European Evidence-based Guidelines Research Articles

Abstract 3381: Establishment of a novel multi-omic biomarker panel in cyst fluid and blood for stratifying patient risk of pancreatic cancer

Abstract Introduction: Pancreatic cancer was responsible for almost 500,000 deaths globally in 2020 according to GLOBOCAN. Pancreatic cystic lesions (PCLs) are fluid-filled protrusions either on or inside the pancreas and can either be benign or pre-malignant. Current clinical guidelines to risk stratify PCL patients are imperfect. Multi-omic profiling of pancreatic cyst fluid (PCF) could aid in the identification of a novel biomarker panel to improve PCL risk stratification. Methods: PCF was collected from 40 patients by EUS-FNA, with matched serum collected prior to EUS. Patients were stratified using the 2018 European evidence-based guidelines into low-risk (n=15), high risk (n=15) and no-risk or pseudocyst (n=10). PCF was sonicated and subsequently processed using an SP3 paramagnetic bead protocol prior to LC-MS. MS-generated LFQ intensity data were analyzed in Perseus (v1.6.13.0) and STRING (v11.5). HTG microRNA whole transcriptome sequencing was run on whole PCF. MiRNA sequencing data were analyzed using HTG EdgeSeq Reveal (v3.1.0). Spearman correlations were generated using R packages ‘Hmisc’ (v4.5-0) and ‘corrplot’ (v0.90). Results: MS-analysis of PCF revealed 8 proteins to be significantly upregulated in high-risk compared to low-risk (p<0.05, FDR=0.05, s0=0.1). All 8 proteins had significantly positive correlations with patient risk and expression of the other seven. LCN-2, REG1A, LGALS3, PIGR and S100A8 have been shown to be elevated in the blood of pancreatic cancer patients. PRSS8 is known to be elevated in the serum of ovarian cancer patients, while MUC6 and TCN1 have not been shown to be differentially expressed in the circulation of cancer patients. STRING analysis revealed 11.8% and 6.8% of the proteins identified to be involved in the innate and adaptive immune responses, respectively. Significant positive correlations were found between 11 immune-associated proteins and patient risk classification (p<0.05). Whole transcriptome sequencing revealed 3 miRNA (miR-216a-5p, miR-216b-5p and HK_SKORA66) to be significantly upregulated in high-risk PCF compared to low-risk, and 5 miRNA (miR-197-5p, miR-6741-5p, miR-3180-3p, miR-3180 and miR-6782-5p) to be significantly upregulated in matched high-risk serum compared to low-risk (adj-p<0.05, FDR=0.05, s0=0.1). Unsupervised hierarchical clustering of patients using the 8 differentially expressed proteins and 3 miRNA from the PCF gave a clustering accuracy of 95.8%, with just 1/24 patients being misclassified. Conclusion: We have identified a putative multi-omic biomarker panel for PCL patient risk stratification. Practically, further refinement of this panel through the inclusion of additional biological compartments is required. These data will be validated in a larger patient cohort, with the aim of generating a less invasive blood-based panel that will aid in the improvement of risk stratification. Citation Format: Laura E. Kane, Gregory S. Mellotte, Rebecca G. Lyons, Eimear Mylod, Simone Marcone, Paul F. Ridway, Finbar MacCarthy, Kevin C. Conlon, Joanne Lysaght, Barbara M. Ryan, Stephen G. Maher. Establishment of a novel multi-omic biomarker panel in cyst fluid and blood for stratifying patient risk of pancreatic cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3381.

Pancreatic intraductal papillary mucinous neoplasms: Current diagnosis and management.

