The Indiana Medical Student Program for Research and Scholarship (IMPRS) facilitates IU School of Medicine medical student participation in various medical research and experiential opportunities including laboratory, clinical, and health research outcomes and community health education. The program strives to make a wide variety of research and clinical opportunities accessible to all students, enhance intellectual inquisitiveness, and support excellence in the development of physicians, physician-scientists, and educators.
Indiana Medical Student Program for Research and Scholarship
Evaluation of Resident Presentations Using a DEI Checklist
Background: In 2021, the Indiana University School of Medicine Department of Emergency Medicine developed a DEI checklist for residents presenting to their colleagues during weekly didactic sessions. The purpose of this present study is to evaluate the implementation of this DEI checklist as determined by its impact on resident presentations. Methods: A Qualtrics survey based on the DEI checklist was produced to collect data from a Kaltura database containing all resident lectures from the years 2018-19 through 2023-24. Ten lectures were analyzed from each year for 50 total lectures. The year 2020-21 was excluded. Data collected was subjected to quantitative statistics using content analysis. Transcripts for each lecture were generated using Otter.ai and analyzed qualitatively to draw conclusions from how residents discussed DEI topics. Results: Each year was assigned an average overall composite score according to the checklist items, with a score of zero indicating complete adherence to the checklist. The results were as follows: 2018-19: 1.8; 2019-20: 2.3; 2021-22: 2.3; 2022-23: 1.2; 2023-24: 0.8. Residents discussed how their topic may affect someone of a diverse background in 70% of lectures in 2018-2019; 70% in 2019-20; 50% in 2021-22; 80% in 2022-23; and 80% in 2023-24. The percentage of presentations with a dedicated DEI/health equity slide gradually increased from 20% of lectures in 2018-19 to 80% in 2023-24. Transcript review revealed residents transitioned from indirectly discussing health equity in 2018 to directly addressing DEI from 2022-24. Conclusion: Our analysis indicates a general trend towards increasing attention to health equity among these residents. Residents showed more intentionality in approaching DEI topics by directly addressing them in later years. Impact and Implications: Current literature provides no widely agreed upon methodology for determining the impact of DEI training in graduate medical education. Our study provides a novel technique for operationalizing this impact.
Copyright (c) 2025 Jared Clark, Andreia Alexander http://creativecommons.org/licenses/by/4.0
Temporal Changes in Neuronal Innervation during Human Inner Ear Organoid Development
Background and Hypothesis: Ribbon synapses are specialized synapses in sensory systems, crucial for tonic neurotransmitter release. Neuronal refinement, involving synaptic elimination and strengthening, is essential for nervous system development. While vestibular neuronal refinement is not well understood, cochlear maturation in mice provides reference for investigation. This study aims to test whether neuronal refinement/pruning, similar to those seen in the mouse inner ear, takes place in human pluripotent stem cell-derived inner ear organoids during development. Experimental Design or Project Methods: A 3D differentiation strategy developed in the laboratory was used to generate inner ear organoids, followed by tissue clearing and immunofluorescence labeling. Confocal microscopy was used to capture 3D volumetric images of vestibular hair cells and neurons at days 80, 120, and 200. Hair cell innervation was quantified by manually counting direct contact points between neurons and hair cells in 3D. NIS Elements annotation software was employed for accurate quantification. Results: The mean number of neuron contacts per hair cell significantly decreases from day 80 to day 200 (x̄ = 2.56, 1.89, and 1.60) respectively. The variability in these contacts reduces, as indicated by the standard deviations (σ = 1.131, 0.8570, and 0.7107). Despite this, there is persistent non-normal distribution of neuronal contact. Conclusion and Potential Impact: This study identifies temporal changes in neuronal contacts with hair cells in the human in vitro model of inner ear development, which is similar to neuronal refinement/pruning in the mouse inner ear during development. Observations include decreased neuronal contacts after differentiation day 80, branching refinement at day 120, and stabilization until day 200. The findings suggest varied maturation rates but increasing system uniformity over time. These results suggest that human inner ear organoids can be used to recapitulate normal and pathological development of ribbon synapses and neuronal innervation, essential components for sensory transduction in the human inner ear.
Copyright (c) 2025 Maria Martinez, Shweta Reddy, Eri Hashino http://creativecommons.org/licenses/by/4.0
Through a Different Lens: Assessing Patient and Clinician Diversity in Medical Education Clinical Practice Media
Background: As demands grow for inclusivity and representation in the workplace, schools, and various other settings, an increased focus has been placed on the lack of diversity in health multimedia. Specifically, textbooks utilized in medical school curriculum often lack photos that depict diverse skin tones, body shapes, sexes, and genders. However, past studies did not analyze the most recent clinical textbooks or emerging clinical video databases. This research focuses on examining patient and clinician clinical diversity in two clinical education resources: Bates’ Guide to Physical Examination and History Taking 13th edition (2021 e-text) and Bates’ Visual Guide to Physical Examination (video series). Methods: We developed a coding scheme for photos and videos based on previous literature that analyzes age, gender, sex, health state, skin tone, hair texture, body composition, SES, and the presence of tattoos and/or piercings. The coding scheme underwent 2 rounds of testing and subsequent modifications with a smaller sample. The final validated scheme was used to assess 576 photos and videos. Results: Of the photos and videos, only 18% exhibited individuals with curly or wavy hair, 1% included individuals with a darker skin tone, and 0.3% of individuals had a larger body type. There were no intersex or nonbinary individuals included. None of the individuals had tattoos, and all the piercings displayed were earlobe piercings, with all but 1 of the individuals being female. Conclusions/Implications: These findings reflect conclusions from previous studies, demonstrating that diversity and representation in medical textbooks can still be improved. Although there was some diversity in the photos and videos, several of the same models were used throughout the sources, which limits the application of such images to a range of diverse individuals. By advancing the diversity of medical school curriculum materials, students can provide more competent and compassionate care.
Copyright (c) 2025 McKenna Major, Stacey Dunham, Valerie O’Loughlin http://creativecommons.org/licenses/by/4.0
Loss of Apolipoprotein E Results in Altered Aqueous Humor Lipidome and Reduced ERG Response in Mice
Purpose: Elevated intraocular pressure (IOP) is a risk factor for primary open-angle glaucoma (POAG). Apolipoprotein E (APOE) is a cholesterol transport protein implicated with POAG risk. Preliminary data from the lab has shown that loss of APOE in-vivo have resulted in IOP elevation in mice. In this study, we aimed to elucidate APOE’s role in IOP homeostasis and POAG pathology via lipid-mediated pathways and analyses. Methods: Wild-type (WT) and ApoEtm1Unc knock-out homozygous (ApoE-/-) mice were used for this study. We performed: aqueous humor (AH) tap (13 mice) and shotgun lipidomics; pathway analyses using MetaboAnalyst 5.0; histology (6 mice) to validate knockout; electroretinogram (ERG) at three flicker intensities (-20, -10, 0 dB), comparing amplitudes of a and b-waves between WT and ApoE-/- mice using LKC Software EMWin 8.1 (n=4). Significance was conducted using Student’s t-test for significance (p<=0.05) using GraphPad Prism 9.0. Results: AH lipidomics showed significant lipid changes in ApoE-/- mice: elevated cholesteryl esters, ceramides, phosphoglycerides, and triglycerides, and decreased sphingomyelins and free fatty acids. Metabolic pathway analysis showed notable changes in mitochondrial β-oxidation and arachidonic acid metabolism pathways. ERG analysis showed reduced amplitude in ApoE-/- mice for both a-wave and b-waves at all intensities. Conclusions: Our study indicates APOE plays a significant role in the aqueous humor lipidome in mice. Reduced ERG response patterns in ApoE-/- mice suggest a phenotypical insult to retinal subcomponents, possibly worsened by prolonged ocular hypertension. Monitoring ERG response progression with IOP changes in mice will help elucidate APOE’s effects through future investigation. Additionally, the observed extracellular ceramide elevation in AH may contribute to age-related pathologies, warranting further investigation in TM outflow pathophysiology. Ongoing and future studies will aim to delineate the metabolic and physiological effects of APOE knockout in human TM tissue culture. Funding Source: NIH/NEI -R01EY029320 and R01EY035412, Ralph W. and Grace M. Showalter Research Trust and the Indiana University School of Medicine, Research Support Funds Grant (RSFG), Challenge Grant from Research to Prevent Blindness (RPB) to IU, and RPB Pilot Grant.
Copyright (c) 2025 Anoop Magesh, Reshma Magesh, Sutha K. John, Jungsu Kim, Padmanabhan P. Pattabiraman http://creativecommons.org/licenses/by/4.0
Addition of Misoprostol to Double-Balloon Catheter for Cervical Ripening Associated with Improved Obstetric Outcomes
Introduction: If induction of labor (IOL) is indicated but the cervix is deemed unfavorable, cervical ripening agents like mechanical dilators and synthetic prostaglandin E1 medications can be used. The objective of this study was to compare labor outcomes of women who underwent cervical ripening with a double-balloon catheter alone or with the addition of concurrent misoprostol. We hypothesized that concomitant use of misoprostol and cervical ripening balloon (CRB) was associated with increased vaginal delivery rates compared to CRB use alone. Methods: We conducted a retrospective cohort analysis consisting of patients who underwent IOL with CRB at Eskenazi Hospital. Comparison between the two cohorts was done using a chisquare/ fishers’ exact test for the categorical variables and t-test for the continuous variables. Results: A total of 134 patients were analyzed in the cohort, with 82 receiving concurrent misoprostol and 52 not receiving any additional pharmaceutical agents. Patients who received misoprostol and CRB had higher vaginal delivery rates (84.2% vs. 51.9%, p<0.01), decreased EBL (388.0 vs. 592.1 mL, p=0.01), and were not more likely to be given terbutaline (90.2% vs. 75%, p=0.02) compared to patients treated with CRB alone. There were no differences in neonatal outcomes (NICU admission, birth weight, or 5-min APGAR scores) or occurrence of uterine tachysystole between the cohorts. The multivariate analyses showed similar trends, although additional medication, medication use before balloon placement, advanced maternal age, and terbutaline use were not strong independent predictors of the vaginal delivery rate. Conclusion and Potential Impact: We found that concurrent use of misoprostol and CRB during IOL was associated with increased vaginal delivery rate and decreased EBL when compared with patients who had CRB alone. Potential impacts of this study include providing evidence-based recommendations on cervical ripening practices as well as guiding future studies investigating the possible benefits with standardization of IOL practices.
Copyright (c) 2025 Allison Li, Kevin Moss, Sarah Carpenter http://creativecommons.org/licenses/by/4.0
Determining the Therapeutic Effect of Human Neuritin 1 on the Restoration of Degenerated Retinal Ganglion Cells from Glaucoma Patients
Background and Hypothesis: Glaucoma is a group of optic neuropathies that affects approximately 76 million people worldwide. The main risk factor is elevated intraocular pressure (IOP) which predominantly affects retinal ganglion cells (RGC), resulting in cell death and permanent vision loss. Current therapeutics for glaucoma involve reducing IOP and halting progression of disease, but no current treatments can revive degenerated RGCs. Our project aims to evaluate the therapeutic effect of human Neuritin 1 (NRN1) in regenerating and protecting RGC loss in glaucoma. By administering NRN1 to the RGCs in culture, we hope to elucidate the efficacy in helping glaucomatous RGCs recover from cell death. Project Methods: Immunofluorescence (IF), gene expression, and karyotyping experiments were performed on iPSCs to confirm they were successfully reprogrammed from donor keratocytes. The iPSCs were differentiated to retinal organoids (RO) to generate RGCs in vitro. After around 30 days of differentiation, the ROs were dissociated to isolate RGCs. The RGCs were seeded at one end of three different in vitro collagen scaffolds. The first received no NRN1 treatment, the second received NRN1 at the cell body, and the third received NRN1 at the opposite end. IF was done on RGC-seeded scaffolds with RBPMS and NEFL antibodies to confirm RGC marker expression and neurite growth. Results: The iPSCs were successfully reprogrammed from donor keratocytes. We successfully generated RGCs from both non-glaucomatous and glaucomatous donor iPSCs. The RGCs effectively integrated within the collagen scaffolds. After NRN1 treatment, non-glaucomatous and glaucomatous RGCs demonstrated differential expression of RGC specific markers. Conclusions and Potential Impact: Our study demonstrates that NRN1 exhibits a therapeutic effect on glaucomatous RGCs. This study lays the foundation that NRN1 could potentially restore vision in glaucoma patients. Additionally, iPSC-derived RGCs can successfully be obtained from human donor eyes and cultured for future research for testing therapeutics.
Copyright (c) 2025 Nathan Hubbard, Shahna Shahul Hameed, Tasneem Sharma http://creativecommons.org/licenses/by/4.0
Clinical Impact and Sustainability of a Standardized Neonatal Nephrology Consult Program
Background/Objective: Acute kidney injury (AKI) is common in high-risk neonates and is associated with increased morbidity and mortality. Standardized programs to identify AKI exist only in a few institutions. The sustainability and clinical impact of such programs have not been described. We characterized changes in AKI incidence, neonatal nephrology consultation, and outpatient neonatal nephrology visits after implementation of a Neonatal Nephrology program. We hypothesized that neonatal AKI incidence would decrease in the post-implementation era. Methods: We instituted a standardized Neonatal Nephrology program in early 2020 to identify AKI in infants admitted to the NICU. Elements included (1) a shared neonatology and nephrology clinical practice guideline including creatinine monitoring, (2) electronic health record alert to identify infants with AKI, and (3) standardized nephrology consultation. All neonates with AKI were seen by nephrology and infants with severe AKI (stage 2 or 3) were referred for outpatient follow-up. Results: There was a sustained and significant decrease in AKI incidence since initiation of the program. AKI incidence decreased from 40% in 2019 before the program began to 19% in 2023. This decrease in AKI incidence correlates temporally to increased AKI identification and inpatient Neonatal Nephrology consults. While the initial burden of neonatal nephrology consults increased, with the decline in AKI incidence there has been a subsequent decrease in consultations. Conclusions: We report a reduction in AKI incidence after implementation of a standardized Neonatal Nephrology program. While reasons are likely multifactorial, it is likely that increased AKI awareness and monitoring contributed to this decline. We believe our single center experience emphasizes the importance of multi-disciplinary work in neonatal nephrology. Future work will focus on risk stratification of outpatient management of high-risk infants, interventions focused on further reduction in AKI incidence, and development of standardized approaches for identification and risk-stratification of infants.
Copyright (c) 2025 Benjamin Holland, Mayra Kotlik, Kathryn Lowe, Samantha Wallace, Anna Latimer, Danielle Soranno, Cara Slagle, Michelle Starr http://creativecommons.org/licenses/by/4.0
Investigating the Associations Between the Perivascular Space, Age, and Cognitive Function in Cognitively Normal and Impaired Individuals
Background and Hypothesis: Perivascular spaces (PVS) are a component of the glymphatic system, which is believed to help remove waste products from the brain. Dilated PVS have been correlated with normal aging and neurological conditions. In this study, we sought to evaluate the associations between age, PVS volume, and Montreal Cognitive Assessment (MoCA) score in cognitively normal participants (CN), as well as those with subjective cognitive decline (SCD), and mild cognitive impairment (MCI). We hypothesize that greater PVS volumes will be associated with lower MoCA scores. Methods: PVS delineation was conducted on MRI images of participants from the Indiana Alzheimer’s Disease Research Center (ages 62-89; with 9 CN, 5 SCD, 1 MCI). For image processing, the enhanced PVS contrast (EPC) was calculated by dividing T1-weighted images by T2-weighted images, followed by Frangi filter to capture the vessel-like PVS structure. Three blinded reviewers used the imaging software FSLeyes to analyze EPC and FLAIR images to correct the mask. Partial correlation was applied to PVS volume normalized to total brain volume and MoCA scores while controlling for age. Results: A partial correlation between MoCA score and PVS volume was -0.24 (p=0.40) after controlling for age. The sample sizes were not sufficient to investigate if these correlations varied among the different research groups. Scientific Implications: Our analysis suggests that enlarged PVS volume might contribute to decline in cognitive function, however, further work is needed to provide more insights to the pathologic alterations of PVS in individuals with cognitive complaints or impairment.
Copyright (c) 2025 Elise Hogarth, Ho-Ching Yang, Yomna Takieldeen, Shannon Risacher, Andrew Saykin, Yu-Chien Wu http://creativecommons.org/licenses/by/4.0
From Birth to Practice: An Analysis of Migration Patterns Among U.S. Orthopaedic Surgeons
Purpose: The purpose of this study is to understand the geographic migration of orthopaedic surgeons from birth, through training, to final practice location, and determine what predicts where orthopaedic surgeons practice. Methods:This retrospective observational study analyzed data gathered by the American Medical Association (AMA) on 8,676 orthopaedic surgeons who completed residency training between 2004 and 2017 and had over 5 years in practice. Data extracted included location of birth, medical school, residency, and final attending practice location as of January 1st, 2023. Relationships were determined using chi-squared analysis and logistic regression. Results: Residency location was the most predictive of attending location, with 96.52% of residents from 2008 – 2017 represented. Attending surgeons located where they completed residency training was census division (CD) dependent and ranged from 16.37% (Mountain West) to 71.59% (Middle Atlantic Northeast) with an average of 49.34%. Significant associations (p<0.00001) were observed between attending location and birth, medical school, and residency locations for all CDs. Heatmapping of ACGME data showcased that residency allocation across the US is not predicated by the population of the given state. Conclusion: This study suggests that birth and training location are highly predictive of where orthopaedic surgeons will practice in the United States. These relationships are stronger in some areas of the country than others. Residency location was most predictive of practice location, and therefore, the geographic allocation of residency positions is likely to influence the distribution of practicing orthopaedic surgeons. Residency allocation and retention is highly variable across the United States, further impacting the distribution. This information should guide decision makers in graduate medical education to ensure that future expansion and/or reallocation of orthopaedic residency positions serves population needs and provides equitable access to orthopaedic care in the United States.
Copyright (c) 2025 Bryce E. Duffett, Samuel T. Jines, Christopher D. Collier http://creativecommons.org/licenses/by/4.0
The Role of Cross-linked Actin Networks in the Proliferation and Senescence of Primary Human Trabecular Meshwork Cells
Purpose: TGFβ2 has been found to be elevated in the trabecular meshwork (TM) of patients with primary open-angle glaucoma. TM cells treated with TGFβ2 form cross-linked actin networks (CLANs). These CLANs are a restructuring of the cells’ actin cytoskeleton that appear as web-like (2D)/spherical (3D) structures. In this study, we used TGFβ2 treated primary human TM (pHTM) cells to illuminate the relationship between CLAN formation and cell proliferation and senescence. Methods: A characterized pHTM cell strain was seeded into a 96-well plate. Some cells were treated with 5ng/mL TGFβ2 for 1 week while the others served as a control. The cells were then fixed and immunostained for cell proliferation (Ki-67) and senescence (p21, H2AX, and β-galactosidase) markers. DAPI was also used to stain nuclei and phalloidin-Alexa-488 to stain F-actin/CLANs. Analysis was conducted through student’s t-tests. Results: TGFβ2-treated pHTM cells formed significantly more CLANs compared to control. The cell proliferation marker Ki-67 was rarely expressed in both groups (not statistically significant) but was mostly observed in CLAN- cells and seen only in the control. Ki-67 was almost completely absent in CLAN+ cells. Among senescence markers, none were expressed significantly differently between the two groups, however TGFβ2 led to an increase in p21 and β-gal. Most CLAN+ cells expressed p21. No cells expressed H2AX. Conclusions: TGFβ2 increases the formation of CLANs in pHTM cells. It seems that CLAN formation inhibits cell proliferation. However, the effect of CLAN formation on cell senescence is not clear. More investigation is needed to help further understand the relationship between CLAN formation and cell proliferation and senescence.
Copyright (c) 2025 Joseph M. Dalloul, Devon Harvey, Jiannong Dai, Chenna Kesavulu Sugali, Weiming Mao http://creativecommons.org/licenses/by/4.0
Exploring the Impact of Plasmin Inhibitors on Clotting Characteristics as a Novel Therapeutic for Thromboembolic Events
Background: Thromboembolisms are common, life-threatening emergencies. Systemic hemorrhaging post-thrombolytic treatment is an adverse reaction, highlighting the need for safer clot-digesting therapeutics. Our research focuses on an endogenous fibrinolytic enzyme, plasmin. We investigated how co-delivery of plasmin and pentamidine, a reversible bivalent plasmin inhibitor, impacts clotting and thrombolysis. Plasmin and pentamidine delivery were tested across ex-vivo stagnant viscoelastic assays (thromboelastography, TEG) and shear-based clot formation and digestion assays (Chandler Loop). This research aims to optimize safer clot-digesting therapeutics that minimize adverse bleeding. Methods: Consenting healthy volunteers (n=13) donated whole blood into citrated tubes using an approved IRB protocol. Whole blood was analyzed via Chandler Loop (20 RPM at 37C for 60min) and TEG (37C for 90min). Pentamidine (0-800μM) and plasmin (0-0.1mg/mL) were tested independently and mixed measuring: clot mass, clot strength (MA), R-time, angle, and K. Results: At increasing pentamidine concentrations, R-time and K increased while MA, angle, clot weight, and clot length decreased. At increasing plasmin concentrations, R-time, K, and angle remained unchanged while MA, clot weight, and clot length decreased. Concentrations >700μM pentamidine and >0.1mg/mL plasmin inhibited clotting. In the presence of fixed pentamidine (50μM in TEG, 200μM in Chandler), the initial impact to clot formation resembled 50μM of pentamidine alone followed by limited impact at increasing plasmin concentrations with a flat decrease in clot MA (18.3%), clot length (19.5%), and clot weight (18.9%) and increase in R-time (43.4%) and K (50.6%). Conclusion/Impact: Increasing plasmin concentrations results in increased clot digestion while increasing pentamidine concentrations functions more akin to an anticoagulant preventing clot formation. Co-administered plasmin with pentamidine demonstrates how an inhibitor can be used to deliver an active clot digesting enzyme. Leveraging the results presented herein, and the principles of multivalency, plasmin inhibitory molecules can be developed to create safer and more effective direct fibrinolytics for clinical use. FUNDING: This research is supported by the NIH NHLBI Award #R01HL167877 and T35 HL110854.
