Search Results (548)

Acute cholecystitis (AC) is one of the most prevalent gastrointestinal emergencies, with laparoscopic cholecystectomy representing the definitive treatment per current guidelines. However, a substantial proportion of patients—particularly elderly individuals with major comorbidities, multiorgan dysfunction, or advanced malignancy—are considered poor surgical candidates in whom operative intervention carries prohibitive risk. Although percutaneous transhepatic gallbladder drainage (PT-GBD) has traditionally served as the first-line non-surgical alternative, its significant morbidity and technical limitations in patients with coagulopathy, massive ascites, or an unsafe percutaneous window have driven the development of endoscopic drainage modalities. This review critically appraises the comparative evidence for two endoscopic gallbladder drainage strategies: endoscopic transpapillary gallbladder drainage (ET-GBD), performed via endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), most commonly using lumen-apposing metal stents (LAMS). In appropriately selected high-risk surgical candidates, EUS-GBD with LAMS has emerged as a preferred endoscopic option, supported by high technical success rates, low recurrent AC rates, AGA expert guidance, and FDA regulatory reclassification of the AXIOS stent for gallbladder drainage. Nevertheless, ET-GBD retains distinct clinical indications, including concurrent biliary intervention, large-volume ascites, high bleeding risk, anticipated surgical candidacy, and resource-limited settings. Optimal management requires a systematic, algorithm-driven multidisciplinary approach integrating comorbidity profile, biliary anatomy, cystic duct patency, and institutional expertise. Full article

Background: Endovascular repair with covered stent is an established minimally invasive treatment for popliteal artery lesions, particularly in elderly or high-risk patients. Infectious complications are exceptionally rare but may result in arterial destruction, limb loss, and death. Salmonella species demonstrate a well-recognized affinity for diseased arterial walls and prosthetic vascular material. Case Presentation: An 82-year-old man with stage G4 chronic kidney disease and previous nephrectomy for renal cell carcinoma, complicated by Salmonella Enteritidis septic shock 20 years earlier, presented with acute left lower limb ischemia caused by a post-traumatic popliteal artery pseudoaneurysm. Urgent endovascular repair was performed using a 6 × 100 mm covered stent (Viabahn) with adjunctive angioplasty of the anterior tibial artery. Two weeks later, he was readmitted with fever, severe popliteal pain, local erythema, and elevated inflammatory markers. Imaging demonstrated early stent occlusion with a large peri-graft abscess and contained arterial rupture. Emergency open conversion included radical debridement, complete graft explantation, and popliteal-to-posterior tibial bypass using an autologous great saphenous vein. Cultures grew Salmonella Enteritidis. Retrospective history revealed a previously undocumented episode of Salmonella Enteritidis bacteremia approximately 20 years earlier. At 2-year follow-up, the patient remained free of recurrent infection with a patent vein graft and preserved ambulatory function. Conclusions: Early Salmonella Enteritidis infection of a popliteal covered stent is an exceptionally rare but life-threatening complication. This case suggests that remote Salmonella bacteremia may represent a potential, hypothesis-generating risk factor for prosthetic graft infection. Prompt graft explantation followed by radical debridement and autologous venous reconstruction remain essential for durable limb salvage. Full article

