Browse
Recent Submissions
Item Social determinants of 30-day congestive heart failure readmissions: The weight of food insecurity(2025-11) Guerrero, Jonathan; Muvuka, Baraka; Blodgett, AlisonIntroduction Social determinants of health (SDOH) are drivers of chronic disease exacerbation and hospital readmissions. Congestive Heart Failure (CHF) is among 6 conditions targeted by the Centers for Medicare and Medicaid Services’ (CMS) Hospital Readmissions Reduction Program. In 2022, CHF represented 13.9% of all-cause deaths and cost $30.7 billion, with 30-day readmissions contributing to these costs. CMS mandates inpatient SDOH screenings and referrals, yet the impact of food insecurity in CHF readmissions remains understudied. This study examined the social determinants of 30-day CHF readmissions. Methods This study employed a participatory research approach and retrospective design to analyze an EHR-generated dataset of CHF hospitalizations from January 2021 to April 2024 across three urban hospitals in Northwest Indiana. The primary outcome was 30-day CHF readmissions. Independent variables included SDOH, demographics, health behaviors, and health outcomes. Descriptive, bivariate, and multivariate analyses (p<0.05) were conducted. Results The sample comprised 5,489 patients with CHF, 36.2% racial/ethnic minorities, 76.2% 65+ years old, and 91.8% publicly insured. The 30-day readmission rate was 22.4%. Bivariate analysis revealed significant associations between 30-day readmissions and ethnicity, sex, language, hospital, insurance type, food insecurity, and depression risk. Food insecurity remained significant (OR=2.128; p=0.033) in multivariate analysis. Discussion This study identified food insecurity as an upstream SDOH linked to 30-day readmissions in patients with CHF, emphasizing the need to address SDOH in acute care settings. This research has informed a partnership to develop food security interventions for patients with CHF, aimed at reducing readmissions and improving health outcomes.Item Diabetes polygenic risk scores and maternal characteristics in Hoosier Moms Cohort participants(Wiley, 2025-08-22) Ellis, Allison; Bhamidipaty-Pelosi, Surya; Aamir, Maha; Kotarski, Aric; Guerrero, Rafael F.; Haas, David M.Introduction: Red cell alloimmunization in pregnancy occurs when a pregnant person develops antibodies against red blood cell antigens that are foreign to her. These antibodies can cross the placenta and cause hemolytic disease in the fetus and newborn (HDFN), which can lead to complications ranging from anemia and hyperbilirubinemia to stillbirth. Historically managed with invasive monitoring via amniocentesis, the approach shifted toward non-invasive Doppler ultrasound of the middle cerebral artery—using a middle cerebral artery peak systolic velocity (MCA PSV) threshold of 1.5 multiples of the median (MoM)—as a sensitive method to detect moderate to severe fetal anemia. However, more data are needed on neonatal outcomes when intrauterine transfusion is not performed. This study aimed to evaluate the characteristics and outcomes of red cell alloimmunized pregnancies requiring MCA PSV Doppler monitoring but not requiring intrauterine transfusion (IUT) and to investigate prenatal associations or predictors among neonates who required postnatal therapy for HDFN. Methods: This was a retrospective cohort study of a single center of level IV maternity and neonatal care units in the United States between January 2018 and December 2023. We included pregnancies with red cell alloimmunization requiring MCA PSV Doppler monitoring for which the fetus or neonate was shown to be at risk either antenatally or postnatally but did not require an IUT procedure. We excluded red cell alloimmunized pregnancies for which no testing was done either antenatally or postnatally to show whether the fetus or neonate was at risk, which required IUT, and which involved multiple gestations. Descriptive statistics were reported for the entire cohort. We then performed a bivariate comparison between two groups: neonates who received postnatal treatment for HDFN and those who did not. Multivariable logistic regression was performed to investigate prenatal associations or predictors among the neonates who required postnatal therapy for HDFN. Results: A total of 40 eligible pregnancies reached critical titers and needed MCA PSV