Sex-related differences of invasive therapy in patients with aneurysmal subarachnoid hemorrhage.

BACKGROUND: Sex-related differences in patients with aneurysmal subarachnoid hemorrhage (aSAH) exist. More females than males are affected. Aneurysm location is associated to sex. The relationship between sex and outcome, however, is unclear. Possible differences in management might influence the occurrence of primary and secondary brain injury and thus outcome. The study compares demographics, intensity of treatment, complications, and outcome among females and males with aSAH. METHODS: All consecutive patients with aSAH admitted to the neurocritical care unit, University Hospital Zurich over a 5-year period were eligible in this retrospective study. Patients' characteristics, comorbidities, aSAH severity, frequency of vasospasm/delayed cerebral ischemia, frequency of invasive interventions, and 3-month outcome were compared by sex. Univariate analysis was performed with the data dichotomized by sex, and outcome. Multivariate analysis for prediction of outcomes was performed. RESULTS: Three hundred forty-eight patients were enrolled (64% females). Women were older than men. Comorbidities, scores at admission, and treatment modality were comparable among males and females. Vasospasm and DCI occurred similarly among females and males. Interventions and frequency of intraarterial spasmolysis were comparable between sexes. In the multivariate analysis, increasing age, female sex, increasing comorbidities, WFNS and Fisher grade, and presence of delayed cerebral ischemia were predictors of unfavorable outcome when considering all patients. However, after excluding death as a possible outcome, sex did not remain a predictor of unfavorable outcome. CONCLUSIONS: In the study population, women with aSAH might have present a worse outcome at 3 months. However, no differences by sex that might explain this difference were found in intensity of treatment and management.

Influence of the spatial distribution of copper sites on the selectivity of the oxygen reduction reaction.

Moving towards a hydrogen economy raises the demand for affordable and efficient catalysts for the oxygen reduction reaction. Cu-bmpa (bmpa = bis(2-picolyl)amine) is shown to have moderate activity, but poor selectivity for the 4-electron reduction of oxygen to water. To enhance the selectivity towards water formation, the cooperative effect of three Cu-bmpa binding sites in a single trinuclear complex is investigated. The catalytic currents in the presence of the trinuclear sites are lower, possibly due to the more rigid structure and therefore higher reorganization energies and/or slower diffusion rates of the catalytic species. Although the oxygen reduction activity of the trinuclear complexes is lower than that of mononuclear Cu-bmpa, the selectivity of the copper mediated oxygen reduction was significantly enhanced towards the 4-electron process due to a cooperative effect between three copper centers that have been positioned in close proximity. These results indicate that the cooperativity between metal ions within biomimetic sites can greatly enhance the ORR selectivity.

Detection of gluten in duplicate portions to determine gluten intake of coeliac disease patients on a gluten-free diet.

This study determined the gluten content of foods and meals consumed by coeliac disease (CD) patients who adhere to a gluten-free diet, and to estimate the total daily intake of gluten of these patients. CD patients fulfilling defined inclusion criteria were preselected and approached for participation in the study. Duplicate portions (DP) of foods and mixed dishes were collected from the CD patients for evaluating complete daily food intake during two individual days. Also, for these days, written food records were completed by the participants. From each DP, a laboratory sample was prepared and analysed for its gluten concentration and total daily gluten intake was calculated. Each individual's total daily intakes of energy and macronutrients were calculated using the Dutch food composition database. In total, twenty-seven CD patients participated, seven males and twenty females, aged between 21 and 64 years. In thirty-two (6 %) of 499 food samples collected in total, more than 3 mg/kg gluten was present. In four of these thirty-two samples, the gluten concentration was above the European legal limit of 20 mg/kg and three of the four samples had a gluten-free label. The maximal gluten intake was 3·3 mg gluten/d. The gluten tolerance for sensitive CD patients (>0·75 mg/d) was exceeded on at least six out of fifty-four study days. To also protect these sensitive CD patients, legal thresholds should be re-evaluated and the detection limit of analytical methods for gluten analysis lowered.

Detecting treatment-subgroup interactions in clustered data with generalized linear mixed-effects model trees.

