The Graduate Medical Scholars Journal (GMSJ) is a student-led publication dedicated to highlighting the research, insights, and perspectives of medical students. Designed as a platform for students to actively engage in academic publishing, GMSJ provides valuable experience in research dissemination, peer review, and scholarly writing—skills essential for careers in academic medicine. GMSJ publishes original research, case reports, reviews, opinion pieces, and more, fostering professional growth and the development of critical appraisal and editorial skills. Each submission undergoes a three-stage review process, with medical students conducting primary and secondary reviews, followed by a final faculty review by attending physicians, PhDs, and residents to uphold academic integrity. Our Mission The Graduate Medical Scholars Journal (GMSJ) is a student-led, peer-reviewed publication committed to showcasing the research and scholarly work of medical trainees. Our mission is to foster academic excellence, promote original research, and provide early opportunities for students to engage in the peer review and publication process. Through mentorship, collaboration, and rigorous standards, we aim to advance medical education and support the next generation of physician-scholars.
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Utilizing a Voice-Guided Mixed Reality and Artificial Intelligence based platform for Difficult Intubation Simulation in Austere Teaching Environments
Background: Intubating a blood-contaminated airway is a high acuity, low occurrence procedure. In resource-limited environments, a high-fidelity bloody airway simulation is restricted by cost, equipment, and a lack of expert feedback. To bridge this gap, we developed a high-fidelity artificial intelligence (AI) and augmented reality (AR) informed simulation tool. Inside an AR headset, an overlay is generated over a standard airway manikin. The user then proceeds through a bloody airway scenario with integrated instructional feedback videos. Methods: We utilized a Unity AR application integrated into an AR Headset that interacts with a laryngoscope and removable pressure, light, and proximity sensors inside a manikin. The sensors and laryngoscope are connected to a Raspberry Pi that transmits sensor and video data via WebSocket to the headset. The headset application also processes audio via Meta’s Wit.AI service for transcription and intent recognition. The application handles simulation logic, sensor / video data handling, and the AR guidance display. A decision tree algorithm enables user interaction and feedback. Results: Both non-medical users at the 2024 DALI exhibition and individuals with emergency medicine backgrounds at the 2025 Society for Academic Emergency Medicine Innovation exhibit reported that the device was educational for difficult airway management. However, challenges have arisen in terms of stable connectivity with the Raspberry Pi under certain internet network conditions. Conclusions: Utilizing readily available AI and AR technologies, a simulation device can be developed to teach difficult airway management in resource-limited areas, providing both experience and constructive feedback from experts.
artificial intelligence in medical simulation
Critical Care medicine and Emergency Medicine
Copyright (c) 2026 Boseong Kim, Anant Shukla, MD, Tuna Ozturk, Helen Cui, Jack Bolitho, Timothy Tregubov, MA, Harman Gill, MD, Scott Lancaster, PhD, Matthew Roginski, MD MPH (Author) https://creativecommons.org/licenses/by-nc/4.0
Applications of Image-Guided Transoral Robotic Surgery for Target Localization
Transoral robotic surgery (TORS) offers functional advantages in head and neck surgery but faces limitations including tissue deformation, deep margins, and lack of haptic feedback. This study evaluated an image-guided navigation (NAV) system designed to enhance localization accuracy in a porcine-based TORS simulation model. Eight participants—including ENT attendings, residents, and medical students—performed paired localization tasks with and without NAV in a randomized crossover design. Use of NAV significantly improved accuracy (p = 0.012) without prolonging task duration. Operator confidence ratings favored the NAV-assisted trials, and cognitive workload trended lower with navigation support. Image overlays integrated directly into the endoscopic field facilitated precise needle-to-target alignment. Future work will incorporate augmented-reality guidance and refine registration frameworks. These results support the potential of NAV-enhanced TORS workflows to improve targeting precision during minimally invasive head and neck procedures.
Copyright (c) 2025 Jose Romero, MS, Sudi Zhao, Michaela Geffert, MS, Phoebe Xu, Yuan Shi, PhD, Ehsan Nasiri, PhD, Michael Kokko, PhD, Ryan Halter, PhD, Joseph A. Paydarfar, MD (Author) https://creativecommons.org/licenses/by-nc/4.0
Building Ultrasound-Guided Procedure Skills in Regional Anesthesia via Formalin-Embalmed Cadaver Simulation
Simulation-based training is essential for developing procedural confidence prior to clinical exposure. This study assessed the feasibility of using formalin-embalmed cadavers for ultrasound-guided femoral nerve block training among first-year medical students (n = 19). Participants received a 15-minute instructional video followed by 20 minutes of one-on-one guided practice. Pre- and post-training surveys showed significant increases in confidence across all measured domains (p < 0.001). Ultrasound visualization of key anatomic structures—including femoral nerve, artery, vein, fascia lata, and fascia iliaca—was consistently clear. In a timed skills test, 18 of 19 students successfully guided the needle to the target zone, averaging 106 seconds and 1.9 attempts. Higher instructor scoring correlated with perceived usefulness of the training. Findings support the use of formalin-embalmed cadavers as an effective, scalable training tool for early procedural education.
