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Background Large language models (LLMs) are emerging artificial intelligence (AI) technologies refining research and healthcare. However, the impact of these models on presurgical planning and education remains under-explored. Objectives This study aims to assess 3 prominent LLMs—Google's AI BARD (Mountain View, CA), Bing AI (Microsoft, Redmond, WA), and ChatGPT-3.5 (Open AI, San Francisco, CA) in providing safe medical information for rhinoplasty. Methods Six questions regarding rhinoplasty were prompted to ChatGPT, BARD, and Bing AI. A Likert scale was used to evaluate these responses by a panel of Specialist Plastic and Reconstructive Surgeons with extensive experience in rhinoplasty. To measure reliability, the Flesch Reading Ease Score, the Flesch–Kincaid Grade Level, and the Coleman–Liau Index were used. The modified DISCERN score was chosen as the criterion for assessing suitability and reliability. A t test was performed to calculate the difference between the LLMs, and a double-sided P-value <.05 was considered statistically significant. Results In terms of reliability, BARD and ChatGPT demonstrated a significantly (P < .05) greater Flesch Reading Ease Score of 47.47 (±15.32) and 37.68 (±12.96), Flesch–Kincaid Grade Level of 9.7 (±3.12) and 10.15 (±1.84), and a Coleman–Liau Index of 10.83 (±2.14) and 12.17 (±1.17) than Bing AI. In terms of suitability, BARD (46.3 ± 2.8) demonstrated a significantly greater DISCERN score than ChatGPT and Bing AI. In terms of Likert score, ChatGPT and BARD demonstrated similar scores and were greater than Bing AI. Conclusions BARD delivered the most succinct and comprehensible information, followed by ChatGPT and Bing AI. Although these models demonstrate potential, challenges regarding their depth and specificity remain. Therefore, future research should aim to augment LLM performance through the integration of specialized databases and expert knowledge, while also refining their algorithms. Level of Evidence: 5

Young male cancer survivors have lower testosterone levels, higher fat mass, and worse quality of life (QoL) than age-matched healthy controls. Low testosterone in cancer survivors can be due to orchidectomy or effects of chemotherapy and radiotherapy. We have undertaken a double-blind, placebo-controlled, 6-month trial of testosterone replacement in young male cancer survivors with borderline low testosterone (7-12 nmol/l). This was a multicentre United Kingdom study conducted in secondary care hospital outpatients. Male survivors of testicular cancer, lymphoma, and leukaemia aged 25-50 years with morning total serum testosterone 7-12 nmol/l were recruited. A total of 136 men were randomised between July 2012 and February 2015 (42.6% aged 25-37 years, 57.4% 38-50 years, 88% testicular cancer, 10% lymphoma, matched for body mass index [BMI]). Participants were randomised 1:1 to receive testosterone (Tostran 2% gel) or placebo for 26 weeks. A dose titration was performed after 2 weeks. The coprimary end points were trunk fat mass and SF36 Physical Functioning score (SF36-PF) at 26 weeks by intention to treat. At 26 weeks, testosterone treatment compared with placebo was associated with decreased trunk fat mass (-0.9 kg, 95% CI -1.6 to -0.3, p = 0.0073), decreased whole-body fat mass (-1.8 kg, 95% CI -2.9 to -0.7, p = 0.0016), and increased lean body mass (1.5 kg, 95% CI 0.9-2.1, p < 0.001). Decrease in fat mass was greatest in those with a high truncal fat mass at baseline. There was no treatment effect on SF36-PF or any other QoL scores. Testosterone treatment was well tolerated. The limitations of our study were as follows: a relatively short duration of treatment, only three cancer groups included, and no hard end point data such as cardiovascular events. In young male cancer survivors with low-normal morning total serum testosterone, replacement with testosterone is associated with an improvement in body composition. ISRCTN: 70274195, EudraCT: 2011-000677-31.

Incidental adrenal masses are commonly detected during imaging for other pathologies. 10% of the elderly population has an 'adrenal incidentaloma', up to 20% of these show low-grade autonomous cortisol secretion and 60% of patients with autonomous cortisol secretion have insulin resistance. Cortisol excess is known to cause insulin resistance, an independent cardiovascular risk marker, however in patients with adrenal incidentalomas it is unknown whether their insulin resistance is secondary to the excess cortisol and therefore potentially reversible. In a proof of concept study we examined the short-term effects of glucocorticoid receptor (GR) antagonism in patients with an adrenal incidentaloma to determine whether their insulin resistance was reversible. In a prospective open-label pilot study, six individuals with adrenal incidentalomas and autonomous cortisol secretion were treated with mifepristone (a GR antagonist) 200 mg twice daily and studied for 4 weeks on a Clinical Research Facility. Insulin resistance at four weeks was assessed by insulin resistance indices, lnHOMA-IR and lnMatsuda, and AUC insulin during a 2-hour glucose tolerance test. Biochemical evidence of GR blockade was shown in all individuals and across the group there was a significant reduction in insulin resistance: lnHOMA-IR (1.0vs0.6; p = 0.03), lnHOMA-%beta (4.8vs4.3; p = 0.03) and lnMatsuda (1.2vs1.6; p = 0.03). Five out of six individuals showed a reduction in insulin AUC >7237 pmol/l.min, and in two patients this showed a clinically significant cardiovascular benefit (as defined by the Helsinki heart study). Short-term GR antagonism is sufficient to reduce insulin resistance in some individuals with adrenal incidentalomas and mild cortisol excess. Further assessment is required to assess if the responses may be used to stratify therapy as adrenal incidentalomas may be a common remediable cause of increased cardiovascular risk. ClinicalTrials.gov NCT00721201.