Copyright (c) 2025 Alexandra Cranston, Abigail Hall, Anushri Umesh, Nathan J. Alves http://creativecommons.org/licenses/by/4.0
Encapsulated Induced Pluripotent Stem Cell Derived Mesenchymal Stromal Cells Promote Muscle Regeneration in a Diabetic Mouse Model of Critical Limb Threatening Ischemia
Critical Limb Threatening Ischemia (CLTI), the end stage of peripheral arterial disease (PAD), represents a significant healthcare challenge, marked by diminished blood flow to the legs, leading to tissue necrosis and eventual amputation. Since 2010, there has been a 50% increase in non-traumatic major amputations related to PAD. Previous studies revealed that autologous bone marrow cell therapy fails to prevent amputations in diabetic patients with limited revascularization options. Allogeneic bone marrow-derived mesenchymal stromal cells (MSCs) have shown promise in stimulating angiogenesis in the muscles of diabetic patients. Induced pluripotent stem cell (iPSC)-derived MSCs might offer superior benefits, including reduced senescence. This study explores the potential of clinically approved human iPSC-MSCs, sourced from Cynata Therapeutics and encapsulated in alginate hydrogel, to enhance muscle regeneration in a diabetic CLTI mouse model. CLTI was induced by ligation/excision of the common femoral artery in male polygenic diabetic TALLYHO mice. iPSC-MSCs or a vehicle control were injected into the gracilis muscle of the ischemic limb 7 days post-ligation. Treated limbs exhibited increased blood perfusion, improved muscle function, reduced pathology, and heightened angiogenesis. Quantitative real-time PCR was employed to assess changes in mRNA expression related to muscle regeneration. Seven days post-iPSC-MSC injection, gastrocnemius and tibialis muscles demonstrated elevated mRNA expression for VEGF-A, MyH3, Mrc1, and Foxp3 compared to vehicle-treated muscles, signifying enhanced angiogenesis, muscle cell regeneration, M2-biased macrophage expression, and increased T regulatory cells. The observed rise in Mrc1 and Treg cells also suggested decreased inflammation in the treated muscle. These findings underscore the efficacy of encapsulated Cynata MSCs in fostering muscle regeneration and angiogenesis in diabetic mice, meriting further investigation to evaluate their potential for limb preservation in diabetic patients with CLTI.
Copyright (c) 2025 Cole Hennigan, Theresa Doiron, Chang-Hyan Gil, Jennifer Stashevsky, Japdeep Kaur, Madelyn Fairbairn, Supriya Chittajallu, Dr, Mackenzie Madison, Michael P Murphy http://creativecommons.org/licenses/by/4.0
Long Term Effects of Transient Romidepsin Exposure on Osteosarcoma Sarcospheres
Background: Osteosarcoma, the most prevalent primary bone cancer, disproportionally affects adolescents and young adults. Despite aggressive chemotherapeutics, prognosis remains poor, highlighting the need for novel therapeutics. Romidepsin, a histone deacetylase inhibitor, emerged as exceptionally potent and minimally toxic in our screen of 114 FDA-approved oncology drugs using three-dimensional osteosarcoma spheroids (sarcospheres). Due to the genetic complexity of pathogenesis, differences in sensitivity exist across cell lines and patient samples. Understanding the mechanism of romidepsin is crucial for determining predictability of treatment response, especially considering its short half-life and weekly administration regimen. Methods: Sarcospheres derived from established cell lines (LM7, MG63.3, and 143B) or patient sample (TT2) were exposed to various concentrations of romidepsin for 24 hours. Metabolic activity was measured by resazurin reduction assays at multiple timepoints following romidepsin removal. Results: Effects of transient romidepsin exposure last at least 14 days. TT2 and LM7 sarcospheres do not increase in size over 48 hours of culture, and recovery is prevented at clinically achievable levels. In contrast, 143B and MG63.3 sarcospheres show growth over 48 hours and romidepsin blocks this growth. For these sarcospheres, concentrations above clinically achievable levels are required to prevent recovery. Conclusions and Potential Impact: Romidepsin is FDA-approved for weekly administration in lymphoma. Effects caused by transient exposure to romidepsin persisted for 14 days in slow growing patient-derived sarcospheres, suggesting weekly administration is likely sufficient for patients with osteosarcoma. Results of this study are consistent with our previous findings that there are two types of responses to romidepsin. Romidepsin causes a G2 cell cycle block and growth inhibition in 143B and MG63.3 sarcospheres, while it causes DNA damage and cell death in LM7 and TT2 sarcospheres. Further exploration of these mechanistic differences has the potential to personalize medicine by providing better predictability of response to treatment and insight into prognosis.
Copyright (c) 2025 Alyssa Walker, Emily Seiden, Piper Wilburn, Ed Greenfield http://creativecommons.org/licenses/by/4.0
Derivation of a Multivariable Model to Assist Emergency Department Triage of Heart Failure Patients by Their Diuretic Treatment Needs
Background: Emergency medicine physicians (EMP) treat 1 million patients with acute decompensated heart failure (ADHF) annually. After emergency department (ED) treatment, EMPs must determine the need for further intravenous loop diuretic (IVLD) therapy in dispositioning patients to home (no further IVLD treatment), short stay observation (≤24hrs treatment), or inpatient hospitalization (>48 hours treatment). We hypothesized that EMPs overestimate IVLD needs, resulting in unnecessary admission, and derived a multivariable prediction model to aid EMP decision making. Methods: We prospectively enrolled 63 patients with ADHF. The primary predicted outcome was the number of guideline-based doses of IVLD (1 dose = 1x home furosemide dose) received during the total acute care encounter. Variables available prior to ED disposition (labs, imaging, risk-scores, structured physical exam {edema, JVP, orthopnea grade, hepatojuglar reflux}, patient symptom scores) were used to derive a multivariable prediction model with linear regression. Control predictor models included A) ED physical exam + symptom score + natriuretic peptide (NP) and B) EMP disposition decision adjusted for risk of 30-day serious adverse events. Models were compared by adjusted R2. Results: EMPs admitted 57 patients for full hospitalization, 5 for observation, and did not discharge any patients directly after ED IVLD treatment. Total-encounter IVLD requirements were median 2.5 guideline-standardized doses (IQR:0.8-4.5). ED disposition was poorly correlated with post-ED treatment needs, explaining only 2.1% of variance in IVLD requirements (i.e. R2=0.021). Physical exam, symptom score, and NP explained 24.7% of IVLD requirements. The new model (predictors: NP, BUN, sodium, troponin, heart rate, blood pressure, chest x-ray, medication adherence, edema severity) explained 54.7% of IVLD requirements. Conclusion: EMPs may increase unnecessary hospitalizations by overestimating post-ED IVLD treatment needs. Our novel model, pending external validation in a new >5000 patient sample, was 26 times more accurate than risk-adjusted ED disposition and twice as accurate as physical exam/symptom score/NPs.
Copyright (c) 2025 Jiayu Tian, Ivonne Cabrera, Chukwuebuka Ojukwu, Nicholas Harrison http://creativecommons.org/licenses/by/4.0
Relationship between Perivascular Space Burden, White Matter Hyperintensities, and Cognitive Function
Introduction: Perivascular space (PVS) is believed to be involved in clearing metabolic waste from the brain. PVS has been found to increase in size in patients with Alzheimer’s disease, but the relationship between PVS enlargement and cognitive function still requires further investigation. This study seeks to clarify the relationship between Montreal Cognitive Assessment (MoCA) scores and the percentage of brain volume occupied by perivascular space. We take into account confounding factors such as white matter hyperintensities (WMH), a biomarker associated with cognitive decline. We hypothesize that PVS enlargement leads to decreased brain waste clearing efficiency, which subsequently leads to cognitive impairment. Methods: The included participants (n = 15, ages 62 to 89, female: n = 9) were recruited for the 3YWU study from the Indiana Alzheimer's Disease Research Center. The sample included the control group (n = 9) and patients with mild cognitive impairment (n = 1) and subjective cognitive decline (n = 5). For imaging processing, the enhanced PVS contrast (EPC) was calculated by dividing T1-weighted images by T2-weighted images, followed by applying the Frangi filter to capture the vessel-like PVS structure. Three trained and blinded reviewers then further manually improved the PVS masks. For the analysis, we calculated the correlation coefficients between the Montreal Cognitive Assessment (MoCA) scores and normalized PVS volume, as well as a partial correlation coefficient while controlling for the normalized WMH volume. Results. We found a negative association between the PVS volume and MoCA scores of -0.28 (p=0.31), and after controlling for WMH, we still observed a negative correlation of -0.34 (pvalue of 0.23). Conclusion. Our results suggest that PVS enlargement is a possible factor in cognitive impairment. However, further investigation is necessary to characterize these correlations.
Copyright (c) 2025 Angela Tang, Ho-Ching Yang, Yomna Takieldeen, Shannon Risacher, Andrew Saykin, Yu-Chien Wu http://creativecommons.org/licenses/by/4.0
Physical Therapy Timing: An Investigation of Physical Therapy Initiation and Case Duration, Restricted Workdays, and Imaging Utilization
Background: Occupational health injuries are common, and many individuals will suffer a workplace injury throughout their career. When employees cannot work for extended periods of time, companies face financial and staffing difficulties. Prior studies have suggested that early referral to physical therapy (PT) is associated with improved patient outcomes and reduced healthcare utilization. However, there has been limited investigation of this in occupational health settings and among diverse types of injuries. Our goal was to investigate how the timing of PT impacted the case duration, restricted workdays, and imaging utilization among injured workers. Methods: We conducted an IRB-approved retrospective chart review of N=1191 patients who received care between 9/2017-6/2023 at Parkview Occupational Health. Timing of PT initiation was categorized as early (0-13 days), delayed (14-20 days), or late (>30 days) from date of first visit. Kruskal-Wallis tests were performed to assess differences in case duration and restricted workdays by PT timing. Chi-square tests evaluated utilization of different imaging modalities by PT timing. Bonferroni-corrected Dunn tests were performed to compare groups. Analyses were performed using Excel and Stata V.18 (alpha=0.05 for significance). Results: Across PT timing groups, median case duration ranged from 44-78 days, median restricted workdays ranged from 12-28 days, and total imaging utilization ranged from 32%-48%. Early PT initiation was associated with a significant reduction in case duration (p<0.001), total imaging (p<0.01), and X-ray utilization (p<0.001) compared to delayed or late PT initiation. Early PT was associated with fewer restricted workdays compared to delayed PT (p<0.001) but not late PT (p=0.054). Conclusion: These results support the benefits associated with utilizing early PT after a workplace injury with earlier utilization showing the greatest benefits.
Copyright (c) 2025 Austin Snider, Amelia Roebuck, Amanda Coupe, T. David Wu, Michael Knipp http://creativecommons.org/licenses/by/4.0
Predicting hypocalcemia in multiple myeloma patients undergoing autologous stem cell collection
Background/Objective: Multiple myeloma is a plasma cell dyscrasia that can be treated with an autologous stem cell transplant, which involves the harvest of autologous hematopoietic cells by apheresis following induction therapy. Citrate anticoagulation-induced hypocalcemia is more common with large volume apheresis, which is defined as processing 3 or more total blood volumes. Although calcium is given parenterally to mitigate this complication, about a third of this patient population still experiences symptoms of hypocalcemia. Total calcium to ionized calcium ratio (T:iCa) has been employed widely to predict iatrogenic hypocalcemia induced by citrate anticoagulation during renal dialysis. Our aim is to assess the utility of total to ionized calcium ratio to predict hypocalcemia in multiple myeloma patients during autologous stem cell collection by leukapheresis. Methods: A retrospective chart review study of a cohort of patients with multiple myeloma, who underwent autologous stem cell collection over a period of 6 months from October 2023 to March 2024 was conducted after an institutional review board approval. Demographic, clinical and laboratory data were obtained from the electronic medical record. The cohort was categorized into two groups: T:iCa ≥ 2.00, and T:iCa < 2.00. The binary outcome variable measured was the presence or absence of symptoms of hypocalcemia. A 2x2 table was constructed to examine the relationship between the two categorical variables. Results: A total of 22 multiple myeloma patients that underwent apheresis for the harvest of autologous stem cells were identified. About 55% of the patients were female; the median age of the patients was 56 years (IQR, 48-62) and the median weight of the patients was 79 kg (IQR, 72-100). The pre-procedure median peripheral CD34+ cell count was 46 cells/μL (IQR, 33-72), the median pre-procedure ionized calcium was 1.14 mmol/L (IQR, 1.1-1.2), and the median preprocedure total calcium was 9.2 mg/dL (IQR, 8.8-9.4). The median duration of the apheresis procedure was 329 mins (IQR, 286-365). During apheresis, the median number of total blood volumes processed was 4.25 (IQR, 3.43-4.88), and the median volume of ACD-A infused was 1504 mLs (IQR, 1241-1914). The overall prevalence of symptoms of hypocalcemia was 27% during the apheresis procedure. The median T:iCa was calculated to be 1.96 (IQR, 1.89-2.06). Results of the analysis of the 2x2 table are as follows: sensitivity 50%, specificity 62.5%, positive predictive value 0.33, and negative predictive value 0.77 using a T:iCa cut-off of 2.00. Conclusion/Potential Impact: Hypocalcemia is highly prevalent among multiple myeloma patients undergoing apheresis for hematopoietic stem cell collection. A third of the patient cohort have an increased probability of developing symptoms of hypocalcemia with a T:iCa of ≥ 2. Additional calcium supplementation in this subset of patients may be helpful in mitigating hypocalcemia during the procedure. A majority of the patient population who have T:iCa of ≥ 2 are likely to undergo autologous stem cell collection without experiencing symptoms of hypocalcemia.
Copyright (c) 2025 Prabhjot Singh Chahal, Esther Soundar http://creativecommons.org/licenses/by/4.0
Optimizing CT Surveillance for Thymic Epithelial Tumors Based on Recurrence Characteristics
Background: Thymic epithelial tumors (TETs), including thymoma and thymic carcinoma, are rare malignancies originating from the thymus gland epithelium. Surgery is the primary treatment for early-stage disease, and post-operative surveillance is crucial for early detection of recurrence, which enhances eligibility for curative-intent treatments. Purpose: The National Comprehensive Cancer Network (NCCN) recommends chest CT scans every 6 months for 2 years, then annually for 10 years for thymoma, and annually for 5 years for thymic carcinoma. However, the optimal duration, frequency, and type of imaging for TET surveillance remain undetermined in published studies. This study hypothesizes that postoperative CT scan surveillance can be tailored based on WHO classification, Masaoka-Koga staging, resection margin status, and common sites of metastasis. Method: The REDCap database includes 1,089 TET patients seen at IU. Applying inclusion criteria of histological classification as thymoma or thymic carcinoma, surgical resection, and documented recurrence yielded 190 patients. Disease characteristics collected included WHO classification, Masaoka-Koga staging, resection margin status, and common sites of metastasis. Time to recurrence was categorized as early (<2 years), late (2-10 years), or very late (>10 years). ANOVA assessed associations between time to recurrence and disease characteristics. Result: WHO classification was the most significant predictor of recurrence timing (p = 0.0465), with higher classifications indicating earlier recurrences. Other disease characteristics were not significant predictors. Eight patients experienced recurrence beyond 10 years. Metastatic sites in 11% of thymomas and 19% of thymic carcinomas were detected via abdominal CT scans, highlighting gaps in current guidelines. Conclusion: The study emphasizes the need to tailor postoperative surveillance based on WHO classification. Findings suggest extending surveillance beyond 10 years and incorporating abdominal imaging to detect metastases. These insights recommend that the NCCN update current guidelines, aiming to improve long-term outcomes for TET patients. Future research will include expanding the cohort to non-recurrent cases to better assess recurrence risk characteristics.
Copyright (c) 2025 Mae Shu, Mohammed Ghazali, Hannah Davis, Rohan Maniar, Patrick Loehrer http://creativecommons.org/licenses/by/4.0
Validating AI-based Pre-operative Prediction of Glioblastoma Recurrence Location
Background and Hypothesis: Glioblastomas (GBM) are aggressive brain cancers with poor prognoses and an average survival of 18 months. Surgical resection is the most effect treatment, but GBM is characterized by recurrence. Artificial intelligence (AI) can identify abnormalities in imaging imperceptible to humans. We plan to utilize a pre-operative MRI-based algorithm that identified regions of higher rates of cancer infiltration where recurrence is likely to occur. The goal is to use this model to guide extra tumor resection of high-risk regions. This model has yet to be validated with an external system, an essential step for machine learning studies. Here, we are working to validate our AI-based model. Methods: We identified patients with pathology-confirmed glioblastoma from 2021 and prior. These patients then were screened by the following requirements: pre-operative MRI scans of T1, T1+Contrast, T2, T2 FLAIR, ADC, DTI, and DSC sequences; initial gross-total resection; and neuro-oncology diagnosed recurrence by change in treatment. The pre-operative scans for patients are pre-processed with NFTI conversion, skull stripping, and noise reduction. Scans are used to validate the AI-based recurrence model by comparison with post-recurrence scans. Results: Results from the multi-institutional consortium of which the model was trained have shown an overall odds ratio of 12.0 and area under curve of 0.80 at 99% confidence intervals. Within our selected patient population of recurrent GBM, we have identified that 63% are male, 50% are over the age of 60 years old, 100% are IDH-wild type, and 63% have demonstrated MGMT promoter methylation. Future Impact: We are currently in the process of collecting and segmenting a large validation cohort. The AI model’s prediction accuracy and robustness is validated with this data outside of the institutions of which the model was trained. The future purpose is to direct supramarginal resection and targeted radiation therapy to areas with higher probability of GBM infiltration.
Copyright (c) 2025 Peter Hellwarth, Matthew Pease, Spyridon Bakas http://creativecommons.org/licenses/by/4.0
Spatial Transcriptomics Demonstrates Tissue-Specific Differential Gene Expression in a Mouse Model of Spinal Muscular Atrophy
Background: Spinal muscular atrophy (SMA) is an autosomal recessive disease resulting from insufficient survival motor neuron (SMN) protein that afflicts ~1 in 10,000 births. Motoneurons are specifically sensitive to low SMN levels and motoneuron death is the hallmark of SMA. We investigated how low SMN levels affect the gene expression profile in multiple tissue types at an early symptomatic disease state. Methods: Spatial transcriptomic data using the Visium platform, collected from lumbar spinal column sections at postnatal day 4 from female normal and severe SMA mice (n=4 each), were analyzed. Systematic literature review identified tissue-specific biomarkers, which were compared to biomarkers calculated from graph-based clustering and compared to microanatomy using Loupe Browser. Clustering and differential gene expression analysis were performed in Partek Flow. Results: Clusters were annotated using biomarker expression patterns. Significant gene expression changes across thirteen tissue types were observed at this early disease state. For example, muscles clustered into type 1, type 2b, and tendon-associated and were significantly affected in SMA mice. Several transcripts associated with muscle atrophy were increased in SMA while hypertrophy mRNAs were unchanged. Interestingly, genes associated with bone resorption and osteoporosis were overexpressed in SMA bone, which may be important as clinical studies show decreased bone density and frequent fractures in children with SMA. Preliminary clustering of ST data from neuronal subtypes and other cells within the spinal cord reveal transcriptional changes in SMA mice. Conclusion: These data demonstrate that low SMN protein levels are associated with extensive tissue-specific gene expression changes early during disease progression. This implies that SMN deficiency may progress to involve multiple organ systems as children treated for SMA live longer. Validation of identified key genes will contribute to understanding of SMA pathogenesis and offer insights for novel treatments to improve outcomes in all stages of SMA.
Copyright (c) 2025 Lillian Hatton, Elliot Androphy, Anne Rietz http://creativecommons.org/licenses/by/4.0
The Impact of Social Demographics, Disease Activity, and Organ Damage on Time to Diagnosis in Pediatric Systemic Lupus Erythematosus
Background/Objective: Pediatric Systemic Lupus Erythematosus (pSLE) is a systemic autoimmune disease with variable clinical presentation. Untreated SLE can cause significant impairment, making early recognition and diagnosis critical in preventing irreversible organ damage. This study aims to understand the relationship between sociodemographic factors, disease activity at diagnosis, and time to diagnosis. Methods: A retrospective chart review of 156 pSLE patients evaluated by the Department of Pediatric Rheumatology at Riley Hospital for Children between 2017 and 2023 examined various sociodemographic and disease-related variables: race, ethnicity, preferred language, sex, insurance type, Area of Deprivation Index, disease activity (SLEDAI-2K score), and cumulative organ damage (SLICC/ACR Damage Index). SLEDAI-2K scores were calculated for 132 (84.6%) of the patient cohort. Time to diagnosis was calculated in weeks from symptom onset to diagnosis. Multiple regressions analysis was conducted using time to diagnosis as the dependent variable and social demographic variables as predictors. Data was collected with REDCap and analyzed with IBM SPSS Statistics (Version 28). Results: No significant correlation was found between time to diagnosis and: age at diagnosis, type of insurance, ethnicity, preferred language, state ADI decile, sex, or SLICC/ACR Damage Index. There was a significant correlation between time to diagnosis and SLEDAI-2K disease activity score calculated at time of diagnosis (Pearson Correlation= -0.245, p<0.005). Conclusion: The study showed no significant correlation between time to diagnosis and several sociodemographic variables. These findings suggest that pSLE patients from racial and ethnic minority groups and those with public insurance may have equitable access to care compared to non-minoritized groups and those with private insurance in Indiana. Additionally, the study did show a significant negative correlation between time to diagnosis and disease activity. Future work can include strategies to find and diagnose low-disease activity patients earlier.