Copyright (c) 2025 Kiran Ganga, Edan Cohen, Isain Zapata, PhD, Aaron Hawke, DO, Meredith Peck, DO, Nena L. Mason, PhD (Author) https://creativecommons.org/licenses/by-nc/4.0
Clinical Disclosure Training With an AI Patient Actor
Disclosure of medical errors is an essential yet under-taught clinical skill. This pilot project evaluated a compact, scalable curriculum combining self-directed learning modules with simulated encounters using Dartmouth’s AI Patient Actor 2.0. Eight second-year medical students completed a baseline AI encounter, video-based pre-work, a didactic lecture, and a second AI scenario. Objective rubric-based scoring improved by an average of 7%, with increases up to 20%, and no learners demonstrating decreased performance. Students rated the AI tool as more natural and effective than earlier models, and unanimously agreed the curriculum improved their confidence with harm-communication skills. Qualitative feedback supported feasibility for integration into On Doctoring or clerkship transitions. Future iterations will refine the rubric and expand testing to larger cohorts. This study demonstrates that AI-based simulation can enhance communication training while reducing the resource burden associated with standardized patients.
Copyright (c) 2025 Angus Mauser, Joel Bradley, MD (Author) https://creativecommons.org/licenses/by-nc/4.0
Associations of Heavy Metals and Hearing Loss in Hispanic Children
Heavy metal exposure contributes to auditory dysfunction, yet subgroup-specific risks remain understudied. Using NHANES 2017–March 2020 data, this study evaluated associations between urine and blood heavy metals and hearing loss among children aged 6–19. Among 2,673 included participants, subgroup analysis revealed that Hispanic children exhibited a significant association between urine mercury levels and all hearing-loss classifications: low-frequency, high-frequency, speech-frequency, and any-frequency hearing loss (p < 0.05 for all). This relationship was not observed in non-Hispanic children, nor with blood mercury levels. Findings may reflect chronic exposure differences, socioeconomic factors, or combined effects of multiple metals. Limitations include small subgroup sample size and missing audiometry or metal-testing data in some participants. Further analysis using elastic-net regression and additional sociodemographic variables is planned to clarify interacting risk factors and identify vulnerable groups.
Copyright (c) 2025 Nihan Z. Ercanli, Marissa Kachadoorian, Christian Kabongo, Chris Niemczak, AuD PhD, Jay C. Buckey, MD, James E. Saunders, MD (Author) https://creativecommons.org/licenses/by-nc/4.0
Impact of the COVID-19 Pandemic on Post-Operative Convalescence After Total Knee Arthroplasty
The COVID-19 pandemic disrupted rehabilitation services nationwide, potentially affecting recovery following total knee arthroplasty (TKA). Using PEPPER Trial data (n = 4,342 across 34 U.S. sites), this study examined changes in physical therapy utilization, length of stay, adverse events, and PROM-based recovery before and after the onset of the pandemic. Preliminary findings from the primary analytic cohort (10 sites, n = 2,842) indicate a meaningful decline in formal physical therapy engagement at 1, 3, and 6 months post-TKA following March 2020. Early analysis of KOOS Jr. and discharge disposition suggests shifts in recovery trends, though patient-level and site-level heterogeneity remain significant. Strengths include standardized multi-institutional follow-up and robust PROM collection; limitations include potential misclassification of tele-rehabilitation and residual confounding. Ongoing mixed-effects modeling will clarify the pandemic’s impact on postoperative recovery patterns and inform future strategies for maintaining rehabilitation access.
Copyright (c) 2025 William C. Sorel, Vincent D. Pellegrini Jr., MD (Author) https://creativecommons.org/licenses/by-nc/4.0
VirtualPNN: Deep Learning for Label-free Visualization of Perineuronal Nets in Brain Tissue
Perineuronal nets (PNNs) are extracellular matrix structures that modulate inhibitory interneuron activity and may contribute to brain tumor–related epilepsy. Because immunohistochemistry (IHC) destroys tissue and is time-intensive, this study introduces VirtualPNN, a generative AI model that simulates aggrecan IHC staining directly from H&E slides. Trained using paired H&E–IHC images and an anti-vessel loss objective, VirtualPNN produced high-fidelity stains, outperforming AI-FFPE, CycleGAN, CUT, and FastCUT, as demonstrated by the lowest Fréchet Inception Distance score. A visual Turing test with board-certified neuropathologists showed high fooling rates, confirming realistic outputs. Importantly, the model minimized false-positive staining of blood vessels through its anti-vessel loss component. VirtualPNN offers a label-free, tissue-preserving method to study PNNs and may serve as a tool for correlating PNN distribution with epilepsy severity in tumor patients. Ongoing work includes validation across larger cohorts and extension to additional staining markers.