Identification of subgroups of patients for whom treatment A is more effective than treatment B, and vice versa, is of key importance to the development of personalized medicine. Tree-based algorithms are helpful tools for the detection of such interactions, but none of the available algorithms allow for taking into account clustered or nested dataset structures, which are particularly common in psychological research. Therefore, we propose the generalized linear mixed-effects model tree (GLMM tree) algorithm, which allows for the detection of treatment-subgroup interactions, while accounting for the clustered structure of a dataset. The algorithm uses model-based recursive partitioning to detect treatment-subgroup interactions, and a GLMM to estimate the random-effects parameters. In a simulation study, GLMM trees show higher accuracy in recovering treatment-subgroup interactions, higher predictive accuracy, and lower type II error rates than linear-model-based recursive partitioning and mixed-effects regression trees. Also, GLMM trees show somewhat higher predictive accuracy than linear mixed-effects models with pre-specified interaction effects, on average. We illustrate the application of GLMM trees on an individual patient-level data meta-analysis on treatments for depression. We conclude that GLMM trees are a promising exploratory tool for the detection of treatment-subgroup interactions in clustered datasets.

Differential efficacy of cognitive behavioral therapy and psychodynamic therapy for major depression: a study of prescriptive factors.

BACKGROUND: Minimal efficacy differences have been found between cognitive behavioral therapy (CBT) and psychodynamic therapies for depression, but little is known about patient characteristics that might moderate differential treatment effects. We aimed to generate hypotheses regarding such potential prescriptive factors. METHOD: We conducted post-hoc model-based recursive partitioning analyses alongside a randomized clinical trial comparing the efficacy of CBT and short-term psychodynamic supportive psychotherapy (SPSP). Severely depressed patients received additional antidepressant medication. We included 233 adults seeking treatment for a major depressive episode in psychiatric outpatient clinics, who completed post-treatment assessment. Post-treatment mean Hamilton Depression Rating Scale scores constituted the main outcome measure. RESULTS: While treatment differences (CBT v. SPSP) were minimal in the total sample of patients (d = 0.04), model-based recursive partitioning indicated differential treatment efficacy in certain subgroups of patients. SPSP was found more efficacious among moderately depressed patients receiving psychotherapy only who showed low baseline co-morbid anxiety levels (d = -0.40) and among severely depressed patients receiving psychotherapy and antidepressant medication who reported a duration of the depressive episode of ⩾1 year (d = -0.31), while CBT was found more efficacious for such patients reporting a duration <1 year (d = 0.83). CONCLUSIONS: Our findings are observational and need validation before they can be used to guide treatment selection, but suggest that knowledge of prescriptive factors can help improve the efficacy of psychotherapy for depression. Depressive episode duration and co-morbid anxiety level should be included as stratification variables in future randomized clinical trials comparing CBT and psychodynamic therapy.

Calibration of the Dutch-Flemish PROMIS Pain Behavior item bank in patients with chronic pain.

BACKGROUND: The aims of the current study were to calibrate the item parameters of the Dutch-Flemish PROMIS Pain Behavior item bank using a sample of Dutch patients with chronic pain and to evaluate cross-cultural validity between the Dutch-Flemish and the US PROMIS Pain Behavior item banks. Furthermore, reliability and construct validity of the Dutch-Flemish PROMIS Pain Behavior item bank were evaluated. METHODS: The 39 items in the bank were completed by 1042 Dutch patients with chronic pain. To evaluate unidimensionality, a one-factor confirmatory factor analysis (CFA) was performed. A graded response model (GRM) was used to calibrate the items. To evaluate cross-cultural validity, Differential item functioning (DIF) for language (Dutch vs. English) was evaluated. Reliability of the item bank was also examined and construct validity was studied using several legacy instruments, e.g. the Roland Morris Disability Questionnaire. RESULTS: CFA supported the unidimensionality of the Dutch-Flemish PROMIS Pain Behavior item bank (CFI = 0.960, TLI = 0.958), the data also fit the GRM, and demonstrated good coverage across the pain behavior construct (threshold parameters range: -3.42 to 3.54). Analysis showed good cross-cultural validity (only six DIF items), reliability (Cronbach's α = 0.95) and construct validity (all correlations ≥0.53). CONCLUSIONS: The Dutch-Flemish PROMIS Pain Behavior item bank was found to have good cross-cultural validity, reliability and construct validity. The development of the Dutch-Flemish PROMIS Pain Behavior item bank will serve as the basis for Dutch-Flemish PROMIS short forms and computer adaptive testing (CAT).

Design and results of an exploratory double blind testing program in firearms examination.