Copyright (c) 2025 Michaela Harter, Rebecca Hetrick, Kiana Johnson, Martha Rodriguez http://creativecommons.org/licenses/by/4.0
Food Insecurity: An Upstream Social Determinant of 30-Day Congestive Heart Failure Readmissions
Background: Approximately 6.7 million Americans have congestive heart failure (CHF), costing the healthcare system over $30 billion annually. Readmissions contribute significantly to these costs, as 20-25% of hospitalized CHF patients are readmitted within 30 days of discharge. The Hospital Readmissions Reduction Program monitors 30-day readmission rates and penalizes hospitals that do not meet targets. Previous research on factors impacting CHF readmissions has largely focused on downstream factors such as race, ethnicity, sex, and clinical practices rather than upstream factors that can potentially inform high-impact interventions. This study explored downstream, midstream, and upstream factors—including demographics, social determinants of health (SDOH), and health behaviors—and their relationship with 30-day CHF readmissions in an urban healthcare system in Northwest Indiana. This was part of an academic-health system participatory research partnership. Methods: This retrospective study analyzed a limited dataset from EPIC™ with SDOH, demographic, health behavior, and health outcomes of adult inpatients between January 2021 and April 2024. Data analysis consisted of descriptive, bivariate (Chi-Square; p<0.05), and multivariate (Binary Logistic Regression; p<0.05) analyses in SPSS 29.0. This study was exempted by the Indiana University Human Research Protection Program (IRB #14040). Results: The sample consisted of 5,489 patients with CHF, predominantly White (63.8%), 65+ years old (76.2%), and publicly insured (91.8%). 30-day readmissions represented 22.4% of CHF admissions. The bivariate analysis revealed significant associations between 30-day CHF readmissions and ethnicity (p=.003), sex (p=.046), language (p=.017), hospital (p=.009), insurance type (p=.003), food insecurity (p=.048), and depression risk (p=.003). Food insecurity remained significantly associated with 30-day CHF readmission (OR=2.128; p=.033) after adjusting for these factors in the multivariate analysis. Conclusion: This study identified food insecurity as an upstream SDOH predicting 30-day CHF readmission. Future research should further explore other upstream factors contributing to 30-day CHF readmissions and evaluate evidence-based food insecurity interventions.
Copyright (c) 2025 Alison Blodgett, Jonathan Guerrero, Baraka Muvuka http://creativecommons.org/licenses/by/4.0
A Comparative Analysis of Re-thrombosis Rates in Acute Lower Limb Ischemia Patients Undergoing Percutaneous Mechanical Thrombectomy vs. Open Thrombectomy
Background: Patients presenting with acute or acute-on-chronic lower limb ischemia often have limited time before viable tissue becomes ischemic. There are several treatment options for acute and subacute ischemia of the lower extremity including local thrombolysis, surgical thrombectomy and percutaneous thrombectomy. While local thrombolysis and surgical thrombectomy approaches have remained relatively unchanged for decades, percutaneous thrombectomy is a constantly evolving modality attributable to the improvements in endovascular technology, yet safety and efficacy of this approach are not well-established. Additionally, patients with Rutherford Classifications of IIb and III are at an increased risk of permanent deficits and/or amputation. Other comorbidities, including obesity, smoking, previous vascular interventions, hypercoagulable state, HLD, and HTN can often lead to a poorer prognosis. The aim of this work is to compare long-term outcomes such as amputation free survival following open versus endovascular thrombectomy within the limb threatening ischemia cohort. Project Methods: This retrospective cohort study analyzed patients who underwent either percutaneous mechanical thrombectomy or open thrombectomy for acute lower limb ischemia. We identified comorbidities that may impact the complexities of their treatment and utilized the Charlson Comorbidity Index as well as the Rutherford Classification of Ischemia to help further categorize patients both by their risk of 10-year mortality and severity of their limb ischemia. Pertinent long-term factors that were assessed include whether the patients underwent arterial reintervention, amputation, and ambulatory status Results: Peri-operative mortality and ipsilateral tissue loss were significantly lower in patients who underwent endovascular intervention. The patency of repair was significantly higher for those who underwent endovascular repair. Percutaneous mechanical thrombectomy leads to shorter recovery times, patients being able to become ambulatory sooner, shorter hospital visits, and lower rates of complications. Potential Impact: This data can help establish the safety and efficacy of a newer surgical approach in percutaneous thrombectomy which has the ability to ease long term recovery following intense procedures of peripheral vascular disease and has the ability to reduce rates of complication in this patient population.
Copyright (c) 2025 Mohammad Z Khan, Supriya Chittajallu, Aniffa Kouton, Mackenzie Madison, Raghunandan L. Motaganahalli http://creativecommons.org/licenses/by/4.0
Nutrition deficiencies are associated with decreased wound healing in patients with peripheral arterial disease (PAD)
Background: Chronic limb threatening ischemia (CLTI) represents end-stage peripheral arterial disease (PAD) and is associated with a 30% annual risk of amputation, often due to non-healing wounds. Wound healing in PAD is multifactorial, but the role of nutritional deficiencies in healing arterial wounds is not well-studied. We sought to delineate the role of macro- and micronutrient malnutrition in healing ischemic wounds in PAD patients. Methods: This was a retrospective chart review of all adult patients with non-invasive vascular laboratory evidence of PAD and distal lower extremity arterial wounds seen at the Comprehensive Wound Center at Indiana University Health from January 2020-May 2024. Primary endpoints were percent of wound healed by area and volume. Statistical analysis was performed with Stata18 (StataCorp LP, College Station, Tex). Chi-square analysis was conducted for categorical variables, with Fisher’s exact test where appropriate. Continuous variables were compared using t-tests. A significance level of 0.05 was used for all analyses. Results: Eighty-three patients met our inclusion criteria. Initial Vitamins B12 and C deficiency were associated with less wound healed by volume (p=.0005) and area (p=0.038), respectively. Fewer patients with hyperlipidemia had wound area decrease by at least 50% (p=0.049). There were no other significant differences in wound area or volume based on other macro- or micronutrients or demographic factors. Positive screening for food insecurity was not associated with macro- or micro-nutrient deficiencies (p=0.673). Conclusions: Vitamin C and Vitamin B12 deficiencies were associated with significantly less wound area and volume healed by the end of the treatment, respectively. Patients with dyslipidemia were less likely to heal 50% of their wounds by area. Nutrient deficiencies were less common than expected from screening. Improved screening methods may help identify at risk patients. Patients with vitamin B12 or C deficiency and dyslipidemia should these deficiencies corrected as part of their comprehensive wound care plan.
Copyright (c) 2025 Muskaan Ramchandani, Rohan Basu, Mackenzie Madison, Gregory Westin http://creativecommons.org/licenses/by/4.0
Analysis of Cerebral Small Vessel Changes in an APOE4 Knock-In AD Mouse Model
Introduction: Alzheimer’s disease (AD) is a complex neurodegenerative disorder and the leading cause of dementia worldwide. Recently approved monoclonal antibody therapy has shown increased instances of amyloid-related imaging abnormalities (ARIA) in patients with the APOE4 allele compared to those with the APOE3 allele. Although it is well established that AD adversely affects cerebral vasculature, the differential pathology between alleles is not fully understood. This study aims to explore and quantify the changes of cerebral small vessels in a human APOE4 vs. APOE3 knock-in AD mouse model. Methods: Brains were collected from APOE3: APP-SAA and APOE4: APP-SAA mouse cohorts at 8 months. Sectioning and staining were completed with immunofluorescence imaging of beta-amyloid (6E10), blood vessel (CD31), and microglia (Iba1) biomarkers. Vessel density, diameter, signal intensity, and vessel-plaque colocalization were analyzed using NIH Fiji software, and t-tests were performed to compare averages between cohorts. Results: Two-tail t tests revealed a vessel density difference of -0.4956±0.4590% (t(8)=1.080;p=0.3118) and a CD31 intensity difference of -269881±169413au (t(8)=1.593;p=0.1498) showing no statistical significance. Further testing showed a vessel diameter difference of -0.4043±0.02431 um (t(700)=16.63;p<0.0001). Additionally, testing showed a plaque-vessel colocalization difference of 16.34±6.307% (t(51)=2.591;p=0.0124). The qualitative assessment showed higher levels of microglial activation, a marker of neuroinflammation, in APOE4: APP-SAA brain samples. Discussion: The APOE4 allele is associated with adverse changes in cerebral small vessels in a controlled APOE3 vs. APOE4 APP-SAA model. The observed pathology of increased neuroinflammation, decreased vessel diameter, and heightened amyloid-beta localization to cerebral small vessels may elucidate the mechanisms by which monoclonal antibody therapy targeting plaque removal results in increased pathological side effects related to vessel damage. These findings warrant further studies on vascular changes responding to AD progression across ages and investigations into how this novel model may respond to monoclonal antibody therapy experiments.
Copyright (c) 2025 Nathan Fuchs, Hallel Paraiso, Hannah Huang, I-Chen Ivorine Yu http://creativecommons.org/licenses/by/4.0
Implementation of Indiana’s Universal Blood Lead Testing Mandate: Interviews with Primary Care Practices in Michiana
Background: Disparities in lead exposure and social determinants of health – including housing, environmental conditions, and nutrition security – influence developmental and health outcomes, plus academic achievement and socioeconomic status through generations. Blood lead testing and follow-up care are essential safety nets for children who may already be lead exposed. Although Indiana Department of Health reports that Indiana’s universal testing statute, House Enrolled Act 1313, has facilitated a statewide testing increase in its first year 2023, lack of implementation direction plus data inconsistencies may hinder decision making at local levels. We study the interpretation and implementation of universal testing by health care practices in Michiana, serving legacy cities, including South Bend, with widespread lead-based paint hazards and proximity to lead crises in East Chicago, Indiana and Flint, Michigan. Methods: Semi-structured interviews were conducted with Michiana key informants selected for their knowledge of the subject through purposive sampling. Frameworks of street-level bureaucracy and WHO’s building blocks of well-functioning health systems guide analysis. Results: Twelve interviewees spoke of varying testing processes and awareness of the new law. Implementation barriers include ambiguous state guidelines, CHIRP reporting issues, and persistent health inequities in primary care access. Although in-office point-of-care analyzers reduce access barriers, the detection limit of 3.3 mcg/dL bars distinction of lead levels below this threshold. Facilitators include adequately-staffed workforces, communication with local social services (e.g., WIC, Head Start) and schools, and increased funding for families. Conclusion: Clear implementation directions are needed to improve service delivery of lead testing by practices, while barriers in information systems, leadership and governance, and medical technologies must be addressed to support medical and environmental management of lead-exposed families. Impact: Gaps in well-child care and health system fragmentation are major barriers to lead testing, necessitating expansion of public health services and collaboration with primary care practices to reach underserved communities.
Copyright (c) 2025 Susie Kim, Mark Fox, Heidi Beldinger-Burnett http://creativecommons.org/licenses/by/4.0
Genetics of Early-Onset Alzheimer’s Disease: Investigation of Rare Variants in the LEADS Cohort
Introduction: Early-Onset Alzheimer’s Disease (EOAD) is a neurodegenerative disease (NDD) with marked heritability, the majority of which is unexplained by known pathogenic variants. We hypothesize that a portion of the genetic etiology of EOAD may be due to rare pathogenic variants in genes associated with other NDDs, including Parkinson Disease (PD), Frontotemporal Dementia (FTD), and Amyotrophic Lateral Sclerosis (ALS). Methods: First, we constructed a gene set comprised of 31 loci commercially screened for both dementia and another NDD, captured by ten commercial dementia and four commercial NDD genetic test panels. We performed gene ontology analysis of this 31-gene set. We then conducted SKAT-O testing for pathway-level enrichment of rare functional variants in whole exome sequencing (WES) data from participants in the Longitudinal Early-Onset Alzheimer’s Disease Study (LEADS) (n = 303) and age-matched controls from the Parkinson’s Progression Markers Initiative (n = 193), with pathways defined by NDD gene panel. We performed post-hoc gene-set tests for individual genes in significant pathway results. Results: SKAT-O analysis showed LEADS participants were enriched in functional SNPs compared to controls within genes in panels for PD and Parkinsonism (p=0.0003) and FTD (p=0.0119). Post-hoc testing revealed significant enrichment in FUS (p = 0.0098), from the FTD panel, and ATP7B (p = 0.0002), from the PD and Parkinsonism panel. Ontology analysis revealed that numerous neurodegeneration-associated biological processes, including mitochondrial organization and function, autophagy, proteasomal catabolism, and oxidative stress were statistically enriched in the original 31-gene set. Conclusion and Scientific Impact: Functional SNP enrichment in PD- and FTD-associated genes in the LEADS cohort suggests shared etiology amongst NDDs. The genes and pathways identified are promising for targeted research capable of detection of specific variants responsible for the missing heritability of clinical EOAD, which would improve diagnostic timeliness and accuracy.
Copyright (c) 2025 Kyle V. Rusin, Trever Jackson, Jeffrey L. Dage, Tatiana M. Foroud, Dustin B. Hammers, Maria C. Carrillo, Bradford C. Dickerson, Gil D. Rabinovici, Liana G. Apostolova, Kelly N. H. Nudelman http://creativecommons.org/licenses/by/4.0
Unequal Burden of Melanoma: How Socioeconomic Status is Associated with Secondary Primary Malignancy Risk and Mortality
Background/Objective: Melanoma is the 5th most common cancer in the U.S. There is limited literature on how socio-economic status (SES) is associated with risk of secondary primary malignancies (SPMs), despite 2.1% of population living with a melanoma history. This study examined the relationship between SES and 1) incidence of SPMs in early-stage melanoma patients, and 2) survival in metastatic melanoma patients. Methods: A retrospective cohort study was conducted using data of 481,603 stage 0/I/II melanoma patients from 2006-2020 and 1,089 metastatic melanoma patients from 2016-2020. Patient’s SES quintile was calculated using census tract level information including median household income, median house value/rent, education index, etc. Data on primary and secondary malignancies and cancer stage at diagnosis were analyzed using binomial and ordinal logistics regression. Survival outcomes were analyzed using Kaplan Meier and multivariate Cox regression. Results: Patients with lower SES have significantly higher risks of developing higher stage SPMs (Stage I/II Group 1-lowest SES: OR 1.39, 95% CI 1.28-1.51) and metastatic SPMs (Stage I/II Group 1: OR 1.35, 95% CI 1.2-1.52). Group 5 (highest SES) served as reference. Conversely, patients with higher SES have a higher overall incidence of SPMs compared to lower SES groups (Stage I/II Group 1: OR 0.82, 95% CI 0.78-0.86). Results were significant across all SES levels, except for Group 4 with stage 0 melanoma. Five-year survival analysis revealed metastatic melanoma patients with lowest SES are most at risk of dying (Group 1: HR 1.54, 95% CI:1.15-2.08). Conclusion/Implications: This study shows the significance of socioeconomic disparities in melanoma outcomes. Patients with lower SES are at greater risk of developing higher stage SPMs and have poorer survival rates, whereas higher SES patients are more likely to be diagnosed with SPMs. Our findings highlight the need for targeted interventions to address SES-related disparities in melanoma prevention and care.
Copyright (c) 2025 Flora Ho, Jonathan Guerrero, Baraka Muyuka http://creativecommons.org/licenses/by/4.0
Decreased Risk of Cardiac and Vascular Complications in Patients with Alpha-1-Antitrypsin Deficiency
Background: Alpha-1-antitrypsin deficiency (AATD) is a genetic disorder characterized by low levels of the antiprotease Alpha-1-antitrypsin protein (AAT) within blood. In AATD, research has shown misfolded AAT accumulates within the liver and poorly controls protease activity in the lungs, resulting in liver and lung sequela. AATD’s impact on cardiac and vascular health is far less researched and conflicting data has emerged. This study aims to determine if AATD’s possible protective role against cardiac and vascular complications is consistent between the COSYCONET and RWEdataLab’s databases. Methods: The IU School of Medicine-Evansville RWEdataLab (CRC/Sidus Insights) psychiatric and cardiac databases were used to select two groups for comparison: patients with AATD and patients without AATD with a diagnosis of COPD, emphysema, or chronic bronchitis, all without a history of lobectomy or lung or liver transplant or malignancy. Differences in diagnosis history were compared using odds ratios. Results: Comparing 879 AATD patient’s diagnoses against 3489 non-AATD patients with lung condition’s diagnoses within the psychiatric database shows a protective role in both vascular and cardiac health with the following odds ratios and respective 95% CIs: 0.501 (0.325-0.771) for cerebrovascular accident, 0.499 (0.430-0.579) for hypertension, 0.377 (0.289-0.494) for chronic heart failure, 0.442 (0.273-0.714) for myocardial infarction, 0.490 (0.398-0.605) for coronary artery disease, and 0.742 (0.589-0.935) for peripheral artery disease. Similar searches were performed in the cardiac database, but too few AATD patients were found to perform calculations with statistical significance. Conclusion and Implications: These findings suggest that AATD may have a protective role in cardiac and vascular health. The mechanism behind these findings is unknown and may highlight an area of potential future study. Additionally, further research is needed to determine if AAT augmentation therapy is affecting this protective aspect.
Copyright (c) 2025 Adele E. Hemmerlein, Michael S. Roscoe http://creativecommons.org/licenses/by/4.0
Late Antenatal Corticosteroid Treatment in Twin Pregnancies and Neonatal Outcomes: A Systematic Review and Meta-Analysis
Objective: To examine the impact of administering late-preterm corticosteroids on neonatal outcomes in twin pregnancies. Study Design: A systematic review of the literature was conducted in four electronic databases between 2000-2024. Studies reporting on neonatal outcomes in twin pregnancies at risk of preterm birth receiving corticosteroid treatment for fetal lung maturity at the gestational age (GA) of 34 weeks and 0 days to 36 weeks and 6 days were included. Studies involving participants with specific conditions (twin-to-twin transfusion syndrome and intrauterine fetal demise of one fetus) were excluded. The primary outcome was incidence of respiratory distress syndrome (RDS). Secondary outcomes included need for mechanical ventilation, continuous positive airway pressure (CPAP), and neonatal hypoglycemia. Comparison groups included those receiving steroids vs those not. The random effect model was used to generate weighted mean differences (MD) and odds ratio (OR) along with their 95% confidence intervals (CI). Heterogeneity was assessed using the I2 value. Results: 267 abstracts were screened of which 15 full-texts were fully reviewed. A total of three studies were included in the final analysis which comprised 489 twin pregnancies receiving steroids and 2807 pregnancies not receiving steroids. There were no differences in obstetric characteristics between groups, including maternal age, body mass index, preeclampsia, diabetes, and type of twin chorionicity. GA at delivery was significantly earlier in the steroids group (MD -0.91, 95% CI -1.50 to -0.32). For neonatal outcomes, there were no significant differences in incidence of RDS and need for mechanical ventilation between groups. There were higher chances for CPAP use (OR 2.69, 95% CI, 1.47 to 4.92) and neonatal hypoglycemia (OR 2.05, 95% CI, 1.18 to 3.56) in the steroids group. Conclusion: This study found that antenatal corticosteroid treatment during the late-preterm period in twin pregnancies was not associated with a reduced risk of neonatal respiratory complications.
Copyright (c) 2025 Elizabeth Roy, Victor Olafusi, Enaja Sambatur, Faezeh Aghajani, Moti Gulersen, Asma Khalil, Vincenzo Berghella, Hiba J. Mustafa http://creativecommons.org/licenses/by/4.0
Kidney Function and Mortality Following Two-Stage Revision Total Joint Arthroplasty for Periprosthetic Joint Infection
Background and Hypothesis: Periprosthetic joint infection (PJI) after total hip and knee arthroplasty (THA, TKA) is reported in up to 2% of cases yet remains a serious complication. The current gold standard of treatment consists of a two-stage surgery involving intravenous antibiotic therapy between stages of implant resection and reimplantation. In addition, studies on the effects of these antibiotics on kidney function after two-stage treatment for PJI are limited. This study evaluated kidney function and mortality before, during, and after two-stage revision for PJI. The hypothesis of the study was that the antibiotics part of the treatment course would not lead to an increased risk of kidney injury. Project Methods: Clinical data on 160 THAs and TKAs undergoing two-stage treatment for PJI were retrospectively reviewed. Standardized protocols were used for all cases consisting of robust medical optimization by a dedicated perioperative medicine specialist and 6-weeks of intravenous antibiotics prior to reimplantation. Kidney function metrics of serum creatinine (Cr), estimated glomerular filtration rate (eGFR), and blood urea nitrogen (BUN) were collected from routine labs in the electronic medical record along with mortality data. A P-value of 0.05 was considered statistically significant. Results: No significant differences were observed in mean serum Cr (1.10, 1.12, 1.13 mg/dL), eGFR (78.6, 77.7, 74.8 mL/min/1.73m2), or BUN levels (19.8, 18.9, 19.0 mg/dL) between pre-resection, the inter-stage period, or post-reimplant, respectively (P ≥ 0.432; Power ≥ 85.3%). Mortality was 0% within 90-days of resection and 1.4% (2/138) within 1-year of resection (both cardiac events unrelated to kidney function). Kaplan-Meier survivorship estimates were 98% at 2-years and 86% at 5-years post-resection. Potential Impact: Kidney function was not adversely impacted by the antibiotics associated with the two-stage revision procedure for PJI. With proper medical management, the two-stage revision for PJI remains the preeminent treatment for PJI following TJA.