Introduction: Gastric ulcer perforation is a life-threatening surgical emergency in which delay is poorly tolerated. In this setting a specimen is taken from ulcer margin to detect possible malignancy risk. The purpose of the present systematic review is to evaluate the need of intraoperative biopsy in gastric ulcer perforations using current biopsy-proven malignancy rates and its effect on complications. Methods: The review was carried out in line with the PRISMA guidelines and was registered (INPLASY202650135). Reports describing adults who operated on for a perforated gastric ulcer were considered. The principal endpoint was detection of malignancy. Malignancy proportions were combined within a random-effects model after Freeman–Tukey double-arcsine transformation, and statistical heterogeneity was quantified with the I² statistic. Results: Twelve reports were eligible for the review, amounting to 1122 patients. Of these, 953 individuals (64% men; average age 52 years) underwent sampling of the ulcer at operation. Twenty-seven patients had biopsy-proven malignancy on intraoperative histology; one additional patient had a false-negative intraoperative biopsy that was confirmed as malignant on postoperative endoscopy, so the biopsy-proven outcome was based on 27 events. The random-effects pooled proportion of biopsy-proven malignancy among patients with no previous gastric cancer diagnosis was 3.1% (95% CI 1.4–5.7%). There was substantial statistical heterogeneity between studies (I² = 72%; Cochran Q = 39.8, df = 11, p < 0.001). Sampling was omitted in 169 patients, and complications in patients with and without biopsy were contrasted in a single report only. In that single retrospective study, both total complications (46.4% vs. 11.8%, p = 0.007) and Clavien–Dindo grade ≥ III complications (34.5% vs. 5.9%, p = 0.017) occurred more often after biopsy since this signal derives from one single-centre comparison and may be confounded by ulcer complexity, so it ought to be treated as a hypothesis to be tested rather than as an established effect. Conclusions: The available evidence does not support the routine biopsy of all perforated gastric ulcers during surgery. However, as the evidence base is almost entirely retrospective and the included studies did not categorize lesions by size or appearance, a selective biopsy or intraoperative frozen section strategy may still be justified for large, chronic, mass-like, or otherwise suspicious ulcers, particularly in elderly patients. Full article

Background/Objectives: Lower gastrointestinal bleeding (LGIB) is a common and potentially life-threatening emergency that disproportionately affects elderly, comorbid patients, yet evidence-based risk stratification tools remain underused. The Oakland Score was developed to identify patients who can be safely discharged. This study aimed to determine prognostic factors in patients presenting with LGIB and to evaluate the relationship between the Oakland Score and adverse clinical outcomes. Methods: In this single-centre, retrospective, descriptive study, patients aged 18 years and older who presented to the emergency department with LGIB between 2015 and 2024, and who were evaluated, treated and followed up by the Department of Gastroenterology at Dokuz Eylül University, and who underwent endoscopic evaluation were reviewed. A total of 890 patients who met the inclusion criteria and had complete medical records, defined as full availability of all Oakland Score variables and primary outcome data, were included in the final analysis. The Oakland Score was calculated for every patient, and its association with mortality, intensive care unit (ICU) admission, blood-product transfusion, early and late rebleeding, and the need for emergency surgery was analysed. Receiver operating characteristic (ROC) analysis was used to assess discriminative performance. Results: The mean age was 69.8 ± 15.6 years, and 50.4% of patients were female. The most frequent comorbidities were hypertension (56.2%), coronary artery disease (28.9%) and diabetes mellitus (25.1%). Diverticular bleeding was the most common aetiology (25.1%). Red blood cell transfusion was required in 52.8% of patients, and the in-hospital mortality rate was 6.1%. The Oakland Score was significantly associated with mortality, ICU admission, blood-product transfusion, early and late rebleeding, and emergency surgery (all p < 0.05). On ROC analysis the score performed best for ICU admission (AUC 0.754) and mortality (AUC 0.706), and was significantly associated with red blood cell, platelet and fresh frozen plasma transfusion requirements (p < 0.001). On multivariable logistic regression, the Oakland Score was an independent predictor of one-month rebleeding (OR 1.082; 95% CI 1.032–1.133; p = 0.001) but did not retain independent significance for mortality or ICU admission after adjustment for malignancy, serum albumin and BUN. Conclusions: The Oakland Score is significantly associated with major adverse outcomes in LGIB and is particularly sensitive for predicting mortality and ICU admission. It is a useful adjunct to clinical judgement for risk stratification, although it should be interpreted alongside the patient’s overall clinical status. Full article

