Citations

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.

ABSTRACT Background Obeticholic acid (OCA) was conditionally approved in 2016 as a second‐line therapy for patients with primary biliary cholangitis (PBC) and incomplete response to ursodeoxycholic acid (UDCA) monotherapy. We aimed to evaluate the impact of OCA add‐on therapy on biochemical outcomes and safety in those patients. Methods We systematically searched MEDLINE, Embase, and Cochrane CENTRAL for papers published up to October 29, 2024, evaluating OCA in patients with PBC at the 12‐month timepoint. Pooled analyses of liver enzymes were performed using the standard mean difference (SMD) and 95% confidence interval (CI) from the OCA baseline. Side effects and the achievement of criteria for adequate response are presented in percentages (95% CI). Results We included 1285 patients from 10 studies, two of which were RCTs. The addition of OCA significantly reduced alkaline phosphatase (ALP) (SMD −0.86; −1.15 to −0.56; p < 0.001) and total bilirubin (SMD −0.29; −0.43 to −0.15; p < 0.001). Overall, 37.23% of the patients (95% CI 31.47–43.39) responded to OCA (POISE criteria). The response rate was greater in the POISE trial results compared with real‐world data (46.15% vs. 30.54%, respectively; p = 0.0089). Pruritus was the most common adverse event (40.23%; 24.65–58.07). Approximately one‐fifth of the patients stopped OCA (18.05%; 12.72–24.99), with pruritus being the main reason for discontinuation (47.70%; 34.15–61.60). Conclusion Adding OCA improves ALP, bilirubin, and biochemical remission rates in patients with PBC who did not respond well to UDCA monotherapy. Real‐world data show an attenuated response. Pruritus is the most common side effect and the leading cause of drug discontinuation.

Background: Fluorescence in situ hybridization (FISH) is recommended as part of multimodality sampling in the evaluation of biliary strictures, but can be false negative in 40%–50% cases. The aim of this study was to comprehensively assess predictors of false-negative FISH in patients with biliary strictures. Methods: Patients undergoing tissue sampling for biliary strictures from October 20 to February 22 were prospectively enrolled (NCT04572711). Procedural factors such as sampling techniques, order, and utilization of combination sampling were recorded. Results of an optimized pancreatobiliary FISH panel with locus-specific probes for 1q21, 7p12, 8q24, and 9p21 were reported per guidelines. Statistical analyses were performed using BlueSky Statistics v.10.3.1, R package v8.81. Results: Of 327 patients, 93 (28.5%) were diagnosed with malignancy. A false-negative pancreatobiliary fluorescence in situ hybridization (PB-FISH) was reported in 40 (43.1%) patients. A history of primary sclerosing cholangitis was associated with lower odds of having a false-negative PB-FISH (aOR=0.38, 95% CI=0.16–0.82, p=0.02), whereas a hilar stricture was associated with a significantly higher false-negative PB-FISH in those with cholangiocarcinoma (aOR=3.2 [1.4–7.9], p=0.009). Dilation of biliary strictures prior to brushing was not associated with a lower rate of false-negative PB-FISH. Conclusions: In this prospective study, hilar strictures were more likely to have false-negative PB-FISH. Dilation of strictures did not affect PB-FISH performance. These results can help guide PB-FISH interpretation.

Background and Aims: The optimal treatment strategy for de novo perihilar cholangiocarcinoma (pCCA) remains debated. This study compares outcomes between liver transplantation following neoadjuvant chemoradiation (RT+LT) and liver resection (LR), with (LR+VR) and without vascular resection (LR w/o VR). Approach and Results: This single-center, retrospective study included patients with de novo perihilar cholangiocarcinoma treated at the Mayo Clinic Rochester (1993–2023) with curative-intent surgery. Patients underwent either (1) LR, classified as LR+VR or LR w/o VR, or (2) RT+LT following the transplant protocol. Overall survival (OS) and recurrence-free survival were analyzed using as-treated and intention-to-treat approaches, incorporating competing risk analysis and direct matching. In the as-treated analysis, RT+LT showed superior median OS compared with LR w/o VR (78.0 vs. 58.2 mo, p =0.03) and LR+VR (25.8 mo, p <0.001). Considering dropout rates (RT+LT: 41%, LR: 28%), intention-to-treat analysis showed no significant OS difference between LR and RT + LT (31.7 vs. 38.5 mo, p =0.19). In matched as-treated analysis, RT + LT had no significant survival benefit over LR w/o VR (50.6 vs. 140.6 mo, p =0.08) or LR+VR (25.8 mo, p =0.11). Perioperative mortality was 4% (RT+LT), 7% (LR w/o VR), and 8% (LR + VR). Conclusions: Both LR and RT+LT achieve excellent oncological outcomes in selected patients with de novo perihilar cholangiocarcinoma. Key challenges remain dropouts during neoadjuvant therapy in patients planned for LT and high perioperative mortality for patients undergoing LR. OS doubles in patients undergoing LR+VR compared with dropouts, supporting LR+VR as a viable option for patients who are ineligible for LT. Appropriate patient selection is crucial, as those not undergoing surgery suffer from a dismal prognosis.