Copyright (c) 2025 Rilee Epley, T. Kyle Stoops, Leonard Buller, Evan Deckard, Peter Caccavallo, R. Michael Meneghini http://creativecommons.org/licenses/by/4.0
Sex-Dependent Effects of Irisin on Bone in an Aged Mouse Model
Irisin is a recently discovered protein that has garnered increasing attention due to its potential impact on metabolic health and disease prevention. This hormone, released from exercising skeletal muscle, is generated through the cleavage of the membrane protein FNDC-5 (fibronectin type III domain-containing protein 5). Irisin has been shown to play a role in the browning of white adipose tissue and serves as a mediator of exercise-induced metabolic improvements. Notably, bone and muscle tissues are known to communicate, influencing each other’s physiology. Previous research on Irisin demonstrated that Irisin’s effects on bone in response to stress exhibit sex-dependent differences. Specifically, female FNDC-5 knockout (KO) mice were protected from adverse bone phenotypes when subjected to a low calcium diet, while male FNDC-5 KO mice showed worse bone phenotypes at baseline, even before the diet began. The prior study focused on 5-month-old mice. Our research aims to investigate the effects of FNDC-5 KO in aged mice, both at baseline and under stress conditions. We utilized 18-month-old wild-type (WT) and FNDC-5 KO male and female mice, feeding them a low calcium diet for 2 weeks. Our findings revealed similar results to the earlier study with younger mice: female FNDC-5 KO mice exhibited partial protection against the low calcium diet’s adverse effects on bone and skeletal muscle. These results suggest that age and sex are critical factors in the bone-muscle crosstalk mediated by Irisin, highlighting the need for personalized approaches in nutritional and exercise interventions. Future research should explore the underlying mechanisms and potential therapeutic applications of Irisin in metabolic and musculoskeletal health.
Copyright (c) 2025 Kyle Richardson, Anika Shimonty, Joshua Huot, Fabrizio Pin, Lynda F. Bonewald http://creativecommons.org/licenses/by/4.0
Evaluating the Prognostic Value of Fetal Magnetic Resonance Imaging Measures on Postnatal Pulmonary Outcomes in the Setting of Omphalocele
Background/Objective: Omphalocele is a disorder of fetal abdominal development with increased risk for respiratory complications after birth secondary to pulmonary hypoplasia. While fetal magnetic resonance imaging (MRI) derived observed-to-expected total fetal lung volume (O/E-TFLV) has been established as an effective measure for prognosticating outcomes in other congenital disorders, it is not well understood whether this measure or others applies to patients with omphalocele. This study aims to assess the ability of fetal MRI measures to predict lung-related morbidity and perinatal outcomes in fetuses with omphalocele. Methods: A retrospective review of fetal MRIs from 2016 to 2024 was performed, identifying 36 patients at 20-34 weeks gestation with omphalocele which were confirmed at birth. Omphalocele defect volume and MRI-derived fetal lung volumes, including O/E-NFLV and lung volume to head circumference ratio (LVHC), were compared with postnatal outcomes. A Mann-Whitney U test was used to evaluate the predictive value of each measure, along with a stepwise regression model for the outcomes of survival, intubation, and discharge with oxygen support. Results: Both O/E-NFLV and LVHC measures predicted mortality, need for intubation, discharge with oxygen support, and tracheostomy placement with statistical significance (p<0.05). LVHC was the best predictor for mortality and discharge with oxygen support, with a LVHC < 0.067 (AUC 0.905) predicting mortality and LVHC < 0.116 (AUC 0.828) predicting need for oxygen at discharge. A percent extra-abdominal liver greater than 29.32% (AUC 0.803) was the best predictor for intubation. Conclusion: This study demonstrated O/E-NFLV and LVHC as effective measures for prognosticating survival and need for postnatal respiratory support in the setting of omphalocele. With this information, fetal MRI can be used to improve the preparation of families and medical teams for necessary postnatal care.
Copyright (c) 2025 Danielle Harold, Lisa Delaney, Megan Marine, Morgan McLuckey, Christopher Newman, Monica Forbes-Amrhein http://creativecommons.org/licenses/by/4.0
Social, Demographic, and Behavioral Determinants of Prolonged Hospital Stay and Readmissions for Postoperative Complications in an Urban Health Care System
Background The relationship between postoperative complications and social determinants of health (SDOH) is a priority issue with implications on quality of care (QOC). Extended length of stay (LOS) and readmissions (RA) are critical QOC indicators, prompting initiatives such as the Hospital Readmission Reduction Program. Surgical outcome disparities in urban settings persist yet remain underexplored. This study examined how SDOH influence readmissions and prolonged LOS among patients experiencing postoperative complications, as part of an academic-health system collaboration in Northwest Indiana. Methods This retrospective study analyzed an EPIC™-generated dataset with SDOH, demographics, health behaviors, and outcomes of adult inpatients hospitalized for postoperative complications at 3 urban hospitals between January 2021 and April 2024. Data analysis comprised descriptive, bivariate (Chi-Square; p<0.05), and multivariate analysis (linear and binary logistic regression; p<0.05) using SPSS 29.0. The study received exemption by Indiana University Human Research Protection Program (IRB # 14040) on 1/28/2022. Results The study included over 900 patients, with 565 readmissions (RA) and 337 extended LOS cases. Patients were primarily over 50 years old (81.8% RA, 81.4% LOS), White (69.4% RA, 86.3% LOS), and publicly-insured (74.8% RA, 74.7% LOS). Bivariate analysis revealed significant associations between postoperative complications and age (p < 0.001 RA, p < 0.011 LOS), veteran status (p = 0.022 RA, p = 0.058 LOS), insurance type (p < 0.001 RA), smoking status (p < 0.001 RA, p = 0.026 LOS), and BMI (p = 0.002 RA). In multivariate analysis, former smoking (OR = 2.144, p < 0.001), underweight (OR = 4.131, p = 0.006), and public insurance (OR = 3.295, p < 0.001) remained significant across all readmission durations. Conclusion This research highlights SDOH and health behaviors associated with prolonged hospital stay and readmissions among urban patients following postoperative complications. Policies addressing these factors before and after surgery may mitigate adverse outcomes.
Copyright (c) 2025 Alexis Dres, Skyler Thompson, Maggie Sullivan, Baraka Muvuka, Jonathan Guerrero http://creativecommons.org/licenses/by/4.0
Dental Abnormalities in Congenital Ichthyoses: Case Report and Review of the Literature
Background/Objective: Ichthyoses are disorders of cornification characterized by “fish-like” scaling of skin due to abnormal differentiation and desquamation resulting in a defective cutaneous barrier. Herein, we describe an infant with keratitis-ichthyosis-deafness (KID) syndrome and natal teeth and investigate spectrum of dental abnormalities, associated ichthyoses, and implications for long-term oral health. Methods: A literature review of ichthyoses and dental abnormalities was conducted using Ovid MEDline (1946-2024) and EMBASE (1974-2024). Inclusion criteria were English-language articles that reported patient(s) with a variant of ichthyosis that manifested a dental abnormality. Exclusion criteria were non-English articles, articles with overlapping ectodermal dysplasia or erythrokeratodermas, and articles that were unobtainable. Sex, age, country of origin, type of ichthyosis, dental findings, and genetic mutation were recorded when available. Ichthyoses were grouped into nonsyndromic and syndromic forms. Dental findings were categorized to reflect the type of anomaly: structure, eruption, number, and caries. Results: Ninety-four articles included in our review described a total of 154 patients, with 74 (48.1%) males, 65 (42.2%) females and 15 (9.7%) patients with unspecified sex. Across all ichthyoses, the two most common dental anomalies reported were caries (51.3%) and structural abnormalities (40.9%), which include defects in shape, size, enamel, and color of teeth. Sjogren-Larsson, KID syndrome, trichothiodystrophy (TTD) and autosomal recessive congenital ichthyosis (ARCI) were most associated with dental anomalies. Conclusion and Implications: We highlight the need for careful oral examination and dental evaluation of patients with ichthyosis. In rare cases of natal teeth, more emergent evaluation is warranted because natal teeth exhibit excess mobility and pose a risk for aspiration. Early referral to pediatric dentistry can help reinforce oral health habits, education, and infection prevention. Long-term follow-up can help limit extractions and improve oral health.
Copyright (c) 2025 Sarah Maarouf, Marie Clark, Anthony Chen, Anita Haggstrom http://creativecommons.org/licenses/by/4.0
Sociodemographic and Behavioral Determinants of Hospitalizations for Labor and Delivery Complications in an Urban Health System
Background: The United States (US) has the highest maternal mortality ratio (MMR) among high-income countries, with Indiana having the 3rd highest MMR in the US. For every maternal death, 20 to 30 more experience life-threatening complications. Labor and delivery complications are key contributors to severe maternal morbidity and mortality, costing over $30 billion. Identifying and addressing underlying social determinants of health (SDOH) are high-impact strategies for improving maternal health outcomes. This study examined a comprehensive group of socio-demographic and behavioral determinants of hospitalization for labor and delivery complications in an urban health system in Northwest Indiana (NWI). Methods: This retrospective study analyzed data generated from inpatient SDOH screenings in EPIC™ at an urban health system in NWI between January 2021 and April 2024, using the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE). Complications of labor and delivery were determined using ICD-10 Codes. Data analysis utilized IBM SPSS V. 29.0 to produce descriptive statistics, bivariate analysis (Chi-Square, Mann-Whitney, Kruskal Wallis; p<0.05), and multivariate analysis (binary logistic regression; p<0.05). Results: The sample consisted of 1444 patients who received labor and delivery services, 36.6% of whom experienced complications. Patients were predominantly non-White (54.6%) with a median age of 27. The bivariate analysis revealed statistically significant associations between labor and delivery complications and race (p<0.001), age (p<0.001), insurance type (p<0.001), family income (p=0.002), smoking (p<0.001), postpartum depression risk (p=0.006), co-morbidities (p<0.001), BMI (p<0.001), and hospital (p<0.001). The multivariate analysis found that age (OR=0.957; p<0.001) and former smoking (OR=0.652; p=0.007) remained significant. Conclusion: Routine hospital-based SDOH screenings and referrals can help identify nonmedical risk and protective factors for complicated labor and delivery, which in turn informs multi-level strategies to improve maternal health outcomes. Future research will validate these findings and further explore SDOH in larger, more diverse samples.
Copyright (c) 2025 Maggie Sullivan, Alexis Dres, Skyler Thompson, Jonathan Guerrero, Baraka Muyuka http://creativecommons.org/licenses/by/4.0
Validation of Rubicon's Autophagy Inhibition Function Through HUNK Phosphorylation
Background and Hypothesis: HER2+ breast cancer uses the human epidermal growth receptor 2 (HER2) protein to grow. As an aggressive form of breast cancer, it accounts for ~20% of all breast cancer diagnoses worldwide. Previous studies show Hormonally Up-regulated Neu-associated Kinase (HUNK) is up-regulated in HER2+ breast cancer. HUNK plays an important role in the cellular process of autophagy, which recycles cellular components into new usable components. Increased autophagy, through HUNK activity, allows for improved survival and proliferation of cancer cells. Autophagy is mediated through a complex of proteins, including Beclin-1, HUNK, Rubicon, UVRAG, and Vps34. In this complex, Rubicon is responsible for the inhibition of autophagy. However, phosphorylation of Rubicon by HUNK inhibits this function, thus promoting autophagy. This phosphorylation of Rubicon is hypothesized to cause its dissociation from the autophagy proteins. To further understand this, we looked at the interaction of Rubicon with UVRAG and SQSTMI in the presence and absence of HUNK, to validate this complex as a means for regulation of the Rubicon interactome. Experimental Design: 293T cells were cultured and transfected with pcDNA, wt-Rubicon, wt-Rubicon+wt-HUNK, or wt-Rubicon+ kinase-deficient HUNK-K91M plasmids. These cells were lysed to perform whole cell extraction and immunoprecipitation. The proteins of interest were visualized via Western blots. Results: Autophagy proteins, UVRAG and SQSTM1, were unable to be visualized after multiple attempts to optimize the protocol. However, it was shown that when HUNK kinase activity was eliminated in HUNK-K91M there was a decrease in HUNK interaction with Rubicon. Conclusion and Potential Impact: Further studies should be done to assess whether HUNK kinase activity is required to stabilize binding to Rubicon. Additionally, alternative techniques, like microscopy or HER2+ cancer cells, should be used to visualize the interaction between Rubicon and autophagy proteins. Understanding the Rubicon interactome and the role of HUNK phosphorylation is imperative for better understanding of HER2+ cancer and effective treatments.
Copyright (c) 2025 Anslyn Freije, Melissa Abt, Tinslee Dilday, Elizabeth Yeh http://creativecommons.org/licenses/by/4.0
Evaluating TAT-FXN Therapy Efficacy on Cardiac Manifestations of Friedreich's Ataxia: Insights from Murine Models and Echocardiography
Background and Hypothesis: Friedreich’s Ataxia (FRDA) is an autosomal recessive disease in which the loss of nuclear-encoded frataxin (FXN) causes loss of iron-sulfur cluster formation in mitochondria. This is associated with progressive loss of motor function and a hypertrophic cardiomyopathy leading to death in the second or third decade of life. In the FRDA murine model of heart failure, treatment with the fusion protein TAT-FXN significantly extends life span and improves gait. TAT-FXN has advanced to Phase II clinical trials, but effective dosing and mechanism of action biomarkers remain challenging. We hypothesized that treatment with TAT-FXN mitigates FRDA metabolic disruption and may result in improved cardiac function. Project Methods: FrdaL2/L2::MCK-Cre (MCK-KO) mice and controls underwent echocardiography at 30, 45, and 65 days of life. The animals were anesthetized with isoflurane and maintained on a warming stage. Parasternal long-axis, short-axis, and apical four-chamber views were used to measure interventricular septum thickness, left ventricular posterior wall thickness, ejection fraction (EF), global longitudinal strain (GLS), and mitral E/A ratio. Statistical analysis included one-way ANOVA and Tukey's multiple comparisons test. Results: Growth trajectories followed logistic curves across all groups. By day 65, MCK-KO mice showed significant impairment in EF, GLS, and cardiac index (CI) compared to controls. However, no significant differences in EF, GLS, or CI were observed between TAT-FXN-treated and vehicle-treated mice. Mitral E/A ratio and LV measurements were not significantly different between groups. Conclusion and Potential Impact: TAT-FXN therapy did not significantly improve cardiac function compared to vehicle in this FRDA murine model. Thus, while TAT-FXN does not worsen cardiac impairment, it may not sufficiently mitigate existing cardiac dysfunction within the study's timeframe. These findings highlight the importance of further research to identify biomarkers of treatment response and elucidate the effects of TAT-FXN treatment on cardiac outcomes.
Copyright (c) 2025 Abigail Spencer, P. Melanie Pride, R. Mark Payne http://creativecommons.org/licenses/by/4.0
Demographic, Social, and Behavioral Predictors of Readmission for Neurodegenerative Diseases in Northwest Indiana
Background: Neurodegenerative diseases, such as Alzheimer's and Parkinson's disease, pose significant challenges given their progressive nature and multifaceted care needs. This research examined the intricate interplay between social determinants of health (SDOH) and hospital readmissions among individuals with neurodegenerative diseases. It is part of a Participatory Research partnership between Indiana University School of Medicine-Northwest and an urban health system in Northwest Indiana (NWI). Methods: This retrospective study analyzed a dataset generated from routine SDOH screenings and referrals in Epic using the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) for inpatient admissions from 3 NWI urban hospitals between January 2021 to April 2024. Data analysis was conducted in SPSS 29.0 with descriptive statistics, bivariate analysis (Chi-square), and multivariate analysis (binary logistic regression). This study received exemption from Indiana University Human Research Protection Program (IRB #14040). Results: The sample consisted of 1,338 patients admitted for neurodegenerative diseases. Patients were predominantly White (68.9%), older adults (73 ± 14), and publicly insured (91.5%). The bivariate analysis found that readmission was significantly associated with age (p<0.001), insurance type (p=0.003), hospital (p<0.001), physical activity level (0.034), and length of stay (p<0.001). The multivariate analysis found higher odds of hospital readmission among patients with public insurance (OR=76.1%; p=0.028), prolonged hospital stay (OR=8.5%; p<0.001), and admission at a small hospital in a medically underserved area (OR=69.6%; p<0.001). Conclusion: Understanding the impact of SDOH on hospital readmissions is crucial for developing targeted interventions to improve outcomes and reduce healthcare costs. These factors can profoundly influence disease management, adherence to treatment plans, and overall health outcomes. Findings from this research underscore the critical need for integrated approaches addressing SDOH as part of comprehensive disease management strategies. By addressing these SDOH, healthcare systems can potentially reduce readmissions, enhance quality of life, and promote health equity.
Copyright (c) 2025 Neon Calumpang, Jonathan Guerrero, Kyle Gospodarek http://creativecommons.org/licenses/by/4.0
Analyzing the Effectiveness of a Pre-Arrival Time-Out in Pediatric Trauma Resuscitations
Background: Time-out checklists are commonplace throughout procedural specialties and have been associated with improved care and decreased errors. The WHO has recommended a checklist for trauma care, particularly focused on the trauma resuscitation, to decrease missed injuries and facilitate an efficient resuscitation. However, this checklist does not address pre-arrival preparations that might facilitate a shared mental model for an upcoming resuscitation. The goal of this study was to draft a pre-arrival time-out at Riley Hospital for Children (RHC), emphasizing provider role introductions, patient details, potential care needs upon patient arrival, and patient disposition. Methods: Pre-arrival preparation for trauma resuscitations were retrospectively reviewed using trauma video review. All resuscitations took place in one of four trauma bays at the RHC Emergency Department. Recordings captured Level 1 trauma activations. The recordings were abstracted for factors which researchers felt would facilitate strong team dynamics and allow for creation of a shared mental model. A REDCap database was created to capture the deidentified data. Results: Twenty-four resuscitations were available for analysis, time-outs occurred in 29.2% (7/24). Time-out attendance was 13.9 (±2.0) personnel. The average length of time-outs was 59.6 (±19.4) seconds and the average time between the end of the time-out and patient arrival was 4 minutes 53.7 seconds (± 3 minutes 37.0 seconds). Introductions were fully completed in 16.7% (4/24) of recordings and in 57.1% (4/7) of occurrences with a time-out performed. A clear team leader was identified in 29.2% (7/24) of resuscitations. Pre-arrival discussions about the case occurred in 83.3% (20/24) of recordings. A stated need for an item (equipment/medication) occurred in 50.0% (12/24) of recorded pre-hospital discussions. Conclusion and Potential Impact: The rates of time-outs, introductions, stating patient details, and stating equipment needs before patient arrival were low in many cases. A formalized pre-arrival time-out discussion prior to pediatric trauma resuscitations could be effective in increasing these rates.
Copyright (c) 2025 Julian Spangler, Jodi Raymond, Matthew Landman http://creativecommons.org/licenses/by/4.0
A Prospective Study of the Impact of Levonorgestrel Intrauterine Devices on Sexual and Bladder Health
<p style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">Background/Objective: Intrauterine devices (IUDs) are highly effective and safe methods of contraception, but concerns grow over their impact on women’s bladder and sexual health. Oral contraceptives (OCPs) have been found to decrease androgen levels in women and can cause bladder dysfunction. Due to the local effects of progesterone from the IUD near the bladder, it is reasonable to propose that similar bladder dysfunction seen in women taking OCPs may be experienced by women with levonorgestrel-IUD (Lng-IUDs). When it comes to women’s sexual health, the literature is mixed on the true side effect profile of IUDs. <p style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">Methods: Using a prospective study design, women aged 18-45 from gynecologic centers at Indiana University opting for a Lng-IUD were recruited. Women within 6 months postpartum, still breastfeeding, or undergoing IUD replacement were excluded. Participants completed standardized REDCap questionnaires pre-placement and at 3- and 6- months post placement to assess sexual function and lower urinary tract symptoms using Female Sexual Function Index and Urinary Distress Inventory, Short Form. <p style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">Results: 11 participants have been recruited and filled out baseline surveys thus far: 81.8% with Mirena placed and 18.2% with Kyleena. Indications for Lng-IUD placement included contraception, irregular or painful meses, menorrhagia, or abnormal bleeding. 50% reported no frequent urination, and 20% no pain or discomfort with urination. 9.1% reported being very satisfied with their overall sexual life over the past 4 weeks and 36.4% reported being moderately satisfied. Participants will continue to be recruited and will receive 3- and 6- month post-IUD questionnaires. <p style="color: #000000; font-family: 'Times New Roman'; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">Conclusion: Few prospective studies in the United States explore the side effect profile of IUDs on sexual health, and international data are inconsistent. In addition, no studies investigate the impact of IUDs on bladder dysfunction. Going forward, we will utilize patient surveys to help make informed reproductive decisions.