Background: Postoperative delirium (POD) is a frequent and serious complication in elderly surgical patients. Liberalising preoperative fluid fasting has been shown to reduce its incidence. However, evidence on long-term cognitive and functional outcomes following POD or liberal fluid fasting remains limited. Objectives: This study investigates whether POD and different fluid fasting regimens are associated with changes in cognitive performance and activities of daily living twelve months after surgery. Methods: As a follow-up to the prospective ‘LFFgertrud’ trial, 89 geriatric patients were contacted by phone twelve months after elective trauma or orthopaedic surgery (March 2023–February 2024). Participants completed four validated questionnaires assessing cognition and everyday functioning: the Short Blessed Test (SBT), EQ-5D-5L, Barthel index (BI), and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Results: The hypotheses regarding the effects of POD and fluid fasting on cognitive and functional outcomes were not statistically supported. In contrast, neurodegenerative disease was strongly associated with poorer outcomes in three of the four follow-up measures (SBT: β = 1.27, p = 0.01; EQ-5D-5L: β = 1.43, p < 0.001; BI: β = −1.63, p < 0.001), and polymedication also emerged as a relevant predictor. Although not statistically significant, descriptive trends indicated that patients who developed POD showed lower cognitive performance and reduced quality of life at twelve months. Conclusions: POD and fluid fasting duration were not significantly associated with long-term cognitive or functional outcomes one year after hospitalisation. The findings highlight the importance of considering pre-existing neurocognitive disease and polypharmacy when assessing the risk of adverse long-term outcomes in older patients. Due to the multifactorial nature of recovery in this population, further research involving larger sample sizes is required in order to gain a better understanding of the factors that influence long-term outcomes. Full article

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) has been linked to atrial fibrillation (AF); however, its relationship with specific AF subtypes remains unclear. This prospective, single-center, observational case–control study investigated whether MASLD is independently associated with AF presence and its subtypes. Materials: A total of 327 participants were analyzed, including 119 controls and 208 patients with AF. Comprehensive clinical history, anthropometric measures, laboratory testing, 24 h Holter ECG, and echocardiography were performed. Clinically inferred MASLD was defined according to the current EASL–EASD–EASO guidelines using clinical and non-invasive indices (Hepatic Steatosis Index, Fatty Liver Index, Fibrosis-4 Index). No liver biopsy or imaging confirmation of steatosis or fibrosis was performed, and therefore, the diagnosis represents a clinically inferred (“probable”) MASLD. To minimize systematic bias and improve baseline comparability between groups, propensity score matching and complementary regression analyses were applied. Results: Overall probable MASLD prevalence did not differ between AF and controls (42% vs. 44%, p = 0.742). A clear phenotypic gradient emerged across subtypes: lowest in permanent AF (PermAF, 27.1%) versus paroxysmal (47.1%) and persistent AF (51.4%) (p = 0.021). PermAF exhibited the most advanced comorbidity—highest CHF (78.6%), CKD (71.4%), HFpEF (48.6%), FIB-4 (median 2.67), the lowest TG/HDL–cholesterol ratio (1.93 vs. 3.32; p < 0.001), and progressive renal impairment. Statin therapy reached 80% in clinically inferred MASLD-positive PermAF. The elevated FIB-4 observed in PermAF must be interpreted with explicit caution: this group was substantially older (median 79.5 years) and carried the highest burden of chronic heart failure and chronic kidney disease; therefore, in this subgroup, FIB-4 most plausibly reflects age and cardio-renal comorbidity rather than histologically confirmed hepatic fibrosis. After matching, MASLD was not an independent predictor of AF presence (OR = 0.96; 95% CI: 0.59–1.46) or its clinical severity. Conclusions: Probable MASLD, defined by clinical and non-invasive indices, was not independently associated with AF in this cohort, but AF subtypes exhibited a clear phenotypic gradient—from a metabolically driven profile in early AF to a cardio-renal and fibrotic pattern in advanced, elderly AF. Elevated FIB-4 values in PermAF most plausibly reflect age and cardio-renal comorbidity rather than true histologically confirmed hepatic fibrosis. These findings support a phenotype- and population-dependent MASLD–AF relationship and underscore the need for imaging- and histology-verified longitudinal studies. Full article