Intraductal papillary mucinous neoplasms (IPMNs) represent approximately 1% of all pancreatic neoplasms and 25% of cystic neoplasms. They are divided into three types: main duct-IPMN (MD-IPPMN), branch duct-IPMN (BD-IPMN), and mixed type-IPMN. In this review, diagnostics, including clinical presentation and radiological investigations, were described. Magnetic resonance imaging is the most useful for most IPMNs. Management depends on the type and radiological features of IPMNs. Surgery is recommended for MD-IPMN. For BD-IPMN, management involves surgery or surveillance depending on the tumor size, cyst growth rate, solid components, main duct dilatation, high-grade dysplasia in cytology, the presence of symptoms (jaundice, new-onset diabetes, pancreatitis), and CA 19.9 serum level. The patient’s age and comorbidities should also be taken into consideration. Currently, there are different guidelines regarding the diagnosis and management of IPMNs. In this review, the following guidelines were presented: Sendai International Association of Pancreatology guidelines (2006), American Gastroenterological Association guidelines, revised international consensus Fukuoka guidelines (2012), revised international consensus Fukuoka guidelines (2017), and European evidence-based guidelines according to the European Study Group on Cystic Tumours of the Pancreas (2018). The Verona Evidence-Based Meeting 2020 was also presented and discussed.

Abstract PO-009: Multi-omic profiling of patient pancreatic cyst fluid for the identification of a novel biomarker panel of patient cancer risk

Abstract Background: Pancreatic cancer was responsible for almost 500,000 deaths globally in 2020 according to GLOBOCAN 2020. Pancreatic cystic lesions (PCLs) are fluid-filled protrusions either on or inside the pancreas. PCLs can either be benign or pre-malignant, however, current guidelines based on clinical features are limited in their ability to accurately stratify patients based on cancer risk. Multi-omic profiling of the pancreatic cyst fluid (PCF) could aid in the identification of a novel biomarker panel of patient cancer risk. Methods: PCF was collected from 40 patients by EUS-FNA. Patients were stratified using the 2018 European evidence-based guidelines into low-risk (n=15), high risk (n=15) and no-risk/pseudocyst (n=10). PCF was sonicated and subsequently processed using a single-pot solid-phase-enhanced sample preparation (SP3) protocol with Sera-Mag SpeedBead carboxylate-modified beads prior to LC-MS. Samples were run on a Thermo Scientific Q Exactive mass spectrometer coupled to a Dionex Ultimate 3000 (RSLCnano) chromatography system. MS-generated proteomic data were analysed in Perseus (v1.6.13). HTG microRNA whole transcriptome sequencing was run on whole PCF. Transcriptomic data were analysed using HTG EdgeSeq Reveal (v3.1). Results: MS-analysis revealed 1,266 proteins present across all PCF samples. Proteins were filtered based on potential contaminants and valid values. Only proteins expressed in a minimum of six PCF samples were included in the analysis. After data clean-up, 465 proteins were examined for differential expression. A total of eight proteins were upregulated in high-risk PCF compared to low-risk (p<0.05, FDR=0.05, s0=0.1). Among them, seven have been shown to be upregulated in pancreatic cancer. Conversely, one protein which is reported to be downregulated in pancreatic cancer, was significantly upregulated in the high-risk patient cohort. A total of 2,096 miRNAs were identified across all PCF samples. MiRNAs were filtered based on fold-change > ±2 between the groups, with 202 miRNAs meeting this criteria. Forty-six miRNAs were significantly upregulated in high-risk PCF compared to low-risk PCF (adj-p<0.05, FDR=0.05, s0=0.1). Five of these miRNAs are known to be upregulated in pancreatic ductal adenocarcinoma (PDAC) tissues. Furthermore, three of the miRNAs are upregulated in the circulation of PDAC patients. Importantly, seven miRNAs identified as being upregulated in high-risk PCF have been shown to be downregulated in PDAC tissues. Differentially expressed proteins and miRNAs are currently being utilised to create an integrated, multi-omic predictive algorithm for patient risk. Conclusion: Multi-omic profiling of pancreatic cyst fluid provides an abundance of potential biomarkers that could be utilised for the stratification of patients into high-and low-risk groups for malignancy. Integration of multi-omic data has the potential to provide more robust biomarker panels of patient risk. Validation of biomarkers in independent patient cohorts will be key to the development of novel clinical biomarkers. Citation Format: Laura E. Kane, Gregory S. Mellotte, Simone Marcone, Barbara M. Ryan, Stephen G. Maher. Multi-omic profiling of patient pancreatic cyst fluid for the identification of a novel biomarker panel of patient cancer risk [abstract]. In: Proceedings of the AACR Virtual Special Conference on Pancreatic Cancer; 2021 Sep 29-30. Philadelphia (PA): AACR; Cancer Res 2021;81(22 Suppl):Abstract nr PO-009.

