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Item Categorization of chronic pain subtypes and contributing biomarkers in heart failure(2026-03-25) Smith, Asa B.; Jung, Miyeon; Wierenga, Kelly L.; Pressler, Susan J.Background: Chronic pain is prevalent among adults with heart failure (HF), yet pain subtypes (i.e., nociceptive, neuropathic, mixed nociceptive-neuropathic), and pain biomarkers remain poorly understood. Candidate biomarkers include interleukin (IL)-10, IL-18, IL-1β, IL-33, IL-6, IL-8, tumor necrosis factor-α, brain derived neurotrophic factor, leptin, adiponectin, and C-reactive protein. Characterizing pain subtypes and biomarkers underlying pain in HF could inform future diagnostic and therapeutic initiatives. Aims: 1) characterize pain subtypes; 2) compare pain severity and levels of biomarkers among pain subtypes; and 3) explore relationships between levels of biomarkers and pain severity. Methods: In this cross-sectional descriptive study, 60 adults with HF and chronic pain were enrolled. Pain subtypes and severity (0-10 scale) were assessed using the PainDETECT questionnaire. Blood samples obtained via venipuncture were analyzed for biomarkers. Data were analyzed using descriptive statistics, Chi-square, analysis of variance, and Spearman correlations. Results: Participants (mean age 70.5 years; 63.3% women; 65.0% White) reported predominantly nociceptive pain (73.3%), with fewer reports of mixed pain (20.0%) and neuropathic pain (6.7%). The mixed pain subtype was associated with higher average pain severity (nociceptive: 4.61/10, neuropathic: 5.75/10, mixed: 7.08/10, p<.05). While biomarker levels did not differ significantly across the subtypes, lower IL-10 (p=.049) and IL-33 (p=.014) were only associated with higher pain severity in the nociceptive subtype. Conclusions: This study highlights the predominance of nociceptive pain in HF and supports potential roles for IL-10 (anti-inflammatory) and IL-33 (both pro- and anti-inflammatory) in nociceptive pain. Larger studies are needed to clarify biomarker contributions to non-nociceptive pain phenotypes.Item Categorization of chronic pain subtypes and contributing biomarkers in heart failure(Oxford Academic, 2026) Smith, Asa B.; Rausch, Jamie; White, Fletcher A.; Perkins, Susan; Wierenga, Kelly L.; Jung, Miyeon; Vorhies, Christele; Jessup, Sean; Pressler, Susan J.Aims: Pain is common among adults with heart failure (HF), but pain subtypes and associated biomarkers are understudied. The aims were to: 1) characterize chronic pain severity, neuropathic pain quality, locations, and subtypes; and 2) compare pain severity and levels of biomarkers among pain subtypes. An exploratory aim was to correlate levels of biomarkers with pain severity. Methods: This pilot descriptive study included cross-sectional data from 60 adults with HF and chronic pain. Pain was evaluated using the PainDETECT questionnaire. Blood biomarkers included interleukin (IL)-10, IL-18, IL-1β, IL-33, IL-6, IL-8, tumor necrosis factor (TNF)-α, brain-derived neurotrophic factor, leptin, adiponectin, and C-reactive protein. Descriptive statistics, Chi-square test of homogeneity, one-way analysis of variance, and Spearman correlation were used for analyses. Results: The mean age was 70.45 (SD 7.92) years. The sample consisted of 63.3% women and 65.0% White race. Participants primarily reported nociceptive pain only (73.3%) with fewer reporting neuropathic pain only (6.7%) and mixed pain (20.0%). Current and 4-week mean pain severity scores were highest in the mixed pain subtype (p both <.05). No biomarkers were significantly different across the pain subtypes, but lower lL-10 (p=.049), and IL-33 (p=.014), were associated with higher pain severity. Conclusions: In this study, chronic pain and its association with underlying biomarkers were characterized. Future research with a larger sample is needed to understand the unique contributions of biomarkers with targeted pain phenotypes.Item Unique contributions of heart failure and chronic pain on physical function and quality of life in older adults(Elsevier, 2026) Smith, Asa B.; Forster, Anna K.; Webster-Dekker, Katelyn E.; Wierenga, Kelly L.Aims: The aims of this study were to investigate if chronic pain presence is significantly increased in older adults with heart failure (HF) compared to those without HF, and if a combination of pain and HF reduced