Copyright (c) 2025 Victoria Snook, Ramzy Burns, Jennifer Hamner http://creativecommons.org/licenses/by/4.0
Metabolic recovery at 12 months postpartum among individuals with glucose intolerance in pregnancy
Background: Gestational diabetes mellitus (GDM) is associated with long-term risk for maternal Type II Diabetes (T2DM). We evaluated β-cell function during pregnancy and at 12 months postpartum in individuals with varying levels of glucose intolerance in pregnancy. Methods: This is a planned follow-up to the Gestational Diabetes Diagnostic Methods (GDM2) trial, which randomized pregnant individuals to either a 75-gram oral glucose tolerance test (OGTT) with GDM diagnosed with ≥1 abnormal value per IADPSG guidelines, or a 100g OGTT with GDM diagnosed with ≥2 abnormal values per Carpenter-Coustan (CC) criteria. All participants with treated GDM, those with untreated mild glucose intolerance (MGI, one abnormal value on CC criteria), and half of participants with normal glucose tolerance were invited for a follow-up visit at 12 months postpartum where they underwent a 75g OGTT measuring insulin and glucose at all time points. Measures assessed included Stumvoll, Matsuda, and Disposition Indices and other metabolic factors to evaluate insulin sensitivity, resistance, and β-cell function. Results: In pregnancy and 12-month postpartum visits, the disposition and Matsuda indices demonstrated significantly more insulin resistance among those with MGI and GDM compared to those without GDM (41.0±41.6, 28.7±26.6, 20.0±15.9, p<0.001), whereas the Stumvoll index was similar among groups. The rate of change from pregnancy to postpartum in both the Matsuda and Stumvoll indices were similar across the three groups, indicating individuals were likely returning to their baseline levels of glucose tolerance rather than recovering from a pregnancy-specific metabolic impairment. Although this study was underpowered for this outcome, there was a trend towards higher rates of prediabetes and T2DM in those with MGI and GDM (14.6%, 25.5%, 24%, p=0.09). Conclusions: Patients with MGI have significant impairments in insulin resistance similar to individuals with treated GDM one year postpartum and should receive follow-up for potential progression to T2DM.
Copyright (c) 2025 Arunabh Sinha, Christina Lalama, Kaleab Abebe, Esa Davis, Patrick Catalano, Christina Scifres http://creativecommons.org/licenses/by/4.0
Factors Associated with Anemia in Infants with and without HIV Exposure in Western Kenya
Background: Anemia is a major global health problem impacting morbidity and mortality, especially in children under 5 years of age. Children living with HIV are more likely to develop anemia, but little is known about children who are HIV exposed but uninfected (HEU). The objective of this study is to evaluate rates of anemia and factors associated with anemia in a population of 6-month-old infants who are HEU and HIV-unexposed and uninfected (HUU) in western Kenya. Methods: This study included a cross-sectional analysis of a large prospective cohort study. The study was conducted as part of the Academic Model Providing Access to Healthcare (AMPATH) and took place at Moi Teaching and Referral Hospital (MRTH) in Eldoret, Kenya. Only those participants with lab values were included in this analysis. Anemia was defined as hemoglobin level ≤10.5 g/dL. Data were analyzed from prenatal and birth records, questionnaires, anthropometric measurements, and blood samples. Two sample t-tests, chi-square, Fisher’s exact tests, and logistic regression were used for analyses. Results: Of the 586 infants with lab values, 95 had anemia (16.2%), with 38 (6.5%) meeting the threshold for moderate-to-severe anemia (≤ 9.4 g/dL). Infant anemia was associated with male sex (p=0.02) and stunting (low height-for-age) status (p=0.04). Furthermore, infants with HIV exposure (OR=2.63, 95%Cl: 1.29, 4.54), preterm birth (OR=3.92, 95%CI: 2.29, 6.70), high maternal blood pressure (OR=2.31, 95%CI: 1.05, 4.90), and interruption of breastfeeding before 6 months of age (OR=2.77, 95%CI: 1.29, 5.88) had increased odds of anemia, even after adjusting for covariates. Conclusions: Infants who are HEU, born prematurely, exposed to maternal hypertension, and with interruption of breastfeeding were more likely to develop anemia, even when accounting for other factors. Health systems should monitor these risk factors to identify children at high risk for having anemia and ensure early referral for treatment.
Copyright (c) 2025 Madeline Cory, Eren Oyungu, Ziyi Yang, Emily Abuonji, Ananda Ombitda, Ben Mosong, Mary Ann Etling, Megan McHenry http://creativecommons.org/licenses/by/4.0
Potential Role of Cigarette Smoke Exposure on Elastin Sensitization and Aortic Pathophysiology in a Mouse Model of Abdominal Aortic Aneurysm
In the US, 200,000 people annually are diagnosed with abdominal aortic aneurysm (AAA) and it accounts for over 15,000 deaths per year. The current paradigm for AAA progression includes cytotoxic T cell activation inducing inflammatory monocyte and macrophage recruitment. These cells secrete collagen and elastin degrading enzymes, leading to loss of structural integrity, aortic dilatation, and eventual rupture. Studies in AAA patients show an increase in cytotoxic T lymphocyte number and activity, a significant decrease in the number and immuno-suppressive activity of the T-regulatory (Treg) cells responsible for governing autoimmune responses, and decreased levels of circulating IL-10. Data from our group suggest that the immune system is sensitized to elastin in patients with early AAA. Cigarette smoking is one of the strongest risk factors for development of AAA in humans and smoke exposure has been shown to exacerbate aneurysm formation in mice. Our working hypothesis is that cigarette smoke causes lung damage via activation of tissue proteases which in turn generates antigenic elastin fragments that trigger an inflammatory reaction in the abdominal aorta resulting in an aneurysm. The current study will evaluate the effect of cigarette smoke exposure in mice on the relative ratios of populations of pro-inflammatory and anti-inflammatory T-cell subtypes, serum levels of IL-10, miRNA related to IL-10, aortic pathology, and an assessment of potential self-sensitization to elastin. The results of this study will be used to develop a delayed type hypersensitivity assay for elastin that could be used to easily assess the presence of AAA in human patients.
Copyright (c) 2025 Supriya Chittajallu, Theresa Doiron, Chang-Hyun Gil, Jacob Saliba, Jennifer Stashevsky, Japdeep Kaur, Madelyn Fairbairn, Cole Hennigan, Steven J. Miller, Mackenzie Madison, Michael P. Murphy http://creativecommons.org/licenses/by/4.0
Generation of Cholangiocyte Organoids Using Human Primary and Immortalized Intrahepatic Cholangiocytes
Background: Developing cellular models for studying cholangiopathies has been challenging. Cholangiocyte (CHOL) organoids offer promise in recapitulating structure and function of in vivo biliary tree. To enhance expansion, isolated CHOLs were immortalized using lentiviral vectors expressing human papillomavirus (HPV) E6/E7. It remains unclear whether immortalization alters other cellular properties. This study aims to determine whether immortalized CHOLs can self-organize into bile duct-like structures ex vivo, providing an avenue for modeling cholangiopathies and biliary tree development. Methods: Human cholangiocytes were isolated from explanted liver tissue (Figure 1A). 5,000 primary or immortalized CHOLs were seeded into a 24-well plate at 50ml/well in a mixture of Matrigel and supplemented media (Figure 1B). At 10 days of growth, diameter and number of organoids from each condition were quantified. Expression of the key markers for CHOLs such as CK19, EpCAM, and others were measured by qPCR. Rhodamine123 transport assay was used to assess functionality of CHOL organoids. Results: Fluorescent microscopy confirmed that cholangiocyte organoids generated with immortalized CHOLs express cholangiocyte-specific cell markers CK19 and CK7 and maintain p-glycoprotein function (Figure 1D). However, organoids derived from immortalized CHOLs showed a significant reduction in diameter (12.68 ± 2.4 vs 20.61 ± 2.8, p<0.01) and number per well (17.3 ± 4.9 vs 27.0 ± 3.2, p<0.02) compared to organoids derived from primary CHOL. qPCR analysis revealed elevated expression of progenitor cell marker EpCAM and reduced expression of mature CHOL marker CK19 in organoids derived from immortalized cell, suggesting immortalization impaired differentiation of CHOLs (Figure 1C). Conclusion: Although establishing immortalized CHOL cell lines from human livers provides cellular models for studying cholangiopathies, caution should be exercised when using them for studies requiring functional, mature CHOL behavior/3D organization. Future work should focus on developing alternative immortalization methods that better preserve the functionality and differentiation of primary cholangiocytes in 3D culture.
Copyright (c) 2025 Emily H. Chestnut, Minh-Uyen T. Le, Barry Wei, Ping Li, Burcin Ekser, Wenjun Zhang http://creativecommons.org/licenses/by/4.0
Antifungal Therapy after Candida-Positive Bile Cultures: Impact on Patient Prognosis
Introduction: The detection of Candida species in bile cultures has been increasingly observed, raising concerns if this represents colonization or an active infection, referred as ‘Candida cholangitis’ or biliary candidiasis. The presence of Candida in bile was linked to poorer prognosis and potential progression to candidemia, however, the necessity of antifungal treatment remains unaddressed. This study aimed to evaluate the epidemiology of patients with Candida-positive bile cultures and the impact of initial antifungal therapy on patient outcomes. Methods: A retrospective observational study was conducted involving 661 bile cultures from ERCPs performed between 2010 and 2016, of which 170 cultures (25.7%) from 151 patients showed Candida species growth. Patient charts were reviewed via Cerner EMR and the Indiana Health Information Exchange’s CareWeb, with death dates confirmed through the Database Registration of Indiana’s Vital Events (DRIVE). Data on patient demographics, medical history, ERCP details, and outcomes were catalogued and analyzed using REDCap, Excel, and GraphPad Prism. Results: Over six years, 25.7% of bile cultures performed post-ERCP showed Candida species. Only 19.2% of these patients received antifungal therapy within seven days of the procedure. A chisquare test for homogeneity showed no significant differences in sex (p=0.09), race/ethnicity (0.26), comorbidities (p=0.47), or other factors between treatment groups. All patients started on antifungals within seven days were inpatient prior to ERCP (p<0.01), potentially indicating more severe prior comorbidities or more diligent monitoring of bile culture results prompting antifungal intervention. Despite antifungal intervention, differences in mortality within one year (p=0.89), recurrence of Candida cholangitis (p=0.96), development of invasive candidiasis (p=0.94), and rehospitalization rates (p=0.42) were not statistically significant between treated and untreated groups. Discussion: Initial results suggest antifungal treatment does not significantly impact patient outcomes within one year. To enhance statistical power, the data sample will be expanded to include ERCP bile cultures from 2017-2023 prior to further manuscript submission or publication.
Copyright (c) 2025 Grace Charpentier, Nicolas Barros http://creativecommons.org/licenses/by/4.0
FoodRx: Exploring Disparities in Food Insecurity and Eye Health Conditions
Background: Good nutrition and chronic disease management are important for eye health; however, little is known about the relationship between food insecurity and eye health outcomes. Marion County is designated as a medically underserved area, and 25% of families rely on food assistance. Additionally, Indianapolis is considered one of the least accessible American cities in terms of healthy food options. Objective: My central research objective was to understand how food insecurity impacts eye health in medically underserved populations. This project had three specific aims: 1) understand the process of identifying food insecurity in an eye clinic setting; 2) implement food insecurity screening in a student run eye clinic; and 3) determine associations of food security status with eye health outcomes among Eskenazi Health patients. Methods: In Aims 1 and 2, I consulted the literature and clinicians from the Eskenazi Health Department of Ophthalmology. I developed a protocol implementing food insecurity screening into the electronic health record of a student-run eye clinic using the clinic-based Hunger Vital Sign (HVS) 2-question screener. For Aim 3, I worked with a Regenstrief Data Core analyst to extract patient and community demographic information, eye health conditions, and food insecurity status from the Eskenazi Health Data Warehouse. Results: I implemented the food insecurity protocol as a quality improvement project into the student-run eye clinic and to date n=12 patients were screened. Additionally, I developed an analytical plan which included consolidating 1,073 eye-related ICD-10 codes into two groups: “nutrition-related eye disease” or “other eye disease.” Conclusion: These exploratory study findings will generate future research questions and quality improvement initiatives to further investigate tailored clinic-community prevention initiatives, such as extending the food insecurity screener to other healthcare settings and integrating community resources with health care.
Copyright (c) 2025 Gloria V. Cabrero, LaKeisha Boyd, Deanna Reinoso, Richard J. Holden, Daniel O. Clark, Titus K. Schleyer, Rebecca L. Rivera http://creativecommons.org/licenses/by/4.0
Association of Post-Traumatic Epilepsy on Recovery from Severe Traumatic Brain Injury: Sliding Scale Approach
Background: Post-Traumatic Epilepsy (PTE) affects one-third of severe traumatic brain injury (TBI) patients and is associated with poor functional outcomes. While TBI is characterized by continued recovery years after injury, the trajectory of functional recovery in PTE patients is not well understood. Using a novel sliding scale, we hypothesized that PTE acts as a ‘second hit’ after TBI, slowing recovery over time. Methods: We performed a retrospective analysis of severe TBI patients (Glasgow Coma Scale (GCS) ≤ 8) treated from 2002 to 2018 at a Level 1 trauma center. We used the International Mission on Prognosis and Analysis of Clinical Trials (IMPACT) model to assign a sliding scale score. This score was based on the difference between the expected threshold for an unfavorable outcome (Glasgow Outcome Scale (GOS) = 1-3) and the actual score. Hence, a sliding score captures the magnitude of change between levels on the GOS according to each patient’s baseline prognosis. Scores ranged from -3 to +2, with positive scores denoting improvement compared to baseline prognosis, as expected in most TBI patients. Thus, a sliding scale score serves as a marker of a patient’s expected recovery over time. We used the Wilcoxon Rank-Sum test to compare the change in sliding scores over time for patients with and without PTE. Results: We had 392 patients with a median age of 33 (interquartile range (IQR)=23-47.5) Improvement for patients with PTE on the sliding scale was less (25.42% compared to 32.62% without PTE) over two years post-injury. PTE patients show a significant decline in functional outcomes compared to non-PTE patients during the 6 to 24-month follow-up period (p=0.04.) Conclusion: Post-traumatic epilepsy is associated with delayed recovery after severe TBI. Future PTE clinical trials should consider a sliding scale approach to explore if early, aggressive treatment improves functional outcomes.
Copyright (c) 2025 Arlec Cabrera, Shawn R. Eagle, David O. Okonkwo, Flora Hammond, Matthew W. Pease http://creativecommons.org/licenses/by/4.0
Effects of Gabapentin and the α2δ1 Voltage Sensitive Calcium Channel Subunit in Skeletal Muscle
Introduction: Gabapentin (GBP) is a neuropathic pain drug prescribed to millions of Americans which binds the auxiliary α2δ1 subunit of voltage sensitive calcium channels (VSCCs) to modulate calcium (Ca2+) influx. GBP functions by decreasing Ca2+ signaling in neurons; however, muscle dysfunction is commonly reported with GBP use. We hypothesized that GBP treatment, and deletion of the α2δ1 subunit, impairs skeletal muscle function by disrupting neuromuscular junction (NMJ) transmission. Methods: Heterozygous breeder pairs for Cacna2d1, the gene encoding α2δ1, were used to generate knockout (KO) mice (male: 9 WT, 9 KO; female: 6 WT, 5 KO). The Aurora muscle contractility system determined maximum torque, rate of contraction, rate of relaxation, and fatigue of the plantarflexors. Compound muscle action potentials (CMAPs) and single motor unit potentials (SMUPs) provided motor unit number estimates (MUNEs). qPCR analyses on skeletal muscle assessed NMJ homeostasis. Male C57BL/6 mice received GBP (150 mg/kg) or vehicle (saline) twice daily via oral gavage (n=8 mice/drug group). Muscle testing was conducted at 0, 2, and 4 weeks. Gene expression in muscle was analyzed by qPCR. Results: Males deplete of α2δ1 had decreased plantarflexion torque (p<0.001), max rate of contraction (p<0.001), max rate of relaxation (p<0.01), SMUP (p<0.001), and MUNE (p<0.01). Plantarflexion torque (p<0.01), and max rate of contraction (p<0.05) were decreased in female KO mice. Hspg2 (p<0.01) and Musk (p<0.05) expression was decreased in Male α2δ1 KO mice. However, expression of these genes was not altered in female mice. GBP treatment resulted in decreased max-torque (p<0.01), rate of contraction (p<0.001), rate of relaxation (p<0.01), and SMUP (p<0.001). Hspg2 (p<0.05), Lrp4 (p<0.05), Agrin (p<0.01), and Chrne (p<0.01) expression was decreased in muscle from GBP treated mice. Conclusion & Significance: As GBP is a widely used neuropathic pain drug, understanding the consequences of chronic use on musculoskeletal tissues is of utmost importance. My data demonstrates that GBP treatment and α2δ1 KO decreased muscle performance. These data will help clinicians consider potential side-effects when prescribing GBP.
Copyright (c) 2025 Alexander Buttars, Jung Min Hong, Meloney Cregor, Elicza Day, Julia M. Hum, Joshua R. Huot, William R. Thompson http://creativecommons.org/licenses/by/4.0
Novel Role of Megakaryocytes in the Skeletal Response to Mechanical Loading
Megakaryocytes (MKs) are the largest and rarest of the cell types in bone marrow. MKs not only play a vital role in thrombopoiesis but are also known to regulate bone mass. Indeed, MKs stimulate osteoblast proliferation and bone formation through a direct cell-to-cell interaction. Bone mass is regulated by mechanical stimulation, primarily through the mechanical sensing osteocytes. Interestingly, MKs are also known to be responsive to mechanical stimulation. Therefore, we hypothesized that bone formation induced by mechanical loading could be attributed, in part, to MK-mediated stimulation of bone formation. To accomplish this, we selectively ablated MKs (~50% reduction) in some mice using diphtheria toxin (DT). The right tibia of mice underwent mechanical loading 5 days/week for 2 weeks. Upon completion of the study, platelets and MKs were measured, and both loaded and non-loaded tibia were analyzed for bone-related parameters via microCT and histomorphometric assessments. Results indicated successful >50% reduction in MKs and platelets. Male and female mice showed no significant change in trabecular volume or thickness with loading but exhibited a trend of lower trabecular bone formation rate due to DT ablation. Female mice in the control group displayed increased number of osteoclasts per bone perimeter due to mechanical loading. This was not the same for the group treated with DT. This suggests that MKs may play a role in bone remodeling due to mechanical loading. While more work is required to further elucidate these preliminary findings, it appears that reduced numbers of MKs for a short time minimally alters trabecular bone responses induced by mechanical stimuli. Importantly, dissecting the mechanisms responsible for skeletal changes may yield insights into potential therapeutic targets which could be developed to improve the bone mass and reduce osteoporotic related fractures in our aging demographic.
Copyright (c) 2025 Ian M. Burke, Amy Creecy, Sonali J. Karnik, Olatundun D. Awosanya, Tyler J. Hesselbrock, Sarah L. Mostardo, Kuldeep Yadav, Rachel J. Blosser, Pratibha Singh, Angela Bruzzaniti, Melissa A. Kacena http://creativecommons.org/licenses/by/4.0
Remote Recurrence/Metastasis of Acinic Cell Carcinoma: a Case Series and Literature Review
Background: Acinic cell carcinoma (ACC) is a relatively indolent salivary gland tumor with recurrence usually occurring within the first five years after the primary resection. Delayed recurrence/metastasis after more than 10 years is rare and often poses diagnostic and treatment challenges. Methods: The study was approved by Indiana University Institutional Review Board. Six patients with remote recurrence/metastasis were identified from 1/2000 to 5/2024. Clinicoradiologic presentation, pathologic findings, treatment, and follow-up were reviewed. Case reports in literature since 1960 were also summarized. Results: The six patients comprised five females and one male (age range: 22 to 47 years). All tumors arose from the parotid gland. The interval between primary resection to recurrence ranged from 10 to 45 years. The most common recurrent/metastatic locations were scalp, lung, bone, and ear canal. High grade transformation was identified in one case. Two of six patients died of the disease including the case with high grade transformation, three patients were still alive, and one died from unrelated condition. Another six cases identified from the literature also involved the parotid gland, including five females and one male (age range: 15 to 60 years). The interval ranged from 11 to 30 years. Bone, lung and cutaneous sites were involved. Four of six patients were still alive, and the follow-up was not available in two patients. Conclusions: Remote recurrence/metastasis of ACC after 10 years of primary resection is very rare. This phenomenon predominantly affects females. Local recurrence usually involves structures near tumor beds. Distant metastasis affects scalp, lung, bone, or skin. Diagnosis can be challenging if patients and/or physicians are unaware of the original diagnosis. Scientific/Clinical/Policy Impact and Implications: The study raises awareness of an unusual clinical and pathological characteristic of ACC. A comprehensive review of medical history is crucial for an accurate diagnosis and appropriate clinical management.
Copyright (c) 2025 Caroline Boyle, Tieying Hou http://creativecommons.org/licenses/by/4.0
Social Determinants of Health Factors Associated with Breast Cancer Screening in Underserved Communities of Northwest Indiana
Background: Despite breast cancer being the second most common type of cancer found in female patients, a large number of female patients have not received a mammogram in the past two years. This disparity is partly due to factors related to social determinants of health. The effects of social determinants of health on positive breast cancer screenings are clearly present in Northwest Indiana, a region containing vastly differing communities with a wide range of income levels and diversity. Nearly two decades of patient data from this area can inform us which social determinants of health are associated with increased risk for breast cancer. Methods: “Hospital System A”, located in Lake County, Indiana, provided data from 111,564 mammograms from the year 2006 to the end of 2023. These 18 years of data provide patient zip code, age, race, insurance category, and screening results. A proportion of positive screenings was calculated for each group and compared using Chi-Square tests. Census information such as mean household income, race, and age was gathered for each zip code in Northwest Indiana and was tested on proportion of positive screenings by regression analysis. Results: When comparing zip codes of Northwest Indiana, lower mean household income was associated with higher rates of breast cancer (p-value = 0.0049). Medicare and Medicaid patient groups both had significantly higher rates of breast cancer than private and self-pay groups (p-value = 1.35x10-10, p-value = 0.0032). Race had almost no impact on breast cancer rates. Potential Impact: Income level has the greatest impact on breast cancer rates. We hypothesize that this relationship may be related to decreased access to care and unhealthy lifestyles because of economic restraints. Additionally, race has little influence on breast cancer rates, which may explain that society may have a greater role in health than individual characteristics.