Evaluating the accuracy of three international guidelines in identifying the risk of malignancy in pancreatic cysts: a retrospective analysis of a surgical treated population.

The international consensus Fukuoka guideline (Fukuoka ICG), The European evidence-based guideline on pancreatic cystic neoplasms (European EBG) and the American Gastroenterological Association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts (AGA IG) are 3 frequently cited guidelines for the risk stratification of neoplastic pancreatic cysts. The aim of this study was to assess the accuracy of detecting malignant cysts by strictly applying these guidelines retrospectively to a cohort of surgically resected pancreatic cysts. 72 resected cysts were included in the analysis. Invasive carcinoma, high grade dysplasia and neuro-endocrine tumour were considered as "malignant cysts" for the purpose of the study. 32% of the resected cysts were malignant. The analysis showed that the Fukuoka ICG, European EBG and AGA IG had a sensitivity of 66,8%, 95,5%, 80%; a specificity of 26,8%, 11,3%, 43,8%; a positive predictive value of 31,8%, 35%, 47,1% and a negative predicted value of 61,1%, 83,3%, 77,8% respectively. The missed malignancy rate was respectively 11,3%, 1,5%, 7,7% and surgical overtreatment was respectively 48,4%, 59,1%, 34,6%. In this retrospective analysis, the European EBG had the lowest rate of missed malignancy at the expense of a high number of "unnecessary" resections. The Fukuoka ICG had the highest number of missed malignancy. The AGA IG showed the lowest rate of unnecessary surgery at the cost of a high number of missed malignancy. There is need to develop better biomarkers to predict the risk of malignancy.

Adherence to European Guidelines for Treatment and Management of Pancreatic Exocrine Insufficiency in Chronic Pancreatitis Patients.

European evidence-based guidelines for the treatment and management of chronic pancreatitis (CP) have been made available following the harmonizing diagnosis and treatment of CP across Europe (HaPanEU) initiative by the United European Gastroenterology (UEG). The aim of this study was to evaluate adherence to the guideline recommendations in the management of patients with pancreatic exocrine insufficiency (PEI) at Karolinska University Hospital in Stockholm. UEG guideline recommendations were evaluated and categorized into 55 different quality indicators (QIs). Data from a retrospective cohort of CP patients being treated at Karolinska University Hospital were evaluated with regard to overall adherence as well as adherence to specific QIs. A total number of 118 patients out of 956 patients diagnosed with CP were eligible for inclusion with mean overall adherence of 61.9% to the defined QIs. A significant difference in mean overall adherence was shown between patients diagnosed with CP prior to 1 January 2016 and following 1 January 2016 (59.3% and 67.7% respectively, p = 0.004), with linear regression analysis also demonstrating improvement correlating to date of diagnosis (p = 0.002). In conclusion, diagnosis and treatment of PEI improved after the HaPanEU guidelines became available and is continuously improving; however, there is room for further improvement.