In 2010, the Netherlands Forensic Institute (NFI) and the University of Amsterdam (UvA) started a series of tests for the NFI's Firearms Section. Ten cartridge case and bullet comparison tests were submitted by various external parties as regular cases and mixed in the flow of real cases. The results of the tests were evaluated with the VU University Amsterdam (VUA). A total of twenty-nine conclusions were drawn in the ten tests. For nineteen conclusions the submitted cartridge cases or bullets were either fired from the questioned firearm or from one and the same firearm, in tests where no firearm was submitted. For ten conclusions the submitted cartridge cases or bullets were either fired from another firearm than the submitted one or from several firearms, in tests where no firearm was submitted. In none of the conclusions misleading evidence was reported, in the sense that all conclusions supported the true hypothesis. This article discusses the design considerations of the program, contains details of the tests, and describes the various ways the test results were and could be analyzed.

The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial.

BACKGROUND: The treatment of substance use disorders is a public health priority, particularly in South Africa where the prevalence of these disorders is high. We tested two peer-counsellor delivered brief interventions (BIs) for risky substance use among adults presenting to emergency departments (EDs) in South Africa. METHODS: In this randomised controlled trial, we enrolled patients presenting to one of three 24-hour EDs who screened at risk for substance use according to the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). Eligible patients were randomly allocated to one of three conditions: Motivational Interviewing (MI), blended MI and Problem Solving Therapy (MI-PST) or a Psycho-educational Control Group (CG). The primary outcome was reduction in ASSIST scores at three months follow-up. RESULTS: Of the 2736 patients screened, 335 met inclusion criteria, were willing to participate in the intervention and were randomised to one of three conditions: 113 to MI, 112 to MI-PST and 110 to CG. ASSIST scores at three months were lower in the MI-PST group than they were in the MI and CG groups (adjusted mean difference of -1.72, 95 % CI -3.36 - -0.08). We recorded no significant difference in ASSIST scores between the CG and MI group (adjusted mean difference of -0.02, 95 % CI -2.01 - 1.96). CONCLUSION: With the addition of minimal resources, BIs are feasible to conduct in EDs in a low resourced country. These preliminary findings report that MI-PST appears to be an effective BI for reducing substance use among at risk participants. Further research is required to replicate these findings with effort to limit attrition, to determine whether reductions in substance use are persistent at 6 and 12 month follow-up and whether parallel changes occur in other indications of treatment outcomes, such as injury rates and ED presentations. TRIAL REGISTRATION: This trial registered with the Pan African Clinical Trial Registry (PACTR201308000591418).

Adverse events of intravenous glucocorticoid pulse therapy in inflammatory diseases: a meta-analysis.

OBJECTIVES: To systematically analyse the literature on reported adverse events (AEs) of intravenous pulse glucocorticoids (GCs) (≥ 250 mg prednisone equivalent) for inflammatory diseases. METHODS: A literature search was done using PubMed, Embase, and Cochrane databases. Studies were selected by two reviewers (NAMS and ND). Available data on the prevalence of GC-related AEs in patients with inflammatory diseases were retrieved. RESULTS: In only 8 studies (344 patients), 4 placebo-controlled and 4 not placebo-controlled studies, intravenous pulse GC-related AEs had been documented (in total 323 AEs), with an AE rate of 35/100 patient-years. In the 4 placebo-controlled studies among RA and systemic sclerosis patients, most of the odds ratios of individual AEs were not statistically significant, except for flushing, heart rhythm disorder, disturbance of taste, lower respiratory infection, and headache. In the 4 not placebo-controlled studies increased diastolic blood pressure was most frequent, followed by flushing and diabetes mellitus. Adverse events seen in more than 15% of patients of all included studies were increased blood pressure, flushing, headache, disturbance of taste, tachycardia and hyperglycemia. CONCLUSIONS: GC pulse therapy results in a high AE rate, i.e. 35/100 patient-years. Cardiovascular AEs are most frequently reported in the literature. Furthermore, flushing had the highest odds ratio in the placebo-controlled studies and also a high event rate in the not placebo-controlled studies.

Hair follicles as a niche of Staphylococcus aureus in the nose; is a more effective decolonisation strategy needed?

Staphylococcus aureus is the major cause of surgical site infections, and meticillin-resistant S. aureus (MRSA) is increasingly accounting for infections worldwide. Preventing surgical site infections by screening and decolonising positive patients reduces the number of infections, but does not completely eradicate the risk. A balance between prevention, costs and the chance of mupirocin-resistant S. aureus needs to be evaluated and decolonisation strategies optimised. It is essential to know the site of S. aureus during colonisation. In this study, for the first time the exact location of S. aureus in the human nose was determined using a histological approach. We showed the presence of S. aureus in the cornified layer of squamous epithelium, associated keratin and mucous debris and within hair follicles in the vestibulum nasi. The presence of S. aureus in hair follicles suggests that this could be the niche from which relapses occur after decolonisation. Decolonisation strategies might have to be reconsidered.

