Oberhelman, Sara S.

Introduction: Adult hepatitis B vaccination coverage in the United States remains low despite updated national recommendations supporting universal adult immunization. Many adults remain unaware of their susceptibility to hepatitis B virus (HBV) infection. This quality improvement (QI) study evaluated a stepwise “Offer–Offer–Test–Vaccinate” workflow designed to improve hepatitis B vaccine uptake among vaccine-hesitant adults in a primary care setting. Methods: This retrospective QI study was conducted at a single primary care clinic in Rochester, Minnesota. Adult patients (≥19 years) seen between October 1, 2022, and October 1, 2024, were routinely offered hepatitis B vaccination during rooming. Two participating physicians implemented an enhanced workflow in which patients who declined vaccination were counseled and then offered serologic screening using the 2023 CDC-recommended triple panel (HBsAg, anti-HBs, and total anti-HBc). Patients with negative serology were notified via the patient portal and reoffered vaccination along with a link to the CDC Vaccine Information Statement. The primary endpoint was initiation of the hepatitis B vaccine series following receipt of negative serology results. Preliminary series-completion data through October 1, 2025, were also assessed. Results: Among 501 eligible adults, 104 (20.8%) accepted vaccination at the initial offer. Of the 397 who declined, 106 (26.7%) agreed to serologic testing; 91 (85.8%) were seronegative. Among seronegative patients, 41 (45.1%) subsequently accepted vaccination. Integrating serologic testing increased overall vaccination uptake from 20.8% to 28.9%, an absolute increase of 8.2 percentage points and a relative increase of 39.4%. Approximately 2.6 serologic tests were required to generate 1 additional first-dose vaccination. Preliminary series-completion rates were 74.0% among those vaccinated at the initial offer and 87.8% among those vaccinated following serologic testing. Discussion: In this primary care setting, incorporating serologic testing into the workflow was associated with modestly improved hepatitis B vaccination uptake among vaccine-hesitant adults. Serologic results may help re-engage patients by providing personalized immunity information. Implementation considerations include staffing needs, laboratory access, patient portal engagement, and insurance coverage. Conclusion: The “Offer–Offer–Test–Vaccinate” strategy was associated with a modest increase in hepatitis B vaccine uptake among hesitant adults. This EMR-integrated, stepwise approach may offer a feasible and scalable strategy to reduce missed vaccination opportunities and support HBV prevention in adult primary care.