Copyright (c) 2025 Seth Allen Bouwer, Basem Altarshan, Pooja Patel, Amy Han http://creativecommons.org/licenses/by/4.0
Assessing a Community-based, Group Care Program Adapted for Pregnant and Parenting Adolescents in Western Kenya: An Acceptability and Feasibility Study
Background: An estimated 21 million adolescent pregnancies occur worldwide, predominantly in low- and middle-income countries (LMICs). These pregnancies often result in poor health outcomes due to low health literacy and limited healthcare interaction. Furthermore, many adolescent parents face disproportionate stigma and are unable to complete their education or seek employment due to parenting obligations. The Chamas for Change program, an existing community-based group care program in Kenya targeted to adult mothers, shows promise in improving maternal, newborn, and child health (MNCH) outcomes in adolescents. This study evaluates the acceptability and feasibility of an adapted Chamas model tailored for pregnant and parenting adolescents. Methods: This mixed-methods study investigated the acceptability and feasibility of an adapted Chamas program for pregnant adolescents in rural Western Kenya. Likert scale surveys (ranging 1-5, 5 = “completely agree”) were conducted at baseline and endline to quantitively assess acceptability of the program. Program attendance, barriers to attendance, and intention to re-enroll were used to assess feasibility. Two Focus Group Discussions (FGDs) conducted at endline were analyzed through a thematic framework to qualitatively assess acceptability and feasibility. Results: Over the course of the study, 85% of participants had attended at least half of the adapted program sessions. At endline, 99% of adolescents reported the program is acceptable and 95% reported it is feasible (score ≥ 4 on the Likert scale). Additionally, 99% indicated they would re-enroll in the program for another cycle and 71% would attend even if no transportation and snacks are offered. Through thematic analysis of FGDs, strong themes of greater peer support and health literacy were noted. Conclusion and Potential Impact: The adolescent Chamas pilot demonstrated strong acceptability and feasibility, with MNCH outcomes being equivalent or better with the intervention. As such, there is potential to scale-up and expand the adapted Chamas program.
Copyright (c) 2025 Om Dalal, Lauren Maldonado, Gertrude Anusu, Laura Ruhl, Maureen Chepkoech, Anjellah Jumah, Joan Keter, Justus Elung’at, Michael Scanlon, Astrid Chrisoffersen-Deb, Edith Apondi, Julia Songok, Julie Thorne http://creativecommons.org/licenses/by/4.0
The Impact of Neuritin 1 on Retinal Ganglion Cell Survival in Human Donor Glaucomatous Eyes using the Translaminar Autonomous System
Purpose: Glaucoma is a progressive optic neuropathy characterized by degeneration of retinal ganglion cells (RGCs), thinning of the retinal nerve layer, and atrophy of the optic nerve. Disease progression is characterized by increased intraocular pressure (IOP) and visual field loss. The only efficacious therapy for treating glaucoma is modification of IOP through pharmacological or surgical intervention. Although these interventions slow disease progression, they do not prevent RGC death entirely. Decreased axonal transport of essential neurotrophic factors contributes to RGC death. Neurotrophic factor supplementation has shown to improve RGC survival and sustain retinal function. We have previously demonstrated that secreted human Neuritin-1 (hNRN1) exhibits neuroprotection, regeneration, and preservation of RGC function in non-glaucomatous human eyes perfused in the ex-vivo Translaminar Autonomous System (TAS). We will investigate the effects of hNRN1 in glaucomatous human donor eyes within the TAS to evaluate if hNRN1 can protect RGC loss in diseased retinas. Methods: Three pairs of glaucomatous human donor eyes were obtained from eye banks in accordance with the Declaration of Helsinki. Posterior cups were perfused using the TAS for 6-7 days under high and normal pressures with and without hNRN1. We then assessed RGC survival by measuring apoptosis, inflammation, and retinal markers using qRT-PCR and immunostaining. Retinal activity was measured using the OcuScience® Ex Vivo electroretinogram. Results: Posterior eye cups were successfully maintained in the TAS under normal and highpressure conditions for 6-7 days. Human NRN1 treated eyes showed differential expression of various inflammatory and apoptotic markers. Decreased extra cellular matrix deposition (Collagen, Fibronectin, Laminin) and improved retinal activity was seen within the treated glaucomatous eyes. Conclusions: The TAS model can mimic pressure induced pathogenesis in human glaucoma. Data from this study shows that hNRN1 may serve as a potential therapeutic target by promoting RGC survival in glaucoma patients.
Copyright (c) 2025 Faith N. Mikolajczyk, Shahna S. Hameed, Tasneem P. Sharma http://creativecommons.org/licenses/by/4.0
Sensitization of APC knock-out cells to Doxorubicin in vitro using KU55933, an ATM inhibitor
Background and Hypothesis: Triple negative breast cancer (TNBC) has the lowest 5-year survival rate among breast cancer subtypes, with Adenomatous Polyposis Coli (APC) mutations/deletions found to be a leading cause of Doxorubicin (DOX) resistance. Additionally, increased expression of pATM/ATM in APC knock-out (APCKO) cells was previously observed, providing a possible explanation to chemotherapy resistance. We hypothesized that treatment with the ATM inhibitor, KU55933, would sensitize APCKO cells to DOX in vitro using γH2AX as a marker of DNA damage. Materials and Methods: The TNBC cell line, MDA-MB-231, was previously modified using CRISPR/Cas9 to knock out APC. The current study uses the non-targeting control (NTC) and 2 clonal knock-out cell lines (APCKO or clones 1 and 2). Cells were cultured in DMEM with 10% FBS, 1% penicillin/streptomycin, and plasmocin, and treated with either H2O, DOX, KU, or DOX+KU for 24 hours. For western blot analysis of γH2AX, membranes were blocked at room temperature in 5% nonfat dry milk and incubated with primary anti-γH2AX overnight at 4°C using actin as an internal control. Immunofluorescence studies included drug treatment of cells with the four previously mentioned treatments and probing for γH2AX using anti-γH2AX antibody. Results: Immunofluorescence studies displayed increased γH2AX expression, indicating DNA damage in the combination (DOX+KU) treatment group in the APCKO cell lines. Western Blot analysis showed a significant difference in the DOX treated 231 NTC and clone 2 cell lines vs H2O treated cells. Conclusion and Potential Impact: Data from this study will be used to pursue further research in the efficacy of KU in sensitizing APCKO cells to DOX treatment and have significant implications for the future of chemotherapy research and dosing for TNBC patients. Future studies may include testing the ability of KU to overcome DOX resistance in vivo and assessment of APCKO cell recovery after drug treatment in different growth media.
Copyright (c) 2025 Isaias Colon, Angelique Wise, Jenifer Prosperi http://creativecommons.org/licenses/by/4.0
Sexual Dimorphism in the Skeleton of Adult and Aged Mice with Alzheimer’s Disease-Related Mutations
Background and Hypothesis: Alzheimer’s disease (AD) is a progressive neurological disease characterized by gradual impairment in cognition and memory. Osteoporosis is another common degenerative disease in aging populations. Recent research has uncovered links between AD and bone biology, as well as potential sex-linked differences in disease progression, but the mechanisms behind this are yet to be fully understood. We hypothesize that at both 4 and 13 months of age, female mice with AD-related mutations will have more age-related adverse effects on bone microstructure and geometry than their male counterparts. Project Methods: Male and female mice expressing humanized forms of AD-linked mutations (Swedish/Artic/Austrian) in the Amyloid Precursor Protein (APP-SAA) were raised until either 4 or 13 months of age to accelerate plaque formation. Dxa/Piximus data was collected for body weight, total bone mineral density (BMD), femur BMD, and spine BMD for both age groups and sexes. Trabecular bone from distal femora and cortical bone from femoral mid-diaphyses were then analyzed by μCT. Sexes were analyzed separately by 2-way ANOVA (Tukey’s post-hoc multiple comparisons) or unpaired t-test. Results: Our results show that among mice with AD-related mutations, female sex is associated with more pronounced age-related effects on bone. Both sexes displayed increases in tissue and marrow area, point of maximal inertia, and tissue mineral density, but females showed a more detrimental effect with age. The deleterious effects of age were more apparent in trabecular bone than cortical, with female APP-SAA mice also displaying significantly lower BV/TV, Tb.N., Tb.Th., and higher Tb.Sp. than male APP-SAA mice at both ages. Conclusion and Potential Impact: AD and osteoporosis are prevalent and debilitating diseases affecting millions of patients throughout the United States. The results from this study will help to understand the relationship between them and identify potential interactions between sex and disease progression.
Copyright (c) 2025 Mark Zhang, Gabriel Ramirez, Alix Teal, Roquelina Pianeta, Lakshmi Chellaganapathy, Dan Horan, Chiaki Yamada, Alyson Essex, Alexandru Movila, Lilian I. Plotkin http://creativecommons.org/licenses/by/4.0
ADHD and Sleep Disordered Breathing in the Pediatric Population – Comparing Real World Prevalence to Literature Estimates
Background/Objective: Literature has demonstrated a bidirectional relationship between attention-deficit hyperactivity disorder (ADHD) and sleep disordered breathing (SDB) in the pediatric population. SDB is a term used to describe a range of disorders that impact and interrupt ventilation patterns during sleep. ADHD and SDB have overlapping symptoms such as inattention, impulsivity, hyperactivity, cognitive impairments, and behavior problems. It is important to recognize SDB in children, as it has been associated with hypertension, cardiovascular disease, atrial fibrillation, growth failure, and negatively impacted school performance. Previous studies estimate a 25 to 57% incidence of SDB in children and adolescents diagnosed with ADHD. The primary goal of this study was to evaluate if the prevalence of SDB in children diagnosed with ADHD, as recorded in a national electronic medical record database, is consistent with previous studies. Methods: Data was obtained from the IU School of Medicine-Evansville RWEdataLab (CRC/Sidus Insights) Psychiatry dataset, which contains de-identified records across the United States from 4.89 million patients with psychiatric diagnoses. Selection criteria included patients currently less than 20 years of age with both an ADHD diagnosis and a SDB diagnosis. Primary retrospective analysis compared patients with an ADHD diagnosis to patients with ADHD+SDB diagnoses. Results: 68,259 patients < 20 years of age were diagnosed with ADHD. 1,959 patients also had a SDB diagnosis, indicating a prevalence of 2.87%. 72.79% of individuals with both diagnoses had ADHD as their first recorded diagnosis or had both ADHD and SDB diagnoses first recorded on the same date. Conclusion and Potential Impact: Prevalence of SDB in children with ADHD was found to be substantially lower than estimated literature prevalence of 25 to 57%. Future research is necessary to identify if current practitioners are regularly screening for SDB in children with ADHD.
Copyright (c) 2025 Sydney Young, Chantae Hollis, Amy Han http://creativecommons.org/licenses/by/4.0
The Regulatory Role of Folate Receptor Beta on Inflammasome Activation
Background and Hypothesis: Group B Streptococcus (GBS) causes intrauterine infection during pregnancy. The inflammatory response of macrophages at the maternal-fetal interface to GBS may contribute to host defense. The NOD-, LRR- and pyrin domain-containing protein 3 (NLRP3) inflammasome regulates macrophage responses, activated by microbial patterns and danger signals, leading to caspase-1-driven release of proinflammatory cytokines like IL-1β and cleavage of gasdermin D (GasD), which induces pyroptotic cell death. Folate receptor beta (FRβ), encoded by the FOLR2 gene, is a GPI-anchored glycoprotein that is highly expressed by macrophages, but its function is unknown. We hypothesize that FRβ regulates NLRP3 activation. Method of Study: The human monocytic cell line THP-1 was CRISPR/Cas9-modified to delete the FOLR2 gene (knock-out, KO) or mock-transfected for wild-type (WT) control cells. WT and FOLR2 KO macrophages were cultured in a physiologic amount of folate (25 nM) for 7d before being treated with phorbol 12-myristate 13-acetate (PMA) to induce macrophage differentiation. WT and FOLR2 KO macrophages were stimulated for 4h with either GBS or FSL-1 (toll-like receptor 2/6 agonist); or for 3h with lipopolysaccharide (LPS) + 30m ATP (LPS+ATP), or LPS + 30m Nigericin (LPS+Nig). Supernatants were analyzed for IL-1β, caspase-1, and cleaved GasD release by ELISA, while lysates were analyzed for IL-1β, caspase-1, and cleaved GasD by Western Blot. Results: FRβ KO macrophages showed a reduced ability to secrete IL-1β after FSL-1 or LPS+Nig stimulation vs WT macrophages, which was not observed in the cellular lysate. Also observed was a significantly reduced ratio of cleaved GasD in FRβ KO macrophages stimulated with LPS+Nig compared to WT macrophages, not seen in the cell supernatant. There was not an observed significant difference between FRβ KO and WT macrophages in the amount of caspase-1 both inside and outside the cell. Both WT and FRβ KO macrophages were weakly, and equally, stimulated with GBS or LPS+ATP. Conclusions: FRβ KO THP-1 cells exhibit a reduced NLRP3-dependent inflammatory response to stimulation, suggesting a proinflammatory regulatory role for FRβ in immune surveillance.
Copyright (c) 2025 Kayla R. Wrobleski, Lisa M. Rogers, Kyle Firestone, David M. Aronoff http://creativecommons.org/licenses/by/4.0
Hammersmith Infant Neurologic Examination (HINE) in the Assessment of Infants with Dysphagia
Background: Over the past several years, significant advancements have been made in the recognition and diagnosis of dysphagia. Intensive therapeutic interventions and diagnostic tools, such as the video fluoroscopic swallow study (VFSS), have been developed to assess and modify swallowing mechanics and ensure safe swallowing to promote growth in children diagnosed with dysphagia. Although there have been significant increases in improving dysphagia, there are minimal tools available to predict the timing of dysphagia resolution. Many children with dysphagia have impaired oromotor function and difficulty in mobilizing and clearing airway secretion. This is partly due to dyscoordination of the muscles involved in swallowing, which has been theorized to be related to reduced muscle tone. The Hammersmith Infant Neurological Examination (HINE) has been specifically designed and optimized to identify differences in motor tone and coordination in infant development. HINE is currently used in the diagnosis and prognosis of infants at risk for developing cerebral palsy (CP). Methods: In this retrospective study 67 patients were examined using VFSS to assess if a lower HINE score is associated with longer resolution times for aspiration. Results: Using this data, it was found that a HINE score below or above the CP cutoff score directly correlated with the recommendation of feeding (bottle modifications, thickening of liquid, or tube feeding) (p=0.018). HINE scores were also utilized to demonstrate a linear regression model capable of predicting the approximate duration of dysphagia resolution (p=0.041). Conclusion: Future research can aim to develop a more comprehensive framework for the resolution of penetration and aspiration associated with dysphagia.
Copyright (c) 2025 Andrea Wright, Emily Scott, Ryan Pitman http://creativecommons.org/licenses/by/4.0
Difficult Cannulations in Neonatal and Pediatric ECMO: Illuminating an Obstruction to Timely Therapy
Background and Objective: ECMO is a vital intervention for neonatal and pediatric patients requiring cardiorespiratory support, yet unanticipated difficulties with peripheral cannulation can hinder timely therapy. Research concerning challenging cannulations is limited, and protocols guiding surgeons to consider alternative approaches in cases of potential difficulty are lacking. The purpose of this study was to identify reasons for cannulation difficulty and pinpoint predisposing diagnostic, anatomical, and operative features of this population. Methodology: We conducted a single-center, five-year retrospective review of neonatal and pediatric patients encountering challenging peripheral cannulations or multiple cannulations for ECMO. Variables included patient demographics, ECMO indications, prior cannulation attempts, surgical challenges encountered, alternative vascular anatomy, and outcomes from cannulation to discharge. Results: An analysis of 65 cannulations (38 subjects, median cannulations per subject=1, range 1-4) revealed that venous cannulations posed challenges more often (n=28) than arterial cannulations (n=11). Intraoperative cannulation challenges were predominantly attributed to small vessel size (43.5%) and unspecified catheter advancement obstructions (23.1%). A substantial proportion of patients in this cohort exhibited congenital heart anomalies (81.6%), and 50.8% of cannulations occurred in the setting of post-procedural support, often postcardiotomy. Alternate neck or groin vascular anatomy was identified in 19 cannulations. The rate of unsuccessful peripheral cannulation was 20.5% (n=8) and patient mortality associated with difficulty cannulating onto ECMO was 15.4% (n=6). Conclusions and Impact: These findings suggest that neonatal and pediatric patients with congenital heart anomalies or a history of recent surgery may face an increased risk of challenging cannulations and poorer ECMO outcomes. Pre-operative neck and groin ultrasound could help surgeons better anticipate and address difficulties like small vessel size or obstruction. Early evaluation of risk factors for challenging cannulations will enhance surgical decision-making regarding cannulation approach and ultimately improve outcomes for children requiring ECMO.
Copyright (c) 2025 Amanda Wissmann Klage, Michael Sobolic, Brian Gray http://creativecommons.org/licenses/by/4.0
Outcomes Associated with Mechanical CPR Devices
Background In the U.S. 350,000 out of hospital cardiac arrests(OHCA) occur annually with 90% resulting in mortality. Delivering timely, high-quality CPR is paramount in promoting favorable patient outcomes. Inherent difficulties in providing out of hospital CPR in addition to first responder shortages have increased mechanical CPR(mCPR) device utilization in out of hospital settings. Previous trials were conducted in urban areas and have shown no significant difference in efficacy, but smaller studies identified a greater risk of resuscitation related injuries with mCPR. We hypothesized that in a rural setting, mechanical would be non-inferior to manual CPR for patient survival but would produce more resuscitation related injuries. Methods This IRB approved retrospective chart review considered all OHCA with attempted resuscitation by Parkview EMS from 1/1/2022–12/31/2023. Pediatric, pregnant, and Do-Not-Resuscitate patient charts were excluded. Traumatic and hypothermic cardiac arrests were also excluded. Data collection was completed via EMR reports. We collaborated with county coroners to obtain autopsy reports with information regarding resuscitation related injuries. Survivability was the primary outcome with cerebral performance category(CPC) scores and resuscitation related injuries as secondary endpoints. A t-test was used for continuous data. Chi-square, odds ratios, and confidence intervals were used for binary data (p<0.05 for significance). Results There were 160 manual and 21 mCPR patients. Injury data was obtained for 117 manual and 11 mCPR patients. 32/160 (20%) manual CPR patients survived and 1/21 (4%) mCPR patients survived (p=0.089). 22/160 (14%) manual CPR patients had favorable CPC scores compared to 1/21 (4%) mCPR patients (p=0.245). While not statistically significant, survival rates and CPC scores may be clinically significant. mCPR patients experienced splenic maceration, liver laceration, lacerated inferior vena cava, and lacerated pericardium significantly more than manual CPR (p=0.001). Conclusion The outcomes in this rural cohort demonstrated noninferiority of mCPR in comparison to manual CPR.
Copyright (c) 2025 Erik Wilhelm, Amy Souers http://creativecommons.org/licenses/by/4.0
Light-Dependent Structural Changes in Photoreceptor Neurons Imaged by OCT
Background: Optical coherence tomography (OCT) is an imaging technique with high spatiotemporal resolution used to monitor the retina, photoreceptor degeneration, and potentially the visual cycle. In this study, we aim to examine how various light conditions impact the photoreceptor structures using OCT. Methods: C57BL/6 wild-type mice raised under a normal 12-hour light/dark cycle (200 lux) were exposed to three different light conditions from postnatal day 21 (P21) to P35: a 12-hour light/dark cycle (200 lux; normal), 12-hour light/dark cycle (2500 lux; bright), or constant darkness. Mice were imaged with OCT at P35 (n = 4 for each group). Results: For the nasal region, the length of the outer segment (OS) to the retinal pigmented epithelium (RPE) were 20.892 ± 2.343 μm and 15.980 ± 2.284 μm for the normal and bright light conditions, respectively (mean ± SD, p = 0.0240). For the temporal region, the lengths were 22.185 ± 2.678 μm and 16.294 ± 2.204 μm for the normal and bright light conditions, respectively (mean ± SD, p = 0.015). For the ventral region, the lengths were 19.210 ± 3.027 μm and 14.875 ± 1.268 μm for the normal and bright light conditions, respectively (mean ± SD, p = 0.038). For the dorsal region, the lengths were 20.556 ± 2.441 μm and 19.247 ± 3.403 μm for the normal and bright light conditions, respectively (mean ± SD, p = 0.555). Conclusions: We observed significant light-dependent changes in photoreceptor and RPE layers for most regions—showing that transitioning from the normal to the bright light cycle impacts the length of the OS to the RPE and that OCT can be applied for monitoring the process of light adaptation in photoreceptor cells. The results of this study will help by improving the diagnosis of vision disorders associated with photoreceptor and RPE dysfunctions.