quality of life and physical function. Methods: Retrospective cross-sectional survey and medical record data from 41,395 participants age ≥65 in the All of Us Research Program were analyzed using linear and logistic regression. Results: Participants with HF had a higher prevalence of chronic pain than those without HF but was not statistically significant. Having pain only, HF only, and both pain and HF were associated with reduced quality of life and physical function when compared to having no HF or pain. However, these associations were the strongest in those with both chronic pain and HF. Conclusions: A combination of HF and chronic pain markedly worsened outcomes, underscoring the need for improved pain management.Item The All of Us Dataset with healthcare access/utilization(2025-11-09) Smith, AsaItem Healthcare-related social determinants of health are associated with pain severity among adults with comorbid heart failure and chronic pain(2025-11-08) Smith, Asa B.; Knopf, Amelia; Webster-Dekker, Katelyn E.; Moore, Scott E.; Wierenga, Kelly L.Introduction: Chronic pain worsens symptom burden, physical function, and quality of life in heart failure (HF). Social determinants of health (SDOH) can shape the trajectory of HF and other disease states. Healthcare-related SDOH may also be related to the severity of pain among people with HF, but these relationships are unexplored. The aims among adults with HF and chronic pain were to: 1) describe healthcare-related SDOH; 2) compare healthcare utilization by pain severity; and 3) examine the relationship between healthcare-related SDOH and pain severity. Methods: In this cross-sectional study, descriptive statistics and multiple linear regression were used to analyze data from 3,988 participants with HF and chronic pain enrolled in the All of Us Research Program. Pain severity was assessed using a 0-10 scale. Healthcare-related SDOH variables were insurance coverage, self-reported access barriers, and healthcare affordability. Healthcare utilization variables were the number of general provider visits, prescribing advanced practice clinician visits, and specialist visits in the past 12 months. Results: The sample was mean age 70.04 years, 58% female, and 69.8% White race. Over 98% of participants had health insurance. The most common self-reported access barrier, unaffordable service, and medication cost-saving behavior was “no transportation” (14.7%), “dental care” (19.7%), and “asking for lower cost prescriptions” (24.2%), respectively (see Figure 1). Most participants saw a provider 2-3 times over 12 months, but those with higher pain severity saw a general provider more frequently than other pain groups (see Figure 2). Participants with a higher number of self-reported access barriers (β = 0.221 ± 0.044, p < .001), and a higher number of unaffordable services (β = 0.165 ± 0.034, p < .001), experienced higher pain severity. In contrast, participants who adopted a higher number of medication cost-saving behaviors experienced significantly lower pain severity (β = -0.108 ± 0.040, p = .007). Participants who were younger, female sex, non-White race, had more comorbidities, a positive depression diagnosis, and lower reported fatigue, experienced significantly higher pain severity (see Table 1). Conclusions: Despite the high percentage of insured participants, there were notable access and affordability barriers, which were associated with pain severity. These barriers should be confirmed with targeted studies that directly examine pain-related services.Item Development of a situation-specific biopsychosocial model of pain in heart failure(Wolters Kluwer, 2025) Smith, Asa; Jung, Miyeon; White, Fletcher; Dorsey, Susan; Giordani, Bruno; Pressler, SusanTheories of pain have been developed in several patient populations, but none currently exist for heart failure (HF) that include contributing factors and associated outcomes. We developed a situation-specific theory of pain in HF by adapting the biopsychosocial model of pain. Existing theoretical and empirical literature in HF samples was utilized to construct the new theory. Components, contributing factors, and associated outcomes of pain in HF are presented in the new theory. Areas in need of additional research are emphasized, and strengths and limitations are discussed. This theory could provide a foundation for future pain research