Introduction: Vitamin D is an essential micronutrient for infant calcium metabolism and bone development. Concentrations of vitamin D in breastmilk are low, despite higher anti-rachitic activity and correlations between infant and maternal serum 25-hydroxyvitamin D (25D) (Taylor, et al., 2008; Oberhelman, et al., 2013). The sulfate-conjugated form of 25D is present in blood at concentrations approximately 40% of unmodified 25D. We hypothesized that sulfate conjugates, vitamin D3-sulfate (VitD-S) and 25-hydroxyvitamin D3-sulfate (25D-S), are present in milk and increase during supplementation. The objectives are (1) developing an LC-MS/MS assay to quantify VitD-S and 25D-S in milk, and (2) determine if these vitamin D sulfates increase with daily vitamin D supplementation. Methods: An LC-MS/MS method was developed to measure VitD-S and 25D-S in milk and in serum. Standards (Toronto Chemicals, Toronto, ON, CA) and internal standard (Glycomyr, Ames, IA) were used to optimize methods. Briefly, Milk (500 uL) and serum (250 uL) were extracted with methanol (MeOH) and resuspended in 150 uL 70% MeOH. Analytes were separated by C18 column with 70% to 100% MeOH with ammonium acetate (NH4OAc) organic phase gradient followed by MS/MS with optimized mass transitions and ESI in negative mode on SCIEX API 5000. An ongoing study is under way for breastmilk and serum collections from healthy lactating women consuming <600 IU vitamin D3/day at enrollment (day 1) and after 28 days of oral 5000 IU vitamin D3/day (day 28). This study was approved by the Mayo Clinic Institutional Review Board. Results: Preliminary analyses have been completed for 3 study participants. Serum 25D status had a trending increase from 30±2 ng/mL 25D on day 1 to 40±2 ng/mL 25D on day 28 ( P=0.1, paired t-test). Limit of detection [signal to noise (s/n) >3] for sulfates were 0.5 ng/mL 25D-S (s/n=7.3) and 0.25 ng/mL VitD-S (s/n=6.2). Upon enrollment, breastmilk sulfates were 3.25±0.12 ng/mL VitD-S (s/n=83.7±20.6) and 0.18±0.02 ng/mL 25D-S (s/n=13.6±3.3), and serum sulfates were 7.5±0.8 ng/mL VitD-S (s/n=39.4±22.5) and 53.2±10.4 ng/mL 25D-S (s/n=22.5±7.2). No statistical differences were observed between day 1 and day 28 in milk or serum sulfates for the 3 participants. However, VitD-S concentrations demonstrated a significant negative correlation between serum and milk ( r=0.87, P=0.03), and serum 25D-S was 21.3 ng/mL greater than unmodified serum 25D ( P=0.009, n=6). This study is ongoing, and data presented will include a greater number of study participants. Conclusions: We have developed an LC-MS/MS assay to measure VitD-S and 25D-S and found that VitD-S and 25D-S are present in freshly expressed breastmilk and in serum from women consuming <600 IU vitamin D3/day. F32 DK128987 & The Mayo Clinic Parker D. Sanders & Isabella G. Sanders Endowed Professorship. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Introduction Patients turn to foods, herbs, and medications to increase milk supply (i.e., galactagogues). Physicians may be asked to prescribe, recommend, or discuss perceived galactagogues despite a lack of evidence for their use. It is unclear how factors such as education, experience, and regulations influence clinical practice. The primary objective of this study was to document Canadian and US-based physicians’ attitudes towards, practice patterns surrounding, and utilization of pharmacologic, nutritional, and herbal products for the management of low milk supply. A secondary objective of this study was to determine factors that influence physicians’ decision-making with respect to the use of pharmacologic agents, foods, and vitamin, mineral, and herbal supplements for the treatment of low milk supply. Methods Physicians were recruited from two Facebook groups to complete an anonymous, online survey about their clinical use of pharmaceutical, supplemental, and nutritional substances perceived to increase milk production. The association between practice patterns and lactation medicine expertise or country for different perceived galactagogues was determined. Results A total of 307 physicians completed the primary portion of the survey. There was no difference in the proportion of physicians in Canada or the United States (US) who were defined as lactation medicine experts. Canadian physicians were more likely to prescribe metformin, levothyroxine, and domperidone, despite limited evidence of their effectiveness as galactagogues. Experts used all of the pharmacologic galactagogues. Canadians and experts were more likely than US-based and non-expert physicians, respectively, to include herbs in their practice. Numerous reasons for recommending or not recommending a given agent were cited, including patient request, personal and clinical experience, and lack of education, research, or access. Discussion The US FDA ban on domperidone affects which pharmacologic agents physicians in North America prescribe for low milk production. Despite having access to domperidone and limited evidence of their effectiveness, Canadian physicians are more likely than US physicians to also discuss, recommend, or prescribe herbal supplements as galactagogues. Conclusion In this online survey about medications, herbs, and foods commonly used in an effort to increase milk supply, Canadian and US-based physicians with and without lactation medicine expertise described their practice patterns and reported limitations in knowledge, medication access, and evidence. Though Canadian physicians prescribed domperidone without limitations, US physicians were less likely to incorporate it into clinical practice.

