inhibin B (an ovarian hormone), and male-like reproductive hormones (e.g., testosterone) that are made by the adrenal glands and the ovaries in the late stages of puberty,” she said.
 

Potential implications for adulthood

“The findings in this study contribute to better understanding how total body fat impacts hormonal findings of puberty,” M. Susan Jay, MD, of the Medical College of Wisconsin and Children’s Hospital of Wisconsin, Milwaukee, said in an interview. “Prior studies have linked weight gain as a factor that contributes to pubertal development, but this study is attempting to longitudinally investigate how body weight may affect clinical and biochemical pubertal markers in girls,” she noted.

“The take-home message is that this study and other earlier studies have illustrated that puberty is not a fixed pattern in all individual girls,” Dr. Jay emphasized. “Rather, there are environmental factors which can impact pubertal course,” she said. “In effect, there are pathways through puberty in individual adolescents that require greater ongoing studies to further identify the arc of puberty and the impact of how the length in various stages may affect exposure to estrogen and other neurohormonal factors,” she explained. These factors impact not only adolescence but also future health in adulthood, she said.

“Ongoing prospective studies are needed to identify how factors such as body weight can affect adolescent pubertal development and the possible impact long after adolescence for health issues such as breast cancer,” Dr. Jay added.

The study findings were limited by several factors including the available data from only two completed study visits for most participants, as well as the racial differences among body weight groups and lack of standardized timing for blood draws, the researchers noted.

The study was supported in part by the National Institute of Environmental Health Sciences, and corresponding author Dr. Shaw disclosed support as a Lasker Clinical Research Scholar. The other researchers, as well as Dr. Jay, had no disclosures.

The American Society for Dermatologic Surgery (ASDS) addresses a worrying knowledge gap with the publication of its first evidence-based clinical practice guidelines for the prevention and treatment of adverse events from injectable fillers.

The recommendations, published in the February issue of Dermatologic Surgery, are from a multidisciplinary task force convened by the ASDS, comprising 11 physicians – 8 board-certified in dermatology, 2 board-certified in plastic and reconstructive surgery, and 1 board-certified in oculoplastic surgery (all ASDS members) – and 2 patient representatives.

While redness, swelling, and other injection site reactions associated with injectable fillers are common, and usually resolve within 1-2 weeks, “rare but more serious adverse events from injectable fillers include vascular occlusion leading to skin necrosis or blindness, inflammatory events, and nodule formation, among others,” the authors wrote. They are “likely underreported” and cases are increasing as injectable fillers become more popular.

He described the two most important cornerstones for preventing vascular occlusion. The first, he said, is “having impeccable knowledge and understanding of vascular anatomy and the cutaneous landmarks for blood vessels that are at risk.” The second pertains to injection techniques, he said, noting that “it’s becoming clearer – although it’s somewhat controversial – that cannulas are safer than needles.”

While anatomical knowledge might seem like the most basic requirement for practitioners who inject fillers, Dr. Jones said it is not. “It is true that we study anatomy in great detail in medical school, but injection anatomy is a completely different bird. Of course someone can study the facial arteries and have a basic understanding, but understanding it in a way that it relates to safe filler injections is a completely different thing. Our understanding of this has evolved over the last couple of decades ... and there are new papers that come out all the time that refine our knowledge.”

In terms of treating an IRVC resulting from hyaluronic acid (HA) filler, “the take-home point is the hyaluronidase is the mainstay of treatment, and not a little bit of hyaluronidase, but a lot of hyaluronidase – hundreds of units injected into the area of ischemia,” he said. However, while the new guidelines emphasize that time is of the essence – “the most cited window of time for reperfusion is 90 minutes” – the authors also strongly advise practitioners to evaluate immediate post-event visual status first, before attempting any intervention.

Dr. Jones said the goal is to untangle some confusion about whether it is the filler or the rescue that does more damage. “There is a lot of controversy with ophthalmology, ophthalmologic surgeons, plastic surgeons, and dermatologists,” he said, and “there has been finger-pointing between specialists when people make an intervention … that the actual rescue procedure created the problem,” which is why “it is imperative to document the visual status prior to doing anything.”

Beyond IRVC, and nonvisual skin ischemia due to vascular occlusion, the document addresses prevention and treatment of nodules, both inflammatory and noninflammatory, that occur either early or more than a month after treatment with HA fillers, as well with semi-permanent and permanent fillers.

For HA-related nodules, “the mainstay of treatment is steroids – either oral or intralesional – antibiotics, and hyaluronidase, which erases the substance,” said Dr. Jones. As for nodules related to permanent fillers, he said that they are difficult to treat, and “tend to respond best to repetitive monthly injections of 5-fluououracil combined with small amounts of triamcinolone.”

Dr. Jones is an investigator or consultant for Allergan, Galderma, Merz, and Revance; other authors had disclosures that included serving as a consultant, investigator, and/or trainer for these and/or other companies; one author received partial funding from ASDS to do this work; and one author had no disclosures.

The American Society for Dermatologic Surgery (ASDS) addresses a worrying knowledge gap with the publication of its first evidence-based clinical practice guidelines for the prevention and treatment of adverse events from injectable fillers.

The recommendations, published in the February issue of Dermatologic Surgery, are from a multidisciplinary task force convened by the ASDS, comprising 11 physicians – 8 board-certified in dermatology, 2 board-certified in plastic and reconstructive surgery, and 1 board-certified in oculoplastic surgery (all ASDS members) – and 2 patient representatives.

While redness, swelling, and other injection site reactions associated with injectable fillers are common, and usually resolve within 1-2 weeks, “rare but more serious adverse events from injectable fillers include vascular occlusion leading to skin necrosis or blindness, inflammatory events, and nodule formation, among others,” the authors wrote. They are “likely underreported” and cases are increasing as injectable fillers become more popular.

He described the two most important cornerstones for preventing vascular occlusion. The first, he said, is “having impeccable knowledge and understanding of vascular anatomy and the cutaneous landmarks for blood vessels that are at risk.” The second pertains to injection techniques, he said, noting that “it’s becoming clearer – although it’s somewhat controversial – that cannulas are safer than needles.”