initiatives in HF.Item Developing and testing a new theoretical model of pain in heart failure(2024-11-16) Smith, Asa; Jung, Miyeon; Pressler, SusanIntroduction: An estimated 23-85% of adults with chronic heart failure (HF) experience comorbid chronic pain, yet no comprehensive theoretical models have been developed or tested that completely capture the salient variables which affect pain. The aim of this study was to construct a preliminary theoretical model of pain in HF and evaluate the associations between identified variables in the model with pain presence. Methods: In this cross-sectional study, baseline data were obtained from the Cognitive Intervention to Improve Memory in Heart Failure Patients study (MEMOIR-HF) (n = 235). The Biopsychosocial Model of Chronic Pain was adapted for an HF-specific population. The dependent variable was pain presence (yes/no), which was measured using the Health Utilities Index Mark-3 (HUI-3). Independent variables were identified for the model using previous literature and univariate analyses comparing patients with vs. without pain in MEMOIR-HF. Logistic regression was used to test for differences between patients with pain present and not present. Results: Demographics were 45.5% men, 54.5% women, 86.4% White, 13.6% Black, mean age 66.39 (SD 12.04) years. Of 235 patients, 159 (67.66%) reported pain on the HUI-3 items. The variables that were included following univariate analysis and literature review were age, self-reported race and gender, comorbid conditions, sleep disturbances, HF severity, B-type natriuretic peptide, brain-derived neurotrophic factor, body mass index, and depression. Patients with pain were more likely to have worse HF severity (NYHA Class II or III compared with Class I) (Class II: OR 5.09 [1.71 – 15.08], p = .003, Class III: 5.05 [1.73 – 14.71], p = .003), more severe depression (OR 1.14 [1.06 – 1.23], p = .001), and worsened daytime sleepiness (OR 0.90 [0.83 – 0.98], p = .017), see Table 1. Conclusions: We believe this study is one of the first to construct and test a preliminary comprehensive model of pain in HF. Complete characterization of pain in HF is needed before treatments can be improved. Future research is needed to explore variables that were not available in the MEMOIR-HF dataset. More robust pain measures are needed to adequately test all variables.Item A Concept Analysis of the Perception of Diabetes Inevitability(2023) Alwine, Jennifer S.; Trueblood Miller, Wendy R.Item The complexities of pain in heart failure: locations, comorbid conditions, medications, subtypes, and limitations with activities(Indiana University School of Nursing, 2025-03-28) Smith, Asa B.; Jung, Miyeon; Pressler, Susan J.Item Therapeutic trust in complex trauma: a unique person – centered understanding(Taylor & Francis, 2024) Chouliara, Zoë; Murray, Jennifer; Coleman, Ann Marie; Burke Draucker, Claire; Choi, Wai Man Anna; School of NursingWe investigated the lived experience of therapeutic trust and its ruptures in working with clients with complex trauma presentations, a vulnerable and under-researched client group. A total of 13 clinicians and key informants, working in the field of complex trauma, were interviewed. Transcripts were analysed using Interpretative Phenomenological Analysis (IPA) to identify recurrent themes. The Nature, Function, Components, Process, and Challenges of building and maintaining therapeutic trust were identified. Therapeutic trust was experienced as a mechanism for reducing threat, processing vulnerability, and enabling accurately symbolisation. Focusing on trust and its ruptures seems key in working with clients presenting with complex traumas and potentially other severe and/or complex presentations. The importance of trust-focused person-centred approaches for addressing key psychological challenges, increasing engagement, and addressing experiences of disengagement in complex trauma is stressed. The central role of trust in the therapeutic relationship as a catalyst of change brings person- centred models to the fore of psychotherapy for complex trauma, as well as severe and/or complex presentations. In a traumatogenic world, therapists will be increasingly called to work with more clients presenting with traumas. A person-centred understanding seems to hold a lot of promise. Strategies for actively facilitating trust – focused, practice are proposed.