Doppler monitoring, from which 39 neonates were included in the final analysis. A total of 18 (46.2%) of the at-risk neonates were admitted to the NICU. A total of 22 neonates (56.4%) required phototherapy of any kind (bililights and/or biliblanket), 1 neonate (2.6%) required exchange transfusion, and 5 neonates (12.8%) required IVIG. A total of 13 neonates (33.3%) only required phototherapy. No neonates received IVIG or exchange transfusion as isolated therapy. A total of 11 neonates (28.2%) required RBC transfusions to treat anemia. Only two neonates (5.1%) received RBC transfusion(s) as isolated therapy. Neonates requiring postnatal therapy for HDFN had higher rates of NICU admission (66.7% vs. 13.3%, p = 0.002) and longer NICU stays (median days 7, IQR 0, 19.5 vs. 0; p < 0.001). The multivariable logistic regression analysis showed that antibody titer at pregnancy onset was a significant predictor (OR = 16.33, 95% CI: 1.35–197.77, p = 0.03), while earlier MCA Doppler monitoring showed a non-significant trend toward reduced treatment need (OR = 0.095, 95% CI: 0.006–1.498, p = 0.09). Conclusion: This study confirms earlier studies in clinical predictive data for neonatal outcomes in red cell alloimmunization and highlights the importance of structured postnatal monitoring and timely follow-up.Item Neonatal outcomes among pregnancies with red cell alloimmunization requiring doppler monitoring without intrauterine transfusion: A retrospective cohort study(Wiley, 2025-08-22) Arkerson, Brittany J.; Aghajani, Faezeh; Modrall , Katherine E.; Salter, Lucy; Stepaniak, Evelyn C.; Shanks, Anthony L.; Mustafa, Hiba J.Introduction: Red cell alloimmunization in pregnancy occurs when a pregnant person develops antibodies against red blood cell antigens that are foreign to her. These antibodies can cross the placenta and cause hemolytic disease in the fetus and newborn (HDFN), which can lead to complications ranging from anemia and hyperbilirubinemia to stillbirth. Historically managed with invasive monitoring via amniocentesis, the approach shifted toward non-invasive Doppler ultrasound of the middle cerebral artery—using a middle cerebral artery peak systolic velocity (MCA PSV) threshold of 1.5 multiples of the median (MoM)—as a sensitive method to detect moderate to severe fetal anemia. However, more data are needed on neonatal outcomes when intrauterine transfusion is not performed. This study aimed to evaluate the characteristics and outcomes of red cell alloimmunized pregnancies requiring MCA PSV Doppler monitoring but not requiring intrauterine transfusion (IUT) and to investigate prenatal associations or predictors among neonates who required postnatal therapy for HDFN. Methods: This was a retrospective cohort study of a single center of level IV maternity and neonatal care units in the United States between January 2018 and December 2023. We included pregnancies with red cell alloimmunization requiring MCA PSV Doppler monitoring for which the fetus or neonate was shown to be at risk either antenatally or postnatally but did not require an IUT procedure. We excluded red cell alloimmunized pregnancies for which no testing was done either antenatally or postnatally to show whether the fetus or neonate was at risk, which required IUT, and which involved multiple gestations. Descriptive statistics were reported for the entire cohort. We then performed a bivariate comparison between two groups: neonates who received postnatal treatment for HDFN and those who did not. Multivariable logistic regression was performed to investigate prenatal associations or predictors among the neonates who required postnatal therapy for HDFN. Results: A total of 40 eligible pregnancies reached critical titers and needed MCA PSV Doppler monitoring, from which 39 neonates were included in the final analysis. A total of 18 (46.2%) of the at-risk neonates were admitted to the NICU. A total of 22 neonates (56.4%) required phototherapy of any kind (bililights and/or biliblanket), 1 neonate (2.6%) required exchange transfusion, and 5 neonates (12.8%) required IVIG. A total of 13 neonates (33.3%) only required phototherapy. No neonates received IVIG or exchange transfusion as isolated therapy. A total of 11 neonates (28.2%) required RBC transfusions to treat anemia. Only two neonates (5.1%) received RBC transfusion(s) as isolated therapy. Neonates