Copyright (c) 2025 Vishva Natarajan, MS, Tanmay Shukla, MS, Naofumi Tomita, MS, Scott Palisoul, Madhumala Sadanandappa, PhD, George J. Zanazzi, MD PhD MS, Jennifer Hong, MD, Saeed Hassanpour, PhD (Author) https://creativecommons.org/licenses/by-nc/4.0
Comparing Epidural Waveform Analysis to Fluoroscopic Guidance for Thoracic Epidural Access
Thoracic epidural catheters provide superior postoperative analgesia but are technically challenging to place, with failure rates up to 30% using standard loss-of-resistance (LOR) techniques. Fluoroscopic confirmation (FC) is the gold standard, yet not widely available. This study evaluates whether epidural waveform analysis (EWA) can reliably confirm needle and catheter placement compared with FC. Using a pressure transducer system and waveform acquisition hardware, EWA was tested in 160 participants. Preliminary data show that waveform presence correlates strongly with successful epidural placement, with early analyses suggesting EWA may outperform LOR alone and approach the accuracy of FC. Differences between needle-based and catheter-based waveforms highlight the importance of fluid dynamics in interpretation. Ongoing analyses aim to calculate positive and negative predictive values of EWA relative to FC and evaluate trainee comfort using EWA. If validated, EWA could serve as an accessible, low-cost confirmation method in settings lacking fluoroscopy.
Copyright (c) 2025 Elizabeth L. Ross, Robert H. Roth, MD, Alexander T. Abess, MD (Author) https://creativecommons.org/licenses/by-nc/4.0
Image Updating After Brain Deformation in Image-Guided Neurosurgery: A Workflow for Image Registration
In image-guided neurosurgery, preoperative MRI (pMR) is used for navigation, yet brain deformation during surgery reduces alignment accuracy and can compromise safe tumor resection. This study outlines a workflow to quantify deformation between pMR and intraoperative MRI (iMR) using stereovision-based measurements. Six retrospective neurosurgical cases with pMR, iMR, and intraoperative stereovision were analyzed. Registration was performed through sequential manual, automatic, and fiducial-based alignment, achieving clinically acceptable fiducial registration errors (0.47–0.90 mm). Deformation was then measured around the resection cavity to guide the generation of updated MR images (uMR). Preliminary results confirm that accurate alignment is achievable, supporting the feasibility of using intraoperative stereovision to update MR guidance in real time. Future steps include generating uMR, validating its accuracy compared to iMR, and investigating ultrasound-based strategies for deeper tissue deformation modeling.
Copyright (c) 2025 Julia M. Zabinska, Xiaoyao Fan, PhD (Author) https://creativecommons.org/licenses/by-nc/4.0
Discordance Between Measured and Perceived Physical Activity Among Breast Cancer Survivors: A Mixed Methods Study
National guidelines emphasize physical activity as essential to survivorship care, yet many breast cancer survivors perceive themselves as inactive despite meeting recommended activity thresholds. In this ancillary mixed-methods study, participants underwent a 10-day accelerometer-based physical inactivity verification period, followed by surveys and semi-structured interviews if they exceeded 90 minutes of moderate-to-vigorous physical activity (MVPA) per week. Preliminary data from the parent study show unusually high MVPA levels despite self-identification as inactive, suggesting possible measurement reactivity, demand characteristics, peak-end recall effects, or cancer-related worry influencing self-perception. Qualitative interviews explore motivations, barriers, emotional context, and perceptions of what “counts” as MVPA. Quantitative measures include objective activity metrics and validated scales assessing fear of recurrence and cancer-related worry. This ongoing study aims to clarify perceptual discrepancies, improve counseling strategies, and guide the design of future activity-based survivorship interventions.
Copyright (c) 2025 Skyler R. Rad, Aislinn E. Mitcham, Mary D. Chamberlin, MD, Catherine H. Saunders, PhD MPH, Courtney J. Stevens, PhD (Author) https://creativecommons.org/licenses/by-nc/4.0
Does Physical Trauma Change Risk-Taking Behavior in Children? A Systematic Review
Traumatic injury is the leading cause of morbidity and mortality in children, yet little is known about how young people interpret the causes of their injuries or how these beliefs influence future risk. This systematic review synthesized evidence across more than 7,700 records to examine causal attributions made by children and adolescents following trauma, and how these beliefs relate to reinjury risk. Early findings from the preliminary screening indicate association between reinjury and factors such as externalized blame, sensation-seeking, ADHD, and high-risk sports participation. Socioeconomic disadvantage was also linked to increased trauma incidence and recurrence. However, research investigating children’s causal explanations—such as attributing injury to bad luck, personal choice, or environmental hazards—remains sparse. Understanding these attributions is critical for designing developmentally tailored prevention strategies. Ongoing full-text review and planned mixed-methods work aim to inform future adolescent-focused counseling tools and reinjury prevention programs.