Diagnostic efficacy for predicting intraductal papillary mucinous neoplasms of the pancreas with high grade dysplasia or invasive carcinoma based on the surgery indications in different guidelines

Objective: To evaluate the performance of the European Evidence-based Guidelines on Pancreatic Cystic Neoplasms (EEGPCN)(2018) and International Association of Pancreatology(IAP) Guideline(Version 2017) in predicting high grade dysplasia/invasive carcinoma-intraductal papillary mucinous neoplasm(HGD/INV-IPMN). Methods: A retrospective analysis of 363 patients,who underwent surgical resection in Changhai Hospital affiliated to Navy Medical University from January 2012 to December 2018 and were pathologically identified as (intraductal papillary mucinous neoplasm, IPMN),was performed. The patients,including 230 males and 133 females,aging (61.7±10.1) years(range:19 to 83 years). The proportion of HGD/INV-IPMN who met with the absolute indication(AI) of EEGPCN and high risk stigma(HRS) of IAP were compared. The binary Logistic regression analysis was used to find the independent risk factors of HGD/INV-IPMN.Eight combinations of risk factors derived from relative indication/worrisome feature or risk factors in this study,were made to evaluate the diagnostic efficacy. The area under curve(AUC) of receiver operating characteristics was used to evaluate the the cutoff value of risk factors(①CA19-9≥37 U/ml,②diameter of main pancreatic duct 5.0-9.9 mm,③enhancing mural nodule<5 mm,④(acute) pancreatiti,⑤acyst diameter ≥40 mm,⑤bcyst diameter ≥30 mm, ⑥thickened or enhancing cyst walls,⑦neutrophile granulocyte to lymphocyte ratio(NLR)≥2, ⑧cyst located in head, uncinate or neck,⑨carcinoembryonic antigen(CEA) ≥5 μg/L) number for predicting HGD/INV-IPMN.The accuracy,sensitivity,specificity,positive predictive value,negative predictive value,true positive,true negative,false positive,false negative,positive likelihood ratio,negative likelihood ratio,Youden index and F1 score were calculated. Results: Ninety-two patients(49.5%) of 186 ones who met AI and 85 patients(48.3%) of 176 ones who met HRS were respectively confirmed as HGD/INV-IPMN. In those patients who were not met AI,tumor location,thickened/enhancing cyst wall,CA19-9 elevated,NLR≥2 and CEA elevated were significantly (P<0.05) correlated with HGD/INV-IPMN. And tumor location(head/uncinate/neck vs. body/tail,OR=3.284,95%CI:1.268-8.503,P=0.014),thickened/enhancement cyst wall (with vs.without,OR=2.713,95%CI:1.177-6.252,P=0.019),CA19-9(≥37 U/L vs.<37 U/L, OR=5.086,95%CI:2.05-12.62,P<0.01) and NLR(≥2 vs.<2,OR=2.380,95%CI:1.043-5.434,P=0.039) were the independent risk factors of HGD/INV-IPMN. Patients with ≥4 risk factors of 9 in combination Ⅷ(①②③④⑤b⑥⑦⑧⑨) were diagnosed as HGD/INV-IPMN with the moderate accuracy(71.0%),moderate sensitivity (62.0%) and moderate specificity (73.0%). Patients with ≥4 risk factors of 9 in Combination Ⅶ(①②③④⑤a⑥⑦⑧⑨) were diagnosed as HGD/INV-IPMN with the highest specificity(83.0%) and patients with ≥3 risk factors of 8 in combination Ⅵ(①②③④⑤b⑥⑧⑨) were diagnosed as HGD/INV-IPMN with the highest sensitivity(74.0%). The AUC for diagnosis of HGD/INV-IPMN in combination Ⅵ,Ⅶ and Ⅷ were 0.72,0.75 and 0.75,respectively. Older patients and younger patients could respectively refer to combination Ⅶ and combination Ⅵ to improve the management of IPMN. Conclusions: Patients who meet AI of EEGPCN should undertake resection, otherwise the method we explored is recommended. The method of improvement for diagnosis of HGD/INV-IPMN is relatively applicable and efficient for decision-making of surgery, especially for younger patients with decreasing of missed diagnosis and elder patients with decreasing of misdiagnosis.