While anatomical knowledge might seem like the most basic requirement for practitioners who inject fillers, Dr. Jones said it is not. “It is true that we study anatomy in great detail in medical school, but injection anatomy is a completely different bird. Of course someone can study the facial arteries and have a basic understanding, but understanding it in a way that it relates to safe filler injections is a completely different thing. Our understanding of this has evolved over the last couple of decades ... and there are new papers that come out all the time that refine our knowledge.”

In terms of treating an IRVC resulting from hyaluronic acid (HA) filler, “the take-home point is the hyaluronidase is the mainstay of treatment, and not a little bit of hyaluronidase, but a lot of hyaluronidase – hundreds of units injected into the area of ischemia,” he said. However, while the new guidelines emphasize that time is of the essence – “the most cited window of time for reperfusion is 90 minutes” – the authors also strongly advise practitioners to evaluate immediate post-event visual status first, before attempting any intervention.

Dr. Jones said the goal is to untangle some confusion about whether it is the filler or the rescue that does more damage. “There is a lot of controversy with ophthalmology, ophthalmologic surgeons, plastic surgeons, and dermatologists,” he said, and “there has been finger-pointing between specialists when people make an intervention … that the actual rescue procedure created the problem,” which is why “it is imperative to document the visual status prior to doing anything.”

Beyond IRVC, and nonvisual skin ischemia due to vascular occlusion, the document addresses prevention and treatment of nodules, both inflammatory and noninflammatory, that occur either early or more than a month after treatment with HA fillers, as well with semi-permanent and permanent fillers.

For HA-related nodules, “the mainstay of treatment is steroids – either oral or intralesional – antibiotics, and hyaluronidase, which erases the substance,” said Dr. Jones. As for nodules related to permanent fillers, he said that they are difficult to treat, and “tend to respond best to repetitive monthly injections of 5-fluououracil combined with small amounts of triamcinolone.”

Dr. Jones is an investigator or consultant for Allergan, Galderma, Merz, and Revance; other authors had disclosures that included serving as a consultant, investigator, and/or trainer for these and/or other companies; one author received partial funding from ASDS to do this work; and one author had no disclosures.

The American Society for Dermatologic Surgery (ASDS) addresses a worrying knowledge gap with the publication of its first evidence-based clinical practice guidelines for the prevention and treatment of adverse events from injectable fillers.

The recommendations, published in the February issue of Dermatologic Surgery, are from a multidisciplinary task force convened by the ASDS, comprising 11 physicians – 8 board-certified in dermatology, 2 board-certified in plastic and reconstructive surgery, and 1 board-certified in oculoplastic surgery (all ASDS members) – and 2 patient representatives.

While redness, swelling, and other injection site reactions associated with injectable fillers are common, and usually resolve within 1-2 weeks, “rare but more serious adverse events from injectable fillers include vascular occlusion leading to skin necrosis or blindness, inflammatory events, and nodule formation, among others,” the authors wrote. They are “likely underreported” and cases are increasing as injectable fillers become more popular.

He described the two most important cornerstones for preventing vascular occlusion. The first, he said, is “having impeccable knowledge and understanding of vascular anatomy and the cutaneous landmarks for blood vessels that are at risk.” The second pertains to injection techniques, he said, noting that “it’s becoming clearer – although it’s somewhat controversial – that cannulas are safer than needles.”

While anatomical knowledge might seem like the most basic requirement for practitioners who inject fillers, Dr. Jones said it is not. “It is true that we study anatomy in great detail in medical school, but injection anatomy is a completely different bird. Of course someone can study the facial arteries and have a basic understanding, but understanding it in a way that it relates to safe filler injections is a completely different thing. Our understanding of this has evolved over the last couple of decades ... and there are new papers that come out all the time that refine our knowledge.”

In terms of treating an IRVC resulting from hyaluronic acid (HA) filler, “the take-home point is the hyaluronidase is the mainstay of treatment, and not a little bit of hyaluronidase, but a lot of hyaluronidase – hundreds of units injected into the area of ischemia,” he said. However, while the new guidelines emphasize that time is of the essence – “the most cited window of time for reperfusion is 90 minutes” – the authors also strongly advise practitioners to evaluate immediate post-event visual status first, before attempting any intervention.

Dr. Jones said the goal is to untangle some confusion about whether it is the filler or the rescue that does more damage. “There is a lot of controversy with ophthalmology, ophthalmologic surgeons, plastic surgeons, and dermatologists,” he said, and “there has been finger-pointing between specialists when people make an intervention … that the actual rescue procedure created the problem,” which is why “it is imperative to document the visual status prior to doing anything.”

Beyond IRVC, and nonvisual skin ischemia due to vascular occlusion, the document addresses prevention and treatment of nodules, both inflammatory and noninflammatory, that occur either early or more than a month after treatment with HA fillers, as well with semi-permanent and permanent fillers.

For HA-related nodules, “the mainstay of treatment is steroids – either oral or intralesional – antibiotics, and hyaluronidase, which erases the substance,” said Dr. Jones. As for nodules related to permanent fillers, he said that they are difficult to treat, and “tend to respond best to repetitive monthly injections of 5-fluououracil combined with small amounts of triamcinolone.”

Dr. Jones is an investigator or consultant for Allergan, Galderma, Merz, and Revance; other authors had disclosures that included serving as a consultant, investigator, and/or trainer for these and/or other companies; one author received partial funding from ASDS to do this work; and one author had no disclosures.

Childhood trauma, which is also called adverse childhood experiences (ACEs), can have lasting detrimental effects on individuals as they grow and mature into adulthood. ACEs may occur in children age ≤18 years if they experience abuse or neglect, violence, or other traumatic losses. More than 60% of people experience at least 1 ACE, and 1 in 6 individuals reported that they had experienced ≥4 ACEs.¹ Subsequent additional ACEs have a cumulative deteriorating impact on the brain. This predisposes individuals to mental health disorders, substance use disorders, and other psychosocial problems. The efficacy of current therapeutic approaches provides only partial symptom resolution. For such individuals, the illness load and health care costs typically remain high across the lifespan.^1,2 

In this article, we discuss types of ACEs, protective factors and risk factors that influence the development of posttraumatic stress disorder (PTSD) in individuals who experience ACEs, how ACEs can negatively impact mental health in adulthood, and approaches to prevent or treat PTSD and other symptoms.

