Retroperitoneal ectopic pregnancy (RPEP) is an exceedingly rare form of trophoblastic implantation within the retroperitoneal compartment, posterior to the parietal peritoneum and anatomically separate from the uterus, fallopian tubes, and ovaries. Proximity to major retroperitoneal vessels, including the abdominal aorta and inferior vena cava, creates potential for severe hemorrhage and complex operative management. Three mechanisms compound this risk by delaying diagnosis: transvaginal ultrasonography is physically limited to the true pelvis and cannot visualize supra-pelvic retroperitoneal implantations; persistent classification as pregnancy of unknown location defers extended imaging; and Zone I implantations may mimic acute pancreatitis, renal colic, or gastrointestinal illness, redirecting assessment away from obstetric consideration. This focused narrative review synthesizes published clinical experience of RPEP to identify recurring diagnostic pitfalls, anatomical patterns, and management themes, and to propose a practical framework for institutional use. The literature search encompassed PubMed/MEDLINE, Embase, Scopus, Google Scholar, and reference lists of relevant publications, from database inception to June 2026, using a structured set of RPEP-specific search terms. No meta-analysis was attempted because the evidence consists of case reports and small case series with heterogeneous reporting. Zone I para-aortic and interaortocaval implantation appears to be the most frequently reported anatomical pattern. Systemic methotrexate alone appears unsuitable as routine definitive therapy for high-risk phenotypes - characterized by elevated beta-hCG, embryonic cardiac activity, or major-vessel proximity. Multidisciplinary operative planning is essential in confirmed or probable cases. Based on this synthesis, we propose diagnostic categories for definite, probable, and possible RPEP; a five-zone surgical anatomical classification intended to support operative planning; and a seven-step institutional escalation framework. These proposals are derived exclusively from very low-certainty evidence consisting predominantly of case reports, small case series, and expert anatomical interpretation. They should be regarded as hypothesis-generating frameworks rather than evidence-based recommendations or validated clinical guidance and require prospective evaluation before clinical adoption.

Objective: To develop and validate a risk scoring system for post-percutaneous coronary intervention (PCI) gastrointestinal bleeding in East Asian patients with acute coronary syndrome (ACS) based on the Fine-Gray model. Methods: This post-hoc analysis was performed on the BleeMACS international multicenter registry study. Patients with ACS undergoing PCI from 15 hospitals across 10 countries between November 2003 and June 2014 were enrolled and stratified into the East Asian group (China and Japan) and the non-East Asian group (other countries). The Fine-Gray model was used to screen predictors and construct an integer-based risk scoring system, with LASSO competing-risk regression for sensitivity analysis. The primary endpoint was gastrointestinal bleeding within 1 year after discharge, with death treated as a competing risk event. Bootstrap resampling was applied for internal validation. Calibration performance was assessed using calibration slope, intercept, and expected-to-observed (E/O) risk ratio. Risk stratification was performed using the Aalen-Johansen cumulative incidence function curve and Gray's test. The temporal distribution of bleeding events was analyzed, and subgroup analyses were conducted according to sex, diabetes mellitus, chronic kidney disease, and dual antiplatelet therapy (DAPT) status. Results: A total of 15 401 ACS patients were enrolled, with an age of (63.6±12.7) years and 3 592 females (23.32%). There were 2 332 patients in the East Asian group and 13 069 in the non-East Asian group. The final model incorporated seven predictors: admission hemoglobin (subdistribution hazard ratio (SHR)=0.82, 95%CI 0.74-0.90), age (SHR=1.02, 95%CI 1.01-1.04), hypertension (SHR=1.57, 95%CI 1.10-2.25), history of heart failure (SHR=1.97, 95%CI 1.08-3.57), peptic ulcer (SHR=3.25, 95%CI 1.41-7.52), proton-pump inhibitor use (SHR=1.54, 95%CI 1.12-2.12), and bleeding history (SHR=1.65, 95%CI 0.98-2.78). The bootstrap-corrected C-index was 0.693 (95%CI 0.652-0.738), with a calibration slope of 0.969 and an E/O ratio of 0.99, indicating favorable overall calibration performance. Risk stratification showed that the bleeding risk in the high-risk group was 3.93 times that in the low-risk group in the overall cohort. For the East Asian group, Gray's test P=0.116, with no significant difference among risk strata. The trend of bleeding risk was consistent with that of the overall cohort, and the ratio of cumulative bleeding risk between the high-and low-risk subgroups was 2.72 in the East Asian group. During the 1-year follow-up, 160 cases of post-PCI gastrointestinal bleeding occurred. The cumulative incidence was higher in East Asian patients than in non-East Asian patients (34 cases (1.46%) vs. 126 cases (0.96%)), with a higher proportion of late bleeding events (181-365 days) (14 cases (41.2%) vs. 41 cases (32.5%)). Subgroup analyses demonstrated stable risk stratification and good calibration performance across clinical subgroups. Conclusions: The gastrointestinal bleeding risk scoring system established in this study exhibits acceptable discrimination and excellent calibration, with stable performance in East Asian populations and various clinical subgroups. East Asian ACS patients have a higher incidence of post-PCI gastrointestinal bleeding with persistent late risk, indicating the need for prolonged monitoring and individualized antithrombotic therapy strategies.