Comparison of Preoperative Evaluation with the Pathological Report in Intraductal Papillary Mucinous Neoplasms: A Single-Center Experience.

The key to the successful management of pancreatic cystic neoplasm (PCN), among which intraductal papillary mucinous neoplasm (IPMN) is the one with the highest risk of advanced neoplasia in resected patients, is a careful combination of clinical, radiological, and histopathological findings. This study aims to perform the comparison of a preoperative evaluation with pathological reports in IPMN and further, to evaluate and compare the diagnostic performance of European evidence-based guidelines on pancreatic cystic neoplasms (EEBGPCN) and Fukuoka Consensus guidelines (FCG). We analyzed 106 consecutive patients diagnosed with different types of PCN, among whom 68 had IPMN diagnosis, at the Clinical Center of Serbia. All the patients diagnosed with IPMNs were stratified concerning the presence of the absolute and relative indications according to EEBGPCN and high-risk stigmata and worrisome features according to FCG. Final histopathology revealed that IPMNs patients were further divided into malignant (50 patients) and benign (18 patients) groups, according to the pathological findings. The preoperative prediction of malignancy according to EEBGPCN criteria was higher than 70% with high sensitivity of at least one absolute or relative indication for resection. The diagnostic performance of FCG was shown as comparable to EEBGPCN. Nevertheless, the value of false-positive rate for surgical resection showed that in some cases, overtreating patients or treating them too early cannot be prevented. A multidisciplinary approach is essential to adequately select patients for the resection considering at the same time both the risks of surgery and malignancy.

Is there an optimal dose of cardiac rehabilitation in coronary artery disease patients?

BackgroundMany studies have shown that participation in cardiac rehabilitation reduces long-term morbidity and mortality after myocardial infarction. Therefore, both American and European evidence-based guidelines recommend cardiac rehabilitation. However, it is still unclear what the optimal dose of cardiac rehabilitation is. MethodologyThe study is a monocenter, retrospective cohort study. We identified patients with stable ischemic heart disease, who participated in at least one phase II center-based cardiac rehabilitation session between 2010 and 2015. A total of 609 patients were included in this study. ResultsWe retrospectively reviewed the medical records of 609 patients. Statistically significant baseline differences between the four groups were observed for index coronary artery revascularization technique, age, dual antiplatelet therapy and smoking status. A total of number of 84 patients (13.8%) had a MACE in the four-year follow-up period. After adjustment for all significant predictors in the univariate analysis, patients who attended 36 or more sessions had a 47% lower risk of MACE (hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.31 to 0.92), patients who attended 24 to 35 sessions had a 68% lower risk of MACE (hazard ratio [HR], 0.32; 95% confidence interval [CI], 0.15 to 0.67), patients who attended 12 to 23 sessions had a 56% lower risk of MACE (hazard ratio [HR], 0.44; 95% confidence interval [CI], 0.21 to 0.92) than those who attended 1 to 11 sessions. ConclusionThere is a clear clinical benefit from participating in more than 11 CR sessions. The best outcomes are achieved in patient who participated between 24 and 35 CR sessions. These results underline again the importance of improving participation and adherence to CR programmes in Europe.

The European evidence-based guidelines on pancreatic cystic neoplasms (PCN) in clinical practice: The development of relative and absolute indications for surgery during prospective IPMN surveillance