Types of trauma and correlation with PTSD

ACEs can be indexed as neglect or emotional, physical, or sexual abuse. Physical and sexual abuse strongly correlate with an increased risk of PTSD.³ Although neglect and emotional abuse do not directly predict the development of PTSD, these experiences foretell high rates of lifelong trauma exposure and are indirectly related to late PTSD symptoms.^4,5 ACEs can impede an individual’s cognitive, social, and emotional development, diminish quality of life, and lead to an early death.⁶ The lifetime prevalence of PTSD is 6.1% to 9.2%.⁷ Compared with men, women are 4 times more likely to develop PTSD following a traumatic event.⁷

The development of PTSD is influenced by the nature, duration, and degree of trauma, and age at the time of exposure to trauma. Children who survive complex trauma (≥2 types of trauma) have a higher likelihood of developing PTSD.⁸ Prolonged trauma exposure has a more substantial negative impact than a one-time occurrence. However, it is an erroneous oversimplification to assume that each type of ACE has an equally traumatic effect.⁶

Factors that protect against PTSD

Factors that can protect against developing PTSD are listed in Table 1.⁷ Two of these are resilience and hope.

Resilience is defined as an individual’s strength to cope with difficulties in life.⁹ Resilience has internal psychological characteristics and external factors that aid in protecting against childhood adversities.^10,11 The Brief Resilience Scale is a self-assessment that measures innate abilities to cope, including optimism, self-efficacy, patience, faith, and humor.^12,13 External factors associated with resilience are family, friends, and community support.^11,13

Hope can help in surmounting ACEs. The Adult Hope Scale has been used in many studies to assess this construct in individuals who have survived trauma.¹³ Some studies have found decreased hope in individuals who sustained early trauma and were diagnosed with PTSD in adulthood.¹⁴ A study examining children exposed to domestic violence found that children who showed high hope, endurance, and curiosity were better able to cope with adversities.¹⁵

Continue to: PTSD risk factors

PTSD risk factors

Many individual and societal risk factors can influence the likelihood of developing PTSD. Some of these factors are outlined in Table 1.⁷

Pathophysiology of PTSD

Multiple brain regions, pathways, and neurotransmitters are involved in the development of PTSD. Neuroimaging has identified volume and activity changes of the hippocampus, prefrontal cortex, and amygdala in patients with early trauma and PTSD. Some researchers have suggested a gross reduction in locus coeruleus neuronal volume in war veterans with a likely diagnosis of PTSD compared with controls.^16,17 In other studies, chronic stress exposure has been found to cause neuronal cell death and affect neuronal plasticity in the limbic area of the brain.¹⁸

Diagnosing PTSD

More than 30% of individuals who experience ACEs develop PTSD.¹⁹ The DSM-5 diagnostic criteria for PTSD are outlined in Table 2.²⁰ Several instruments are used to determine the diagnosis and assess the severity of PTSD. These include the Clinician-Administered PTSD Scale for DSM-5,²¹ which is a 30-item structured interview that can be administered in 45 to 60 minutes; the PTSD Symptom Scale Self-Report Version, which is a 17-item, Likert scale, self-report questionnaire; and the Structured Clinical Interview: PTSD Module, which is a semi-structured interview that can take up to several hours to administer.²¹

Other disorders. In addition to PTSD, individuals with ACEs are at high risk for other mental health issues throughout their lifetime. Individuals with ACE often experience depressive symptoms (approximately 40%); anxiety (approximately 30%); anger; guilt or shame; negative self-cognition; interpersonal difficulties; rumination; and thoughts of self-harm and suicide.²² Epidemiological studies suggest that patients who experience childhood sexual abuse are more likely to develop mood, anxiety, and substance use disorders in adulthood.^23,24

Psychotherapeutic treatments for PTSD

Cognitive-behavioral therapy (CBT) addresses the relationship between an individual’s thoughts, emotions, and behaviors. CBT can be used to treat adults and children with PTSD. Before starting CBT, assess the patient’s current safety to ensure that they have the coping skills to manage distress related to their ACEs, and address any coexisting substance use.²⁵

Continue to: According to the American Psychological Association...

According to the American Psychological Association, several CBT-based psychotherapies are recommended for treating PTSD²⁶:

Trauma-focused–CBT includes psychoeducation, trauma narrative, processing, exposure, and relaxation skills training. It consists of approximately 12 to 16 sessions and incorporates elements of family therapy.

Cognitive processing therapy (CPT) focuses on helping patients develop adaptive cognitive domains about the self, the people around them, and the world. CPT therapists assist in information processing by accessing the traumatic memory and trying to eliminate emotions tied to it.^25,27 CPT consists of 12 to 16 structured individual, group, or combined sessions.

Prolonged exposure (PE) targets fear-related emotions and works on the principles of habituation to extinguish trauma and fear response to the trigger. This increases self-reliance and competence and decreases the generalization of anxiety to innocuous triggers. PE typically consists of 9 to 12 sessions. PE alone or in combination with cognitive restructuring is successful in treating patients with PTSD, but cognitive restructuring has limited utility in young children.^25,27

Cognitive exposure can be individual or group therapy delivered over 3 months, where negative self-evaluation and traumatic memories are challenged with the goal of interrupting maladaptive behaviors and thoughts.²⁷ 

Continue to: Stress inoculation training

Stress inoculation training (SIT) provides psychoeducation, skills training, role-playing, deep muscle relaxation, paced breathing, and thought stopping. Emphasis is on coaching skills to alleviate anxiety, fear, and symptoms of depression associated with trauma. In SIT, exposures to traumatic memories are indirect (eg, role play), compared with PE, where the exposures are direct.²⁵

The American Psychological Association conditionally recommended several other forms for psychotherapy for treating patients with PTSD²⁶:

Brief eclectic psychotherapy uses CBT and psychodynamic approaches to target feelings of guilt and shame in 16 sessions.²⁷