requiring postnatal therapy for HDFN had higher rates of NICU admission (66.7% vs. 13.3%, p = 0.002) and longer NICU stays (median days 7, IQR 0, 19.5 vs. 0; p < 0.001). The multivariable logistic regression analysis showed that antibody titer at pregnancy onset was a significant predictor (OR = 16.33, 95% CI: 1.35–197.77, p = 0.03), while earlier MCA Doppler monitoring showed a non-significant trend toward reduced treatment need (OR = 0.095, 95% CI: 0.006–1.498, p = 0.09). Conclusion: This study confirms earlier studies in clinical predictive data for neonatal outcomes in red cell alloimmunization and highlights the importance of structured postnatal monitoring and timely follow-up.Item Suffering in Silence: A Mixed Methods Analysis Exploring the Relationship between Clinically Significant Distress & Mental Health Service Use in Breast Cancer Survivors(2024-03-07) Danner, Ana; Hays, Matthew; Li, Yang; Johns, ShelleyBreast cancer survivors (BCS) have an increased risk of psychological distress, including symptoms of depression, anxiety, and post-traumatic stress, compared to healthy controls. Fear of cancer recurrence (FCR) is an especially prevalent form of distress, with approximately 50% of BCS reporting clinically significant FCR. This mixed-methods study explored relationships between psychological distress, mental health service (MHS) use, and barriers to MHS use among BCS. Baseline data from 384 early-stage, post-treatment BCS with clinically significant FCR at screening enrolled in a randomized controlled trial comparing 3 FCR interventions were analyzed. The prevalence of clinically significant FCR, anxiety, depression, and post-traumatic stress symptoms was measured. Associations between distress measures and MHS use were assessed. Qualitative interviews were conducted with 15 distressed BCS to elucidate barriers hindering their use of MHS. Clinically significant levels of at least one form of distress besides FCR were reported in 226 (58.85%) BCS. Of 298 (77.60%) BCS with at least one significant distress score including FCR, only 61 (20.47%) reported using any MHS within the 3 months before baseline. Clinically significant anxiety (p = 0.0027), depression (p = 0.0015), and post-traumatic stress symptoms (p = 0.0227) were significantly associated with MHS use. Conversely, FCR was significantly associated with fewer visits to certain MHS. Qualitative interviews revealed personal and systemic barriers contributing to underutilization of MHS in BCS, including avoidant coping, financial constraints, inaccessibility to providers speaking the survivor’s first language, and limited timely care options. Only a minority of clinically distressed BCS use MHS. Anxiety, depression, and post-traumatic stress symptoms may be better predictors of MHS use than FCR given the tendency for fearful survivors to cope with avoidance. Interventions emphasizing alternatives to avoidant coping may benefit BCS with FCR. Further research is needed to identify solutions to the multifaceted barriers impeding MHS use among BCS.Item Optimizing Detection and Management of Brain Metastases in Patients with HER-2/neu+ Breast Cancer(2024-03-22) Bell, Libby; Danner, Ana; Bell, Katey; Gettelfinger, April; Newton, ErinBackground: Brain metastases (BM) are more prevalent in patients with HER-2/neu+ breast cancer and indicate poorer prognosis. Anti-HER-2/neu agents have led to improved patient outcomes yet show decreased efficacy in BM. Best practice generally combines local and systemic interventions based on clinical discretion and ability to cross the blood brain barrier. Distinguishing radiation changes from metastatic progression complicates defining disease progression and treatment implications. Case Description: A 31-year-old female with a palpable left breast mass was diagnosed with Stage II ER-, PR-, HER-2/neu+ breast cancer. She underwent neoadjuvant chemotherapy, mastectomy with axillary node dissection, and adjuvant chest wall radiation. A year later, she was hospitalized with new seizures and found to have multiple BM which were treated with stereotactic radiosurgery (SRS). Intermittent seizures continued, and it was unclear if they were due to disease progression, radiation changes, or both. A functional MRI revealed definitive disease progression for which she ultimately underwent metastasectomy of the largest