IntroductionThe European evidence-based guidelines on PCN recommend surveillance for IPMN patients who are fit for surgery but who have no indication for immediate surgery. Our aim was to demonstrate the feasibility of the new guidelines in clinical practice. MethodsThis is a prospective cohort study of patients included in the IPMN register in Tampere University Hospital, Finland. IPMN was diagnosed from January 1, 2013 to December 31, 2018. Patients were analyzed for surveillance and indications for surgery according to the European guidelines on PCN. ResultsOut of 128 patients in register 23 was decided to operate upfront and 105 patients were included in the surveillance programme. Invasive carcinoma was found in 4/23 of operated patients. Median follow-up time was 26 months (6–69). Median size of the cyst at the beginning and end of the surveillance was 16 mm (4–58 mm). During surveillance 0/105 (0.0%) patients had or developed an absolute indication for surgery. Relative indication for surgery was present in 8/105 (7.6%) patients in the beginning surveillance and 9/105 (8.6%) patients developed at least one relative indication for surgery during surveillance. From the surveillance cohort 2/105 patients were operated. Surveillance was abandoned in 15/105 (14.1%) patients all due to poor general condition or other medical conditions. ConclusionsIn clinical practice, surveillance of IPMN according to the European guidelines on PCN is feasible. Among our patients 16% were detected to have relative indications for surgery during the median 26 (range 3–135) months of surveillance. Nearly 15% became surgically unfit during surveillance period.

Validation of European evidence‐based guidelines and American College of Gastroenterology guidelines as predictors of advanced neoplasia in patients with suspected mucinous pancreatic cystic neoplasms

The European evidence-based guidelines (EEG) and American College of Gastroenterology Guidelines (ACGG) have been published to guide the management of pancreatic cystic lesions. We aim to evaluate the value of both guidelines in predicting advanced pancreatic cystic lesions (A-PCLs) with preoperatively imaging-suspected cystic mucinous pancreatic neoplasms (cMNs). One hundred ninety-eight patients who underwent resections from 2013 to 2019 for suspected cMNs were retrospectively reviewed. Receiver operating characteristic curves were calculated and compared with measure diagnostic value. Sixty-two patients were diagnosed with A-PCLs pathologically. Cross-imaging modalities had comparable diagnostic accuracy to endoscopic ultrasound in type classification and A-PCLs prediction. Receiver operating characteristic curve comparison analyses showed that EEG absolute+MCN (EEGAM ) and EEG relative+MCN (EEGRM ) having at least one indications criteria were comparable to the ACGG (P=0.21 and P=0.45). For the criteria having at least two indications, ACGG was superior to EEGAM (P=0.001) but comparable to EEGRM (P=0.12). EEGAM ≥1 indication criteria was superior to ≥2 indications criteria (P=0.02). EEGRM ≥1 indication criteria had comparable diagnostic performance with ≥2 indications criteria (P=0.86). ACGG ≥2 indications criteria was superior to ≥1 indication criteria (P=0.02). On the basis of cross-imaging evaluations, both sets of guidelines were found to be helpful in identifying A-PCLs in suspected cMNs with comparable performance. EEGAM ≥1 indication criteria was superior to ≥2 indications criteria. ACGG ≥2 indications criteria was superior to ≥1 indication criteria.

Validation of Indications for Surgery of European Evidence-Based Guidelines for Patients with Pancreatic Intraductal Papillary Mucinous Neoplasms

BackgroundWhich patients with pancreatic intraductal papillary mucinous neoplasms (IPMNs) should undergo surgical intervention remains a controversial issue. The aim of this retrospective study was to validate the new European evidence-based guidelines on pancreatic cystic neoplasms (EEBGPCN) for the management of IPMNs. MethodsOne hundred fifty-eight patients with resected IPMNs at National Taiwan University Hospital between January 1994 and December 2016 were enrolled. Clinical information, including new-onset diabetes mellitus (DM) and preoperative CA 19-9 levels, were collected. All patients were stratified into three groups—absolute, relative indications, and conservative approach—according to EEBGPCN. The performance characteristics of EEBGPCN for high-grade dysplasia (HGD)/invasive carcinoma (IC) of IPMNs were calculated. ResultsOne hundred seven (67.7%) patients with low-grade dysplasia and 51 patients with HGD/IC, including 10 HGD and 41 IC, were analyzed. The missed rate for HGD/IC by EEBGPCN was 1.9% (3/158). The sensitivity, specificity, positive and negative predictive values, and accuracy of the absolute or relative indications for resecting IPMN according to EEBGPCN were 94.1%, 28.0%, 38.4%, 90.9%, and 49.4%. Jaundice, enhancing mural nodule < 5 mm, cyst diameter > 40 mm, increased levels of serum CA 19-9, new-onset DM, and main pancreatic duct dilation were associated with HGD/IC. ConclusionsThe missed rate for HGD/IC is low by EEBGPCN. Increased serum CA 19-9 and new-onset DM in EEBGPCN were verified as the indications for the surgical resection of IPMNs.