Background/Objectives: Acute cholecystitis is a common surgical emergency associated with significant morbidity in elderly, frail, and critically ill poor surgical candidates. Early laparoscopic cholecystectomy remains the standard of care for low-risk patients, but interventional radiology (IR) modalities have been increasingly used in high-risk patients for gallbladder decompression, source control, and/or definitive non-operative treatment. Methods: A narrative review of the literature was performed to investigate current percutaneous IR options in acute cholecystitis. Evidence from international guidelines, randomized trials, systematic reviews, meta-analyses, and experimental novel techniques were reviewed. The patient selection approaches, timing of intervention, efficacy, complications, and risk of recurrence were summarized. Results: Percutaneous cholecystostomy remains the most commonly performed IR procedure for acute cholecystitis, offering decompression and source control in patients unfit for surgery. Percutaneous gallstone extraction and gallbladder chemical ablation, or cryoablation, have been used to reduce recurrence and long-term catheter dependence with promising results, but are still limited by complications and insufficient evidence. The variability in practice patterns and the absence of standardized treatment algorithms contribute to mixed results, ranging from long-term/definitive symptom control to the prolonged dependence on indwelling catheters and readmissions for catheter-related complications. Conclusions: IR plays an important role in the management of high-risk patients with acute cholecystitis. The careful selection of patients based on disease severity, physiologic reserve, frailty, and patient-centered goals is frequently limited by institutional resources. A structured clinical decision framework to guide IR-based interventions in acute cholecystitis is of the utmost importance to achieve optimal outcomes. Future studies should focus on standardized algorithms, patient-centered outcomes, recurrence, tube-free survival, and quality of life. Full article

Background: The prevalence of sacral insufficiency fractures resulting from minor trauma has been on the rise in parallel with the globally aging population. For similar injuries typical to the elderly population, such as hip fractures, surgery and early mobilization have been shown to improve postoperative mortality and morbidity rates. As such, there has been a recent increase in the literature in studies advocating for early surgical fixation for sacral insufficiency fractures. However, traditional fluoroscopic techniques are technically demanding and bear an inherent complication risk even in experienced hands. Robotic-assisted surgery has emerged as a promising technological advancement in spinal and pelvic surgery. We share our experience with this surgical technique. Methods: We conducted a retrospective analysis of five consecutive patients with sacral insufficiency fractures who failed non-operative management. Using the Mazor X robotic system, patients underwent CT-planned, guided placement of fenestrated sacroiliac screws followed by cement augmentation. Primary outcomes included surgical time, radiation exposure, complications, and mobilization, with a minimum three-month follow-up. Results: The cohort consisted of five females with a mean age of 78 years. The mean operative time was 36 min (15–47), and the median fluoroscopy count was 13 shots (6–19). All patients reported significant pain relief and achieved successful mobilization on postoperative day 1. No operative or postoperative complications were recorded. Conclusions: This pilot study suggests that robotic-assisted percutaneous sacroiliac fixation with cement augmentation is a safe, efficient, and minimally invasive approach for the treatment of sacral insufficiency fractures. The precision of the robotic system facilitates stable fixation, providing immediate pain relief and early mobilization with a favorable complication profile. Further studies should be performed to verify these findings. Full article

Objective: Disorders of gut–brain interaction (DGBIs) are characterized by functional impairments without identifiable organic causes, with their prevalence increasing with age. Emerging evidence suggests that selective serotonin reuptake inhibitors (SSRIs), such as escitalopram oxalate, may influence DGBIs through the brain–gut axis, though the precise mechanisms driving their therapeutic effects remain unclear. This study investigated the impact of escitalopram oxalate on elderly patients with DGBIs in an outpatient department to elucidate these mechanisms. Methods: This study was an observational cohort study. We recruited elderly patients diagnosed with DGBIs. Patients receiving standard treatment alone were assigned to the control group, while patients receiving standard treatment plus 10 mg of escitalopram oxalate daily were assigned to the exposure group. Emotional and gastrointestinal symptoms were assessed at baseline and after 12 weeks of treatment using validated symptom scales. Additionally, stool samples were collected at both time points and analyzed via 16S amplicon sequencing to evaluate the changes in gut microbiota. Results: A total of 83 elderly patients with DGBIs were included in the study, comprising 40 patients in the control group and 43 in the exposure group. After 12 weeks, the exposure group showed significantly greater reductions in their scores on the Gastrointestinal Symptom Rating Scale (GSRS), Short-Form Leeds Dyspepsia Questionnaire (SF-LDQ), Zung Self-Rating Depression Scale (SDS) and Zung Self-Rating Anxiety Scale (SAS) compared with the control group (e.g., GSRS: 17.00 ± 0.85 vs. 22.58 ± 3.18, p < 0.001; p < 0.01 for all other scale comparisons), with higher effective and recovery rates. Notably, the exposure group showed significant alterations in the abundance of four genus-level taxa (Blautia, Butyricicoccus, Prevotellaceae UCG-003, and Streptococcus) and two species-level taxa (Eubacterium-hallii-group and Parabacteroides-merdae). Conclusions: The escitalopram oxalate treatment was associated with significant improvements in both emotional and gastrointestinal symptoms in elderly patients with DGBIs. These improvements may be linked to alterations in specific gut microbiota taxa, offering a preliminary hypothesis for further investigating the underlying mechanisms of the gut–brain axis. Full article