Copyright (c) 2025 Brandon Block, Shimpei Takita, Yoshikazu Imanishi http://creativecommons.org/licenses/by/4.0
Impact of Social Determinants of Health on Stroke Severity in Northwest Indiana
Introduction: Stroke significantly contributes to mortality and disability in the United States, yet geographical disparities exist across regions like Northwest Indiana, where stroke incidences and mortality rates are 2-4 times higher than the national average. Social and demographic determinants of health are known factors of stroke risk and outcomes. This study aims to investigate the associations between specific determinants and stroke severity of Stroke Center patients from Lake County, Indiana. Methodology: Data elements were extracted from patients hospitalized at Community Hospital, St. Mary’s Medical Center, and St. Catherine Hospital under Powers Health between January 2022 and May 2024. Data was recorded with the AHA’s GWTG Stroke Case Record Form. Our retrospective study conducted bivariate analysis, using R, on predictor variables of age, sex, race, Hispanic ethnicity, ZIP code, payment sources, and mode of arrival to the ordinal scores of the modified Rankin Scale (mRS) and the National Institutes of Health Stroke Scale (NIHSS). Results: Analysis of 1563 patients, excluding non-residents and transfer patients, revealed notable variations in social and demographic characteristics. Patients from certain urban ZIP codes with comparatively lower median household incomes and secondary education attainment had higher, more severe, mean NIHSS and discharge mRS scores (p<0.05). When age-adjusted, Black patients had a 2.5 point higher mean initial and 1.9 point higher mean discharge NIHSS score than White patients (p<0.001, p<0.01). Patients with higher mean scores across all measures were those associated with using Medicare versus private insurance (p<0.0001) and those arriving to the hospital via EMS versus private transport (p<0.01). Conclusions: This research addresses the significance of surveying region-specific social determinants of health for its insight into clinical stroke care and future preventative and quality improvement initiatives. Implementation of interventions and policies can mitigate disparities and impact overall stroke management and prevention strategies.
Copyright (c) 2025 Jacobus Barnard, David Lin, Miranda Cash, Grace Armstrong, Neon Calumpang, Amy Han http://creativecommons.org/licenses/by/4.0
Retrospective Analysis of Drug Overdose Deaths in Allen County, Indiana from 2008-2023
Introduction: Deaths caused by drug overdose have been rising at the national, state, and local level. Research on drug overdose deaths at the local level is insufficient and not as well understood. The aim of this study is to analyze and assess the drug overdose deaths in Allen County, Indiana from 2008-2023. Methods: Data was collected from Allen County Coroner’s Reports and Allen County Department of Health death certificates on 1,435 decedents. Data included decedent demographic information, employment, education level, and toxicology report results. Data was entered into a spreadsheet for analysis. Chi-squared analyses were completed to assess significance and descriptive statistics were completed. Results: 1435 drug overdose deaths were identified (1,298 accidental, 110 intentional, 27 undetermined) with a median age of death of 39. 66.4% of deaths were males. Multiple substances were found in nearly 67% of decedents. Race and ethnicity data reflected anticipated results for Allen County based on census data. Deaths in the study period tended to be accidental (83.6%) and most decedents had a high school education or less (71.1%) and were currently employed individuals (75.7%). Naloxone was found in twice as many toxicology reports after policy change occurred in 2015. There was a significant relationship between the age and manner of death in males and females with ages 64+ being more likely to die from an intentional overdose than those under 64, X2 =49.7, p < 0.00001. Conclusion: Governments can have an impact on drug overdose outcomes through policy change if demographic and locational information is better understood and resources are allocated to at-risk populations. Education efforts should be focused on those with a high school education or less, additional attention should be made for those ages 64+, and Naloxone distribution should be major points of emphasis going forward.
Copyright (c) 2025 Lucas Boha, Jana Sanders, Thomas Gutwein http://creativecommons.org/licenses/by/4.0
Planning for Dementia Diagnoses: The Physician’s Role in Developing Firearm Retirement Plans in Aging Populations
Introduction: Firearm ownership poses a critical risk to people living with dementia (PLWD) and their caregivers. Out of 241 veteran suicides that took place from 2001-2005, 73% were carried out using firearms with most suicides occurring in patients newly diagnosed with dementia. However, little is understood regarding how clinicians can effectively approach the subject of gun safety and cognitive decline. Methods: A prospective survey was given to patients over 60 to assess attitudes and preferences regarding physician intervention in firearm safety planning in the case of cognitive decline. A second survey was distributed by the Marion County Youth Violence Prevention Coalition to determine the rate at which physicians discussed firearm safety with the caregivers of aging patients. Results: Before participating in this study, 67% (n=12) of participants stated that they had never had a conversation about firearm safety and cognitive decline. 50% (n=9) reported that they were open to discussing firearm safety with their physician, with 11% (n=2) selecting that they were “undecided.” After the survey, 72% (n=13) of participants planned on having a conversation related to firearm safety planning in the case of cognitive decline. The survey directed toward caregivers reported that 21% (n=5) of participants discussed firearm safety with a healthcare provider. Conclusion: Before taking this survey, only 33% of participants had discussed firearm safety in the case of cognitive decline. After participating, 72% planned to have that conversation. We will continue this project by determining the preferences of caregivers regarding physician intervention in firearm safety planning and discover the resources physicians need to assist in these conversations. When the most efficacious intervention strategy is understood, physicians can use their influential roles to equip aging populations with the ability to protect themselves and their families from firearm related injuries and deaths in the case of cognitive decline.
Copyright (c) 2025 Haley Harkness, Sam Kay, Ashley Meagher, Linda Schutzman http://creativecommons.org/licenses/by/4.0
UGT2B10 Variant Effects on Dexmedetomidine Metabolism Using Nicotine Studies
Background: Dexmedetomidine is a procedural sedative primarily metabolized by the UDP-glucuronosyltransferase (UGT) 2B10. UGT2B10 also contributes to nicotine metabolism. Most research on the effect of gene variants on UGT2B10’s glucuronidation efficacy has focused on nicotine. This study outlines current data on the relationship between UGT2B10 pharmacogenomics, nicotine pharmacokinetics, and race, then extrapolates that information to dexmedetomidine. Methods: A literature review was conducted on UGT2B10 variants and dexmedetomidine or nicotine in PubMed. Due to lack of studies on dexmedetomidine glucuronidation, studies using nicotine were used to classify variants as poor, intermediate, or extensive metabolizers; characterize their expression in African/African Americans (AA) and Europeans (C), and establish their respective activity based on nicotine metabolite percentages. Results: UGT2B10 accounts for about 20% of nicotine metabolism. The UGT2B10 variants rs61750900 (AA= 37.62%; C=0.18%) and rs2942857 (AA=4.42%; C=9.28%) are nonfunctional. Poor metabolizers (PM) are homozygous for one of these variants and see a 97% decrease in UGT2B10 metabolites. Intermediate metabolizers (IM) have one variant allele and one wild-type allele, with a 32% decrease in UGT2B10 metabolites. Extensive metabolizers (EM), have two wild-type alleles. Metabolites from other pathways increase as UGT2B10 metabolites decrease. These results were superimposed onto dexmedetomidine metabolism to predict metabolite percentages in UGT2B10 IM and PM. In PM, only 1.02% of dexmedetomidine metabolites were predicted to be from UGT2B10. Conclusion: Nicotine metabolism data suggests variants of UGT2B10 significantly impact dexmedetomidine metabolism. PMs have 97% decreased nicotine UGT2B10 metabolism and a compensatory increase in nicotine’s other metabolites. UGT2B10 accounts for the largest portion of dexmedetomidine metabolism. Thus, UGT2B10 PMs may have decreased glucuronide metabolites, with increased proportion of other pathways. Giving the same dose of dexmedetomidine to PM or ultrarapid metabolizers (UM) may result in toxicity or undersedation, respectively. More research needs to be done on UGT2B10 variants to optimize patient care.
Copyright (c) 2025 Cassidy N. Hardin, Aislinn O’Kane, Sara Quinney http://creativecommons.org/licenses/by/4.0
Evolving Trends in Intervention Types for Pediatric Pancreatic Pseudocysts
Background: Pancreatic pseudocysts (PP) have various treatment options, including careful monitoring without intervention and procedural interventions (endoscopic, percutaneous, surgical excision). The composition of procedures and optimal management in pediatric patients remains unclear. Therefore, this study aims to (1) identify characteristics and outcomes of patients associated with PP intervention types and (2) evaluate trends over time of intervention types for pediatric PP. Methods: The Pediatric Health Information System (PHIS) database was used to evaluate patient characteristics, procedures, and outcomes. Identification codes (ICD-9 and -10) identified patients less than 18 yo with PP from 2005-2022 and their associated interventions. Interventions related to their pseudocysts were categorized as endoscopy, interventional radiology (IR), surgery, or multiple and were compared using bivariate analysis. Results: Data was analyzed from 2718 patients of which 697 had a procedural intervention. Most patients were Male (52%), Caucasian (51%), not Hispanic or Latino (58%), and had a mean age of 12.2 years (SD 7.6 years). Procedures consisted of surgery (48%), endoscopy (23%), IR (20%), and multiple (9%). There were no differences in gender across intervention subtypes. Patients were significantly younger for those undergoing surgical intervention (11.5±8years) versus endoscopy (14.0±7.2years) and IR (12.2±7.7years) (p<0.001). More endoscopy procedures were performed in PHIS hospitals in the Midwest (29%) and South (34%) vs the Northeast (13%) and West (24%). The proportion of patients undergoing a procedure has decreased from 30% to 18% from 2005-2022. Surgical procedure proportion has decreased over time from 18% to 5% of patients. Whereas endoscopic procedures have increased over time from 2% to 15% of patients. This increase began around 2014 and has been steadily increasing since then. Conclusion: For pediatric patients with PP, surgical procedures are more common in younger patients. Endoscopic procedures have become most frequently utilized for intervention for PP, while surgical procedures have decreased over time.
Copyright (c) 2025 Rhea Gupta, Kristen N. Kaiser, Ella G. Boardley, Thomas K. Maatman, Brian A. Mcferron, Brian W. Gray http://creativecommons.org/licenses/by/4.0
Parent-Reported Outcomes Following Type B Ulnar Polydactyly Excision in the Clinic Versus the Operating Room
Background: Ulnar polydactyly is the presence of an extra finger on the post-axial aspect of the hand. It is one of the most common congenital abnormalities and causes aesthetic and functional impairments that can be treated with surgical excision in the office or the operating room (OR). Our goal was to compare outcomes between type B ulnar polydactyly surgery performed in OR vs. office. Methods: We reviewed treatment outcomes and administered a satisfaction survey via telephone or email link via REDCaps to parents of children with type B ulnar polydactyly treated at Riley Children’s Hospital between 2020 and 2024. We assessed satisfaction with treatment decisions, outcomes, and motivational factors. Outcomes were assessed via visual analog scale from 1 to 10; 1 equating to minimum satisfaction, 10 equating to maximum satisfaction. Results: In total, 34 of the 165 (20%) parents agreed to participate in the study. Of those 34, 17 parents elected for excision in the OR and 17 chose the office. There were no significant differences in race, education, or marital status between groups. In total, 15 families had a history of polydactyly and chose the operating room 64.3% of the time compared to 38.9% of the time from the families without a history of polydactyly. There was no significant difference in average comfort, satisfaction of outcome, function, and appearance VAS scores when stratified by family history of ulnar polydactyly. There were no significant differences in satisfaction between excision in the office or OR. Conclusions: Office-based excision faces challenging logistics—sufficient lighting, staffing, and cooperation from parents and children. Parents who choose surgical excision in the office are satisfied with the treatment outcomes, would not change any of their treatment decisions, and would recommend their treatment process to others. While challenges exist, excision in the office may result in lower healthcare costs while providing similar outcomes.
Copyright (c) 2025 Joshua D. Gerstein, Khoa Tran, Nikhi P. Singh, Gregory H. Borschel, Joshua M. Adkinson http://creativecommons.org/licenses/by/4.0
Glaucomatous E50K Mutation in the Optineurin Gene Causes Mitophagy Defects for Retinal Ganglion Cells but Not for Motor Neurons
Background: Clearance of damaged mitochondria by lysosomes, known as mitophagy, is critical for maintaining mitochondrial homeostasis and cellular energy balance. Optineurin (Optn) is the central player for mitophagy found to be mutated among normal tension glaucoma (OPTNE50K) and in some familial forms of amyotrophic lateral sclerosis (OPTNE478G) patients. It is critical to understand how mitophagy mechanisms are altered for these inherited mutations in stem cells and differentiated neurons to gain insight into the disease’s developmental aspect. Methods: We utilized human embryonic stem cell-derived retinal ganglion cells (hRGCs) and induced motor neurons (iMNs) with and without the OPTNE50K mutation. The cells were treated with DMSO (vehicle control) or with 10 M CCCP, an uncoupler that induces mitochondrial damage. We then analyzed the activation status of critical mitophagy players including Optn, Parkin, Pink and Lc3b. We further analyzed if OptnE50K mutant forms aggregate in iMNs as observed for hRGCs. Results: We found that OPTNE50K mutation causes attenuated activation for Optn, Parkin, and LC3b in hRGCs under mitochondrial damage, while iMNs and hPSCs maintained healthy mitophagy. Additionally, mutant iMNs do not display distinct Optineurin aggregates, unlike in mutant hRGCs. Conclusion: Our results suggest that the OptnE50K mutation may disrupt mitophagy in hRGCs but not in iMNs and stem cells. In addition, the lack of Optn aggregates in the OPTNE50K mutant iMNs suggests an alternative pathway that inhibits the aggregate formation, presumably for maintaining healthy mitophagy for longer survival. Impact: The results from this project lay the groundwork for further investigation of the mechanisms behind mitophagy and its relation to glaucoma and ALS. Understanding what causes certain cell types to degrade while others remain healthy is key to understanding the genotype-phenotype specificity for inherited gene disorders.
Copyright (c) 2025 Harshavardhan Sanaka, Michelle Surma, Leah LaCross, Kavitha Anbarasu, Arupratan Das http://creativecommons.org/licenses/by/4.0
Emergency Medicine Residency Program Expansion and Characteristics of Rural Rotations
Background: Despite concerns surrounding a potential surplus of emergency medicine (EM) physicians through at least 2036, there has been no corresponding increase in the number of EM trained physicians working in rural emergency departments. Previous studies suggest that the integration of rural rotations into EM residency curricula encourages more physicians to select rural EM positions. However, many EM residency programs do not offer rural rotations due to barriers such as insufficient finances, lack of resident interest, or lack of physician supervisors. No known studies since 2020 have explored rural rotations in EM residency programs. Following the covid-19 impact, it is worth re-examining the current state of EM residency programs and exploring attitudes about implementing rural rotations into new and existing programs. Objectives: To examine attitudes surrounding the expansion of EM residency programs and to explore characteristics of rural rotations in EM residency programs. Methods: A Qualtrics survey was distributed through the Council of Residency Directors in Emergency Medicine (CORD-EM) listserv. Survey responses continue to be collected in order to analyze the trends present in the aggregate data. Results: Data collection remains in progress regarding availability, characteristics, and interest in rural rotations in EM residency programs. Data revealing attitudes surrounding the need for additional rural rotations in existing EM programs and the need for the development of new EM programs with a rural focus are also being collected. Conclusion/Impact: Preliminary conclusions based on current data suggest that there are needs to increase EM resident interest in pursuing both rural rotations and jobs in rural sites, to find solutions to the barriers which hinder the implementation of rural rotations in EM residency programs, and to consider how future programs can incorporate a rural focus and address these issues.
Copyright (c) 2025 Kayley Ryan, Christine Motzkus, Aloysius Humbert http://creativecommons.org/licenses/by/4.0
Development of a Fitting Algorithm and Mobile Application for Portable Electrochemical Impedance Spectroscopy
Introduction: Electrochemical impedance spectroscopy (EIS) is a technique that utilizes alternating-current (AC) signals for analyzing charge transfer and chemical reaction kinetics. This technique has several clinical applications including biomolecular detection. While many potentiostats have been developed to make EIS more accessible, such as HELPStat, current portable potentiostat designs with EIS capabilities rely on external hardware for control of the device or for data analysis, limiting designs to non-portable applications. Methods: To address this issue, a Levenberg-Marquardt fitting algorithm was implemented in the HELPStat firmware, allowing approximation of charge transfer resistance from empirical impedance measurements. The developed algorithm was compared to a MATLAB script, and both were evaluated using impedance data for ideal Randles circuits as well as potassium ferricyanide and cortisol aptamer binding Redox reactions. Results were analyzed using paired t-tests comparing absolute value of residuals and root-mean-squared-error (RMSE). In addition, an Android application was developed to perform bidirectional communication between the HELPStat potentiostat and a mobile device using Bluetooth Low-Energy (BLE), with a serial monitor being used to confirm that potentiostat measurements were being configured as expected. Results: Testing of the fitting algorithm demonstrated a statistically significant difference between the developed algorithm and a similar MATLAB implementation. Further analysis revealed that the developed fitting algorithm had statistically comparable or lower errors. In addition, testing with a cortisol aptamer was able to successfully differentiate between 1.5 ng/ml and 7 ng/ml samples of cortisol. By developing a novel Android application and enabling true wireless functionality through BLE, we enable a better bridge of communication between user and device. Conclusion: We developed a fitting algorithm in device firmware along with a novel Android application that allows device control and data analysis with the HELPStat potentiostat. By implementing this without dependence on external hardware, we enable device portability for point-of-care applications.
Copyright (c) 2025 Shannon Riegle, Kevin Bautista, Jacqueline Linnes http://creativecommons.org/licenses/by/4.0
Three-Dimensional Modeling of Anterior Communicating Artery Aneurysm for Surgical Simulation
Background: A ruptured cerebral aneurysm is a common cause of life-threatening subarachnoid hemorrhage and can be treated using open surgical clipping or endovascular coiling and stenting. Most aneurysms arise on typical sites on the circle of Willis and its terminal branches with the anterior communicating artery being the most common site. The recent shift towards endovascular procedures has decreased the frequency of open surgical aneurysm clipping. This provides less opportunities for neurosurgical residents to develop procedural skills needed to successfully clip an aneurysm. To fill the gap, three-dimensional (3D) modeling and printing can be adapted to create a surgical simulator. 3D models can provide realistic surgical practice in a low acuity setting. Methods: A preexisting model of a skull was remodeled to print with a pre-cut pterional craniotomy. A 3D model of a circle of Willis with an anterior communicating artery aneurysm was constructed using a patient’s computed tomography angiography data. The model was segmented and optimized for 3D printing. A prototype was printed using acrylonitrile-butadienestyrene (ABS). The ABS skeleton was then coated with silicone containing red pigment. The ABS was dissolved using acetone to create a hollow silicone cast of the aneurysm and the circle of Willis. Results: Following successful printing and casting, the hollow vascular model was positioned within the skull and a simulation was assembled. Comparing the similarity between the view of the aneurysm model through the pterional craniotomy window and the actual surgical perspective, suggested the necessity to move the craniotomy window more anteriorly. Future Directions: 3D printing and silicone casting of cerebrovascular models is a feasible method to create surgical simulators as it can approximate the anatomy and tactile characteristics of vasculature. Further models will be created and used to assemble surgical simulators for resident education.
Copyright (c) 2025 Aditi Ravikumar, Matthew Tobin, Bradley Bohnstedt http://creativecommons.org/licenses/by/4.0
MRI Prediction of Surgical Treatment for Juvenile Osteochondritis Dissecans (OCD)
Juvenile osteochondritis dissecans (OCD) is an abnormality of joint cartilage and its underlying bone. It is a leading cause of joint pain in children (affecting approximately 1 in every 1,000 children) and predisposes patients to early osteoarthritis and osteonecrosis. Its precise cause remains unknown, though repetitive trauma and multiple other factors have been implicated. Magnetic resonance imaging (MRI) aids patient management by assessing the mechanical stability of the bone and cartilage defects. Unfortunately, imaging criteria established for adults do not translate well to juvenile patients. This study aimed to determine whether quantitative analysis of standard MRI sequences of knee, elbow, and ankle joints could predict the need for surgery. The proposed hypothesis was that signal intensity could distinguish between those receiving conservative management and those requiring surgery. Using pretreatment MRI sequences from the IU Health Radiology Information Systems, 41 skeletally immature patients with OCD were analyzed retrospectively to quantify the cartilage signal on standard anatomy (PD or T1) and fluid-sensitive sequences (STIR or T2 fat saturation). The entire cartilage portion of the lesion was quantified using manual segmentation (with signal intensity normalized to the opposite condyle as an internal control). Logistic regression assessed whether lesion signal intensity could discriminate surgical or non-surgical management with receiver operator characteristic (ROC) curves obtained to identify the optimal signal intensity threshold. Unfortunately, neither type of sequence could discriminate between surgical and non-surgical patients. Likewise, signal intensity was not a good predictor of surgical stability in patients undergoing surgery. Future studies will assess signal intensity at individual joints. In addition, future studies will evaluate cartilage-specific clinical sequences to determine if quantitative cartilage analysis can improve diagnostic accuracy in these patients.
