The Geisel School of Medicine is the medical school of Dartmouth College, an Ivy League research university located in Hanover, New Hampshire, United States. The fourth-oldest medical school in the United States, it was founded in 1797 by New England physician Nathan Smith and grew steadily over the course of the 19th century. Several milestones in medical care and research have taken place at Dartmouth, including the first clinical X-ray (1896), the first intensive care unit in the United States (1955), and the Brattleboro rat (1961).Today, Dartmouth's Geisel School of Medicine continues to grant the Doctor of Medicine (M.D.) and Doctor of Philosophy (Ph.D.) degrees, as well as a Master of Public Health (M.P.H.) and Master of Science (M.S.) degrees. The school has a student body of about 700 students and more than 2,300 faculty members and researchers. Geisel organizes research through over a dozen research centers and institutes, receiving more than $140 million in grants annually. The Geisel School of Medicine is one of seven Ivy League medical schools and is ranked as a "top medical school" by U.S. News & World Report for both primary care and biomedical research. Dartmouth's medical school has numerous clinical partners, including Dartmouth-Hitchcock Medical Center, White River Junction Veterans Administration Medical Center, California Pacific Medical Center, and Manchester Veterans Administration Medical Center.
Pseudomonas aeruginosa is an important agent of acute or chronic airway infections. A complex set of genetic and environmental factors determine the outcome of a P. aeruginosa airway infection. P. aeruginosa can undergo genetic adaptation to fine tune the expression of a type III secretion system (T3SS) and other virulence factors in response to selective pressures encountered during infection. Genetic and environmental factors predispose many patient groups for P. aeruginosa infections, including people with cystic fibrosis (pwCF). CF is a genetic disorder resulting in areas of hypoxia and thick mucus that fosters P. aeruginosa airway infection. Resident alveolar macrophages (AMs) help coordinate immune responses to P. aeruginosa in airways by producing proinflammatory cytokines such as IL-1β, which can be important for infection resistance. AMs infected with laboratory strains of P. aeruginosa detect the T3SS and activate the NLRC4 inflammasome, resulting in IL-1β release. Studies of inflammasome responses in AMs to a clinical CF isolate of P. aeruginosa have not been reported. Here, we characterized the CF clinical isolate DH1137 and found that it has a downregulated but functional T3SS, is adapted to grow in hypoxia, and induces significant production of the inflammasome cytokines IL-1β and IL-1α during lung infection in a CF mouse model. Inflammasome gene expression was primed in AMs by LPS stimulation, and upon DH1137 infection these cells released IL-1[beta]. Intriguingly, we found that infection of AMs with DH1137 in hypoxia resulted in significantly dampened inflammasome activation compared to normoxia. These data describe a new mechanism that P. aeruginosa may exploit to evade immune detection by tissue-resident lung macrophages in the context of CF.
Vicarious trauma-witnessing serious harm to others-produces systemic neuroimmune effects in animal models. However, its brain, autonomic, and immune consequences in humans remain unclear. We scanned 88 participants with fMRI during a naturalistic movie-viewing paradigm depicting either industrial cruelty to farm animals (Vicarious Trauma, VT) or positive human-animal interactions (Vicarious Community, VC) with concurrent autonomic physiology and gene expression in circulating monocytes. VT, compared to VC, evoked sustained sympathetic arousal lasting 40 minutes post-viewing and primed innate immune cells to elicit elevated pro-inflammatory (upregulating IL1B and CXCL8) and reduced anti-inflammatory (TGFB1) responses. VT reduced integration in a frontoparietal control system and increased coupling between a salience/action-mode system with paralimbic, basal ganglia, and sensorimotor regions. Disrupted negative coupling between frontoparietal/default-mode and hippocampal systems predicted VT-related CXCL8 increases. These findings shed light on how the brain translates vicarious trauma into the priming of innate immunity.
Older adults are disproportionately vulnerable to adverse outcomes during postoperative care transitions. While evidence-based care transition interventions exist, such as the Care Transitions Intervention (CTI), their core components have not been systematically adapted for surgical populations. Concurrently, geriatric surgery co-management models, such as the Optimization of Senior Care and Recovery (OSCAR) model, improve outcomes but do not address the post-discharge transition. To bridge this gap, we merged the geriatrics-informed, inpatient co-management model of OSCAR with the patient-empowering, coaching-based approach of the CTI to create a novel integrated care transition model - OSCAR-S. We describe the use of implementation science approaches to characterize adaptations and refinements of this merged model to enhance its feasibility and contextual fit for older colorectal surgery patients. Our adaptation process was informed by the ADAPT framework and the Framework for Reporting Adaptations and Modifications - Expanded (FRAME). Guided by these frameworks, we explored stakeholder perspectives to inform the adaptation of OSCAR-S. We conducted a total of 41 semi-structured interviews with 35 healthcare providers, three care partners, and three older colorectal surgery patients. We performed inductive content analysis of suggested adaptations, which were documented and classified using FRAME. Applying the ADAPT and FRAME frameworks supported a process that identified core intervention components and optimal adaptations. Interviewees expressed widespread support for the intervention’s core components, particularly the role of the geriatric surgery nurse coach as a critical liaison and patient advocate during the vulnerable post-discharge period and geriatrics-focused assessments and personalized geriatrics care panning in older surgical patients. The adaptations made in response to stakeholder feedback, including adjustments to timing, delivery methods, and communication pathways, enhance the model’s feasibility while preserving fidelity to core elements. We systematically adapted and refined the merged OSCAR and CTI models to enhance the feasibility and contextual fit of the resulting OSCAR-S model for older colorectal surgery patients. We documented stakeholder-informed modifications using FRAME to ensure the model preserved core elements while optimizing its delivery. Future research will focus on evaluating the effectiveness of this adapted model on improving clinical outcomes, patient experience, and implementation success. Not applicable.
Introduction Delirium is an underrecognized medical emergency that commonly affects hospitalized older adults. Medical trainees need to be able to diagnose delirium as a core geriatrics competency. We created an objective structured clinical examination (OSCE) with a standardized patient case, pilot tested with medical students, then implemented with internal medicine residents and family medicine residents. Methods This 30-minute OSCE features an older adult who has been hospitalized for overnight observation after a procedure and develops confusion and inattention consistent with delirium. The learner interacts with the patient and bedside nurse to develop an assessment and plan. We prepared training guides for standardized patients and faculty evaluators to ensure standardization. Learners and faculty evaluated the OSCE. Results The OSCE results in the pilot group of 6 students demonstrated opportunities to integrate geriatrics content through a longitudinal curriculum. The OSCE was subsequently used among 46 internal medicine and family medicine residents. No students and only 28% of residents assessed attention; half of the students and 30% of residents also failed to assess baseline mental status. Learners had variable managerial strategies, with some mastering nonpharmacologic strategies and others relying on chemical restraints. These results informed the programs’ teaching strategies. The tool was adapted for a variety of settings, formal and informal, to the satisfaction of both learners and faculty evaluators. Discussion The delirium OSCE is a promising tool to conduct formative assessment of learner competencies in geriatric medicine, and to prepare trainee participants to deliver age-friendly care for older adults.