Background: This review aims to provide a comprehensive and practical overview of the evolving role of autologous transplantation in leukaemias, a strategy that was once largely abandoned but has recently regained interest in selected clinical settings. Methods: We reviewed the historical development of autologous transplantation in acute leukaemias, including the early period during which autologous transplantation was considered inferior to allogeneic approaches because of limited graft purification techniques and the inability to induce effective graft-versus-leukaemia (GVL)-like immune responses. We further summarise more recent experimental strategies aimed at improving stem cell purification and enhancing anti-leukaemic immune activity in autologous settings. In addition, we discuss how advances in measurable residual disease (MRD) assessment and molecular risk stratification have contributed to the renewed interest in autologous transplantation in selected subgroups of leukaemia patients. Results: This review identifies clinical situations in which autologous transplantation remains an important therapeutic option, including plasma cell leukaemia, where it continues to represent a standard first-line approach. We also discuss well-defined patient subgroups, particularly selected AML subtypes with intermediate-risk molecular profiles and acute promyelocytic leukaemia (APL) in second remission, in which outcomes following autologous transplantation may be comparable to, or occasionally superior to, those achieved with allogeneic transplantation. In contrast, autologous transplantation currently plays only a limited role in diseases such as chronic lymphocytic leukaemia (CLL) and chronic myeloid leukaemia (CML). Although attempts to induce potent anti-leukaemic immune effects in autologous settings have so far shown limited clinical efficacy, several emerging strategies appear promising and may further expand the role of autologous transplantation, particularly in elderly or frail patients. Discussion: Overall, current molecular and MRD-based risk stratification strategies, together with emerging immunological and graft-manipulation approaches, may redefine the role of autologous transplantation as a personalised therapeutic option in selected subgroups of leukaemia patients. Full article

In recent years, with the significant decline in fine particulate matter (PM_2.5) concentrations, ozone (O₃) has emerged as a major composite air pollutant during the warm season in China, attracting increasing attention due to its associated health burden and economic costs. This study focuses on Tianjin, using ozone monitoring data from 2017 to 2023 combined with health statistics to assess the health impacts and economic losses attributable to ozone pollution. First, ozone exposure indicators and compliance criteria were constructed based on national air quality standards, and the interannual variation and spatial differences of O₃ levels were analyzed at both citywide and district scales. Second, multiple machine learning classification models, including logistic regression, decision tree, k-nearest neighbors, and gradient boosting, were developed using ozone and meteorological variables to predict the occurrence risks of five diseases: cardiovascular diseases, respiratory diseases, hand-foot-and-mouth disease (HFMD), influenza, and dengue fever. Finally, excess cases were estimated using health impact functions, and the associated economic losses were quantified by combining the value of a statistical life (VSL) with cost-of-illness and willingness-to-pay (WTP) approaches. The results showed that the annual evaluation value of ozone in Tianjin, defined as the 90th percentile of the daily maximum 8 h average O₃ concentration, exhibited a pattern of initially increasing, then decreasing, and subsequently rebounding. It peaked at 201 µg/m³ in 2018, declined to a minimum of 164 µg/m³ in 2021, and rebounded to 188 µg/m³ in 2023. Machine-learning results indicated that the logistic regression model showed relatively stable overall performance across predictions of different diseases, while the gradient boosting tree model also achieved high accuracy in predicting certain infectious diseases. Overall, ozone pollution exhibits significant heterogeneous effects across different disease types, and the associated health-related economic losses show stage-wise fluctuations in response to pollution levels. Based on these findings, it is recommended to implement refined control measures during periods of high ozone exceedance and in key regions, while strengthening protection for vulnerable populations such as the elderly, children, and patients with respiratory diseases, in order to achieve synergistic improvements in air quality management and public health outcomes. Full article