Additional value of external ultrasonography of the neck after CT and PET scanning in the preoperative assessment of patients with esophageal cancer.

INTRODUCTION: Lymphatic dissemination of a (non-cervical) esophageal tumor to the neck is generally considered as distant metastasis. The aim of this study was to determine the additional value of external ultrasonography (US) to detect lymphatic metastasis to the neck after normal CT scan (CT) with or without normal PET scan (PET). METHODS: Between January 2003 and December 2005, 306 patients were analyzed for esophageal cancer in our department. A total of 233 patients underwent both CT and external US of the neck. PET was performed in 109 of these patients as part of a prospective cohort study. Fine needle aspiration (FNA) was only performed if external US reported suspected lymph nodes. FNA was defined as gold standard. RESULTS: In 176 patients (76%), CT did not identify any suspected nodes, but external US disagreed in 36 of them. In 9 of these patients, FNA confirmed metastasis, resulting in an additional value of external US after normal CT scanning of 5% (9/176). In 74 patients (68%), CT and PET did not identify any suspected nodes, but external US disagreed in 11 of them. In 3 of these patients, FNA confirmed metastasis, resulting in an additional value of external US after normal CT and PET of 4% (3/74). CONCLUSION: Considering its minimal invasiveness and wide availability in combination with the importance of the potential therapeutic consequences, we conclude that external US of the neck should be part of the routine diagnostic work-up in patients with esophageal cancer, even after normal CT and PET scanning.

One-year follow-up results of a randomized controlled clinical trial on internet-based cognitive behavioural therapy for subthreshold depression in people over 50 years.

BACKGROUND: Internet-based cognitive behaviour therapy (CBT) is a promising new approach for the treatment of depressive symptoms. The current study had two aims: (1) to determine whether, after 1 year, an internet-based CBT intervention was more effective than a waiting-list control group; and (2) to determine whether the effect of the internet-based CBT differed from the group CBT intervention, 1 year after the start of treatment. METHOD: A total of 191 women and 110 men (mean age=55 years, s.d.=4.6) with subthreshold depression were randomized into internet-based treatment, group CBT (Lewinsohn's Coping with Depression Course), or a waiting-list control condition. The main outcome measure was treatment response after 1 year, defined as the difference in pretreatment and follow-up scores on the Beck Depression Inventory (BDI). Missing data were imputed using the multiple imputation procedure of data augmentation. Analyses were performed using multiple imputation inference. RESULTS: In the waiting-list control group, we found a pretreatment to follow-up improvement effect size of 0.69, which was 0.62 in the group CBT condition and 1.22 with the internet-based treatment condition. Simple contrasts showed a significant difference between the waiting-list condition and internet-based treatment (p=0.03) and no difference between both treatment conditions (p=0.08). CONCLUSIONS: People aged over 50 years with subthreshold depression can still benefit from internet-based CBT 1 year after the start of treatment.

A randomized trial comparing levothyroxine with radioactive iodine in the treatment of sporadic nontoxic goiter.

A randomized clinical trial was performed in consecutive patients with sporadic nontoxic nodular goiter to compare efficacy and side effects of iodine-131 ((131)I) therapy with suppressive levothyroxine (L-thyroxine) treatment. Sixty-four patients were randomized after stratification for sex and menopausal age to receive (131)I (4.44 MBq/g thyroid; group A) or suppressive L-thyroxine treatment aiming at TSH values between 0.01 and 0.1 mU/L (group B). The main outcome measurements after 2 yr were goiter size by ultrasound, serum thyroid function tests, markers of bone turnover, and bone mineral density (BMD). Fifty-seven patients completed the trial. Goiter size was reduced after 2 yr by 44% in group A and by 1% in group B (P< 0.001). Nonresponders (goiter reduction <13%) were 1 of 29 patients in group A and 16 of 28 patients in group B (P = 0.00001). In responders, goiter reduction in group A (46%) was greater than in group B (22%; P< 0.005). In group A, 45% of patients developed hypothyroidism. In group B, 10 patients experienced thyrotoxic symptoms, requiring discontinuation of treatment in 2 (in 1 because of atrial fibrillation). Markers of bone formation and bone resorption increased significantly in group B, related to a mean decrease of 3.6% of BMD at the lumbar spine after 2 yr (from 1.09 +/- 0.22 to 1.05 +/- 0.23 g/cm(2); P< 0.001), both in pre- and postmenopausal women. No changes in BMD were observed in group A. In conclusion, (131)I therapy is more effective and better tolerated than L-thyroxine treatment in patients with sporadic nontoxic goiter. Suppressive L-thyroxine treatment results in significant bone loss.