Haemorrhagic ascites (HA) is an uncommon clinical entity commonly caused by cirrhosis, malignancy and iatrogenic intervention. In the absence of these causes, it poses a diagnostic challenge. We present a case of a female with recurrent massive HA with a negative extensive work-up of common causes of HA. Laparoscopically obtained tissue eventually confirmed the diagnosis of endometriosis. This case demonstrates important diagnostic pitfalls in HA and highlights consideration of rarer causes.

Despite four decades of translational research, no pharmacological agent has been approved for acute traumatic spinal cord injury (SCI) based on class-I evidence. The current narrative review critically examines the seven agents evaluated in phase-II to -III clinical trials-methylprednisolone (MPSS), GM-1 monosialotetrahexosylganglioside, minocycline, riluzole, anti-Nogo-A antibody NG101, VX-210, and granulocyte colony-stimulating factor (G-CSF)-with emphasis on quantitative effect estimates, confidence intervals, and mechanisms of translational failure. Polylaminin, under phase-I evaluation approved by the Brazilian Health Regulatory Agency (Agência Nacional de Vigilância Sanitária, ANVISA, in Portuguese), is discussed in the context of disproportionate public communication relative to the stage of evidence; available human data are limited to a small, uncontrolled, unreviewed pilot study insufficient for efficacy inferences. High-dose MPSS conferred no motor recovery benefit in a meta-analysis of 1,863 participants and was significantly associated with gastrointestinal hemorrhage (odds ratio [OR] = 2.07; 95%CI: 1.02-4.20) and respiratory infections (OR = 1.73; 95%CI: 1.12-2.68). Furthermore, GM-1 ganglioside, G-CSF, and VX-210 failed to meet the prespecified primary endpoints. Minocycline produced inconclusive results in an underpowered phase-II study. Riluzole (Riluzole in Spinal Cord Injury Study [RISCIS]), which was prematurely terminated at 55% of enrollment due to the coronavirus disease 2019 (COVID-19) pandemic, showed a significant motor benefit in patients classified as grade C according to the American Spinal Injury Association (ASIA) Impairment Scale (AIS) (+8.0 points; 95%CI: 1.5-14.4; 2-tailed p = 0.034). The Nogo Inhibition in Spinal Cord Injury (NISCI) trial (2025), the most methodologically rigorous SCI trial to date, demonstrated no primary endpoint benefit but identified functional signals in motor-incomplete injuries. In total, six structural domains of translational failure are identified and methodological solutions proposed.

Hemorrhage is a clinically important emergency in gastric cancer, occurring in an estimated 3-36% of patients (with the incidence varying substantially by disease stage, tumor morphology, and the operational definition of hemorrhage applied), and potentially becoming life-threatening within 24 h. This review synthesizes evidence from the past two decades to propose a multidisciplinary, stepwise framework for managing gastric cancer-associated bleeding. Endoscopic hemostasis remains the first-line intervention and achieves initial bleeding control in 83-92.9% of cases, although 30-day rebleeding occurs in up to 28-41%. Transcatheter arterial embolization is an important option for persistent bleeding or hemodynamic instability, with a reported clinical success of approximately 72%. Palliative radiotherapy provides effective hemostasis in 68-88.5% of cases, and a biologically effective dose (BED10) exceeding 39 Gy may improve bleeding control. Surgery should be individualized according to disease stage, resectability, physiological reserve, and treatment intent, ranging from emergency vessel ligation to curative resection. Importantly, hemostasis should be regarded not as a final endpoint but as a therapeutic bridge enabling definitive anticancer therapy. Successful bleeding control followed by systemic chemotherapy is associated with improved overall survival. Management therefore requires coordinated decision-making among gastroenterology, interventional radiology, surgery, radiation oncology, and medical oncology teams.

Objective: To evaluate the real-world effectiveness and tolerability of Iron Hydroxide Adipate Tartrate (IHAT[TM]) in women with iron deficiency across three common obstetric and gynecologic clinical settings: pregnancy, the postpartum period, and abnormal uterine bleeding. Methods: This prospective multicenter observational real-world study included women with iron deficiency managed in routine clinical practice across Italy. Participating gynecologists collected data using standardized case report forms. Patients received IHAT[TM] according to routine clinical practice and were followed for approximately three months. Baseline demographic and hematologic parameters were recorded, including hemoglobin and ferritin levels. The primary outcome was the change in hemoglobin between baseline and follow-up. Secondary outcomes included changes in ferritin levels, treatment adherence, and tolerability. Results: A total of 517 women was included in the analysis. The study population included pregnant women (N = 287, 55.5%), women with abnormal uterine bleeding (N = 161, 31.1%), and women in the postpartum period (N = 69, 13.3%). Improvements in hemoglobin were observed across all clinical settings, with hemoglobin increasing from 10.35 g/dL at baseline to 11.63 g/dL at three months, corresponding to a mean increase of 1.28 g/dL. Mean ferritin levels increased from 22.50 ng/mL to 37.74 ng/mL in three months. Treatment adherence was high or moderate in 93.4% of patients. Gastrointestinal adverse events were infrequent, with constipation (9.7%) and nausea (4.8%) among the most reported. Conclusions: In this prospective real-world multicenter study, treatment with IHAT[TM] was associated with meaningful improvements in hemoglobin and iron stores in women with iron deficiency across pregnancy, postpartum, and abnormal uterine bleeding. The treatment showed good adherence and a favorable tolerability profile in routine clinical practice.

