Transition to practice: Red flag for safety?

Most Hirschsprung's disease (HD) are diagnosed in young children with increased risk ("red flag"). Older children (>6 months) require open rectal biopsy (ORB) with its own impact on risk and resources. We investigated if "red flag", age, and sex used in combination could exclude HD. "Red flags" are risk factors associated with HD, including neonatal bowel obstruction, genetic association, failure of passage of meconium in <48 hours, infantile constipation, distension with vomiting, or family history. All rectal biopsies (2015-2018) were reviewed for indications, methods, and histopathological findings. Logistic regression analysis was adopted to assess predictive value of "red flag," age, and sex (p < 0.05* was significant). A total of 187 children underwent 84 suction rectal biopsies and 113 ORBs (n = 197 in total). Final histopathological diagnoses were non-HD (n = 154) and HD (n = 43). Total 78% of rectal biopsies were non-HD, of which 63% by ORB. Non-HD was associated with absence of "red flag" (49 vs. 16%*), increased age at biopsy (22 months vs. 28 days*), >6 months old (62 vs. 30%*), and female gender (54 vs. 16%*), compared with HD. In the absence of "red flag," 7/82 (9%) had HD (negative predictive value = 91%). Logistic regression analysis found absent "red flag" predicted non-HD biopsy with odds ratio 4.77 (1.38, 16.47), corrected for age and sex. Negative rectal biopsy rate for HD is very high. The majority required ORB. Although "red flag" and gender, but not age, have strong predictive values, it is inadequate for excluding HD. This study supports the need for alternative strategies in excluding HD.

Introduction: With new and emerging disease-modifying therapies for cardiac amyloidosis (CA), there is a growing impetus for improved awareness and early diagnosis of this condition. Several groups have identified comorbid conditions, termed ‘red flag’ systemic symptoms and diagnostic findings, that occur commonly in patients with CA. To better understand the prevalence and temporal relationship of these ‘red flag’ comorbid conditions to a CA diagnosis, we used automated extraction of clinical data stored in the electronic health record (EHR) at a single institution. Methods: Patients with confirmed light-chain (AL) and transthyretin (ATTR) cardiac amyloidosis were identified at a single institution. The dates of diagnosis of ‘red flag’ comorbid conditions and for CA were extracted from the EHR via ICD-9 and ICD-10 codes, electrocardiogram intervals, and echocardiogram reports. Frequency and time between the diagnoses of red flags and CA were assessed. Results: Of 175 CA patients (85% ATTR), mean age was 72.7 years with majority (76.6%) male patients. Patients were most commonly black (52.6%) followed by Caucasian (42.3%). A diagnosis code for amyloidosis was found in 89.1% of patients, followed by heart failure in 84.6% of patients. ‘Red flag’ comorbid conditions were more likely to have been diagnosed before rather than after CA. When the ‘red flag’ was diagnosed prior to CA, the greatest average intervals between diagnoses were seen in carpal tunnel syndrome (8.3 years), spinal stenosis (5.9 years), and atrial fibrillation (2.8 years) (Table 1). Conclusions: EHR data from a single institution demonstrates that the diagnosis of CA is often delayed following the diagnosis of ‘red flag’ comorbid conditions. Our automated extraction of EHR data provides a foundational step in the ongoing development of an EHR-based warning score aimed at improving clinician awareness of the possibility of CA in appropriate patients.

Red flags: correlates of impaired species recovery

Red flags phenotyping: A systematic review on clinical features in atypical parkinsonian disorders

Objective To review the evidence on diagnostic accuracy of red flag signs and symptoms to screen for fracture or malignancy in patients presenting with low back pain to primary, secondary,...