Percutaneous balloon dilatation for benign hepaticojejunostomy strictures.

BACKGROUND: Percutaneous balloon dilatation of biliary tract strictures is generally accepted as a safe and inexpensive procedure. The effectiveness in selected groups of patients remains under discussion. The purpose of this study was to evaluate the results of percutaneous balloon dilatation in patients with a benign stricture of a hepaticojejunostomy. METHODS: Fifteen patients with a benign stricture of a hepaticojejunostomy were examined between 1993 and July 1997. An ultrasound-guided percutaneous transhepatic cholangiography (PTC) procedure was performed, followed by a balloon dilatation. Follow-up was performed prospectively by outpatient visits and laboratory testing. RESULTS: Percutaneous dilatation was successful in 14 patients. Three patients developed a recurrence. In one of these patients, the procedure was repeated successfully. Gastrointestinal bleeding occurred in one patient. The success rate for balloon dilatation in this group of patients was 73% after a mean follow-up of 30 months. When the procedure was repeated, the success rate was 80% after a mean follow-up of 33 months. CONCLUSIONS: Percutaneous balloon dilatation for benign hepaticojejunostomy strictures is feasible in the majority of patients and produces acceptable medium-term to long-term results. Advantages are its minimal invasive character and the fact that all options remain open in case of failure.

Imaging and staging of biliopancreatic malignancy: role of ultrasound.

Most patients with a pancreatic head carcinoma, periampullary carcinoma or a cholangiocarcinoma of the liver hilum (Klatskin tumor) present with obstructive jaundice and therefore ultrasound often is the first imaging modality. Visualization is sufficient in more than 90% of cases for adequate diagnosis and staging. Even most small papillary tumors can be diagnosed with conventional abdominal ultrasound. In pancreatic head and periampullary carcinoma vascular involvement is the most important determinant for local irresectability and can often be assessed by color Doppler US. An abnormal pulsed Doppler signal obtained from the portal venous system due to severe narrowing or occlusion is highly suspicious for major involvement and irresectability of the tumor. However, a normal pulsed Doppler signal does not exclude involvement, if the tumor has continuity with the vessel with interruption of the hyperechoic tumor vessel interface. Enlarged lymph nodes are not a major diagnostic parameter, because a reliable differentiation between reactive and malignant lymph nodes is generally not possible. Very tiny liver and peritoneal metastases are missed by abdominal US and only detectable by laparoscopy and/or laparascopic US. In cholangiocarcinoma of the liver hilum extensive biliary and vascular involvement are considered the most important factors for determining irresectability. Portal venous involvement can be assessed by color Doppler US with a high accuracy (91%). Although cholangiography (ERCP and PTC) is considered the best imaging modality in detecting proximal extension of the tumor into the biliary system US can provide useful additional information. If dilated ducts are seen without clear communication among each other within a liver lobe, extension of the tumor into the segmental bile ducts can be concluded. We consider color Doppler US, a valuable tool for preoperative imaging and staging of biliopancreatic malignancy.

Ultrasonographic versus scintigraphic measurement of thyroid volume in patients referred for 131I therapy.

The activity of 131I to be administered as therapy to patients with thyroid disease is usually calculated from 24 h radioiodine uptake and thyroid volume. The aim of the present study was to compare thyroid volume, measured by scintigraphy and ultrasonography, to evaluate the impact of these methods on the calculated 131I dose. Forty patients (20 with diffuse toxic goiter and 20 with multinodular toxic or nontoxic goiter) were investigated. On the same day, thyroid volume was measured by ultrasonography (using transverse scans at 5 mm intervals) and by scintigraphy, using either the ellipsoid formula (SC-E: [symbol: see text]/6 x height x width x depth) or the Himanka formula (SC-H: 0.33 x (planimetric surface in pixels)3/2). With ultrasonography, the size of diffuse goiters was smaller than that of nodular goiters (median values and range: 18 ml (11-46) and 50 ml (14-198) respectively, P < 0.001). Both scintigraphic methods, however, failed to demonstrate a significant difference between diffuse and nodular goiter size. In patients with diffuse goiter, thyroid volume measured by SC-E did not differ from that measured by ultrasonography, whereas thyroid size was overestimated by 53% using the Himanka formula. In contrast, in patients with nodular goiter, thyroid volume measured by SC-H did not differ from that measured by ultrasonography, whereas the ellipsoid formula underestimated thyroid size by 48%. The overestimation of diffuse goiter size by the Himanka formula resulted in a relatively modest median excess of 96 MBq (range -118 to +248 MBq) of the calculated 131I dose. The underestimation of nodular goiter size by the ellipsoid formula resulted in a calculated dose that was 278 MBq lower (range -1624 to +141 MBq). The median calculated 131I dose based on the Himanka formula was not different from that based on ultrasound, but large differences in calculated 131I dose (up to 1280 MBq) were found in individual cases. In conclusion, thyroid volume can be assessed with accuracy by scintigraphy using the ellipsoid formula in patients with diffuse goiter. Wide differences, however, are observed in the size of nodular goiters measured by scintigraphy and ultrasonography.