Copyright (c) 2025 Garrison Verner, Karina Lukovitz, Heather B. Blunt, Elaine J. Vitale, Reto Baertschiger, MD PhD (Author) https://creativecommons.org/licenses/by-nc/4.0
Seven Cases of Pediatric Acute-Onset Neuropsychiatric Syndrome with Celiac or Eosinophilic Esophagitis: Autoimmune Interplay and the Gut–Brain Axis
Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) is an immune-mediated neuropsychiatric disorder characterized by abrupt onset of OCD, anxiety, tics, and behavioral dysregulation, often triggered by infection. This case series describes seven children evaluated at the Dartmouth Neuroimmune Psychiatric Disorders Clinic who exhibited both PANS and either celiac disease (CD) or eosinophilic esophagitis (EoE). All GI autoimmune diagnoses preceded or coincided with PANS onset, suggesting potential immune priming through chronic gut inflammation. Clinical histories revealed symptom escalation with GI flares and improvement following gluten-free diets or EoE-targeted therapies in select cases, raising the possibility of bidirectional gut–brain immune signaling. Mechanistically, increased gut permeability, cytokine release, and dysbiosis may contribute to systemic inflammation and neuroinflammation. Treatment regimens included immunomodulators, antibiotics, cognitive-behavioral therapy, and dietary interventions. Larger prospective studies assessing microbiome composition, permeability biomarkers, and psychiatric outcomes are needed to clarify this emerging autoimmune interplay.
Copyright (c) 2025 Clare Boldt, Jiaxin Jessica He, Juliette Madan, MD (Author) https://creativecommons.org/licenses/by-nc/4.0
QI and Evaluation of GI Care Follow-Up After Rwandan Endoscopy Week 7.5: A Pilot Analysis of 4/9 Sites
Rwandan Endoscopy Week (REW) provides high-volume gastrointestinal (GI) diagnostics and treatment across multiple hospitals each year, yet patient follow-up after REW remains inconsistent. This quality-improvement project assessed follow-up outcomes across four of nine REW 7.5 sites, reviewing 884 total cases and identifying 398 patients requiring follow-up—most commonly for H. pylori eradication. Chart review and phone outreach revealed substantial barriers: inconsistent survey data collection, variable use of electronic medical records, and limited patient awareness or motivation to pursue follow-up. Financial barriers, symptom improvement, and communication gaps further contributed to low adherence. Organizational limitations affected the ability to track outcomes effectively. Recommendations include standardizing data collection, improving communication regarding follow-up instructions, and enhancing access pathways for care continuity. These findings underscore the need for integrated organizational and patient-centered strategies to strengthen longitudinal GI care in Rwanda.
Copyright (c) 2025 Kamila Zakowicz, Josiane Izere, Prosper Ingabire, MD, Marie S. Mukanumviye, MD, Steve Bensen, MD, Vincent Dusabejambo, MD (Author) https://creativecommons.org/licenses/by-nc/4.0
Evaluating Measurement Challenges and Methods in Rural Areas: Implications for Sunscreen Desert Definitions in New England
Limited access to sunscreen may increase the risk of skin cancer, particularly in rural regions where retail availability is sparse. This study identifies methodological challenges in defining “sunscreen deserts” across New Hampshire and Vermont. A literature review of access-mapping frameworks revealed inconsistencies in how previous research measures retail availability, socioeconomic vulnerability, and geographic barriers. Using retailer databases and USDA-derived population data, this project mapped sunscreen retailer density by census tract and evaluated disparities across rural and urban communities. Key challenges include misclassification of semi-rural areas using binary RUCA codes, overreliance on median income, and aggregation at the county level that obscures neighborhood-level inequities. Additionally, travel distance underestimates real-world access, particularly in mountainous regions. Findings highlight the need for refined metrics that capture both physical access and contextual factors—such as affordability, transportation, product preferences, and sun-protection behaviors. Developing an accurate definition of sunscreen deserts is essential for targeted public health interventions aimed at reducing future skin cancer disparities in New England.
Copyright (c) 2025 Nikolas G. Hernandez, Jonathan S. Glass, MD, Lynn Foster-Johnson, PhD (Author) https://creativecommons.org/licenses/by-nc/4.0
The Impact of Patient Travel Time and Rurality on Outcomes After Total Joint Arthroplasty
Patients undergoing total joint arthroplasty (TJA) often face geographically driven barriers to preoperative, perioperative, and postoperative care. Using data from the multicenter PEPPER Trial (≈9,000 patients), this study investigates whether travel time to clinical sites and rural residence influence patient-reported outcomes—including HOOS, KOOS, PROMIS scores—and adverse events following total hip or knee arthroplasty. Travel time was calculated using GIS-based estimations between patient home zip codes and clinical sites, while rurality was defined via RUCA classifications. The study hypothesizes that patients with longer travel times or rural residence may experience delayed follow-up, reduced access to postoperative care, and poorer functional recovery. Planned analyses will evaluate changes in functional scores at 1, 3, and 6 months post-surgery, as well as correlations with emergent and non-emergent adverse events. With rural patients disproportionately affected by transportation, cost, and resource limitations, this work aims to clarify how geographic inequities influence recovery trajectories and to inform targeted care models that support postoperative rehabilitation for geographically isolated populations.