See https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD014461.pub2/full for a more recent review that covers this topic and has superseded this review. Low-back pain (LBP) is a common condition seen in primary care. A principal aim during a clinical examination is to identify patients with a higher likelihood of underlying serious pathology, such as vertebral fracture, who may require additional investigation and specific treatment. All 'evidence-based' clinical practice guidelines recommend the use of red flags to screen for serious causes of back pain. However, it remains unclear if the diagnostic accuracy of red flags is sufficient to support this recommendation. To assess the diagnostic accuracy of red flags obtained in a clinical history or physical examination to screen for vertebral fracture in patients presenting with LBP. Electronic databases were searched for primary studies between the earliest date and 7 March 2012. Forward and backward citation searching of eligible studies was also conducted. Studies were considered if they compared the results of any aspect of the history or test conducted in the physical examination of patients presenting for LBP or examination of the lumbar spine, with a reference standard (diagnostic imaging). The selection criteria were independently applied by two review authors. Three review authors independently conducted 'Risk of bias' assessment and data extraction. Risk of bias was assessed using the 11-item QUADAS tool. Characteristics of studies, patients, index tests and reference standards were extracted. Where available, raw data were used to calculate sensitivity and specificity with 95% confidence intervals (CI). Due to the heterogeneity of studies and tests, statistical pooling was not appropriate and the analysis for the review was descriptive only. Likelihood ratios for each test were calculated and used as an indication of clinical usefulness. Eight studies set in primary (four), secondary (one) and tertiary care (accident and emergency = three) were included in the review. Overall, the risk of bias of studies was moderate with high risk of selection and verification bias the predominant flaws. Reporting of index and reference tests was poor. The prevalence of vertebral fracture in accident and emergency settings ranged from 6.5% to 11% and in primary care from 0.7% to 4.5%. There were 29 groups of index tests investigated however, only two featured in more than two studies. Descriptive analyses revealed that three red flags in primary care were potentially useful with meaningful positive likelihood ratios (LR+) but mostly imprecise estimates (significant trauma, older age, corticosteroid use; LR+ point estimate ranging 3.42 to 12.85, 3.69 to 9.39, 3.97 to 48.50 respectively). One red flag in tertiary care appeared informative (contusion/abrasion; LR+ 31.09, 95% CI 18.25 to 52.96). The results of combined tests appeared more informative than individual red flags with LR+ estimates generally greater in magnitude and precision. The available evidence does not support the use of many red flags to specifically screen for vertebral fracture in patients presenting for LBP. Based on evidence from single studies, few individual red flags appear informative as most have poor diagnostic accuracy as indicated by imprecise estimates of likelihood ratios. When combinations of red flags were used the performance appeared to improve. From the limited evidence, the findings give rise to a weak recommendation that a combination of a small subset of red flags may be useful to screen for vertebral fracture. It should also be noted that many red flags have high false positive rates; and if acted upon uncritically there would be consequences for the cost of management and outcomes of patients with LBP. Further research should focus on appropriate sets of red flags and adequate reporting of both index and reference tests.