Background/Objectives: Prehospital advanced airway management significantly affects patient outcomes. The King Laryngeal Tube (King LT) has been a standard method for managing compromised airways in various emergency medical services (EMSs). However, in-depth analyses of first-attempt success and influencing factors are limited. This study explores the use of the King LT in Saudi Arabia to assess the first-attempt success rate and predictors of successful management. Methods: This retrospective cross-sectional study was conducted to analyze cases requiring the King LT in the main EMS provider in Saudi Arabia between October 2021 and September 2022. A descriptive analysis was employed for categorical data, and Chi-square test, Fisher’s exact test, and a regression analysis were applied to assess the significance of the association. Results: Of the 239 analyzed cases, adults (58.6%) and males (70.7%) were predominant. The highest proportions of cases were medical cases (36.8%) and indoor incidents (69.9%), with a significant association of indoor incidents with female and elderly patients (p = 0.001). The first-attempt success rate reached 82.4%, with significant success likelihood in afternoon incidents (adjusted odds ratio [OR] = 2.92, 95% confidence interval [CI] [0.53–3.57]; p = 0.03). Conclusions: This first nationwide study of King LT outlines advanced airway management characteristics in Saudi Arabia. The high use rates in adults, males, medical cases, and indoor incidents could suggest tailored training strategies. Noted temporal variations may provide insights for policy improvements. While first-attempt success rates are high, reflecting literature findings; performance could improve with further training. Full article

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor remains the cornerstone of antithrombotic management after myocardial revascularization. However, the traditional “one-size-fits-all” approach to DAPT duration and intensity fails to account for marked interindividual variability in drug response—driven by genetic polymorphisms, notably CYP2C19 variants like CYP2C19*2, which reach a frequency of up to 75% in specific groups like the Melanesian population—comorbidities such as diabetes and chronic kidney disease, and dynamic clinical factors including age and concomitant medications. We examine the current landscape of precision medicine tools for individualizing DAPT, including platelet function testing, point-of-care genotyping, validated clinical risk scores, and emerging artificial intelligence (AI)–based predictive models. Evidence from landmark trials is synthesized to evaluate escalation, de-escalation, and duration-tailoring strategies within the ischemic–bleeding trade-off framework. Special populations requiring individualized approaches are reviewed, including patients with atrial fibrillation, the elderly, and those requiring urgent noncardiac surgery with perioperative bridging. Future directions, including multi-omics integration, novel antiplatelet agents, and AI-driven clinical decision support systems, are also explored. As a narrative review, conclusions should be interpreted as reflective of current evidence synthesis rather than systematic-review-grade evidence, given the absence of formal risk-of-bias scoring or meta-analytic pooling. Personalized DAPT guided by complementary genetic and phenotypic testing, integrated with dynamic risk stratification, offers a paradigm shift from empiric therapy toward precision-guided antithrombotic management with the potential to simultaneously reduce ischemic and bleeding complications. Full article