Narrative exposure therapy consists of 4 to 10 group sessions in which individuals provide detailed narration of the events; the focus is on self-respect and personal rights.²⁷

Eye movement desensitization and reprocessing (EMDR) is a 6- to 12-session, 8-phase treatment that uses principles of accelerated information processing to target nonverbal expression of trauma and dissociative experiences. Patients with PTSD are suggested to have disrupted rapid eye movements. In EMDR, patients follow rhythmic movements of the therapist’s hands or flashed light. This is designed to decrease stress associated with accessing trauma memories, the emotional/physiologic response from the memories, and negative cognitive distortions about self, and to replace negative cognition distortions with positive thoughts about self.^25,27

Continue to: Accelerated resolution therapy

Accelerated resolution therapy is a derivative of EMDR. It helps to reconsolidate the emotional and physical experiences associated with distressing memories by replacing them with positive ones or decreasing physiological arousal and anxiety related to the recall of traumatic memories.²⁸

Pharmacologic treatments

Selective serotonin reuptake inhibitors (SSRIs). Multiple studies using different scales have found that paroxetine, sertraline, and fluoxetine can decrease PTSD symptoms. Approximately 60% of patients treated with SSRIs experience partial remission of symptoms, and 20% to 30% experience complete symptom resolution.²⁹ Davidson et al³⁰ found that 22% of patients with PTSD who received fluoxetine had a relapse of symptoms, compared with 50% of patients who received placebo.

Serotonin-norepinephrine reuptake inhibitors (SNRIs) and other antidepressants. The SNRIs venlafaxine and duloxetine can help reduce hyperarousal symptoms and improve mood, anxiety, and sleep.²⁶ Mirtazapine, an alpha 2A/2C adrenoceptor antagonist/5-HT 2A/2C/3 antagonist, can address PTSD symptoms from both serotonergic pathways and increase norepinephrine release by blocking autoreceptors and enhancing alpha-1 receptor activity. This alleviates hyperarousal symptoms and promotes sleep.²⁹ In addition to having monoaminergic effects, antidepressant medications also regulate the hypothalamic–pituitary–adrenal (HPA) axis response to stress and promote neurogenesis in the hippocampal region.²⁹

Adrenergic agents

Adrenergic receptor antagonists. Prazosin, an alpha-1 adrenoceptor antagonist, decreases hyperarousal symptoms, improves sleep, and decreases nightmares related to PTSD by decreasing noradrenergic hyperactivity.²⁹

Beta-blockers such as propranolol can decrease physiological response to trauma but have mixed results in the prevention or improvement of PTSD symptoms.^29,31

Continue to: Glucocorticoid receptor agonists

Glucocorticoid receptor agonists. In a very small study, low-dose cortisol decreased the severity of traumatic memory (consolidation phase).³² Glucocorticoid receptor agonists can also diminish memory retrieval (reconsolidation phase) through intrusive thoughts and flashbacks.²⁹ 

Anticonvulsants, benzodiazepines, and antipsychotics

These medications have had a limited role in the treatment of PTSD.^26,29

Future directions: Preventive treatments

Because PTSD has a profound impact on an individual’s quality of life and the development of other illnesses, there is strong interest in finding treatments that can prevent PTSD. Based on limited evidence primarily from animal studies, some researchers have suggested that certain agents may someday be helpful for PTSD prevention²⁹:

Glucocorticoid antagonists such as corticotropin-releasing factor 1 (CRF1) antagonists or cholecystokinin 2 (CCK2) receptor antagonists might promote resilience to stress by inhibiting the HPA axis and influencing the amygdala by decreasing fear conditioning, as observed in animal models. Similarly, in animal models, CRF1 and CCK2 are predicted to decrease memory consolidation in response to exposure to stress. 

Adrenoceptor antagonists and agonists also might have a role in preventive treatment, but the evidence is scarce. Prazosin, an alpha-1 adrenoceptor antagonist, was ineffective in animal models.^29,31 Propranolol, a beta-adrenoceptor blocker, has had mixed results but can decrease trauma-induced physiological arousal when administered soon after exposure.²⁹ 

Continue to: N-methyl-d-aspartate (NMDA) receptor antagonists

N-methyl-d-aspartate (NMDA) receptor antagonists. NMDA receptor function decline has also been hypothesized to decrease the reconsolidation symptoms of PTSD.²⁹ One study examined the prevalence of PTSD in service members who were treated for burns in a military treatment center.³³ The use of the NMDA receptor antagonist ketamine lowered the prevalence of PTSD among service members who were treated for burns.The suggested mechanism is preventing memory consolidation after trauma exposure.³³

Bottom Line

Adverse childhood experiences (ACEs) are strong predictors for the development of posttraumatic stress disorder (PTSD) and other mental health or medical issues in late adolescence and adulthood. Experiencing a higher number of ACEs increases the risk of developing PTSD as an adult. Timely psychotherapeutic and pharmacologic interventions can help limit symptoms and reduce the severity of PTSD.

Related Resources

• Smith P, Dalglesih T, Meiser-Stedman R. Practitioner review: posttraumatic stress disorder and its treatment in children and adolescents. J Child Psychol Psychiatry. 2019;60(5):500-515.
• North CS, Hong BA, Downs DL. PTSD: a systematic approach to diagnosis and treatment. Current Psychiatry 2018;17(4):35-43.

Drug Brand Names

Duloxetine • Cymbalta
Fluoxetine • Prozac
Mirtazapine • Remeron
Paroxetine • Paxil
Prazosin • Minipress
Propranolol • Inderal, Pronol
Sertraline • Zoloft
Venlafaxine • Effexor

Childhood trauma, which is also called adverse childhood experiences (ACEs), can have lasting detrimental effects on individuals as they grow and mature into adulthood. ACEs may occur in children age ≤18 years if they experience abuse or neglect, violence, or other traumatic losses. More than 60% of people experience at least 1 ACE, and 1 in 6 individuals reported that they had experienced ≥4 ACEs.¹ Subsequent additional ACEs have a cumulative deteriorating impact on the brain. This predisposes individuals to mental health disorders, substance use disorders, and other psychosocial problems. The efficacy of current therapeutic approaches provides only partial symptom resolution. For such individuals, the illness load and health care costs typically remain high across the lifespan.^1,2 

In this article, we discuss types of ACEs, protective factors and risk factors that influence the development of posttraumatic stress disorder (PTSD) in individuals who experience ACEs, how ACEs can negatively impact mental health in adulthood, and approaches to prevent or treat PTSD and other symptoms.

