Citations

Background: Revisional bariatric surgery for recurrent weight gain is becoming more common, though it carries higher risks and may be less effective than primary bariatric surgery. This study compares clinical outcomes between primary and revisional duodenal switch (DS) in patients with a body mass index (BMI) > 55 kg/m2. Methods: A retrospective cohort study was conducted on 20 patients who underwent either primary or revisional duodenal switch (DS) surgeries, including biliopancreatic diversion with duodenal switch (BPDDS) and Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-s), between January 2015 and December 2023. Revisional DS was defined as the conversion from Sleeve Gastrectomy (SG) to either BPDDS (C-BPDDS) or SADI-S (C-SADI-S). Perioperative and postoperative variables were analyzed. A statistical analysis was performed using chi-square and McNemar tests for categorical variables and Student’s t-test for continuous variables. A p-value of <0.05 was considered significant. Results: Eleven primary DS patients (six BPDDS, five SADI-s) and nine revisional DS patients (five C-BPDDS, four C-SADI-s) were included. The revisional group had a slightly higher preoperative BMI (57.56 ± 5.92 kg/m2 vs. 55.93 kg/m2 ± 6.91 kg/m2). Although operative times were shorter in the revisional group (153.20 ± 53.26 vs. 193.27 ± 46.79 min), the length of stay was longer (2.70 ± 1.25 vs. 2.18 ± 1.16 days). Primary DS patients experienced three minor late complications (dehydration, nephrolithiasis), whereas the revisional group had one major complication (internal hernia requiring reoperation). At the 12-month follow-up, both groups demonstrated similar outcomes in terms of percentage of total weight loss (%TWL) (primary DS: 25.25% ± 12.38 vs. revisional DS: 30.31% ± 10.79) and percentage of excess weight loss (%EWL) (primary DS: 48.41% ± 22.93 vs. revisional DS: 53.24% ± 14.48). Conclusions: Revisional DS was associated with shorter operation times and similar weight loss to primary DS. Additionally, it was accomplished safely and led to adequate and sustained weight loss in patients with a BMI greater than 55 kg/m2.

Background Olfactory dysfunction (OD) is a common symptom in patients with coronavirus disease 2019 (COVID-19) with limited treatment options. Objective This pilot study aimed to investigate an acupuncture protocol in patients with COVID-19 related OD. Methods Thirty patients were randomized into 2 groups. The standard group was treated with budesonide nasal irrigation and olfactory training. The acupuncture group received ten sessions of acupuncture therapy in addition to the standard group treatment. Olfaction was assessed using the University of Pennsylvania Smell Identification Test, 10-point visual analog scale, and Sino-Nasal Outcome Test at baseline and after 3 months of treatment. Differences between study arms were compared using Fisher’s exact and Wilcoxon rank sum tests. Results Eighteen of the 30 (60%) enrolled patients completed the study, including 11 (73%) in the standard and 7 (47%) in the acupuncture group. Reasons for participant drop-out included cost of travel and time constraints. There were no acupuncture complications. Conclusions Acupuncture as an adjunct therapy for COVID-19 related OD is well tolerated. Subsequent studies with larger sample sizes are needed to assess the effect of acupuncture on OD.

Abstract Objective Unlocking clinical information embedded in clinical notes has been hindered to a significant degree by domain-specific and context-sensitive language. Identification of note sections and structural document elements has been shown to improve information extraction and dependent downstream clinical natural language processing (NLP) tasks and applications. This study investigates the viability of a dynamic example selection prompting method to section classification using lightweight, open-source large language models (LLMs) as a practical solution for real-world healthcare clinical NLP systems. Materials and Methods We develop a dynamic few-shot prompting approach to classifying sections where section samples are first embedded using a transformer-based model and deposited in a vector store. During inference, the embedded samples with the most similar contextual embeddings to a given input section text are retrieved from the vector store and inserted into the LLM prompt. We evaluate this technique on two datasets comprising two section schemas, including varying levels of context. We compare the performance to baseline zero-shot and randomly selected few-shot scenarios. Results The dynamic few-shot prompting experiments yielded the highest F1 scores in each of the classification tasks and datasets for all seven of the LLMs included in the evaluation, averaging a macro F1 increase of 39.3% and 21.1% in our primary section classification task over the zero-shot and static few-shot baselines, respectively. Discussion and Conclusion Our results showcase substantial performance improvements imparted by dynamically selecting examples for few-shot LLM prompting, and further improvement by including section context, demonstrating compelling potential for clinical applications.