Background: Patients with mild traumatic brain injury (mTBI) have a small but clinically relevant risk of intracranial injury (ICI), requiring timely detection. Computed tomography (CT) remains the diagnostic gold standard but is costly and exposes patients to ionising radiation. Combining blood-based biomarkers, glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), with clinical decision rules may allow safe exclusion of ICI without CT, reducing unnecessary imaging, radiation exposure, and resource use. Methods: A systematic review of clinical and economic studies in patients with mTBI was registered in PROSPERO (CRD420251051158). Searches were conducted in January 2025 and updated in May 2025 in MEDLINE, Embase, and the Cochrane Library. The aim was to assess the diagnostic accuracy and economic value of the combination of GFAP and UCH-L1 compared with CT scanning to rule out ICI in both adults and children with mTBI. Where available, studies directly comparing GFAP and UCH-L1 with S100β were also analysed descriptively. The quality of the clinical evidence was assessed with QUADAS-2 and GRADE. Meta-analyses used a bivariate random-effects model, with heterogeneity and sensitivity analyses explored. Results: Overall, 21 studies were considered in our review. Moderate- to high-quality evidence indicates that GFAP and UCH-L1, when used together with clinical assessment, have very high sensitivity and can reliably rule out ICI in adults with mTBI presenting within 12 h to the emergency department. Evidence for paediatric populations shows promise but remains very limited. Specificity is low, particularly in older adults, which limits the ability to reduce CT use in this high-risk group. Research on age-adjusted cut-offs is ongoing and may help to reduce the proportion of false positive tests without compromising sensitivity. Few studies directly compared GFAP and UCH-L1 with S100β, with slightly higher to equivalent sensitivity for GFAP and UCH-L1. Economic evaluations suggest possible cost savings and reduced CT utilisation, but these analyses rely on assumptions unsupported by robust data and are highly context-dependent. There is a lack of clarity in the included studies regarding whether existing clinical head rules were used to define the study populations (i.e., to determine which patients would be recommended for CT scanning) and, if so, which specific rules were applied. Conclusions: Evidence shows that GFAP and UCH-L1 can safely exclude ICI in adults with mTBI in whom a CT scan would otherwise be considered based on clinical assessment or decision rules. Nevertheless, real-world evidence and cost-effectiveness data are scarce. Further prospective studies, including paediatric and elderly populations, and integration with clinical decision rules will be informative to ensure optimal use in clinical practice. Full article

Background: Soft tissue sarcomas (STS) disproportionately affect older adults, yet patients aged ≥65 years remain markedly underrepresented in pivotal trials, limiting evidence on pazopanib in this population. We aimed to characterise the real-world efficacy and safety of pazopanib in elderly patients with advanced STS. Methods: This multicentre retrospective cohort study included consecutive patients aged ≥65 years with locally advanced unresectable or metastatic STS who received pazopanib between July 2010 and June 2022 at four tertiary Turkish oncology centres. The primary endpoint was progression-free survival (PFS); secondary endpoints were overall survival (OS) and the safety profile. Results: A total of 109 patients (median age, 70 years; 50.5% female; 48.6% with Eastern Cooperative Oncology Group [ECOG] performance status ≥ 2) were analysed. The objective response rate was 11.0% (95% CI, 5.8–18.4), and the disease control rate was 45.9%. Median PFS was 4.11 months (95% CI, 3.25–4.47), and median OS was 7.85 months (95% CI, 6.91–9.00) over a median follow-up of 17.6 months. PFS showed a borderline difference across age tertiles (log-rank p = 0.078), whereas a marked monotonic OS gradient was observed (9.00, 7.86, and 5.71 months for ages 65–69, 70–74, and ≥75 years, respectively; p < 0.001). In age-stratified multivariable Cox analysis, ECOG ≥ 2 (adjusted hazard ratio [aHR], 1.68; 95% CI, 1.01–2.80; p = 0.045) and female sex (aHR, 1.66; 95% CI, 1.02–2.72; p = 0.043) were independently associated with shorter OS. Grade ≥ 3 treatment-emergent adverse events occurred in 27.5% of patients, most commonly hypertension. Because only the single most clinically prominent treatment-emergent adverse event per patient was recorded, these figures represent a conservative, non-cumulative estimate of toxicity. No treatment-related deaths occurred. Conclusions: Pazopanib retains clinically meaningful activity in unselected patients aged ≥65 years with advanced STS. Performance status, rather than chronological age, is the dominant predictor of overall survival and should guide treatment decisions in this population. Full article