Introduction: Transgender and gender diverse individuals may choose to provide their infants with human milk. Lactating transgender men may experience gender dysphoria and desire to initiate or reinitiate gender-affirming testosterone therapy. However, there is limited safety data regarding use of testosterone during lactation. Main Issue: A 30-year-old G2P2 transgender man with gender dysphoria sought to initiate gender-affirming testosterone therapy while lactating. Management: Subcutaneous testosterone was self-administered beginning at 13 months post-partum. We prospectively collected data on circulating testosterone concentrations in parent serum, milk, and infant serum over 5 months until the infant self-weaned. The infant was monitored for growth and development at routine pediatric outpatient appointments. Parent serum testosterone concentrations rose with the initiation of testosterone therapy, reaching therapeutic concentrations by Day 14. Milk testosterone concentrations also increased with a maximum concentration of 35.9 ng/dl when the lactating parent was on a dose of 80 mg subcutaneous testosterone cypionate weekly. The calculated milk/plasma ratio remained under 1.0 and the calculated relative infant dose remained under 1%. The infant had no observable side effects, and his serum testosterone concentrations remained undetectable throughout the study period. Conclusion: This is the first study with data regarding human milk and infant serum testosterone concentrations during the initiation of gender-affirming testosterone therapy in a lactating individual. This evidence can help families and clinicians with decisions regarding lactation and testosterone use.

Vitamin D supplementation of breastfed infants is recommended because breast milk levels are low. We sought to determine if maternal supplementation would increase breast milk levels to achieve sufficiency in their infants. Forty mothers with exclusively breastfed infants were randomized to receive oral cholecalciferol (vitamin D3) 5000 IU/d for 28 days or 150,000 IU once. Maternal serum, breast milk and urine were collected on days 0, 1, 3, 7, 14 and 28 and infant serum on days 0 and 28. In mothers receiving daily vitamin D, serum and breast milk cholecalciferol attained steady levels of 18 and 8 ng/ml, respectively, from day 3 through 28. In mothers given the single dose, serum and breast milk cholecalciferol peaked at 160 and 40 ng/ml, respectively at day 1, before rapidly declining. Breast milk and maternal serum cholecalciferol were related (r=0.87). Infant serum 25OHD (mean±SD) increased from 17±13 to 39±6 ng/ml in the single dose group and from 16±12 to 39±12 ng/ml in the daily dose group (P= 0.88). All infants achieved sufficient 25OHD serum levels (≥20ng/mL). This study suggests that maternal supplementation can achieve sufficient infant serum levels of 25OHD via breastfeeding. A large single dose of vitamin D was equivalent to daily dosing for optimizing infant vitamin D status. This research was funded by the National Center for Research Resources and Mayo Clinic. Grant Funding Source : NCRR and Mayo Clinic

The American Academy of Pediatrics (AAP) recommends that all breastfed infants be supplemented with 400 IU of vitamin D daily, beginning soon after birth. We surveyed all Family Medicine providers at a single, academic medical institution regarding their perceptions and practices of infant vitamin D supplementation. Of 99 surveys solicited, 56 (57%) responded. Respondents were aware of the AAP recommendation with 52 (93%) correctly identifying the AAP’s recommended dose. The self‐reported median (interquartile range) proportion of visits in which the provider recommended supplementation to exclusively or partially breastfed infants were 80% (50 ‐ 97%) and 50% (25 ‐ 80%), respectively. The most common reason (82%) for recommending supplementation was “to follow the AAP recommendations.” Thirty (54%) reported recommending vitamin D supplementation within the first two weeks of life. Of all respondents, 49 (88%) recommend infant vitamin D drops as the route of supplementation. Finally, 49 (88%) respondents would prefer to supplement the mother instead of the infant or offer the parents a choice if this were an adequate and safe option for vitamin D supplementation, and 17 (30%) would prefer monthly to daily supplementation. In conclusion, Family Medicine providers are aware of current AAP recommendations, but vary in their practices; they are open to maternal vitamin D supplementation as an alternative option.