left-sided lesions. She continues with the same well-tolerated systemic therapy. Clinical Significance: Despite HER-2/neu+ breast cancer patients’ higher risk for BM, there are no current screening recommendations for CNS surveillance. Diagnosis of BM typically occurs with onset of neurological symptoms. This timing is crucial as those with BM at diagnosis have better outcomes than those diagnosed with symptomatic BM later in treatment. While SRS is a standard treatment for BM, it can cause imaging changes that mimic tumor progression leading to unnecessary interventions. Increasing serial MRI frequency and an ongoing multidisciplinary approach for patients with prior SRS may aid in differentiation between SRS-induced pseudoprogression and true disease progression, thus improving neurologic outcomes. Conclusion: Greater incidence of BM in HER-2/neu+ breast cancer calls for standardization of BM detection and management.Item A Mixed-Methods Analysis of a Telephone-Based Acceptance and Commitment Therapy Intervention Aimed at Reducing Anxiety in Dementia Caregivers(2020-09-25) Danner, Ana; Stutz, Patrick; Gowan, Tayler; Johns, ShelleyOver 5.8 million people in the U.S. have Alzheimer’s disease or a related dementia (ADRD). Eighty percent of those with ADRD receive care in their homes, often unpaid care from family and friends. Due to the considerable physical and mental demands of providing care to a loved one with ADRD, these caregivers are especially prone to increased anxiety. A paradigm-shifting approach that may be useful for ADRD caregiver anxiety is acceptance and commitment therapy (ACT). ACT focuses on mindfulness and values-based action to increase psychological flexibility in managing life stress. This non-randomized pilot study enrolled unpaid ADRD caregivers (N=15) with clinically significant anxiety (Generalized Anxiety Disorder-7 [GAD-7] scale score ≥10). Using a mixed-methods approach, the effectiveness of TACTICs (Telephone Acceptance and Commitment Therapy Intervention for Caregivers of adults with ADRD) in decreasing anxiety was evaluated. Participants completed the GAD-7 at baseline, post-intervention, and 3 months later, along with a post-intervention qualitative interview. Interviews were transcribed verbatim, and each interview was analyzed thematically by at least two members of the TACTICs team. Mean GAD-7 scores were 13.33 (SD=2.79) at baseline and decreased to a mean of 8.36 (SD=3.00) post-intervention. This is a statistically large effect (d=1.72). Maintenance of effects on anxiety at 3 months post-intervention will be reported upon study completion in June. In post-intervention qualitative interviews, participants described their experiences with TACTICs and offered suggestions for improving the intervention. Participants reported reduced emotional reactivity, greater compassion for self and others, and increased psychological flexibility, which may explain how the intervention decreased caregiver anxiety. Participants’ suggestions for improvement will be summarized and used to improve the TACTICs program to better meet the needs of ADRD caregivers. 1 https://www.alz.org/alzheimers-dementia/facts-figures 2 https://www.cdc.gov/aging/caregiving/alzheimer.htmItem Suffering in Silence: A Mixed Methods Analysis Exploring the Relationship between Clinically Significant Distress & Mental Health Service Use in Breast Cancer Survivors(2024-10-18) Danner, Ana; Hays, Matthew; Li, Yang; Johns, ShelleyIntroduction: Breast cancer survivors (BCS) have an increased risk of psychological distress, including symptoms of depression, anxiety, and post-traumatic stress, compared to healthy controls. Fear of cancer recurrence (FCR) is an especially prevalent form of distress, with approximately 50% of BCS reporting clinically significant FCR. This mixed-methods study explored relationships between psychological distress, mental health service (MHS) use, and barriers to MHS use among BCS. Methods: Baseline data from 384 early-stage, post-treatment BCS with clinically significant FCR at screening enrolled in a randomized controlled trial comparing 3 FCR interventions were analyzed. The prevalence of clinically significant FCR, anxiety, depression, and post-traumatic stress symptoms was measured. Associations between distress measures and MHS use were assessed. Qualitative interviews were conducted with 24 