HISTORY AND PHYSICAL EXAMINATION A 19-yr-old man with a medical history of obesity presented to the emergency department with a 6-mo history of low back pain. The pain began as an intermittent pain localized over the spinous processes in the lower thoracic and upper lumbar spine without radiation. It was described as a dull ache with 3–4/10 intensity and was aggravated by lying down and with movement in all planes. The patient denied alleviating factors and took acetaminophen without relief. Over the past 2 wks, the patient had developed worsening of the pain, now described as a constant, “stabbing” pain rated as an 8/10. The patient now had radiation of the pain into his left leg down to his foot consistent with a L3 and L4 distribution. He also had weakness throughout his bilateral lower limbs, worse in his ankle dorsiflexors resulting in a foot drop, leading to frequent falls. The patient denied symptoms related to bowel, bladder, or saddle anesthesia. He was eventually unable to ambulate and required a wheelchair for mobility, which caused the patient to come to the hospital for evaluation. Physical examination revealed an obese man in no acute distress. Cranial nerve examination was unremarkable. Inspection of the back revealed no deformities, skin changes, or muscle atrophy. The patient experienced severe point tenderness over the spinous processes of T11, T12, and L1. Manual muscle testing revealed 5/5 strength throughout the upper limbs. He had 2/5 strength in the bilateral hip flexors, knee flexors, knee extensors, and ankle plantar flexors with 0/5 strength bilaterally with ankle dorsiflexion and toe extension. Sensation was intact to light touch, pinprick, and temperature in the bilateral lower limbs. The pain was exacerbated with straight leg raise in the left lower limb. Patellar and Achilles reflexes were 1–2+ bilaterally with absent clonus. Patient had a negative Babinski sign. DIFFERENTIAL DIAGNOSIS The differential diagnosis is concerning for an injury to the spinal cord or spinal nerve roots because of the presence of both bilateral strength deficits in the lower limbs and bilateral pain. Most importantly, surgical emergencies, such as spinal cord infarction, spinal cord compression, cauda equina syndrome, and conus medullaris syndrome, must be ruled out. Certain “red flag” questions must be asked to promptly rule these conditions out, such as the presence of profound weakness or sensory disturbances, saddle anesthesia, and bowel or bladder dysfunction (Table 1). It is important to assess for the presence of multiple “red flags” in these instances as a systematic review has shown that in isolation, the diagnostic accuracy of these questions is low, but the combination of multiple “red flags” should raise suspicion for serious pathology.1 TABLE 1 - Red flags as diagnostic clues Myelopathy/cauda equina syndrome • Bowel/bladder incontinence • Loss of anal sphincter tone • Sexual dysfunction • Saddle anesthesia • Progressive/severe motor weakness Cancer • History of cancer • Fever • Unexplained weight loss • Night pain • Failure to improve with conservative management Infection • Fever • Intravenous drug use • Recent infection • Immunosuppression • Steroid use • Failure to improve with conservative management Fracture • History of trauma • Steroid use • History of osteoporosis IMAGING CONSIDERATIONS Imaging is rarely indicated in the evaluation of acute low back pain. In patients with low risk for a serious underlying condition, such as cauda equina syndrome, fracture, cancer, or spinal infection, imaging can be deferred in favor of a 6-wk trial of conservative management.2 Unnecessary imaging can lead to radiation exposure, invasive procedures, and increased cost to the patient and healthcare system. In this patient who presents with acute on chronic axial low back pain, however, imaging is warranted. The choice of imaging modality is dependent on the possible diagnosis, the acuteness of the diagnosis, and any comorbidities that may affect the ideal imaging modality, such as renal failure limiting the use of contrast or retained metal preventing the use of magnetic resonance imaging (MRI).2 In the presence of “red flag” symptoms, MRI of the spine with and without intravenuos contrast is likely the best radiologic procedure depending on the specific indication.2 Superior imaging of the bony structures to assess for fractures, spondylosis, and stenosis can be obtained with computed tomography; however, computed tomography is less useful for detailing soft tissue pathology.2,3 Computed tomography with myelography can be useful if MRI is unable to be obtained as it can assess the patency of the spinal canal through injection of contrast into the subarachnoid space.2 DIAGNOSTIC STUDIES In the emergency department, x-ray of the thoracolumbar spine with anterior-posterior and lateral views showed no acute fractures, normal vertebral alignment, and no degenerative changes (Fig. 1). Magnetic resonance imaging with and without intravenuos contrast of the cervical, thoracic, and lumbar spine revealed a large, heterogeneous, multicystic mass arising at T11 (Fig. 2A) compressing the spinal canal (Fig. 2B). There was also enhancing tissue around the cystic foci that seemed to displace but not invade the dural sac. There was no disc bulge, herniation canal narrowing, or foraminal narrowing. The vertebral bodies all had normal alignment and height. The differential diagnosis for a spinal mass varies based on the epidemiology, location, and imaging findings of the mass (Table 2). The radiologic differential diagnosis for a heterogeneous multicystic mass includes an aneurysmal bone cyst, giant cell tumor, osteoblastoma, and osteosarcoma.3FIGURE 1: Thoracolumbar spine x-ray showing no acute fractures, normal vertebral alignment, and no degenerative changes.FIGURE 2: Sagittal (A) and axial (B) views of a T2-weighted MRI of the thoracolumbar spine. A large, heterogeneous, multicystic mass arising at lateral T11 and T12 (A) extends into the vertebral bodies and the spinal canal displacing and compressing the dural sac and its contents centrally and to the right (B) with enhancing tissue around a cystic foci that displaces the dural sac measuring approximately 57 × 38 × 74 mm (AP, LR, CC). TABLE 2 - Typical presentations of common spinal cord tumors Population Tumor Location MRI Findings Ependymoma Adult Intradural Intramedullary T1: Isointense or hypointense T2: Hyperintense Contrast: Focal contrast enhancement Astrocytoma Pediatric Intradural Intramedullary T1: Isointense or hypointense T2: Hyperintense Contrast: Irregular enhancement Nerve sheath tumors Adult Intradural Extramedullary T1: Isointense or hypointense T2: Hyperintense Contrast: Diffuse enhancement Meningioma Adult Intradural Extramedullary T1: Isointense or hypointense T2: Isointense to hyperintense Contrast: Moderate homogenous