Abstract Background Preexisting diabetes (PDM) increases the risk of maternal and perinatal mortality and morbidity. Reduction of maternal hyperglycemia prior to and during pregnancy can reduce these risks. Despite compelling evidence that preconception care (PCC), which includes achieving strict glycemic goals, reduces the risk of congenital malformations and other adverse pregnancy outcomes, only a minority of individuals receive PCC. Suboptimal pregnancy outcomes demonstrated in real-world data highlight the need to further optimize prenatal glycemia. New evolving technology shows promise in helping to achieve that goal. Dysglycemia is not the only driver of poor pregnancy outcomes in PDM. The increasing impact of obesity on pregnancy outcomes underscores the importance of optimal nutrition and management of insulin sensitizing medications during prenatal care for PDM. Objective To provide recommendations for the care of individuals with PDM that lead to a reduction in maternal and neonatal adverse outcomes. Methods The Guideline Development Panel (GDP) composed of a multidisciplinary panel of clinical experts, along with experts in guideline methodology and systematic literature review, identified and prioritized 10 clinically relevant questions related to the care of individuals with diabetes before, during and after pregnancy. The GDP prioritized randomized controlled trials (RCTs) evaluating the effects of different interventions (eg, PCC, nutrition, treatment options, delivery) during the reproductive life cycle of individuals with diabetes, including type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). Systematic reviews queried electronic databases for publications related to these 10 clinical questions. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology was used to assess the certainty of evidence and develop recommendations. The approach incorporated perspectives from 2 patient representatives and considered patient values, costs and resources required, acceptability and feasibility, and impact on health equity of the proposed recommendations. Results In individuals with diabetes mellitus who have the possibility of becoming pregnant, we suggest asking a screening question about pregnancy intention at every reproductive, diabetes, and primary care visit. Screening for pregnancy intent is also suggested at urgent care/emergency room visits when clinically appropriate (2 | ⊕OOO). This was suggested based on indirect evidence demonstrating a strong association between PCC and both reduced glycated hemoglobin (HbA1c) at the first prenatal visit and congenital malformations. In individuals with diabetes mellitus who have the possibility of becoming pregnant, we suggest use of contraception when pregnancy is not desired (2 | ⊕⊕OO). This was suggested based on indirect evidence in women with diabetes, where PCC—including contraception as a key component—showed a clinically significant association with improvements in first-trimester HbA1c and the rate of congenital malformations, together with indirect evidence from the general population regarding the reduction of unplanned pregnancies and pregnancy terminations with the use of contraception. In individuals with T2DM, we suggest discontinuation of glucagon-like peptide-1 receptor agonist (GLP-1RA) before conception rather than discontinuation between the start of pregnancy and the end of the first trimester (2 | ⊕OOO). This was suggested based on limited data on risk of exposure to GLP-1RA receptor agonists during pregnancy. In pregnant individuals with T2DM already on insulin, we suggest against routine addition of metformin (2 | ⊕OOO). This was suggested based on the GDP judgment that the benefit of adding metformin to insulin to achieve decrease in rates of large for gestational age infants did not outweigh the potential harm of increasing the risk of small for gestational age infants or adverse childhood outcomes related to changes in body composition. In individuals with PDM, we suggest either a carbohydrate-restricted diet (&lt;175 g/day) or usual diet (&gt;175 g/day) during pregnancy (2 | ⊕OOO). This was suggested based on the GDP judgment that the available evidence was limited and very indirect, resulting in significant uncertainty about the net benefits or harms. As such, the evidence was insufficient to support a recommendation either for or against a carbohydrate intake cutoff of 175 g/day. In pregnant individuals with T2DM, we suggest either the use of a continuous glucose monitor (CGM) or self-monitoring of blood glucose (SMBG) (2 | ⊕OOO). There is lack of direct evidence supporting superiority of CGM use over SMBG for T2DM during pregnancy. There is indirect evidence supporting improved glucometrics with the use of CGM for individuals with T2DM outside of pregnancy, substantial improvements in neonatal outcomes for individuals with T1DM using CGM during pregnancy and the potential for decreasing adverse pregnancy outcomes with improved glucometrics in individuals with T2DM. In individuals with PDM using a CGM, we suggest against the use of a single 24-hour CGM target &lt;140 mg/dL (7.8 mmol/L) in place of standard-of-care pregnancy glucose targets of fasting &lt;95 mg/dL (5.3 mmol/L), 1-hour postprandial &lt;140 mg/dL (7.8 mmol/L), and 2-hour postprandial &lt; 120 mg/dL (6.7 mmol/L) (2 | ⊕OOO). This was suggested based on indirect evidence that associated adverse pregnancy outcomes with a fasting glucose &gt; 126 mg/dL (7 mmol/L). In individuals with T1DM who are pregnant, we suggest the use of a hybrid closed-loop pump (pump adjusting automatically based on CGM) rather than an insulin pump with CGM (without an algorithm) or multiple daily insulin injections with CGM (2 | ⊕OOO). This was suggested based on a meta-analysis of RCTs which demonstrated improvement in glucometrics with increased time in range (MD +3.81%; CI −4.24 to 11.86) and reduced time below range (MD −0.88%; 95% CI: −2.04 to 0.27) with the use of hybrid closed-loop pump technology. In individuals with PDM, we suggest early delivery based on risk assessment rather than expectant management (2 | ⊕OOO). This was suggested based on indirect evidence that risks may outweigh benefits of expectant management beyond 38 weeks gestation and that risk assessment criteria may be useful to inform ideal delivery timing. In individuals with PDM (including those with pregnancy loss or termination), we suggest postpartum endocrine care (diabetes management), in addition to usual obstetric care (2 | ⊕OOO). As the postpartum period frequently overlaps with preconception, this was suggested based on indirect evidence demonstrating a strong association between PCC and both reduced HbA1c at the first prenatal visit and congenital malformations. Conclusion The data supporting these recommendations were of very low to low certainty, highlighting the urgent need for research designed to provide high certainty evidence to support the care of individuals with diabetes before, during, and after pregnancy. Investment in implementation science for PCC is crucial to prevent significant mortality and morbidity for individuals with PDM and their children. RCTs to further define glycemic targets in pregnancy and refinement of emerging technology to achieve those targets can lead to significant reduction of harm and in the burden of diabetes care. Data on optimal nutrition and obesity management in pregnancy are lacking. More research on timing of delivery in women with PDM is also needed.