distressed BCS to elucidate barriers hindering their use of MHS. Results: Clinically significant levels of at least one form of distress besides FCR were reported in 226 (58.85%) BCS. Of 298 (77.60%) BCS with at least one significant distress score including FCR, only 61 (20.47%) reported using any MHS within the 3 months before baseline. Clinically significant anxiety (p = 0.0027), depression (p = 0.0015), and post-traumatic stress symptoms (p = 0.0227) were significantly associated with MHS use. Conversely, FCR was significantly associated with fewer visits to certain MHS. Qualitative interviews revealed personal and systemic barriers contributing to underutilization of MHS in BCS, including avoidant coping, financial constraints, inaccessibility to providers speaking the survivor’s first language, and limited timely care options. Conclusions and Implications: Only a minority of clinically distressed BCS use MHS. Anxiety, depression, and post-traumatic stress symptoms may be better predictors of MHS use than FCR given the tendency for fearful survivors to cope with avoidance. Interventions emphasizing alternatives to avoidant coping may benefit BCS with FCR. Further research is needed to identify solutions to the multifaceted barriers impeding MHS use among BCS.Item In Their Words: The Barriers to Mental Health Service Use in Breast Cancer Survivors – and What WeCan Do to Help(2024-03-22) Danner, Ana; Hays, Matthew; Li, Yang; Johns, ShelleyWith over 4.1 million in the United States, breast cancer survivors (BCS) have been found to be at increased risk for psychological distress, including severe depression and anxiety. Fear of cancer recurrence (FCR) is an especially prevalent form of distress in many cancer survivors, with approximately 50% of BCS reporting clinically significant FCR. To address this unmet need, a randomized controlled trial (RCT) comparing 3 FCR interventions is currently being conducted with 384 early-stage, post-treatment BCS with clinically significant FCR. A secondary analysis of data collected from self-report questionnaires at baseline in this RCT revealed that 226 (58.9%) participants reported clinically significant levels of at least one form of psychological distress (depression, anxiety, and post-traumatic stress symptoms) in addition to clinically significant FCR. Despite this, only 61 participants (20.47%) reported using any mental health services (MHS) within the 3 months prior to baseline. This project aims to elucidate the barriers to MHS use in BCS through qualitative interviews. Interviews with distressed BCS have revealed a plethora of personal and systemic barriers contributing to underutilization of MHS. Common themes have been identified through qualitative analysis. Deeply intertwined with FCR, avoidant coping was a prevalent barrier for many survivors. Financial constraints were voiced, particularly the fear of not finding a compatible provider who is also covered by insurance. Scheduling barriers due to work and family responsibilities on top of an already exhausting list of medical appointments were expressed. Sociodemographic factors were discussed as well, such as inaccessibility to providers speaking the survivor’s first language. Even for BCS who reached out for MHS, many were discouraged by the lack of providers accepting new patients. In addition to pinpointing such barriers, valuable suggestions for improvement were obtained that may allow current and future healthcare providers to better address the holistic needs of BCS.Item Breaking the Silence: Unveiling Barriers to Mental Health Service Use in Breast Cancer Survivors with Clinically Significant Distress – A Mixed Methods Study(2025-03-08) Danner, Ana; Gowan, Tayler; Schwarz, Madison; Hays, Matthew; Li, Yang; Johns, ShelleyBackground: Breast cancer survivors (BCS) have an increased risk of psychological distress, including symptoms of depression, anxiety, and post-traumatic stress, compared to healthy controls. Fear of cancer recurrence (FCR) is an especially prevalent form of distress, with approximately 50% of BCS reporting clinically significant FCR. This mixed methods study explored relationships between psychological distress, mental health service (MHS) use, and barriers to MHS use among BCS. Methods: A mixed methods sequential explanatory design was utilized. Initially, baseline data from 384 