Objective: To develop and validate a risk score for predicting post-transplant recurrence in perihilar cholangiocarcinoma (pCCA) patients. Background: pCCA is an aggressive malignancy with a poor prognosis. Although neoadjuvant chemoradiation (CRT) followed by liver transplantation (LT) offers a potential cure for patients with unresectable, early-stage de novo or primary sclerosing cholangitis (PSC)-associated pCCA, post-transplant recurrence negatively impacts survival. Currently, no risk stratification tools exist. Methods: This retrospective study included consecutive patients with unresectable de novo or PSC-associated pCCA who underwent neoadjuvant CRT followed by LT at Mayo Clinic (1993–2024). Predictors of post-transplant recurrence were identified using multivariable Cox regression with LASSO variable selection. The Perihilar Cholangiocarcinoma Risk Estimation of Tumor Recurrence after Transplant (PRETREAT) risk score was created by assigning points from model coefficients. Score performance was evaluated by discrimination (c-statistic), internally validated with 10-fold cross-validation, and externally validated in a separate cohort. Survival outcomes were compared across 3 PRETREAT risk groups and between 2 time periods. Results: This study included 399 patients (development: 301; validation: 98). The 5-year cumulative incidence of post-transplant recurrence was 29.7% in the development cohort and 27.6% in the validation cohort. Multivariable analysis identified 4 independent predictors: macroscopic residual tumor on explant [hazard ratio (HR): 12.4], vascular encasement (HR: 2.18), lymphovascular invasion (HR: 2.04), and radial tumor diameter (HR: 1.02/mm). The PRETREAT score (0–22), based on these factors, demonstrated excellent performance in both internal and external validation (C-index 0.83 and 0.85, respectively). Patients were stratified into low-risk (0–7), moderate-risk (8–15), and high-risk (16–22) groups. The 5-year recurrence-free survival rates significantly differed across low-risk, moderate-risk, and high-risk groups (89.0%, 38.3%, and 15.4%, respectively; P<0.001). Over the last decade, overall survival improved significantly only in moderate-risk patients (70.4% vs 46.9%, P=0.024), without significant improvement in recurrence-free survival. Conclusions: The PRETREAT score provides a valuable tool for guiding post-transplant management of pCCA, enabling risk-stratified surveillance, and laying the foundation for future clinical trials.

Abstract Rationale: Critical illness survivors often experience anxiety, depression, and post-traumatic stress disorder (PTSD) due to traumatic experiences, sedation, and delirium. Early interventions of psychological support may help mitigate mental health deficits post-ICU. Memory of the ICU stay may play a key role in addressing trauma and facilitating therapeutic engagement. Therefore, we sought to determine the relationship between ICU memory recollection, in-ICU delirium, and mental health outcomes at 1-month follow-up in a critical illness recovery center. Methods: We analyzed data collected at 1-month follow-up in a critical illness recovery center seeing adults who had ICU stays of &gt;4 days with sepsis, respiratory failure, and/or delirium. Patients were asked, “Do you remember your experience in the ICU, and if so, can you describe your most impactful memories?” and we qualitatively coded responses for A) presence/absence of memories and B) type of memories described. We analyzed unadjusted associations between demographic, clinical, and mental health measures (anxiety, depression, and PTSD) and memory recollection using chi-square and Wilcoxon rank-sum tests. Results: Among 196 patients seen at 1-month follow-up, 96 (49%) reported memories of their ICU stay. Of these, 44 (46%) described support they received in the ICU (e.g., feeling “safe and watched” by ICU staff, spouse at bedside), 36 (38%) recalled delusions and/or hallucinations (e.g., being kidnapped), 35 (37%) remembered specific treatments (e.g., cardioversion), and 33 (34%) described symptoms (e.g., pain, constipation). Baseline characteristics and critical illness features are shown in the Table. Patients who reported no memories of their ICU stay were more frequently admitted with neurological diagnoses, whereas those who reported memories were more often admitted with trauma or burns (p&lt;0.001). Those without memories had more delirium days than those reporting memories (p=0.02). Although PTSD and anxiety symptoms at 1-month follow-up were not associated with memories, patients who remembered their ICU stay had fewer depression symptoms (p=0.04). Conclusions: One month after their critical illness, half of survivors recalled their ICU experience, with memories ranging from supportive interactions to distressing experiences. In unadjusted analyses, memory recollection was associated with fewer depressive symptoms during follow-up, but a larger study is needed to determine whether this association persists after adjusting for potential confounders. Memories of the ICU may provide a therapeutic foundation for interventions targeting depression after critical illness, such as exposure therapy or ICU diaries, which may improve mental health outcomes in critical illness survivors.