Copyright (c) 2025 Isabel Rosenberg, Carol A. Lambourne, PhD, Heather Carlos, MS, Vincent D. Pellegrini Jr., MD (Author) https://creativecommons.org/licenses/by-nc/4.0
The Pain of Inequality: How Socioeconomic Status and Healthcare Affordability Shape the Link Between Pain and Depression
Chronic pain and depression frequently co-occur, shaped by shared biological pathways—including inflammation and stress-axis dysregulation—and overlapping psychosocial burdens. Using U.S. National Health Interview Survey data, this study examined how demographic and socioeconomic barriers modify the relationship between pain frequency and depression. Individuals reporting higher pain were significantly more likely to endorse frequent depressive symptoms, and this association was strongest among respondents who delayed or forwent medical care due to cost. Although lower income was associated with greater depression overall, poverty did not significantly moderate the pain–depression relationship, suggesting that cumulative structural inequities may outweigh short-term financial strain. Race and ethnicity significantly influenced the association: Asian and White non-Hispanic respondents displayed higher depression levels across pain strata compared to Black and Hispanic respondents, indicating that cultural and structural factors shape symptom reporting and lived experience. Healthcare affordability emerged as a central determinant of depression risk, with foregone care predicting markedly worse mental health irrespective of insurance status. These findings highlight the importance of addressing both structural barriers and inequities in care access to reduce the psychological burden among people living with chronic pain.
Copyright (c) 2025 Anita Singh, Charles J. Mazof, Caleb Richmond, H. Nephi Seo, Lynn Foster-Johnson, PhD (Author) https://creativecommons.org/licenses/by-nc/4.0
Six Cases of Intussusception After Roux-en-Y Gastric Bypass in Patients on GLP-1 Therap
Intussusception is an uncommon but serious complication following Roux-en-Y gastric bypass (RYGB), historically occurring in 0.4–3.9% of postoperative patients. Amid rising GLP-1 receptor agonist prescribing, this case series describes six RYGB patients presenting with intussusception while actively or recently using GLP-1 therapy. Presentations typically involved acute abdominal pain, with imaging frequently demonstrating jejunojejunal intussusception near the anastomosis. Most cases required laparoscopic exploration, while one involved ischemic bowel requiring resection. A broader Dartmouth Health–wide analysis from 2017–2025 revealed no significant temporal association between GLP-1 prescribing and intussusception rates, suggesting isolated clustering rather than a system-level trend. These findings contextualize concern regarding GLP-1–related bowel complications and underscore the need for continued surveillance as GLP-1 use expands.
Valentina Fernandez-Rodriguez Fernandez-Rodriguez
Copyright (c) 2025 Valentina Fernandez-Rodriguez , Elizabeth J. Honigsberg, MD MPH, Thadeus L. Trus, MD (Author) https://creativecommons.org/licenses/by-nc/4.0
Efficacy and Safety of 12-Week Alternating Topical Steroid Regimens in Early-Stage Mycosis Fungoides
Topical corticosteroids are widely used as first-line therapy for early-stage mycosis fungoides (MF), yet standardized treatment protocols remain lacking. This retrospective cohort study evaluated early-stage MF patients treated at Dartmouth Health with a 12-week alternating regimen of high-potency and medium-potency topical steroids. Clinical response rates were high (94.5%), with significant reductions in body surface area involvement, particularly among stage IB patients. Lesion morphology emerged as the strongest predictor of recurrence; individuals with mixed patch-and-plaque morphology demonstrated a 4.4-fold higher recurrence hazard relative to patch-only lesions. Although adverse events were mild and infrequent (12.3%), stage IB patients had higher risk of requiring subsequent treatment. Findings support the safety and effectiveness of alternating steroid regimens while highlighting the importance of morphology-driven counseling and tailored follow-up strategies.
Copyright (c) 2025 Ayushya Ajmani, Nicole A. Trepanowski, MD, Sarah Lange, Frederick Lansigan, MD, Joi B. Carter, MD (Author) https://creativecommons.org/licenses/by-nc/4.0
Improving the Care of Patients with Serious Infections and Injection Drug Use
People who inject drugs (PWID) face substantial barriers to optimal treatment of serious infections, including high rates of self-directed discharge, fragmented follow-up, and limited eligibility for outpatient parenteral antimicrobial therapy (OPAT). A needs assessment at Dartmouth Health identified significant gaps in addiction treatment engagement, social support, and access to safe home environments. A multidisciplinary intervention was implemented incorporating Behavioral Intervention Team consultation, structured team meetings, harm-reduction counseling, and coordinated care navigation. Preliminary post-intervention data showed improved addiction treatment engagement (99%), increased discharge on home IV therapy (19% vs. 7%), and reduced need for prolonged inpatient IV therapy. Chart review indicated a 77% clinical cure rate at end of therapy, with manageable rates of adverse events and PICC complications. Continued evaluation will assess financial implications and feasibility in rural settings.