Introduction: Medical schools have an enduring need to provide ongoing faculty development and to foster educational alliances between teachers and learners, so that feedback provided to learners is both frequent and of high quality. We hypothesized that medical students trained as academic detailers with a mission to increase the emphasis on feedback could serve in this role during our clerkship, while still being evaluated as students in our clerkship rotation. Methods: The family medicine clerkship at Mayo Clinic School of Medicine launched a revised curriculum in 2016 in which students were taught how they might build an educational alliance with preceptors, were taught characteristics of high-quality feedback, and practiced requesting more useful feedback when initial quality was poor. After utilizing a clerkship-specific curriculum with small group sessions on receiving feedback, and training students and preceptors on the SNAPPs model, students were then directed to request feedback from their preceptors and model successful feedback conversations for preceptors. The study evaluated the medical students’ summative evaluations to compare the rate from the preintervention year (2015-2016) and the intervention year (2016-2017) at which preceptors added comments on students’ use of feedback. Results: Preceptors’ written comments about students seeking feedback increased at about a four-fold rate (74.4% vs 18.8%, P&lt;.001) after implementing a suite of changes to our clerkship curriculum. Conclusions: Using medical students to change preceptor behaviors was an important part of our suite of interventions. This intervention directed preceptor attention toward our instructional goal of increased medical student feedback.

Background: The American Academy of Pediatrics and the National Academy of Medicine recommend vitamin D supplementation for breastfeeding infants. However, compliance with this recommendation is poor. Maternal supplementation with vitamin D is a safe and effective alternative to achieving vitamin D sufficiency in breastfeeding infants, and mothers have indicated a preference for self-supplementation over infant supplementation. Research aim: We sought to explore Family Medicine clinicians’ knowledge, attitudes, and practices regarding vitamin D supplementation recommendations for breastfeeding dyads. Methods: Fifty-six Family Medicine clinicians (including faculty physicians, resident physicians, and nurse practitioners/physician assistants) completed an online, anonymous survey regarding their knowledge and practices concerning vitamin D supplementation for breastfeeding infants. Results: The vast majority of clinicians (92.9%) correctly identified the American Academy of Pediatrics’ 2008 recommended dose for vitamin D supplementation in breastfeeding infants and estimated recommending vitamin D supplementation of exclusively breastfeeding infants 70.1% of the time. If all options were equivalent, clinicians would prefer to offer maternal or infant supplementation (50%) or maternal supplementation (37.5%) over infant supplementation (12.5%). Most (69.6%) preferred daily over monthly supplementation regimens. Conclusion: Family Medicine clinicians are knowledgeable regarding current recommendations for vitamin D supplementation in breastfeeding infants. They are also open to recommending maternal supplementation or offering parents a choice of maternal or infant vitamin supplementation.

Depression symptoms contribute to significant morbidity and health care utilization. The aim of this study was to determine the impact of symptom improvement (to remission) on outpatient clinical visits by depressed primary care patients. This study was a retrospective chart review analysis of 1733 primary care patients enrolled into collaborative care management (CCM) or usual care (UC) with 6-month follow-up data. Baseline data (including demographic information, clinical diagnosis, and depression severity) and 6-month follow-up data (Patient Health Questionnaire scores and the number of outpatient visits utilized) were included in the data set. To control for individual patient complexity and pattern of usage, the number of outpatient visits for 6 months prior to enrollment also was measured as was the presence of medical comorbidities. Multiple logistic regression analysis demonstrated that clinical remission at 6 months was an independent predictor of outpatient visit outlier status (>8 visits) (odds ratio [OR] 0.609, confidence interval (CI) 0.460–0.805, P <0.01) when controlling for all other independent variables including enrollment into CCM or UC. The OR of those patients not in remission at 6 months having outpatient visit outlier status was the inverse of this at 1.643 (CI 1.243–2.173). The most predictive variable for determining increased outpatient visit counts after diagnosis of depression was increased outpatient visits prior to diagnosis (OR 4.892, CI 3.655–6.548, P <0.01). In primary care patients treated for depression, successful treatment to remission at 6 months decreased the likelihood of the patient having more than 8 visits during the 6 months after diagnosis. ( Population Health Management 2014;17:180–184)