Acid sphingomyelinase deficiency (ASMD) is an autosomal recessive lysosomal storage disorder caused by mutations in the SMPD1 gene, resulting in sphingomyelin accumulation. With a birth prevalence of 0.25-0.6 per 100,000, it is more prevalent in Ashkenazi Jewish and Middle Eastern populations. The disease features a clinical spectrum ranging from severe, early-onset neurodegeneration (infantile neurovisceral ASMD) to chronic, non-neurological visceral involvement (chronic visceral ASMD) and intermediate forms (chronic neurovisceral ASMD). The chronic visceral form is characterized by liver dysfunction, respiratory symptoms, and hepatosplenomegaly, which can lead to secondary thrombocytopenia. The majority of patients exhibit thrombocytopenia and/or mild bleeding manifestations, most commonly easy bruising and epistaxis, whereas clinically significant bleeding events, including gastrointestinal or variceal hemorrhage, occur less frequently. Systematic platelet-function studies in patients with ASMD are currently lacking. Evidence retrieved from biological models indicates that ASMD contributes to platelet dysfunction, including impaired secretion and thrombin generation, mediated by complex pathological mechanisms. These findings underscore the importance of hematological monitoring and further research in patients with this condition and could potentially offer new therapeutic possibilities.

Background/Objectives: Gastrointestinal (GI) bleeding in patients with malignancy is frequently refractory to endoscopic and conservative management. Transarterial embolization (TAE) is an established treatment option, but whether the presence of contrast extravasation on preprocedural computed tomography (CT) influences outcomes remains unclear. This study aimed to evaluate the efficacy and safety of TAE for malignancy-related GI bleeding in patients with and without CT-detected contrast extravasation. Methods: From January 2012 to December 2023, 40 consecutive patients who underwent TAE for malignancy-related GI bleeding were retrospectively analyzed and categorized into CT extravasation (n = 25) and CT no-extravasation (n = 15) groups based on preprocedural CT findings. Technical success, clinical success, 30-day mortality, overall survival (OS), and procedure-related complications were compared between groups, and factors associated with OS were evaluated using Cox regression. Results: The technical and clinical success rates were 100% (40/40) and 82.5% (33/40), respectively. Clinical success did not differ between the CT extravasation and no-extravasation groups (84.0% [21/25] vs. 80.0% [12/15]; p = 0.747). Two of 40 patients (5.0%) died within 30 days, one in each group (p = 0.708). OS did not differ significantly (log-rank p = 0.707; median, 147 vs. 187 days). A shock index > 1 was independently associated with worse OS (hazard ratio, 2.308; 95% confidence interval, 1.071-4.972; p = 0.033). No major procedure-related complications occurred. Conclusions: TAE achieved high technical success and comparable short-term clinical outcomes in patients with and without CT extravasation. Hemodynamic instability, rather than CT extravasation, was independently associated with OS.

Background/Objectives: This study aims to analyze safety and effectiveness of imipenem/cilastatin sodium (IPM/CS) as an off-label embolic agent in acute lower gastrointestinal bleeding (LGIB). Methods: This is a multicentric prospective study including patients treated in emergency with endovascular embolization for acute LGIB. IPM/CS particles were prepared using one vial containing 500 mg/500 mg of IPM/CS in powder diluted with 5 mL of pure iodine contrast agent. Inclusion criteria were: acute bleeding managed with IMP/CS embolization, unfeasible/ineffective endoscopic management, availability of a pre-procedural contrast-enhanced Computed Tomography (CT) scan, pre- and post-procedural blood count, pre- and post-procedural hemodynamic balance evaluation, and follow-up to 30 days. Exclusion criteria were: patients treated in elective conditions, LGIB embolization performed without IMP/CS, IMP/CS adoption after other embolics, incomplete clinical-laboratoristic follow-up, and age < 18 years. Technical success was intended as angiographic disappearance of extravasation or significant reduction/stasis of blood flow to the target; clinical success was considered as hemoglobin values increase and/or stop transfusions and/or hemodynamic restoration. Result: Twenty-one patients were enrolled; bleeding etiologies included angiodysplasia, diverticular disease, gastrointestinal tumor-related bleeding, and post-surgical hemorrhage. Technical success rate was 100%, and clinical success rate at 30 days was 85.7%. Rebleeding occurred in three patients: two managed with surgery and one with coil re-embolization. Neither major and IPM/CS related complications occurred. Conclusions: In this study IPM/CS was a safe and feasible embolic agent in selected patients with acute LGIB; no bowel ischemia occurred during the 30 day follow-up. Future studies with larger samples are required to confirm these findings to include IPM/CS as an off-label alternative embolic agent in LGIB.