Minimally invasive treatments for Dupuytren’s disease (DD), such as percutaneous needle fasciotomy (PNF) and collagenase clostridium histolyticum (CCH), have become alternatives to open surgeries. This meta-analysis compared these treatments in terms of complications, patient satisfaction, clinical outcomes, and recurrence. Relevant studies up to June 2024 were identified through major databases, following PRISMA guidelines, and the study was registered on PROSPERO. Statistical analysis using Review Manager 5.4 found PNF had lower post-operative rates of oedema (RR = 0.15, 95% CI [0.09, 0.27], p < 0.00001), lymphadenopathy (RR = 0.09, 95% CI [0.02, 0.38], p = 0.0010), and pruritus (RR = 0.1, 95% CI [0.01, 0.73], p = 0.02) compared to CCH. However, there were no significant differences in skin tears, recurrence, reintervention, extension deficit, or residual flexion at metacarpal and proximal interphalangeal joints (p > 0.05). Patient-reported outcomes, including QuickDASH and URAM scores, also showed no significant differences. Eleven studies involving 1443 patients were analysed, and most were at a low-to-moderate risk of bias, as assessed using the Cochrane or Newcastle–Ottawa tools. While PNF showed fewer minor complications, overall clinical and patient-reported outcomes were comparable between the treatments. These findings highlight the need to tailor treatment choices to patient preferences and clinical context.

IntroductionCortisol is an essential stress hormone and failure of its production, known as adrenal insufficiency (AI), is associated with significant mortality due to adrenal crisis. The Short Synacthen Test (SST) is the current diagnostic test of choice for AI, but it is both invasive and resource intensive. Globally, there is an unmet need for a non-invasive, cost-effective test. A novel formulation, Nasacthin, has been developed, which can be delivered intranasally, with the resultant glucocorticoid levels measured in saliva instead of blood. The Salivary Test of Adrenal Response to Liquid Intranasal Tetracosactide (STARLIT-2) study aims to clinically validate the Nasacthin test in healthy volunteers.Methods and analysisSTARLIT-2 is a randomised, placebo-controlled, double-blinded, four-way crossover trial. 32 healthy adults and children will be randomised to receive each of four study drugs (Synacthen, Nasacthin and their respective placebos) over four study visits (one per visit). Paired blood and saliva samples will be collected from participants at baseline, and then at 30, 60, 90 and 120 min after drug administration. Additional salivary samples will be collected at 180, 240, 360 and 480 min after drug administration. The primary outcome measures are to compare the mean serum cortisol at 30 min after Synacthen or Nasacthin dose, with a view to determine non-inferiority; and to compare the mean change from baseline in serum cortisol at 30 min after active and placebo doses of both Synacthen and Nasacthin, aiming to demonstrate superiority of active over placebo. In addition, the proportion of participants for which Nasacthin produces a rise above a preset serum cortisol threshold at 30 min will be determined, with the negative per cent agreement with the SST calculated using the SST as the reference standard.Ethics and disseminationThe study and its amendments have been reviewed and approved by South Central–Hampshire A Research Ethics Committee. Results will be disseminated in peer-reviewed journals and conference presentations, and feedback to trial participants will be facilitated following consultation with patient and public involvement and engagement groups.Trial registration number ISRCTN62724177

A 78-year-old man was admitted to hospital for treatment of stage IIIa squamous cell carcinoma of the lung. He reported a 4 week history of pain, erythema, and oedema in the left middle finger tip, which impaired his sleep and hand function.

Sleep disturbances are among the most commonly endorsed symptoms of post-traumatic stress disorder (PTSD). Treatment modalities that are effective for the waking symptoms of PTSD may have limited efficacy for post-traumatic sleep problems. The aim of this review is to summarize the evidence for empirically supported and/or utilized psychotherapeutic and pharmacological treatments for post-traumatic nightmares and insomnia. While there are few controlled studies of the applicability of general sleep-focused interventions to the management of the sleep disturbances in PTSD, evidence is growing to support several psychotherapeutic and pharmacological treatments. Future investigations should include trials that combine treatments focused on sleep with treatments effective in managing the waking symptoms of PTSD.