The European evidence-based guidelines on pancreatic cystic neoplasms (PCN) in clinical practice: the development of relative and absolute indications for surgery during prospective IPMN surveillance

To elucidate predictive factors for malignant main duct type IPMN (MD-IPMN).All 29 subjects had mural nodules (MNs) in the main pancreatic duct (MPD) on preoperative endoscopic ultrasonography and underwent surgery (19, malignant; 10, benign). Possible predictive factors for malignancy such as background, imaging, and histological factors including histological subtype (HS), were evaluated.Multivariate analysis revealed an MPD diameter of ≥12 mm (p = 0.042) and non-gastric type (p = 0.001) to be the statistically significant predictive factors for malignancy. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy to detect malignancy by using “an MPD diameter of ≥12 mm and/or non-gastric type” were 95%, 70%, 86%, 88%, and 86%, respectively. In 7 subjects in whom HS was preoperatively evaluated using pancreatic specimens obtained before surgery, the agreement rate of the preoperative HS with definitive HS evaluated using resected specimens was 86%.For MD-IPMNs with MNs, “an MPD diameter of ≥12 mm and/or non-gastric type” are indicated for surgery. On the other hand, careful surveillance without immediate pancreatic surgery may be an option for MD-IPMNs showing both an MPD diameter of <12 mm and gastric type.

Risk of advanced lesions in patients with branch-duct IPMN and relative indications for surgery according to European evidence-based guidelines

BackgroundEuropean evidence-based guidelines proposed surgery for branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) based on the presence of 1–2 relative indications, depending on the comorbidity burden. AimsTo assess the accuracy of the guidelines in patients with relative indications in a surgical cohort of demonstrated BD-IPMNs. MethodsThis report describes a multi-centre, observational, retrospective study. All consecutive patients with relative indications and histologically confirmed BD-IPMN were included. The main outcome was risk of invasive carcinoma in patients with relative indications. ResultsNinety-one patients with BD-IPMN underwent surgery because of absolute (n = 21), relative (n = 60), or no formal indications (n = 10). In total, there were 60 patients (mean age: 66 ± 9, 50% male) with one (n = 35, 58.3%) or ≥2 relative indications (n = 25, 41.7%). The global advanced lesion and invasive carcinoma rates were 40% and 13.3%, respectively. No risk factor was associated with high-grade dysplasia or invasive carcinoma. Patients with one indication had a lower risk of invasive carcinoma than did those with ≥2 relative indications (5.7% vs. 24%, respectively, p = 0.048); however, the advanced lesion rates were comparable (37.1% vs. 44%, p = 0.593). ConclusionsInvasive carcinoma is considerably more frequent in patients with two or more relative indications. The surgical strategy in these selected cases should be decided on an individual basis.

An excerpt of European evidence-based guidelines on pancreatic cystic neoplasms (2018)

An excerpt of European evidence-based guidelines on pancreatic cystic neoplasms (2018)

European evidence-based guidelines on pancreatic cystic neoplasms

Evidence-based guidelines on the management of pancreatic cystic neoplasms (PCN) are lacking. This guideline is a joint initiative of the European Study Group on Cystic Tumours of the Pancreas, United...

Nursing care for stroke patients: A survey of current practice in 11 European countries.