Outpatient Parenteral Antimicrobial Therapy
Copyright (c) 2025 Milan Stolpman, Colleen Kershaw, MD (Author) https://creativecommons.org/licenses/by-nc/4.0
Interpretable Classification of Renal and Colonic Neoplasia Using Prototypical Explainability
Interpretable artificial intelligence tools are increasingly needed in pathology to overcome the opacity of black-box models and improve clinician trust. This study applied a prototypical part network—a deep learning architecture that compares regions of an input image to learned prototypes—to classify renal cell carcinoma (five subtypes) and colorectal lesions (hyperplasia vs. sessile serrated adenoma). Trained on DHMC datasets of whole-slide images and biopsy patches, the model achieved accuracies of 92.3% (renal) and 85.5% (colonic). The prototype-based approach enabled visualization of class-specific features, assisting in understanding both correct and incorrect predictions. Subpatch-level activation maps highlighted regions of suspected malignancy, aligning closely with pathologist annotations. This transparent decision-making framework may enhance diagnostic confidence and supports future clinical deployment of AI pathology tools.
Copyright (c) 2025 Achilles Gatsonis, Saeed Hassanpour, PhD (Author) https://creativecommons.org/licenses/by-nc/4.0
Single-Nuclei RNA Sequencing Reveals Inhibitory Network Dysregulation in Focal Cortical Dysplasia
Focal cortical dysplasia (FCD) is a leading cause of drug-resistant epilepsy, driven largely by somatic mutations that hyperactivate the mTOR pathway and disrupt neural circuitry. This study compiled single-nuclei RNA sequencing datasets from five published reports to analyze inhibitory neuron populations within temporal lobe specimens from patients with FCD, non-FCD epilepsy, and non-epileptic controls. After batch correction and quality filtering, analyses revealed a significant reduction in GABAergic neurons and interneurons in FCD samples, accompanied by the emergence of a dysmorphic neuronal population expressing early progenitor markers. mTOR pathway elements, particularly S6, were markedly upregulated in dysmorphic neurons. These findings reinforce the central role of mTOR dysregulation in FCD pathogenesis and highlight candidate cellular markers for further investigation. Future work will validate findings in Dartmouth surgical specimens and explore neuroinflammatory and extracellular matrix pathways contributing to epileptogenesis.
Copyright (c) 2025 Charles Mazof, Petra Bachanova, H. Robert Frost, PhD, George J. Zanazzi, MD PhD MS, Jennifer Hong, MD (Author) https://creativecommons.org/licenses/by-nc/4.0
Outcomes of Outpatient Total Thyroidectomy for High-Risk Patients: A Single-Site Retrospective Cohort Study
With growing interest in outpatient thyroidectomy, questions remain regarding the safety of this approach for high-risk patients, including individuals with obstructive sleep apnea, anticoagulant or anti-platelet use, substernal goiter, or Graves’ disease. This retrospective study evaluated 513 outpatient thyroidectomy cases at a high-volume endocrine surgery center, comparing postoperative complications and 30-day outcomes between high-risk and low-risk groups. Despite older age, higher comorbidity burden, and higher ASA class, high-risk patients demonstrated no significant increase in hematoma, recurrent laryngeal nerve injury, hypocalcemia, readmissions, reoperations, or ED encounters. Secondary analyses accounting for unplanned admissions and distance from the hospital confirmed similar safety profiles across groups. These findings support expanding outpatient eligibility among appropriately selected high-risk patients, emphasizing the importance of surgeon experience and structured perioperative protocols.
Copyright (c) 2025 Aidan Wright, Emery Boudreau, MD, Alice Jo, MD MPH, Laura E. Newton, MD, Pablo Martinez-Camblor, PhD, Maria F. Bates, MD, Meredith J. Sorensen, MD (Author) https://creativecommons.org/licenses/by-nc/4.0
Beyond the Cuff: A Clinician’s Guide to Continuous Non-Invasive Blood Pressure Monitoring
Continuous non-invasive blood pressure (CNIBP) monitoring seeks to bridge the gap between intermittent oscillometric cuff measurements and invasive arterial lines, providing beat-to-beat hemodynamic data without the risks of cannulation. This review synthesizes clinical validation data for commercially available CNIBP systems, including ClearSight, CNAP, Finapres NOVA, and the Cardiowatch PTT-based wearable. Literature review revealed that volume clamp–based systems demonstrate the strongest accuracy across perioperative and acute care settings, with ClearSight having the broadest validation, particularly for mean arterial pressure tracking. However, all devices exhibit diminished accuracy in extreme physiological states, including severe shock, obesity, and peripheral arterial disease. This guide summarizes device mechanisms, validated use cases, and limitations to support informed clinician adoption. Continued research is needed to expand validation across diverse clinical scenarios and develop CNIBP technologies capable of reliable performance at physiological extremes.