Types of trauma and correlation with PTSD

ACEs can be indexed as neglect or emotional, physical, or sexual abuse. Physical and sexual abuse strongly correlate with an increased risk of PTSD.³ Although neglect and emotional abuse do not directly predict the development of PTSD, these experiences foretell high rates of lifelong trauma exposure and are indirectly related to late PTSD symptoms.^4,5 ACEs can impede an individual’s cognitive, social, and emotional development, diminish quality of life, and lead to an early death.⁶ The lifetime prevalence of PTSD is 6.1% to 9.2%.⁷ Compared with men, women are 4 times more likely to develop PTSD following a traumatic event.⁷

The development of PTSD is influenced by the nature, duration, and degree of trauma, and age at the time of exposure to trauma. Children who survive complex trauma (≥2 types of trauma) have a higher likelihood of developing PTSD.⁸ Prolonged trauma exposure has a more substantial negative impact than a one-time occurrence. However, it is an erroneous oversimplification to assume that each type of ACE has an equally traumatic effect.⁶

Factors that protect against PTSD

Factors that can protect against developing PTSD are listed in Table 1.⁷ Two of these are resilience and hope.

Resilience is defined as an individual’s strength to cope with difficulties in life.⁹ Resilience has internal psychological characteristics and external factors that aid in protecting against childhood adversities.^10,11 The Brief Resilience Scale is a self-assessment that measures innate abilities to cope, including optimism, self-efficacy, patience, faith, and humor.^12,13 External factors associated with resilience are family, friends, and community support.^11,13

Hope can help in surmounting ACEs. The Adult Hope Scale has been used in many studies to assess this construct in individuals who have survived trauma.¹³ Some studies have found decreased hope in individuals who sustained early trauma and were diagnosed with PTSD in adulthood.¹⁴ A study examining children exposed to domestic violence found that children who showed high hope, endurance, and curiosity were better able to cope with adversities.¹⁵

Continue to: PTSD risk factors

PTSD risk factors

Many individual and societal risk factors can influence the likelihood of developing PTSD. Some of these factors are outlined in Table 1.⁷

Pathophysiology of PTSD

Multiple brain regions, pathways, and neurotransmitters are involved in the development of PTSD. Neuroimaging has identified volume and activity changes of the hippocampus, prefrontal cortex, and amygdala in patients with early trauma and PTSD. Some researchers have suggested a gross reduction in locus coeruleus neuronal volume in war veterans with a likely diagnosis of PTSD compared with controls.^16,17 In other studies, chronic stress exposure has been found to cause neuronal cell death and affect neuronal plasticity in the limbic area of the brain.¹⁸

Diagnosing PTSD

More than 30% of individuals who experience ACEs develop PTSD.¹⁹ The DSM-5 diagnostic criteria for PTSD are outlined in Table 2.²⁰ Several instruments are used to determine the diagnosis and assess the severity of PTSD. These include the Clinician-Administered PTSD Scale for DSM-5,²¹ which is a 30-item structured interview that can be administered in 45 to 60 minutes; the PTSD Symptom Scale Self-Report Version, which is a 17-item, Likert scale, self-report questionnaire; and the Structured Clinical Interview: PTSD Module, which is a semi-structured interview that can take up to several hours to administer.²¹

Other disorders. In addition to PTSD, individuals with ACEs are at high risk for other mental health issues throughout their lifetime. Individuals with ACE often experience depressive symptoms (approximately 40%); anxiety (approximately 30%); anger; guilt or shame; negative self-cognition; interpersonal difficulties; rumination; and thoughts of self-harm and suicide.²² Epidemiological studies suggest that patients who experience childhood sexual abuse are more likely to develop mood, anxiety, and substance use disorders in adulthood.^23,24

Psychotherapeutic treatments for PTSD

Cognitive-behavioral therapy (CBT) addresses the relationship between an individual’s thoughts, emotions, and behaviors. CBT can be used to treat adults and children with PTSD. Before starting CBT, assess the patient’s current safety to ensure that they have the coping skills to manage distress related to their ACEs, and address any coexisting substance use.²⁵

Continue to: According to the American Psychological Association...

According to the American Psychological Association, several CBT-based psychotherapies are recommended for treating PTSD²⁶:

Trauma-focused–CBT includes psychoeducation, trauma narrative, processing, exposure, and relaxation skills training. It consists of approximately 12 to 16 sessions and incorporates elements of family therapy.

Cognitive processing therapy (CPT) focuses on helping patients develop adaptive cognitive domains about the self, the people around them, and the world. CPT therapists assist in information processing by accessing the traumatic memory and trying to eliminate emotions tied to it.^25,27 CPT consists of 12 to 16 structured individual, group, or combined sessions.

Prolonged exposure (PE) targets fear-related emotions and works on the principles of habituation to extinguish trauma and fear response to the trigger. This increases self-reliance and competence and decreases the generalization of anxiety to innocuous triggers. PE typically consists of 9 to 12 sessions. PE alone or in combination with cognitive restructuring is successful in treating patients with PTSD, but cognitive restructuring has limited utility in young children.^25,27

Cognitive exposure can be individual or group therapy delivered over 3 months, where negative self-evaluation and traumatic memories are challenged with the goal of interrupting maladaptive behaviors and thoughts.²⁷ 

Continue to: Stress inoculation training

Stress inoculation training (SIT) provides psychoeducation, skills training, role-playing, deep muscle relaxation, paced breathing, and thought stopping. Emphasis is on coaching skills to alleviate anxiety, fear, and symptoms of depression associated with trauma. In SIT, exposures to traumatic memories are indirect (eg, role play), compared with PE, where the exposures are direct.²⁵