To conduct a survey of the clinical nursing practice in European countries in accordance with the European Stroke Strategies 2006 and to examine to what extent the European Stroke Strategies have been implemented in stroke care nursing in Europe. Stroke is a leading cause of death and disability globally. Optimal organisation of interdisciplinary stroke care is expected to ameliorate outcome after stroke. Consequently, universal access to stroke care based on evidence-based guidelines is a priority. This study is a descriptive cross-sectional survey. A questionnaire comprising 61 questions based on the European Stroke Strategies and scientific evidence in nursing practice was distributed to representatives of the European Association of Neuroscience Nurses, who sent the questionnaire to nurses active in stroke care. The questionnaire covered the following areas of stroke care: organisation of stroke services, management of acute stroke and prevention including basic care and nursing, and secondary prevention. Ninety-two nurses in stroke care in 11 European countries participated in the survey. Within the first 48hr after stroke onset, 95% monitor patients regularly, 94% start mobilisation after 24hr when patients are stable, and 89% assess patients' ability to swallow. Change of position for immobile patients is followed by 73%, and postvoid residual urine volume is measured by 85%. Some aspects needed improvement, for example, staff education (70%), education for patients/families/carers (55%) and individual care plans in secondary prevention (62%). The participating European countries comply well with the European Stroke Strategies guidelines, particularly in the acute stroke care, but not all stroke units have reached optimal development in all aspects of stroke care nursing. Our study may provide clinical administrators and nurses in stroke care with information that may contribute to improved compliance with the European Stroke Strategies and evidence-based guidelines.

Methods report on the development of the European evidence-based (S3) guideline for the treatment of acne - update 2016.

Methods report on the development of the European evidence-based (S3) guideline for the treatment of acne - update 2016.

European evidence-based (S3) guideline for the treatment of acne - update 2016 - short version.

European evidence-based (S3) guideline for the treatment of acne - update 2016 - short version.

The Guidelines Management of Work-related Asthma as an example of necessary international collaboration

It is a pleasure to write this in honour of Xaver Bauer’s Festschrift. Xaver Baur’s enthusiasm and persistence carried this project to a very successful conclusion, providing the first European evidence-based guidelines for the management of occupational asthma (Baur, Sigsgaard et.al. 2012). The problems to overcome were considerable; the project had 13 contributors from 8 political administrations, speaking 7 native languages with one leader. The guidelines define occupational asthma as “a disease characterised by variable airflow limitation and/or hyper-responsiveness associated with inflammation due to causes and conditions attributable to a particular occupational environment and not to stimuli encountered outside the workplace” (Baur, Sigsgaard et.al. 2012). European countries interpret this differently as reflected in national statistics. The numbers (per million workers/year) recorded with occupational asthma is shown in figure 1 (Baur, Aasen et al 2012). It is very unlikely that the incidence of occupational asthma differs more than twentyfold between European countries. The differences are much more likely to reflect the rules for compensation and access to specialist centres. Defining a disease legally rather than medically is a dangerous way forward and unlikely to lead to the best care for patients and the necessary control of exposures needed to reduce occupational asthma. Finland probably has the best services and standards of care for workers with occupational asthma, and some of the better working conditions. The high numbers (which they believe are an underestimate) are likely to reflect countrywide standards of diagnosis and care, rather than rely on pockets of enthusiasm which is the more common European approach.

Recent therapeutic developments for acne

Current therapeutic concepts of acne vulgaris have to consider that acne is now understood as a primary inflammatory and chronic disease aggravated by genetic, microbial and environmental factors. Recent developments still focus on topical fixed combinations of substances with complementary effects in order to optimize efficacy without promoting bacterial resistance, which is a major concern resulting from inadequate use of antibiotics. New innovative therapeutic targets of acne pathophysiology are rare. Easy, convenient application and patient education are the basis to ensure patient adherence, which has been identified as a vital factor of therapeutic success of this chronic disease. The implementation of the European evidence-based S3 guidelines represents a major advancement in supporting therapeutic decisions based on literature review instead of expert opinion alone and traded therapy concepts.