Copyright (c) 2025 Alec Fields, MS, Ethan Ho, Akshay Kelshiker, Xing Wei, John X. J. Zhang, PhD, Alexander Abess, MD (Author) https://creativecommons.org/licenses/by-nc/4.0
Comparative Efficacies of TMR vs. RPNI in Reducing Phantom Limb and Neuroma Pain in Below-Knee Amputees
Phantom limb pain and neuroma pain affect up to 80% of amputees, prompting interest in advanced nerve-targeting surgical techniques. This study compared pain outcomes in below-knee amputee patients undergoing Targeted Muscle Reinnervation (TMR) versus Regenerative Peripheral Nerve Interface (RPNI). Patient-reported outcomes included PROMIS Pain Interference 6b and 0–10 numerical pain ratings. Both techniques demonstrated similarly low residual pain levels: average phantom limb pain was 2.28 (TMR) vs. 2.0 (RPNI), and neuroma pain was 1.0 (TMR) vs. 2.3 (RPNI). PROMIS T-scores approximated the U.S. population mean, indicating minimal long-term pain interference. Satisfaction was universally high, with all patients stating they would undergo the procedure again. These results suggest that TMR and RPNI offer comparable and effective pain control, though larger and more diverse cohorts are required to evaluate outcomes across different amputation levels and activity profiles.
Copyright (c) 2025 Annie Cao, Omri Ayalon, MD (Author) https://creativecommons.org/licenses/by-nc/4.0
Establishing a Murine Model of Acute Pancreatitis: Toward Cytokine-Based Therapeutic Strategies
Acute pancreatitis (AP) remains a major clinical challenge without targeted pharmacologic therapy. This study established a cerulein-induced murine model to characterize cytokine responses and evaluate IL-6 inhibition as a therapeutic strategy. Mice received hourly cerulein injections followed by isotype or anti–IL-6 antibody treatment. Histology confirmed edema and inflammatory infiltration in pancreata and lungs of cerulein-treated animals. Luminex cytokine profiling showed markedly elevated IL-6, IL-10, KC, MCP-1, MIP-1β, and IL-12 in untreated AP mice. Anti–IL-6 therapy significantly reduced circulating IL-6 and multiple associated mediators, suggesting a downstream anti-inflammatory effect. Serum IL-6 levels differed significantly between groups (p = 0.00044). Future plans include expanding cytokine profiling, quantifying histologic injury over multiple timepoints, and validating IL-6 blockade as a potential therapeutic avenue. This model provides a platform for evaluating cytokine modulation in AP.
Copyright (c) 2025 Ana Rivadeneira, Dawn Fischer, Kerrington Smith, MD, Timothy B. Gardner, MD MS (Author) https://creativecommons.org/licenses/by-nc/4.0
Development of Screening and Confirmatory LAMP–CRISPR Assay for Trichophyton Species Identification in Onychomycosis
Tinea capitis and onychomycosis are prevalent pediatric fungal infections for which current diagnostic methods remain slow, costly, and inaccessible, leading to frequent empiric treatment and delays in appropriate care. This project aims to develop a rapid, low-cost point-of-care molecular diagnostic assay using loop-mediated isothermal amplification (LAMP) followed by CRISPR-Cas12a detection to accurately identify dermatophyte species. Conserved TOPII gene regions were targeted for primer and guide RNA design across Microsporum, Epidermophyton, and Trichophyton genera. Preliminary results demonstrate successful amplification and CRISPR-mediated detection of Trichophyton species with high specificity and no cross-reactivity. Colorimetric LAMP detection produced visible signals within 20–25 minutes. Future work involves developing a guide RNA for the emerging, terbinafine-resistant T. indotineae and integrating Nanopore sequencing to refine primer design and confirm assay specificity. This assay has the potential to significantly improve diagnostic accessibility, reduce overtreatment, and streamline clinical decision-making in dermatology.
Copyright (c) 2025 Roya E. Rochell, Christine Hodge, Katherine E. Bradley, MD, Brian J. Simmons, MD, Jillian F. Rork, MD, Matthew S. Hayden, MD PhD (Author) https://creativecommons.org/licenses/by-nc/4.0
Strengthening Maternal Health in New Hampshire: Perspectives from the NH Perinatal Quality Collaborative (NHPQC)
New Hampshire has recently experienced rising inequities in maternal morbidity and mortality, with mental health and substance use contributing to over half of pregnancy-related deaths from 2019–2023. This qualitative project explores the early development of the New Hampshire Perinatal Quality Collaborative (NHPQC), a statewide, community-driven initiative to improve maternal outcomes. Using maximum-variation sampling, interviews were conducted across four regional coalitions—Nashua, Manchester, Claremont, and Rochester/Dover—to understand emerging priorities, organizational structure, and implementation challenges. Preliminary thematic analysis identified recurring needs for improved communication pathways, streamlined coordination, integration of social services, and addressing maternity care deserts following multiple hospital obstetric unit closures. Participants emphasized the importance of community partnerships and equitable resource distribution to reduce preventable postpartum deaths, 79% of which were deemed preventable. Ongoing analysis will inform NHPQC strategic planning, stakeholder engagement, and statewide quality-improvement recommendations.