ABSTRACTBackgroundSkip lesions in bone sarcoma are a poorly described entity. Reports on skip lesions in osteosarcoma and Ewing sarcoma suggest that whole bone MRI should be obtained to evaluate for additional tumor foci given the association with worse outcomes. However, there is limited evidence to support whole bone imaging in chondrosarcoma.MethodsBetween 1995 and 2022, 129 patients with long bone chondrosarcoma were evaluated at our institution. Lesions were located most commonly in the femur in 64 patients and the humerus in 54 patients. All imaging studies and pathology reports were reviewed to determine the presence of skip lesions, defined as an area of histology‐confirmed chondrosarcoma that was separated from the primary lesion by normal bone on pathology.ResultsWhole bone imaging was obtained during initial staging in 107 patients with two‐thirds of patients receiving MRI, CT, or bone scan. Five patients (3.9%) were found to have skip lesions in the same bone as the primary tumor. There were no transarticular skip lesions. Skip lesions were detected in three patients with low grade chondrosarcoma (4.6%) and two patients with high grade chondrosarcoma (3.2%). All lesions were within 2 cm of the primary tumor. All were visible on MRI and CT of the primary site and one was visible on plain radiographs. The presence of skip lesions did not alter the type of surgical treatment in any patients.ConclusionSkip lesions in long bone chondrosarcoma are rare. All skip lesions in this study were in close proximity to the primary tumor and the same grade as the main lesion. Our results suggest that advanced imaging of the whole bone may be of low utility for evaluating the presence of skip lesions. The clinical significance of skip lesions in chondrosarcoma remains unclear, however, their presence did not impact the treatment plan in this series.