Lean body mass as a determinant of thyroid size.

OBJECTIVE: Males have a larger thyroid gland than females, and this has been related to the difference in body weight. In view of the different body composition of men and women, we hypothesized that lean body mass is a better determinant of thyroid volume than body weight. DESIGN: A cross-sectional study in an area not deficient in iodine. SUBJECTS: 44 non-obese healthy adults (group I, 21 men, 23 women with equal distribution of sexes in age groups between 21 and 70 years) and 20 adults with marked obesity (group II, 8 men, 12 women, BMI > 30 kg/m2) were studied. None used medication and all had normal thyroid function tests. MEASUREMENTS: Thyroid volume was measured by ultrasonography, and lean body mass with a body impedance analyser. RESULTS: The thyroid volume in men was larger than in women in both groups; it was also larger in the obese than in the non-obese subjects. In the nonobese subjects, thyroid volume was related both to body weight (r = 0.42, P < 0.005) and to lean body mass (r = 0.55, P = 0.0001). In the obese subjects, thyroid volume was no longer related to body weight (r = 0.23, NS) but was still correlated with lean body mass (r = 0.54, P = 0.01). Taking both groups together, the correlation between thyroid volume and lean body mass (r = 0.64, P < 0.001) was stronger than between thyroid volume and body weight (r = 0.50, P < 0.001). Thyroid volume was also related to body length (group I, r = 0.42, P < 0.005; group II, r = 0.54, P = 0.01), but to body-surface area only in the non-obese subjects (group I, r = 0.45, P < 0.01; group II, r = 0.38, NS). The larger thyroid size in the obese was associated with slightly but significantly higher TSH and lower free T4 serum concentrations as compared to the non-obese subjects. CONCLUSIONS: In healthy adults, lean body mass rather than body weight explains the differences in thyroid volume between males and females and between obese and non-obese subjects. Lean body mass appears to be a major determinant of thyroid size.

Incidence and clinical findings of benign, inflammatory disease in patients resected for presumed pancreatic head cancer.

BACKGROUND: The differentiation between cancer and benign disease in the pancreatic head is difficult. The aim of this study was to examine common features in a group of patients that had undergone pancreatoduodenectomy for a benign, inflammatory lesion misdiagnosed as pancreatic head cancer. METHODS: Among 220 pancreatoduodenectomies performed on the suspiscion of pancreatic head cancer, an inflammatory lesion in the pancreas or distal common bile duct was diagnosed in 14 patients (6%). Of these patients, all preoperative clinical information and radiologic images (ultrasound, endoscopic retrograde cholangio-pancreaticography [ERCP]) were critically reassessed. For each examination, the suspicion of cancer was scored on a 0/+/++ scale. RESULTS: Clinical presentation (pain, weight loss, jaundice) raised a suspicion of cancer in 12 patients. On ultrasound, a tumor (mean size: 2.8 cm) was found in the pancreatic head in 13 patients; 12 of 14 ultrasound examinations raised a suspicion of cancer. ERCP showed a distal common bile duct stenosis (length: 1 to 4 cm), stenosis of the pancreatic duct (length: 1 to 5 cm), or a "double duct" stenosis, suspicious for cancer in 13 evaluable patients. The overall index of suspicion was + in seven patients and ++ in seven patients, confirming the initial interpretation of preoperative data. CONCLUSION: When undertaking pancreatoduodenectomy for a suspicious lesion in the pancreatic head, it is necessary to expect at least a 5% chance of resecting a benign, inflammatory lesion masquerading as cancer.