The American Psychological Association conditionally recommended several other forms for psychotherapy for treating patients with PTSD²⁶:

Brief eclectic psychotherapy uses CBT and psychodynamic approaches to target feelings of guilt and shame in 16 sessions.²⁷

Narrative exposure therapy consists of 4 to 10 group sessions in which individuals provide detailed narration of the events; the focus is on self-respect and personal rights.²⁷

Eye movement desensitization and reprocessing (EMDR) is a 6- to 12-session, 8-phase treatment that uses principles of accelerated information processing to target nonverbal expression of trauma and dissociative experiences. Patients with PTSD are suggested to have disrupted rapid eye movements. In EMDR, patients follow rhythmic movements of the therapist’s hands or flashed light. This is designed to decrease stress associated with accessing trauma memories, the emotional/physiologic response from the memories, and negative cognitive distortions about self, and to replace negative cognition distortions with positive thoughts about self.^25,27

Continue to: Accelerated resolution therapy

Accelerated resolution therapy is a derivative of EMDR. It helps to reconsolidate the emotional and physical experiences associated with distressing memories by replacing them with positive ones or decreasing physiological arousal and anxiety related to the recall of traumatic memories.²⁸

Pharmacologic treatments

Selective serotonin reuptake inhibitors (SSRIs). Multiple studies using different scales have found that paroxetine, sertraline, and fluoxetine can decrease PTSD symptoms. Approximately 60% of patients treated with SSRIs experience partial remission of symptoms, and 20% to 30% experience complete symptom resolution.²⁹ Davidson et al³⁰ found that 22% of patients with PTSD who received fluoxetine had a relapse of symptoms, compared with 50% of patients who received placebo.

Serotonin-norepinephrine reuptake inhibitors (SNRIs) and other antidepressants. The SNRIs venlafaxine and duloxetine can help reduce hyperarousal symptoms and improve mood, anxiety, and sleep.²⁶ Mirtazapine, an alpha 2A/2C adrenoceptor antagonist/5-HT 2A/2C/3 antagonist, can address PTSD symptoms from both serotonergic pathways and increase norepinephrine release by blocking autoreceptors and enhancing alpha-1 receptor activity. This alleviates hyperarousal symptoms and promotes sleep.²⁹ In addition to having monoaminergic effects, antidepressant medications also regulate the hypothalamic–pituitary–adrenal (HPA) axis response to stress and promote neurogenesis in the hippocampal region.²⁹

Adrenergic agents

Adrenergic receptor antagonists. Prazosin, an alpha-1 adrenoceptor antagonist, decreases hyperarousal symptoms, improves sleep, and decreases nightmares related to PTSD by decreasing noradrenergic hyperactivity.²⁹

Beta-blockers such as propranolol can decrease physiological response to trauma but have mixed results in the prevention or improvement of PTSD symptoms.^29,31

Continue to: Glucocorticoid receptor agonists

Glucocorticoid receptor agonists. In a very small study, low-dose cortisol decreased the severity of traumatic memory (consolidation phase).³² Glucocorticoid receptor agonists can also diminish memory retrieval (reconsolidation phase) through intrusive thoughts and flashbacks.²⁹ 

Anticonvulsants, benzodiazepines, and antipsychotics

These medications have had a limited role in the treatment of PTSD.^26,29

Future directions: Preventive treatments

Because PTSD has a profound impact on an individual’s quality of life and the development of other illnesses, there is strong interest in finding treatments that can prevent PTSD. Based on limited evidence primarily from animal studies, some researchers have suggested that certain agents may someday be helpful for PTSD prevention²⁹:

Glucocorticoid antagonists such as corticotropin-releasing factor 1 (CRF1) antagonists or cholecystokinin 2 (CCK2) receptor antagonists might promote resilience to stress by inhibiting the HPA axis and influencing the amygdala by decreasing fear conditioning, as observed in animal models. Similarly, in animal models, CRF1 and CCK2 are predicted to decrease memory consolidation in response to exposure to stress. 

Adrenoceptor antagonists and agonists also might have a role in preventive treatment, but the evidence is scarce. Prazosin, an alpha-1 adrenoceptor antagonist, was ineffective in animal models.^29,31 Propranolol, a beta-adrenoceptor blocker, has had mixed results but can decrease trauma-induced physiological arousal when administered soon after exposure.²⁹ 

Continue to: N-methyl-d-aspartate (NMDA) receptor antagonists

N-methyl-d-aspartate (NMDA) receptor antagonists. NMDA receptor function decline has also been hypothesized to decrease the reconsolidation symptoms of PTSD.²⁹ One study examined the prevalence of PTSD in service members who were treated for burns in a military treatment center.³³ The use of the NMDA receptor antagonist ketamine lowered the prevalence of PTSD among service members who were treated for burns.The suggested mechanism is preventing memory consolidation after trauma exposure.³³

Bottom Line

Adverse childhood experiences (ACEs) are strong predictors for the development of posttraumatic stress disorder (PTSD) and other mental health or medical issues in late adolescence and adulthood. Experiencing a higher number of ACEs increases the risk of developing PTSD as an adult. Timely psychotherapeutic and pharmacologic interventions can help limit symptoms and reduce the severity of PTSD.

Related Resources

• Smith P, Dalglesih T, Meiser-Stedman R. Practitioner review: posttraumatic stress disorder and its treatment in children and adolescents. J Child Psychol Psychiatry. 2019;60(5):500-515.
• North CS, Hong BA, Downs DL. PTSD: a systematic approach to diagnosis and treatment. Current Psychiatry 2018;17(4):35-43.