Copyright (c) 2025 Edith Ben-Eboh, Sanam Roder-Dewan, MD DrPH (Author) https://creativecommons.org/licenses/by-nc/4.0
Coronal Plane Alignment of the Knee (CPAK) Classification After Total Knee Arthroplasty and Post-Operative Patient-Reported Outcomes
Anatomic alignment plays a crucial role in total knee arthroplasty (TKA) durability and long-term functional outcomes. This study examines postoperative changes in coronal plane alignment using the nine-type CPAK classification system and evaluates associations with PROMIS-10, KOOS Jr., and Modified SANE scores. Pre-operative CT measurements were used to determine arithmetic hip-knee-ankle angle and joint line obliquity, which were compared with postoperative values. Of 1,033 eligible TKA patients, 741 have completed CPAK classifications to date, with most categorized as Type I or II preoperatively. Remaining analyses will compare pre- and postoperative CPAK classifications to determine alignment shifts and their relationship with patient-reported outcomes at 1–2 years. This work aims to clarify whether maintaining a patient’s constitutional alignment confers superior function and satisfaction, and may help guide alignment strategy selection between mechanical and kinematic techniques.
Copyright (c) 2025 Caolin Mathers, Wayne Moschetti, MD, Lawrence Guindine, Eric Colomb, MD, Peter Schilling, MD, Paul Werth, PhD, Alexandria Zagaria, MPH (Author) https://creativecommons.org/licenses/by-nc/4.0
Clinical and Peripheral Blood Markers Predict Relapsed/Refractory Multiple Myeloma Prior to Autologous Stem Cell Transplant
Relapse after autologous stem cell transplant (ASCT) remains a major challenge in multiple myeloma management, underscoring the need for accessible predictors of treatment resistance. This study evaluated whether baseline complete blood count (CBC) and comprehensive metabolic panel (CMP) markers could predict relapse in kappa- and lambda-restricted myeloma patients using random forest modeling. Heatmaps and variable-importance analyses revealed distinct laboratory predictors across subtypes. In kappa-restricted disease, white blood cell count, lymphocyte counts and percentages, red blood cell indices, and liver enzymes (ALT, AST) were the strongest contributors to classification accuracy. In lambda-restricted disease, lymphocyte percentage, mean corpuscular indices (MCV, MCH), red cell distribution width, ALT, and sodium were the top predictors. These findings highlight potential subtype-specific immune and metabolic features associated with relapse risk. However, limited sample sizes—especially in the lambda subgroup—reduce generalizability. Future directions include expanding cohorts, integrating clinical and molecular markers such as cytogenetics or minimal residual disease, and constructing multimodal predictive models. This work demonstrates the feasibility of using routine lab values combined with machine learning to identify patients at higher risk of relapse following ASCT.
Copyright (c) 2025 Julienne Chaquor, Hannah Stolrow, Brock Christensen, PhD (Author) https://creativecommons.org/licenses/by-nc/4.0
From Shunt to Shear: Understanding Post-TIPS Hemolytic Anemia and Revision Strategies
Hemolytic anemia is a rare but clinically significant complication following transjugular intrahepatic portosystemic shunt (TIPS) placement, historically occurring more frequently with bare-metal stents due to increased intraluminal turbulence and shear stress. With the advent of PTFE-covered stents, this complication has become less common, but optimal management strategies remain poorly defined. This proposed descriptive study aims to characterize cases of suspected post-TIPS hemolytic anemia at Dartmouth Health from 2011–2025, focusing on clinical presentation, laboratory abnormalities, and revision strategies. Key variables include type of revision intervention—such as diameter reduction, angioplasty, conversion to covered stents, accessory shunt embolization, or complete shunt replacement—as well as trends in hemolysis markers, including bilirubin fractions, LDH, haptoglobin, and reticulocyte count. Given the rarity of this condition, a small case series is anticipated; however, documenting revision outcomes may provide meaningful insight into which strategies are most effective for reversing hemolysis while maintaining shunt patency. This study will also clarify situations in which anemia is attributable to alternative etiologies, supporting more accurate diagnosis and management.
Transjugular Intrahepatic Portosystemic Shunt
Copyright (c) 2025 H. Nephi Seo, Thomas Burdick, MD (Author) https://creativecommons.org/licenses/by-nc/4.0