Copyright (c) 2025 Andrew Puthran, Deva Chan, Christopher Newman http://creativecommons.org/licenses/by/4.0
Social Determinants of Health and Pain Coping Strategies in Pediatric Patients with Sickle Cell Disease
Background: Sickle cell disease (SCD) is a hematologic disease characterized by sickle-shaped red blood cells due to abnormal hemoglobin. SCD causes painful vaso-occlusive crises (VOC), which occur in patients as young as 6 months old. SCD affects approximately 100,000 people in the US, 90% of whom are non-Hispanic Black or African American. This study's objective was to assess pain coping strategies of children with SCD, as well as the impact of social determinants of health (SDoH). Methods: A retrospective chart review was performed on pediatric patients with SCD who had baseline data for the PedsQL Coping Inventory. This assessment includes 4 open-response questions and 42 coping strategies with multiple-choice options. For patients 5 to 18 years old, both patients and parents or primary caregivers were surveyed. The Area Deprivation Index (ADI) and Child Opportunity Index (COI) values were obtained as indices of SDoH. Descriptive statistics were performed for demographic variables and ADI/COI. Univariate and multivariable regression analyses were performed on PedsQL coping domains and ADI/COI. Results: Regression analyses demonstrated that total parent score was significantly associated with age of child. For every 1-year increase in the child’s age, parent total coping score increased by 0.05 (p<0.000). In univariate and multivariate analyses when controlling for age, total parent score was not associated with child/teen score total. Total parent, child, and teen scores were not associated with ADI/COI. Teen sub-scores for catastrophizing, social support, and distractibility were associated with state ADI (p=0.0016, 0.0075, 0.0216 respectively). Teen problem-solving and cognitive coping sub-scores were not associated with ADI/COI. Parent/child sub-scores were not associated with ADI/COI. Conclusion: This study provides a preliminary understanding of the relationship between pain coping skills in pediatric patients and SDoH. Further investigation could yield clarity to the relationship between these measures and elucidate how patient pain management is being affected.
Copyright (c) 2025 Arya L. Bolla, Jillian Bouck, Julia LaMotte, Seethal A. Jacob http://creativecommons.org/licenses/by/4.0
Orexin Blockers’ Role in Glucose Homeostasis and Diabetic Retinopathy
Background: Diabetic retinopathy (DR) is the most common complication of diabetes and can lead to blindness if untreated. Orexin is a neuropeptide produced by the hypothalamus that regulates the sleep/wake cycle. Orexin-blockers are prescribed for insomnia, which recent studies have shown to decrease blood glucose levels, suggesting a potential therapeutic for DR. This study aims to explore orexin-blockers’ role in glucose homeostasis and diabetic retinopathy through in-vitro, in-vivo, and chart-review methods. Methods: In-vitro: Glucose uptake by human retinal endothelial cells (HRECs) was determined by exposure to varying levels of suvorexant, a commonly prescribed orexin blocker, and orexin-A. Additionally, Orexin expression under high glucose concentrations was examined using fluorescent staining. Pre-clinical: Diabetic (db/db) and non-diabetic (db/m) mice were injected with suvorexant daily. Mice weights and blood glucose were regularly compared with the vehicle control. Clinical Chart-review: A review that examines individuals retrospectively to determine if orexin-blockers decrease percentages of developing vision-threatening DR or macular edema compared to patients NOT taking orexin-blockers. Results: In-vitro: HRECs exposed to suvorexant had increased glucose uptake, while those exposed to orexin had a decreased glucose uptake. There were no significant changes in orexin expression in HRECs exposed to high glucose. Pre-clinical: Mice treated with suvorexant showed a downward trend in body weight, food intake, and better glucose tolerance than vehicle control diabetic mice. Clinical Chart-review: 41 patients treated with orexin blockers were identified. Fewer patients taking suvorexant developed vision-threatening DR than those without treatment. Additionally, there was a trend of decreasing HbA1c while taking suvorexant. Conclusion: The results of the in-vitro, pre-clinical, and clinical chart review studies indicate suvorexant has blood glucose-lowering properties. Data will continue to be collected for the clinical chart review to further determine the effects of orexin blockers on diabetic retinopathy and HbA1c.
Copyright (c) 2025 Braden Baker, Rupinder Kaur Sodhi, Neha Mahajan, Ashay Dilip Bhatwadekar http://creativecommons.org/licenses/by/4.0
A Clinically Interpretable Deep Learning Framework for the Detection and Grading of Diabetic Retinopathy
Objective: One of the leading causes of blindness in working age adults is diabetic retinopathy (DR) which can result in vision loss if uncontrolled. DR can be detected and graded by fundus retinal imaging, however the amount of images requiring grading creates a burden on ophthalmologists. Thus, a growing demand exists for an optimized DR image reading process. To accomplish this, we propose the use of a deep learning artificial intelligence model to detect and grade DR using lesion feature extraction with clinical interpretation. Methods: Retinal fundus images were collected from two sources for training (n=608): E-Ophthalmology, and a private Indiana University Eugene & Marilyn Glick Eye Institute dataset. Each dataset was divided into 70% (training), 20% (validation), and 10% (testing) subgroups. An external dataset, the UKBB, was also used (n=944) for evaluation. The AI model assigned images to 5 categories based on lesion features. The model operated through 2 stages: a multi-scale DeepLabV3+ to segment retinal lesions from input fundus images, followed by segmentation predictions for lesion. A classifier incorporates data to predict whether DR is present and the grade for images with DR. Results: AI performance was analyzed using several metrics to compare against human grading. Developmental results for segmentation were: 0.88 (precision), 0.70 (recall), 0.78 (f1 score), 0.99 (accuracy), 0.94 (AUC), and 0.76 (IOU). Classification of DR results were: 0.89 (precision), 0.6 (recall), 0.78 (f1 score), 0.62 (accuracy), and 0.8 (AUC). External dataset results were: 0.47 (precision), 0.58 (recall), 0.52 (f1 score), 0.58 (accuracy), and 0.65 (AUC). Conclusions: The proposed deep learning AI framework demonstrates good DR lesion detection and grading performance. Further improvement may allow AI to replace human grading, saving ophthalmologists time and standardizing the grading process. The current approach may be improved by including more lesion features and larger sample sizes.
Copyright (c) 2025 Frank Bogan, Hunter Mathias Gill, Doaa Hassan Salem, Michael Happe, Sarath Chandra Janga, Amir Reza Hajrasouliha http://creativecommons.org/licenses/by/4.0
Assessing Mouse Model Based Femur mRUST Scores via Intelligent Fracture Detection and Deep Learning Neural Networks
Bone fractures are a major issue worldwide. Beyond the physical affects, fractures may result in substantial economic burden due to hospitalization costs, surgical procedures, and rehabilitation. Modified Radiographic Union Score for Tibia fractures (mRUST) is a method for evaluating longbone fracture healing in humans using plain radiographs. Preliminary data from mRUST scored femoral midshaft mouse femurs proved the utility of mRUST in murine models. While mRUST is a reliable technique, it can be a time consuming and labor-intensive process. Additionally, there are concerns about inter-rater reliability. Radiographs are taken twice weekly for 42 days, and each radiograph must be prepared by cropping the image to include the femurs only for assessment. We proposed that artificial intelligence (AI) can be used to expedite the scoring of radiographic images and create uniformity throughout the process to enhance the consistency of the analysis of mRUST scores and produce results faster than humans. Using an AI/machine learning (ML) algorithm we allowed AI to analyze femoral shaft fracture radiographs that previously received an mRUST score by our orthopaedic surgeons. Following analysis, mRUST scores generated from AI were compared to the scores generated from the orthopaedic surgeons. Results indicated that the mRUST scores generated by AI matched the scores produced by the surgeons with 96% accuracy. Based on these findings, our team was able to enhance the production of mRUST scores by limiting the time that is required to score radiographs. Future studies will determine whether comparable results can be obtained for different skeletal sites and with human x-rays. Eventually, we hope to predict early after surgery who is likely to heal or go on to nonunion. Early intervention could substantially decrease pain, morbidity, and healthcare costs.
Copyright (c) 2025 Cooper R. Parish, Jie Chen, Sarah L. Mostardo, Sonali J. Karnik, Rachel J. Blosser, Istvan Gergely, Nian Wang, Roman M. Natoli, Melissa A. Kacena http://creativecommons.org/licenses/by/4.0
Analysis of Amyloid Beta Plasma Biomarkers in Intensive Care Unit Delirium Survivors
Background & Objective: Intensive care unit (ICU) delirium occurs in up to 70% of patients with 20-40% later developing dementia post-discharge. Plasma amyloid-beta (Aβ) levels have been associated with Alzheimer’s Disease. Whether ICU delirium compared to subsyndromal delirium (SSD) is associated with higher plasma Aβ levels at hospital discharge is not well described. Methods: This is a secondary analysis of the IMPROVE randomized controlled trial. Subjects were ICU delirium survivors aged 50 years or older who provided venous blood samples at discharge. Delirium was assessed twice daily until discharge using Confusion Assessment Measurement in the ICU (CAM-ICU). SSD is a less severe form of delirium with one abnormal CAM-ICU feature. Samples were analyzed using a Multiplex Luminex Assay (Thermofisher), values were reported in pg/mL, and compared using the Wilcoxon Rank Sum Test using SAS. The detection range is 451 – 1846900pg/mL for Aβ1-40 vs. 0.68 – 2800pg/mL for Aβ1-42. Results: In total, 68 subjects were included, 45% experienced SSD, and 54% had delirium. The mean age in the SSD group was 63.7 years [SD 7.3] vs. 64.4 years [SD 7.1] in the delirium group (p=0.667). The SSD group had a mean education of 13.6 years [SD 2.6] vs. 13.1 years [SD 2.3] (p=0.441) in the delirium group. Median plasma Aβ1-40 levels were 200.55 pg/mL (IQR 137.76, 286.57) in the SSD group, and 189.35 (IQR 150.38, 283.00) in the delirium group. The median plasma values of Aβ1-42 were 0.02 (IQR 0.02, 0.72) for the SSD group and 0.67 (IQR 0.02, 1.85) for the delirium group. There were no significant differences in plasma levels between the two groups (Aβ1-40: p=0.936; Aβ1-42: p=0.178). Conclusion & Impact: There were no significant differences in plasma Aβ levels between ICU delirium and SSD. Further studies are needed to explore the relationship between delirium and plasma Aβ levels.
Copyright (c) 2025 Abigail Olbina, Anthony J. Perkins, Kyle Gannon, Brendan Devine, Sujuan Gao, Babar Khan, Sikandar Khan http://creativecommons.org/licenses/by/4.0
Exploring Lung Cancer Screening in the ED: Collecting Patient and Provider Insights
Background/Objective: Lung cancer remains the primary cause of cancer-related death in adults, with 1.6 million deaths worldwide caused by this disease annually. The high morbidity and mortality associated with lung cancer underlies the importance of screening opportunities for detecting cancer early and improving overall rates of treating individuals. Despite this, only 5.8% of individuals who are eligible for a lung cancer screening participate. Many barriers may limit a patient’s access to screening, among which may be lack of education regarding screenings and inability to receive a timely appointment. The ED may provide both education and referrals for screening. Research focuses on identifying effective methods to engage providers and ED patients, increasing education, and addressing concerns to enhance attendance at screenings and improve long-term patient outcomes. Methods: Research involved conducting a preplanned topical analysis derived from semi-structured individual interviews of one hundred participants. Participants included providers and ED patients. Participants provided information regarding potential ED intervention tools to increase lung cancer screening education and uptake alongside their subjective experiences and challenges with lung cancer screenings. Themes will be identified inductively utilizing constant comparative analysis. Results/Conclusion: It is expected that patients and providers will express interest in learning about implementation of lung cancer screenings during an ED visit but will differ in the most effective method of lung cancer screening education. Findings will optimize interventions to increase lung cancer screening uptake among ED patients in a future randomized control trial. Impact and Implications: This study will establish the feasibility of utilizing the ED to provide services for patient needs that are not emergencies, specifically the lung cancer screening. Implementation of lung cancer screening services in the ED will allow for earlier diagnosis of lung cancer and increase opportunities to treat this disease, bettering patient outcomes and improving quality of life.
Copyright (c) 2025 Erin O’Farrell, Nicholas Pettit http://creativecommons.org/licenses/by/4.0
Using Implementation Science to Advance Hearing Health Equity in Older Adults
Background/Objectives: Hearing loss is highly prevalent among the 1.2 million older adults who live in Senior Living Communities (SLCs). Under-detection of hearing loss and under-use of hearing devices among residents of SLCs is a significant healthcare disparity, which places older adults at an increased risk for dementia, falls, and depression. Our long-term objective is to improve the hearing health, emotional well-being, and quality-of-life of older adults living in SLCs by implementing hearing healthcare into standard clinical care. Methods: We focused on the first two of the four interrelated phases of implementation science: exploration and initiation. We partnered with the largest SLC in Indiana and onboarded three of their communities. Each of these communities provide four levels of care, and residents vary across Social Determinants of Health (SDoH), allowing our team to compare hearing health outcomes as a function of residents’ physical/cognitive abilities and SDoH. Results: As part of the exploration phase, we identified five barriers to hearing healthcare in SLCs: 1) hearing health literacy in the care staff and residents, 2) poor management of hearing devices, 3) poor management of cerumen – ear hygiene – which hinders access to sound, 4) underuse of effective screening tools, and 5) lack of connections to an audiologist and neurotologist. As part of the initiation phase, we collaborated with community stakeholders to create the infrastructure for screening, referring, & implementation of clinical healthcare. Conclusions/Implications: Implementation science is applying an already known evidence-based practice to a particular problem; in this case, we anticipate that providing effective screening tools, management of cerumen, and access to an audiologist and neurotologist will improve the hearing health, emotional well-being, & quality-of-life in older adults living in SLCs. Our research program will continue to develop, test, and refine our implementation strategies to achieve equity in hearing health outcomes.
Copyright (c) 2025 Kaitlyn O’Donnell, Rick Nelson, Irina Castellanos http://creativecommons.org/licenses/by/4.0
Effect of Cigarette Smoking and Alcohol Use on White Matter Tract Integrity
Background: Cigarette smoking (CS) is highly comorbid with alcohol use disorder (AUD). Both are associated with lower white matter (WM) integrity, with potentially additive effects. This study is a starting point to determine the individual and combined effects of CS and AUD on WM integrity. Methods: Thirty subjects with varying CS and alcohol use (40.0 ± 12.9 years, 13 females, 17 males) underwent structural (T1-weighted) and diffusion weighted magnetic resonance imaging. Indices of WM integrity, fractional anisotropy (FA) and mean diffusivity (MD), were calculated at a voxel-wise level. Parametric maps of FA and MD were spatially normalized to Montreal Neurological Institute space. Average FA and MD values were extracted for 48 WM tracts from the Johns Hopkins University WM tract atlas. Alcohol drinking and CS were characterized by: DSM-5 AUD symptom checklist, Obsessive Compulsive Drinking Scale (OCDS, including obsessive and compulsive subscales), Timeline Followback (TLFB; drinks/drinking day and drinks/week), Alcohol Use Disorders Identification Test (AUDIT), Fagerstrom Test for Nicotine Dependence (FTND), self-reported pack years, and cigarettes/day. Linear regression was performed between FA and MD with alcohol and CS metrics. Results: We found significant negative correlations (p<0.01) between bilateral cingulate gyri FA and total OCDS score and subscales, drinks/drinking day, drinks/week, and AUDIT. Right inferior cerebellar peduncle FA was negatively correlated with FTND and cigarettes/day. Bilateral superior cerebellar peduncle MD was positively correlated with FTND and cigarettes/day. Left cingulate hippocampus MD was positively correlated with OCDS compulsivity. Conclusion: Alcohol use was negatively correlated with cingulate gyrus WM FA, which is implicated in goal-directed behavior and salience attribution. CS was negatively correlated with cerebellar peduncle FA; however, the interpretation of this is unclear. Our results support the hypothesis that both CS and AUD negatively impact WM integrity. Future work will determine the potentially additive effects of smoking and alcohol use.
Copyright (c) 2025 Andrew T. Nguyen, Mario Dzemidzic, Evgeny Chumin, Timothy C. Durazzo, Karmen K. Yoder http://creativecommons.org/licenses/by/4.0
Evaluating the Role of Pretherapy Scans in Post-Thyroidectomy Thyroid Cancer Management: Predictive Value, Management Impact, and Efficacy
Background: Thyroid cancer management typically involves radioiodine ablation (RAI) therapy post-thyroidectomy to eliminate residual thyroid tissue and cancerous cells. Pretherapy imaging and dose selection are contentious subjects. This study evaluates the comparative effectiveness of different imaging modalities and doses. Methods: This retrospective IRB approved study included 98 thyroid cancer cases of patients who underwent ablation therapy from January 2022 onwards. Data was collected through the electronic health record system. Imaging studies were evaluated by 2 separate readers. 39 cases were excluded for imaging congruency due to the absence of SPECT/CT. Cure rate analysis excluded 15 cases due to missing post-ablation Tg levels. The data was stratified into N1b (metastasis to cervical lymph nodes) and non-N1b cancer. Results: Results indicate that pretherapy planar and SPECT/CT imaging findings were congruent in the non-detection of extrathyroidal disease. Both I-123 and I-131 isotopes demonstrated high congruence with post-planar scans, with I-123 showing 85.48% congruency and I-131 showing 82.86% congruency. Cure rates varied only minimally by RAI dosage with the highest cure rates observed in the 33-56 mCi range (92.31%) and the lowest in the 110+ mCi range (81.82%). In N1b cases, the highest cure rate was 100% in the 33-56 mCi range, while non-N1b cases showed the highest cure rate of 94.12% in the 56-110 mCi range. Conclusions: No advantage was found using SPECT/CT or I-123 for detecting extra-thyroidal diseases. Higher treatment doses beyond 110 mCi do not yield better outcomes. Scientific/Clinical/Policy Impact and Implications: The study's findings underscore important considerations regarding cost-effectiveness of imaging and appropriate dose section in thyroid cancer ablation management.
Copyright (c) 2025 Yousif Mukatash, Mark Tann http://creativecommons.org/licenses/by/4.0
Disparities in Timeliness of Care in Anal Cancer: A Retrospective Chart Review
Background and Objective: Approximately 10,540 new cases of anal cancer (AC) will be diagnosed in the USA in 2024, but its incidence has increased two-to-four-fold in the past few decades. Areas with higher social vulnerability have decreased odds of colorectal cancer screening, resulting in delayed healthcare presentation. This project describes the elapsed time between initial symptomatic presentation and diagnosis of AC across 3 possible points of process failure and explores the impact of patient factors and social vulnerability on time to diagnostic resolution. Project Methods: Patients diagnosed with AC within the Indiana University Health system from 2020-2024 were identified using the electronic health record. Cases were reviewed (n=478); demographics and the following timepoints were noted: initial symptomatic presentation, specialist referral, diagnostic testing, and AC diagnosis. The primary outcome was time between presentation and diagnosis, with diagnostic delay classified as more than six weeks. Patient factors and clinical characteristics were compared to calculate risk ratios to explore associations between these factors and diagnostic delay. Results: After exclusions, analysis of the cohort (n=193) showed that 99 patients (51.3%) did not experience a delay, and 94 did (48.7%), with a total median SVI of 0.51 (IQR=0.29-0.75) and delay of 39d (IQR=17-90). Patients with a delay (SVI=0.53; IQR=0.30-0.76) had similar SVIs to those without a delay (SVI=0.51; IQR=0.22-0.75; p=0.462). Older patients had a higher risk of experiencing a delay than a younger patient (RR=1.005; CI=1-1.01; p=0.038). Patients working full-/part-time have an increased risk of delay than those retired (RR=0.832; CI=0.721-0.96; p=0.012) or unemployed (RR=0.849; CI=0.746-0.967; p=0.014). Conclusion and Potential Impact: Older age and employment status are drivers of diagnostic delay after AC presentation. No measures of social vulnerability were associated with delayed care. Further work exploring the process failures to diagnostic resolution will inform interventions targeting barriers and facilitators. As barriers-to-care are reduced, more patients can have improved cancer outcomes and quality of life.
Copyright (c) 2025 Aryan Mishra, Jacob Steffen, Emma Holler, Hannah Allison, Sanjay Mohanty http://creativecommons.org/licenses/by/4.0
Pediatric Histoplasmosis in the Midwest: A Retrospective Chart Review
Background: Histoplasma capsulatum is the most prevalent endemic mycosis in North America, particularly in the Ohio and Mississippi River Valleys. Disease severity ranges from asymptomatic to life-threatening, with up to 90% of residents in endemic areas exposed to H. capsulatum. While Histoplasmosis in adults is well-studied, pediatric data are limited. This study aims to elucidate the disease course, health outcomes, diagnosis, and epidemiology of Histoplasmosis in children through a retrospective chart review, intending to enhance diagnosis and recognition in this population. Future research will investigate whether the enzyme immunoassay antibody test is more sensitive than other modalities for pediatric diagnosis. Methods: We retrospectively reviewed charts of pediatric patients (≤18 years old) diagnosed with Histoplasmosis at IU Health-affiliated centers between 2010 and 2021 (n=100). Data on Histoplasma testing (antibody, antigen, histopathology, cytology), epidemiology, clinical manifestations, outcomes, treatment course, and immune status were collected. Chi-squared tests were used to determine relationships between categorical variables in our preliminary analysis. In the future, we will ascertain the sensitivity for each testing modality and conduct more comprehensive analyses of the clinical data. Results: Preliminary findings illustrate the demographics and clinical manifestations of pediatric Histoplasmosis, identifying cough, fever, and headache as the most common symptoms, with mediastinal and hilar lymphadenopathy being the predominant lymphatic manifestations. The liver and spleen were the primary sites of extrapulmonary dissemination. Chi-squared analysis confirmed our sample’s representativeness of the Indiana population in terms of race, ethnicity, and residence. Interestingly, a relationship between gender and disease severity/classification emerged, necessitating further investigation. Potential Impact: Our understanding of adult Histoplasmosis is extensive, but limited data in the pediatric population has led to a lack of pediatric-specific protocols. This study, comprising the largest cohort of pediatric histoplasmosis cases in the US, aims to expand our knowledge to improve early recognition and diagnosis of pediatric Histoplasmosis.
Copyright (c) 2025 Wynne Milhouse, Alex Smith, Christian Huntington, Aneesha Kamath, Jackson Schneider, John Christenson, L. Joseph Wheat, Lindsey Kirkpatrick http://creativecommons.org/licenses/by/4.0