Drug Brand Names

Duloxetine • Cymbalta
Fluoxetine • Prozac
Mirtazapine • Remeron
Paroxetine • Paxil
Prazosin • Minipress
Propranolol • Inderal, Pronol
Sertraline • Zoloft
Venlafaxine • Effexor

Childhood trauma, which is also called adverse childhood experiences (ACEs), can have lasting detrimental effects on individuals as they grow and mature into adulthood. ACEs may occur in children age ≤18 years if they experience abuse or neglect, violence, or other traumatic losses. More than 60% of people experience at least 1 ACE, and 1 in 6 individuals reported that they had experienced ≥4 ACEs.¹ Subsequent additional ACEs have a cumulative deteriorating impact on the brain. This predisposes individuals to mental health disorders, substance use disorders, and other psychosocial problems. The efficacy of current therapeutic approaches provides only partial symptom resolution. For such individuals, the illness load and health care costs typically remain high across the lifespan.^1,2 

In this article, we discuss types of ACEs, protective factors and risk factors that influence the development of posttraumatic stress disorder (PTSD) in individuals who experience ACEs, how ACEs can negatively impact mental health in adulthood, and approaches to prevent or treat PTSD and other symptoms.

Types of trauma and correlation with PTSD

ACEs can be indexed as neglect or emotional, physical, or sexual abuse. Physical and sexual abuse strongly correlate with an increased risk of PTSD.³ Although neglect and emotional abuse do not directly predict the development of PTSD, these experiences foretell high rates of lifelong trauma exposure and are indirectly related to late PTSD symptoms.^4,5 ACEs can impede an individual’s cognitive, social, and emotional development, diminish quality of life, and lead to an early death.⁶ The lifetime prevalence of PTSD is 6.1% to 9.2%.⁷ Compared with men, women are 4 times more likely to develop PTSD following a traumatic event.⁷

The development of PTSD is influenced by the nature, duration, and degree of trauma, and age at the time of exposure to trauma. Children who survive complex trauma (≥2 types of trauma) have a higher likelihood of developing PTSD.⁸ Prolonged trauma exposure has a more substantial negative impact than a one-time occurrence. However, it is an erroneous oversimplification to assume that each type of ACE has an equally traumatic effect.⁶

Factors that protect against PTSD

Factors that can protect against developing PTSD are listed in Table 1.⁷ Two of these are resilience and hope.

Resilience is defined as an individual’s strength to cope with difficulties in life.⁹ Resilience has internal psychological characteristics and external factors that aid in protecting against childhood adversities.^10,11 The Brief Resilience Scale is a self-assessment that measures innate abilities to cope, including optimism, self-efficacy, patience, faith, and humor.^12,13 External factors associated with resilience are family, friends, and community support.^11,13

Hope can help in surmounting ACEs. The Adult Hope Scale has been used in many studies to assess this construct in individuals who have survived trauma.¹³ Some studies have found decreased hope in individuals who sustained early trauma and were diagnosed with PTSD in adulthood.¹⁴ A study examining children exposed to domestic violence found that children who showed high hope, endurance, and curiosity were better able to cope with adversities.¹⁵

Continue to: PTSD risk factors

PTSD risk factors

Many individual and societal risk factors can influence the likelihood of developing PTSD. Some of these factors are outlined in Table 1.⁷

Pathophysiology of PTSD

Multiple brain regions, pathways, and neurotransmitters are involved in the development of PTSD. Neuroimaging has identified volume and activity changes of the hippocampus, prefrontal cortex, and amygdala in patients with early trauma and PTSD. Some researchers have suggested a gross reduction in locus coeruleus neuronal volume in war veterans with a likely diagnosis of PTSD compared with controls.^16,17 In other studies, chronic stress exposure has been found to cause neuronal cell death and affect neuronal plasticity in the limbic area of the brain.¹⁸

Diagnosing PTSD

More than 30% of individuals who experience ACEs develop PTSD.¹⁹ The DSM-5 diagnostic criteria for PTSD are outlined in Table 2.²⁰ Several instruments are used to determine the diagnosis and assess the severity of PTSD. These include the Clinician-Administered PTSD Scale for DSM-5,²¹ which is a 30-item structured interview that can be administered in 45 to 60 minutes; the PTSD Symptom Scale Self-Report Version, which is a 17-item, Likert scale, self-report questionnaire; and the Structured Clinical Interview: PTSD Module, which is a semi-structured interview that can take up to several hours to administer.²¹

Other disorders. In addition to PTSD, individuals with ACEs are at high risk for other mental health issues throughout their lifetime. Individuals with ACE often experience depressive symptoms (approximately 40%); anxiety (approximately 30%); anger; guilt or shame; negative self-cognition; interpersonal difficulties; rumination; and thoughts of self-harm and suicide.²² Epidemiological studies suggest that patients who experience childhood sexual abuse are more likely to develop mood, anxiety, and substance use disorders in adulthood.^23,24

Psychotherapeutic treatments for PTSD

Cognitive-behavioral therapy (CBT) addresses the relationship between an individual’s thoughts, emotions, and behaviors. CBT can be used to treat adults and children with PTSD. Before starting CBT, assess the patient’s current safety to ensure that they have the coping skills to manage distress related to their ACEs, and address any coexisting substance use.²⁵

Continue to: According to the American Psychological Association...

According to the American Psychological Association, several CBT-based psychotherapies are recommended for treating PTSD²⁶:

Trauma-focused–CBT includes psychoeducation, trauma narrative, processing, exposure, and relaxation skills training. It consists of approximately 12 to 16 sessions and incorporates elements of family therapy.

Cognitive processing therapy (CPT) focuses on helping patients develop adaptive cognitive domains about the self, the people around them, and the world. CPT therapists assist in information processing by accessing the traumatic memory and trying to eliminate emotions tied to it.^25,27 CPT consists of 12 to 16 structured individual, group, or combined sessions.