Abstract Rationale: ICU nurses can experience high levels of burnout and job dissatisfaction due to stressors associated with high-stakes patient care, uncertain outcomes, and constant exposure to death. Witnessing patient recovery and/or disability status in the weeks or months after hospital discharge through reconnection with survivors of critical illness and their families may offer emotional and professional benefits to ICU nurses. However, the impact of connecting with patients’ post-ICU outcomes on nursing clinical practice and job satisfaction has not been well explored. This study aimed to investigate pragmatic perspectives from ICU nurses related to their insights on long-term patient outcomes after critical illness with a goal of identifying key mechanisms that may be associated with impacts on clinical practice and job satisfaction. Methods: A web-based investigator-designed survey was distributed to ICU nurses with endorsement from the American Association of Critical-Care Nurses for completion via their website and annual conference. Survey items included quantitative and open-ended prompts to examine the impact of reconnecting with ICU survivors on clinical practice and job satisfaction. Thematic analysis was performed on free-text responses. Results: Fifty-four ICU nurses (76% female) participated in the survey (June 2023-May 2024), with a median age of 41 years and a median of 7 years of critical care experience. Among them, 89% reported that reconnecting with survivors positively impacted their job satisfaction, and 78% felt that reconnecting influenced their clinical practice. Thematic analysis revealed three themes: Empathy and Human Connection – Nurses felt validated and fulfilled knowing their care positively impacted patients’ lives, reinforcing the meaning of their work. These interactions fostered greater empathy, reminding nurses of the real-life impact of their care.Validation of Effort and Accomplishment – Nurses reported a stronger sense of accomplishment seeing the positive outcomes of their work. Reconnecting with survivors reaffirmed the importance of their roles, strengthening nurses’ sense of purpose and commitment.Positive Emotional Impact and Job Satisfaction – Interactions with survivors provided emotional uplift, enhancing job satisfaction and reminding nurses of the rewarding aspects of their roles. Gratitude and progress from survivors motivated nurses, helping them manage the emotional challenges of ICU work. Conclusion: Reconnecting with ICU survivors and their families may have positive impacts on job satisfaction and clinical practice by providing emotional rewards, reinforcing nurses’ professional purpose, and validating their contributions to patient recovery. Embedding structured, low-cost re-engagement activities with critical illness survivors could offer valuable benefits to the ICU nurse workforce.

Objective To develop and validate classification criteria for pediatric chronic nonbacterial osteomyelitis (CNO) jointly supported by EULAR and the American College of Rheumatology (ACR). Methods This international initiative had 4 phases: (1) candidate items were proposed in a survey of pediatric rheumatologists, (2) criteria definition and reduction by Delphi and nominal group technique exercises, (3) criteria weighting using multicriteria decision analysis, and (4) refinement of weights and threshold score in a development cohort of 441 patients and validation in another cohort of 514 patients. Results The new EULAR/ACR classification criteria for CNO require typical radiographic or magnetic resonance imaging findings and bone pain as an obligatory entry criterion and exclusion criteria of malignancy, infection, vitamin C deficiency, and hypophosphatasia, followed by additive weighted criteria in 5 clinical (site of bone lesions, pattern of bone lesions, age at onset, coexisting conditions, fever) and 4 pathology/laboratory domains (bone biopsy findings if done, anemia, C‐reactive protein level, and erythrocyte sedimentation rate). A total score ≥55 is required for classification as CNO. The new criteria had a sensitivity of 82% and specificity of 98% in the validation cohort. Conclusion These new classification criteria for pediatric CNO developed with international input reflect current views about CNO, have high specificity and good sensitivity, and provide a key foundation for future CNO research.