Background: Dupuytren’s fibroproliferative disease affecting the hand’s palmar fascia leads to progressive finger contractures and functional limitations. Management of this condition relies heavily on the expertise of hand surgeons, who tailor interventions based on clinical assessment. With the growing interest in artificial intelligence (AI) in medical decision-making, this study aims to evaluate the feasibility of integrating AI into the clinical management of Dupuytren’s disease by comparing AI-generated recommendations with those of expert hand surgeons. Methods: This multicentric comparative study involved three experienced hand surgeons and five AI systems (ChatGPT, Gemini, Perplexity, DeepSeek, and Copilot). Twenty-two standardized clinical prompts representing various Dupuytren’s disease scenarios were used to assess decision-making. Surgeons and AI systems provided management recommendations, which were analyzed for concordance, rationale, and predicted outcomes. Key metrics included union accuracy, surgeon agreement, precision, recall, and F1 scores. The study also evaluated AI performance in unanimous versus non-unanimous cases and inter-AI agreements. Results: Gemini and ChatGPT demonstrated the highest union accuracy (86.4% and 81.8%, respectively), while Copilot showed the lowest (40.9%). Surgeon agreement was highest for Gemini (45.5%) and ChatGPT (42.4%). AI systems performed better in unanimous cases (accuracy up to 92.0%) than in non-unanimous cases (accuracy as low as 35.0%). Inter-AI agreements ranged from 75.0% (ChatGPT-Gemini) to 48.0% (DeepSeek-Copilot). Precision, recall, and F1 scores were consistently higher for ChatGPT and Gemini than for other systems. Conclusions: AI systems, particularly Gemini and ChatGPT, show promise in aligning with expert surgical recommendations, especially in straightforward cases. However, significant variability exists, particularly in complex scenarios. AI should be viewed as complementary to clinical judgment, requiring further refinement and validation for integration into clinical practice.

Monitoring cortisol replacement therapy in congenital adrenal hyperplasia (CAH) patients is vital to avoid serious adverse events such as adrenal crises due to cortisol underexposure or metabolic consequences due to cortisol overexposure. The less invasive dried blood spot (DBS) sampling is an advantageous alternative to traditional plasma sampling, especially in pediatric patients. However, target concentrations for important disease biomarkers such as 17α-hydroxyprogesterone (17-OHP) are unknown using DBS. Therefore, a modeling and simulation framework, including a pharmacokinetic/pharmacodynamic model linking plasma cortisol concentrations to DBS 17-OHP concentrations, was used to derive a target morning DBS 17-OHP concentration range of 2–8 nmol/L in pediatric CAH patients. Since either capillary or venous DBS sampling is becoming more common in the clinics, the clinical applicability of this work was shown by demonstrating the comparability of capillary and venous cortisol and 17-OHP concentrations collected by DBS sampling, using a Bland-Altman and Passing-Bablok analysis. The derived target morning DBS 17-OHP concentration range is a first step towards providing improved therapy monitoring using DBS sampling and adjusting hydrocortisone (synthetic cortisol) dosing in children with CAH. In the future, this framework can be used to assess further research questions, e.g., target replacement ranges for the entire day.

Background and Objectives: Despite CTAs being critical for preoperative planning in autologous breast reconstruction, experienced plastic surgeons may have differing preferences for which side of the abdomen to use for unilateral breast reconstruction. Large language models (LLMs) have the potential to assist medical imaging interpretation. This study compares the perforator selection preferences of experienced plastic surgeons with four popular LLMs based on CTA images for breast reconstruction. Materials and Methods: Six experienced plastic surgeons from Australia, the US, Italy, Denmark, and Argentina reviewed ten CTA images, indicated their preferred side of the abdomen for unilateral breast reconstruction and recommended the type of autologous reconstruction. The LLMs were prompted to do the same. The average decisions were calculated, recorded in suitable tables, and compared. Results: The six consultants predominantly recommend the DIEP procedure (83%). This suggests experienced surgeons feel more comfortable raising DIEP than TRAM flaps, which they recommended only 3% of the time. They also favoured MS TRAM and SIEA less frequently (11% and 2%, respectively). Three LLMs—ChatGPT-4o, ChatGPT-4, and Bing CoPilot—exclusively recommended DIEP (100%), while Claude suggested DIEP 90% and MS TRAM 10%. Despite minor variations in side recommendations, consultants and AI models clearly preferred DIEP. Conclusions: Consultants and LLMs consistently preferred DIEP procedures, indicating strong confidence among experienced surgeons, though LLMs occasionally deviated in recommendations, highlighting limitations in their image interpretation capabilities. This emphasises the need for ongoing refinement of AI-assisted decision support systems to ensure they align more closely with expert clinical judgment and enhance their reliability in clinical practice.