Prolonged exposure (PE) targets fear-related emotions and works on the principles of habituation to extinguish trauma and fear response to the trigger. This increases self-reliance and competence and decreases the generalization of anxiety to innocuous triggers. PE typically consists of 9 to 12 sessions. PE alone or in combination with cognitive restructuring is successful in treating patients with PTSD, but cognitive restructuring has limited utility in young children.^25,27

Cognitive exposure can be individual or group therapy delivered over 3 months, where negative self-evaluation and traumatic memories are challenged with the goal of interrupting maladaptive behaviors and thoughts.²⁷ 

Continue to: Stress inoculation training

Stress inoculation training (SIT) provides psychoeducation, skills training, role-playing, deep muscle relaxation, paced breathing, and thought stopping. Emphasis is on coaching skills to alleviate anxiety, fear, and symptoms of depression associated with trauma. In SIT, exposures to traumatic memories are indirect (eg, role play), compared with PE, where the exposures are direct.²⁵

The American Psychological Association conditionally recommended several other forms for psychotherapy for treating patients with PTSD²⁶:

Brief eclectic psychotherapy uses CBT and psychodynamic approaches to target feelings of guilt and shame in 16 sessions.²⁷

Narrative exposure therapy consists of 4 to 10 group sessions in which individuals provide detailed narration of the events; the focus is on self-respect and personal rights.²⁷

Eye movement desensitization and reprocessing (EMDR) is a 6- to 12-session, 8-phase treatment that uses principles of accelerated information processing to target nonverbal expression of trauma and dissociative experiences. Patients with PTSD are suggested to have disrupted rapid eye movements. In EMDR, patients follow rhythmic movements of the therapist’s hands or flashed light. This is designed to decrease stress associated with accessing trauma memories, the emotional/physiologic response from the memories, and negative cognitive distortions about self, and to replace negative cognition distortions with positive thoughts about self.^25,27

Continue to: Accelerated resolution therapy

Accelerated resolution therapy is a derivative of EMDR. It helps to reconsolidate the emotional and physical experiences associated with distressing memories by replacing them with positive ones or decreasing physiological arousal and anxiety related to the recall of traumatic memories.²⁸

Pharmacologic treatments

Selective serotonin reuptake inhibitors (SSRIs). Multiple studies using different scales have found that paroxetine, sertraline, and fluoxetine can decrease PTSD symptoms. Approximately 60% of patients treated with SSRIs experience partial remission of symptoms, and 20% to 30% experience complete symptom resolution.²⁹ Davidson et al³⁰ found that 22% of patients with PTSD who received fluoxetine had a relapse of symptoms, compared with 50% of patients who received placebo.

Serotonin-norepinephrine reuptake inhibitors (SNRIs) and other antidepressants. The SNRIs venlafaxine and duloxetine can help reduce hyperarousal symptoms and improve mood, anxiety, and sleep.²⁶ Mirtazapine, an alpha 2A/2C adrenoceptor antagonist/5-HT 2A/2C/3 antagonist, can address PTSD symptoms from both serotonergic pathways and increase norepinephrine release by blocking autoreceptors and enhancing alpha-1 receptor activity. This alleviates hyperarousal symptoms and promotes sleep.²⁹ In addition to having monoaminergic effects, antidepressant medications also regulate the hypothalamic–pituitary–adrenal (HPA) axis response to stress and promote neurogenesis in the hippocampal region.²⁹

Adrenergic agents

Adrenergic receptor antagonists. Prazosin, an alpha-1 adrenoceptor antagonist, decreases hyperarousal symptoms, improves sleep, and decreases nightmares related to PTSD by decreasing noradrenergic hyperactivity.²⁹

Beta-blockers such as propranolol can decrease physiological response to trauma but have mixed results in the prevention or improvement of PTSD symptoms.^29,31

Continue to: Glucocorticoid receptor agonists

Glucocorticoid receptor agonists. In a very small study, low-dose cortisol decreased the severity of traumatic memory (consolidation phase).³² Glucocorticoid receptor agonists can also diminish memory retrieval (reconsolidation phase) through intrusive thoughts and flashbacks.²⁹ 

Anticonvulsants, benzodiazepines, and antipsychotics

These medications have had a limited role in the treatment of PTSD.^26,29

Future directions: Preventive treatments

Because PTSD has a profound impact on an individual’s quality of life and the development of other illnesses, there is strong interest in finding treatments that can prevent PTSD. Based on limited evidence primarily from animal studies, some researchers have suggested that certain agents may someday be helpful for PTSD prevention²⁹:

Glucocorticoid antagonists such as corticotropin-releasing factor 1 (CRF1) antagonists or cholecystokinin 2 (CCK2) receptor antagonists might promote resilience to stress by inhibiting the HPA axis and influencing the amygdala by decreasing fear conditioning, as observed in animal models. Similarly, in animal models, CRF1 and CCK2 are predicted to decrease memory consolidation in response to exposure to stress. 

Adrenoceptor antagonists and agonists also might have a role in preventive treatment, but the evidence is scarce. Prazosin, an alpha-1 adrenoceptor antagonist, was ineffective in animal models.^29,31 Propranolol, a beta-adrenoceptor blocker, has had mixed results but can decrease trauma-induced physiological arousal when administered soon after exposure.²⁹ 

Continue to: N-methyl-d-aspartate (NMDA) receptor antagonists

N-methyl-d-aspartate (NMDA) receptor antagonists. NMDA receptor function decline has also been hypothesized to decrease the reconsolidation symptoms of PTSD.²⁹ One study examined the prevalence of PTSD in service members who were treated for burns in a military treatment center.³³ The use of the NMDA receptor antagonist ketamine lowered the prevalence of PTSD among service members who were treated for burns.The suggested mechanism is preventing memory consolidation after trauma exposure.³³

Bottom Line

Adverse childhood experiences (ACEs) are strong predictors for the development of posttraumatic stress disorder (PTSD) and other mental health or medical issues in late adolescence and adulthood. Experiencing a higher number of ACEs increases the risk of developing PTSD as an adult. Timely psychotherapeutic and pharmacologic interventions can help limit symptoms and reduce the severity of PTSD.

Related Resources

• Smith P, Dalglesih T, Meiser-Stedman R. Practitioner review: posttraumatic stress disorder and its treatment in children and adolescents. J Child Psychol Psychiatry. 2019;60(5):500-515.
• North CS, Hong BA, Downs DL. PTSD: a systematic approach to diagnosis and treatment. Current Psychiatry 2018;17(4):35-43.

Drug Brand Names

Duloxetine • Cymbalta
Fluoxetine • Prozac
Mirtazapine • Remeron
Paroxetine • Paxil
Prazosin • Minipress
Propranolol • Inderal, Pronol
Sertraline • Zoloft
Venlafaxine • Effexor