Background Treatment of in-stent restenosis (ISR) accounts for 10% of percutaneous coronary interventions in the USA. Paclitaxel-coated balloons (PCBs) are an alternative to uncoated balloons (UCBs) for ISR. Methods We systematically searched PubMed, Scopus, and Cochrane Central for studies comparing PCB with UCB in treating ISR. Outcomes included late lumen loss, binary restenosis, target lesion revascularization (TLR), and major adverse cardiovascular events (MACE). Results Eight trials including 1410 patients [PCB in 865 (61%), follow-up 6 months to 10 years) were identified. Angiographic outcomes of late lumen loss [mean difference: −0.50 mm; 95% confidence interval (CI): −0.66 to −0.33; P < 0.01] and binary restenosis [relative risk (RR): 0.22; 95% CI: 0.13–0.40; P < 0.01] at 6–8 months were lower with PCB. TLR at 6 months (RR: 0.16; 95% CI: 0.06–0.40; P < 0.001) and 1 year (RR: 0.45; 95% CI: 0.31–0.66; P < 0.001), MACE at 6 months (RR: 0.25; 95% CI: 0.16–0.38; P < 0.001), MACE at 3–5 years (RR: 0.54; 95% CI: 0.37–0.80; P = 0.002), and TLR at 3–5 years (RR: 0.51; 95% CI: 0.29–0.90; P = 0.021) were lower with PCB. Meta-regression revealed that ISR lesions in the left anterior descending artery were associated with lower rates of binary restenosis while the opposite was observed for left circumflex lesions. Conclusion Revascularization of coronary ISR with PCB is associated with reduced late lumen loss, binary restenosis, TLR, CCE, and MACE. PCB may be a preferred strategy for coronary ISR.

Abstract: Background: Extended patch testing beyond the standard series is commonly performed in patients with allergic contact dermatitis. This broader testing allows for more precise and complete allergen identification, ultimately leading to improved clinical outcomes. Objective: To report the Mayo Clinic Contact Dermatitis Group (MCCDG) patch testing results using a custom extended series from 2010 to 2023. Methods: A retrospective review of patch testing results using the MCCDG extended standard series at the Mayo Clinic was conducted. Data from 2010 to 2023 were analyzed. Results: Patch testing with the extended standard series was performed in 3,767 unique patients, with a total of 3834 extended standard patch tests administered (81.8% in women, 18.2% in men). The top 5 allergens eliciting positive reactions were gold (I) sodium thiosulfate (10.4%), benzisothiazolinone (10.4%), carmine (9.4%), thimerosal (9.3%), and hydroperoxides of linalool (8.8%). Conclusions: The extended standard series expands the diagnostic scope for patients in whom the standard series incompletely identifies relevant allergens. Preservatives and fragrances remain among the most common sensitizers, emphasizing the need for ongoing allergen surveillance, periodic review, and updates to patch test series to enhance diagnostic accuracy and patient care.