early-stage, post-treatment BCS with clinically significant FCR at screening enrolled in a randomized controlled trial comparing 3 FCR interventions were analyzed. The prevalence of clinically significant FCR, anxiety, depression, and post-traumatic stress symptoms was measured. Associations between distress measures and MHS use were assessed. The quantitative findings prompted qualitative follow-up consisting of interviews with 24 distressed BCS to elucidate barriers hindering their use of MHS. Results: Clinically significant levels of at least one form of distress besides FCR were reported in 226 (58.85%) BCS. Of 298 (77.60%) BCS with at least one significant distress score including FCR, only 61 (20.47%) reported using any MHS within the 3 months before baseline. Clinically significant anxiety (p = 0.0027), depression (p = 0.0015), and post-traumatic stress symptoms (p = 0.0227) were significantly associated with MHS use. Conversely, FCR was significantly associated with fewer visits to certain MHS. Qualitative interviews revealed personal and systemic barriers contributing to underutilization of MHS in BCS, including avoidant coping, financial and logistical constraints, inaccessibility to providers with certain patient-preferred skillsets or backgrounds, such as speaking the survivor’s first language, and limited timely care options. In addition to pinpointing such barriers, valuable suggestions for improvement were elicited that may allow current and future providers to better meet the needs of BCS. Conclusions and Implications: Only a minority of clinically distressed BCS use MHS. Anxiety, depression, and post-traumatic stress symptoms may be better predictors of MHS use than FCR given the tendency for fearful survivors to cope with avoidance. Interventions emphasizing alternatives to avoidant coping may benefit BCS with FCR. Further research is needed to identify solutions to the multifaceted barriers impeding MHS use among BCS.Item Suffering in Silence: A Mixed Methods Analysis Exploring the Relationship between Clinically Significant Distress & Mental Health Service Use in Breast Cancer Survivors(2025-04-05) Danner, Ana; Hays, Matthew; Li, Yang; Johns, ShelleyIntroduction: Breast cancer survivors (BCS) have an increased risk of psychological distress, including symptoms of depression, anxiety, and post-traumatic stress, compared to healthy controls. Fear of cancer recurrence (FCR) is an especially prevalent form of distress, with approximately 50% of BCS reporting clinically significant FCR. This mixed-methods study explored relationships between psychological distress, mental health service (MHS) use, and barriers to MHS use among BCS. Methods: Baseline data from 384 early-stage, post-treatment BCS with clinically significant FCR at screening enrolled in a randomized controlled trial comparing 3 FCR interventions were analyzed. The prevalence of clinically significant FCR, anxiety, depression, and post-traumatic stress symptoms was measured. Associations between distress measures and MHS use were assessed. Qualitative interviews were conducted with 24 distressed BCS to elucidate barriers hindering their use of MHS. Results: Clinically significant levels of at least one form of distress besides FCR were reported in 226 (58.85%) BCS. Of 298 (77.60%) BCS with at least one significant distress score including FCR, only 61 (20.47%) reported using any MHS within the 3 months before baseline. Clinically significant anxiety (p = 0.0027), depression (p = 0.0015), and post-traumatic stress symptoms (p = 0.0227) were significantly associated with MHS use. Conversely, FCR was significantly associated with fewer visits to certain MHS. Qualitative interviews revealed personal and systemic barriers contributing to underutilization of MHS in BCS, including avoidant coping, financial constraints, inaccessibility to providers speaking the survivor’s first language, and limited timely care options. Conclusion: Only a minority of clinically distressed BCS use MHS. Anxiety, depression, and post-traumatic stress symptoms may be better predictors of MHS use than FCR given the tendency for fearful survivors to cope with avoidance. Interventions emphasizing alternatives to avoidant coping may benefit BCS with FCR. Further research is needed to identify solutions to the multifaceted barriers impeding MHS use among BCS.