Aims The EURO-ENDO registry aimed to study the management and outcomes of patients with infective endocarditis (IE). Methods and results Prospective cohort of 3116 adult patients (2470 from Europe, 646 from non-ESC countries), admitted to 156 hospitals in 40 countries between January 2016 and March 2018 with a diagnosis of IE based on ESC 2015 diagnostic criteria. Clinical, biological, microbiological, and imaging [echocardiography, computed tomography (CT) scan, 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT)] data were collected. Infective endocarditis was native (NVE) in 1764 (56.6%) patients, prosthetic (PVIE) in 939 (30.1%), and device-related (CDRIE) in 308 (9.9%). Infective endocarditis was community-acquired in 2046 (65.66%) patients. Microorganisms involved were staphylococci in 1085 (44.1%) patients, oral streptococci in 304 (12.3%), enterococci in 390 (15.8%), and Streptococcus gallolyticus in 162 (6.6%). 18F-fluorodeoxyglucose positron emission tomography/computed tomography was performed in 518 (16.6%) patients and presented with cardiac uptake (major criterion) in 222 (42.9%) patients, with a better sensitivity in PVIE (66.8%) than in NVE (28.0%) and CDRIE (16.3%). Embolic events occurred in 20.6% of patients, and were significantly associated with tricuspid or pulmonary IE, presence of a vegetation and Staphylococcus aureus IE. According to ESC guidelines, cardiac surgery was indicated in 2160 (69.3%) patients, but finally performed in only 1596 (73.9%) of them. In-hospital death occurred in 532 (17.1%) patients and was more frequent in PVIE. Independent predictors of mortality were Charlson index, creatinine > 2 mg/dL, congestive heart failure, vegetation length > 10 mm, cerebral complications, abscess, and failure to undertake surgery when indicated. Conclusion Infective endocarditis is still a life-threatening disease with frequent lethal outcome despite profound changes in its clinical, microbiological, imaging, and therapeutic profiles.
Pancreatic cancer is one of our most lethal malignancies. Despite substantial improvements in the survival rates for other major cancer forms, pancreatic cancer survival rates have remained relatively unchanged since the 1960s. Pancreatic cancer is usually detected at an advanced stage and most treatment regimens are ineffective, contributing to the poor overall prognosis. Herein, we review the current understanding of pancreatic cancer, focusing on central aspects of disease management from radiology, surgery and pathology to oncology. Historical remarks & present stateThe first known description of pancreatic cancer is attributed to Giovanni Battista Morgagni in his 1761 publication 'de Sedibus Et Causis Morborum Per Anatomen Indagatis Libri Quinque' [1]. However, the lack of a microscopic evaluation makes the true diagnosis of ductal adenocarcinoma uncertain. The next important advancement in our understanding of pancreatic cancer did not come until 1858, when Jacob Mendez Da Costa revisited Morgagni's original work and also described the first microscopic diagnosis of adenocarcinoma, manifesting pancreatic cancer as a true disease entity [2].The history of pancreatic surgery is fairly recent and involves a combination of brave surgical pioneers, the development of surgical anesthesia and modern aseptic techniques. Some landmarks in the history of pancreatic surgery deserve to be mentioned. The first reported attempt at a pancreaticoduodenectomy was performed in 1898 by the Italian surgeon Alessandro Codivilla for a tumor involving the head of the pancreas [3]; however, the patient did not survive the postoperative period. In the same year, William Stewart Halsted from Johns Hopkins Hospital performed the first successful resection for ampullary cancer by excising portions of the duodenum and the pancreas [4]. The first successful pancreaticoduodenectomy is credited to the German surgeon Walther Carl Eduard Kausch, as part of a two-stage procedure [5]. In 1914, Georg Hirschel performed the first successful pancreaticoduodenectomy in one stage [6] and then in 1935, Allen Oldfather Whipple presented the results of a two-stage procedure involving the resection of the head of the pancreas and duodenum for ampullary carcinoma at the annual meeting of the American Surgical Association, which renewed interest in pancreatic surgery [7]. During his career, Whipple performed 37 pancreaticoduodenectomies, with the procedure evolving into a one-stage technique [8,9], and 1964-1968 1969-1973 1974-1978 1979-1983 1984-1988 1989-1993 1994-1998 1999-2003 2004-2008 2009-2013 Period of diagnosis Whipple is generally credited with popularizing the operation that still bears his name. In 1937, Alexander Brunschwig performed the first successful pancreaticoduodenectomy for pancreatic adenocarcinoma [10]. Today, with the concentration of experience in high-volume hospitals, pancreatic surgery has become a safe procedure associated with an operative mortality below 3% [11][12][13]. While major advances have been made ...
for the European Study Group for Pancreatic Cancer IMPORTANCE The patterns of disease recurrence after resection of pancreatic ductal adenocarcinoma with adjuvant chemotherapy remain unclear. OBJECTIVE To define patterns of recurrence after adjuvant chemotherapy and the association with survival. DESIGN, SETTING, AND PARTICIPANTS Prospectively collected data from the phase 3 European Study Group for Pancreatic Cancer 4 adjuvant clinical trial, an international multicenter study. The study included 730 patients who had resection and adjuvant chemotherapy for pancreatic cancer. Data were analyzed between July 2017 and May 2019. INTERVENTIONS Randomization to adjuvant gemcitabine or gemcitabine plus capecitabine. MAIN OUTCOMES AND MEASURES Overall survival, recurrence, and sites of recurrence. RESULTSOf the 730 patients, median age was 65 years (range 37-81 years), 414 were men (57%), and 316 were women (43%). The median follow-up time from randomization was 43.2 months (95% CI, 39.7-45.5 months), with overall survival from time of surgery of 27.9 months (95% CI, 24.8-29.9 months) with gemcitabine and 30.2 months (95% CI, 25.8-33.5 months) with the combination (HR, 0.81; 95% CI, 0.68-0.98; P = .03). The 5-year survival estimates were 17.1% (95% CI, 11.6%-23.5%) and 28.0% (22.0%-34.3%), respectively. Recurrence occurred in 479 patients (65.6%); another 78 patients (10.7%) died without recurrence. Local recurrence occurred at a median of 11.63 months (95% CI, 10.05-12.19 months), significantly different from those with distant recurrence with a median of 9.49 months (95% CI, 8.44-10.71 months) (HR, 1.21; 95% CI, 1.01-1.45; P = .04). Following recurrence, the median survival was 9.36 months (95% CI, 8.08-10.48 months) for local recurrence and 8.94 months (95% CI, 7.82-11.17 months) with distant recurrence (HR, 0.89; 95% CI, 0.73-1.09; P = .27). The median overall survival of patients with distant-only recurrence (23.03 months; 95% CI, 19.55-25.85 months) or local with distant recurrence (23.82 months; 95% CI, 17.48-28.32 months) was not significantly different from those with only local recurrence (24.83 months; 95% CI, 22.96-27.63 months) (P = .85 and P = .35, respectively). Gemcitabine plus capecitabine had a 21% reduction of death following recurrence compared with monotherapy (HR, 0.79; 95% CI, 0.64-0.98; P = .03). CONCLUSIONS AND RELEVANCEThere were no significant differences between the time to recurrence and subsequent and overall survival between local and distant recurrence. Pancreatic cancer behaves as a systemic disease requiring effective systemic therapy after resection.
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