enhancement Metastasis a Adult Extradural Varies based on origin aMost common tumor overall. THERAPEUTIC INTERVENTION AND FINAL DIAGNOSIS Neurosurgery was emergently consulted given the compression of the mass on the spinal canal and the progressive weakness. The patient underwent T10, T11, and T12 laminectomies, resection of the epidural spinal tumor, and pedicle screw fixation with posterolateral arthrodesis with both locally harvested and cancellous chip allograft. A biopsy of the mass was sent to pathology, which was found to be a highly cellular neoplasm containing a mixture of cells with spindled cytology as well as multinucleated giant cells. It also contained blood-filled cystic spaces and dilated venous structures with multifocal regions of osteoid formation. While the pathologic differential included a giant cell tumor variant or an osteosarcoma variant, it was ultimately determined that this was a solid variant of an aneurysmal bone cyst. PATIENT OUTCOME The patient was subsequently admitted to our acute inpatient rehabilitation hospital and found to be an L1 ASIA Impairment Scale grade D on the American Spinal Injury Association Impairment Scale. His pain was largely improved by the operative resection of the mass. Some nociceptive pain persisted but was controlled with acetaminophen, ibuprofen, and oxycodone. Over the next 2 wks, the patient progressed in his mobility from requiring maximum assistance with ambulation to ambulating 200 ft with modified independence with a rolling walker. His motor strength progressed in the right lower limb to a 5/5 throughout and in the left lower limb to a 4/5 in the hip flexors and 5/5 in the knee and ankle flexors and extensors. Parents and friends of the patient were involved early and throughout the process to help the patient cope with his injury as well as training in providing functional support. The patient has been followed in the outpatient setting for 5 mos with continued improvement of his functional deficits and no recurrence of his weakness. DISCUSSION The solid variant of an aneurysmal bone cyst was first reported in 1983 as a lesion with a combination of “fibroblastic, osteoclastic, osteoblastic, aneurysmal, and fibromyxoid elements” and was coined as a “solid” variant of aneurysmal bone cyst.4 These cysts are rare, with a prevalence of 0.14 per 100,000 individuals, and seem to be equally common in male and female individuals.5 The solid variant is even less common, accounting for 3.4%–7.5% of all aneurysmal bone cysts.6 Aneurysmal bone cysts develop most commonly in adolescents during periods of skeletal growth; the median age of discovery is 13 yrs with 90% found before the age of 30 yrs.5 It is a benign lesion that presents with pain and swelling in the affected area, most commonly occurring in the metaphyses of long bones.7 When it occurs in the spinal canal, pain is the most common presenting symptom with weakness and numbness in a spinal nerve distribution often accompanying it.6 Radiologic diagnosis of solid aneurysmal bone cysts can be difficult as it can appear similarly to a malignant bone tumor.3,6 X-ray can be unrevealing and MRI may reveal what is generally described as “fluid-fluid levels,” which results from the layering of blood as well as septations on gadolinium-enhanced T1- or T2-weighted images; however, these septations are less commonly present in the solid variant.6,8 Biopsy with histopathology confirms the disease and is important to differentiate it from a malignant lesion.3,6 For this patient, the radiologic imaging was more consistent with the aneurysmal bone cyst, but the differential also included a telangiectasia osteogenic sarcoma and an osteosarcoma. Histopathological diagnosis was more difficult because of a variety of elements found in pathology (cells with spindled cytology, multinucleated giant cells, less-prominent blood-filled cystic spaces, and multifocal regions of osteoid formation) consistent with not only a solid variant of an aneurysmal bone cyst but also an osteosarcoma variant or a giant cell tumor variant. The management of these cases would drastically differ without pathologic confirmation. Current recommended treatments for the solid variant of the aneurysmal bone cyst vary but preoperative arterial embolization, followed by total operative resection, and spinal fusion seems to be most successful with the lowest rate of recurrence.6,7 Recurrence is rare, and patients can be surveilled with repeat imaging to monitor, although there are no formal guidelines on this matter.6,7 Patients with weakness from nerve compression from these large masses likely would benefit from rehabilitation.9 The goal of rehabilitation is to improve patients’ functional independence, symptoms, and focus on quality-of-life measures.9,10 Patients benefit from strength and transfer training as well as range-of-motion exercises with both physical and occupational therapies.9 Pain has been shown to be a significant barrier to functional improvement in patients with spinal masses and can be due to the tumor or postsurgical.10 Treatment options include medications, modalities, and further surgery depending on the etiology of the pain.9,10 In the case of this patient, surgical resection of the mass, followed by a 2-wk acute inpatient rehabilitation admission, focused on lower limb strengthening, gait training, and balance re-education, resulted in an improved functional outcome with the patient discharging at modified independence of ambulation. CONCLUSIONS The solid variant of an aneurysmal bone cyst is a rare variant that can be mistaken for malignancy radiologically.3,6 It should be included in the differential for adolescent patients with imaging findings suspicious for a malignant bone tumor.3,6 Prompt screening for pathology of the spine with imaging, especially MRI, should be undertaken in patients with a constellation of “red flag” symptoms to determine the presence of any conditions requiring urgent intervention.1–3 Treatment with surgical resection results in the best outcomes with reduced rates of recurrence.6,7 In this condition, biopsy is important to distinguish from any malignant lesion to help guide future treatment.3,6 Patients should be monitored functionally and radiographically periodically for recurrence.6,7 Rehabilitation after surgery likely can improve functional outcomes in these patients.9 This study conforms to all American Journal of Physical Medicine and Rehabilitation Resident and Fellow Section CARE guidelines and reports the required information accordingly (see Supplemental Checklist, Supplemental Digital Content 1, https://links.lww.com/PHM/B202).

Background Cardiac amyloidosis (CA) is a relevant and treatable aetiology of heart failure. Despite substantial developments in the therapeutic options for CA, its time-sensitive identification often remains challenging. Red flags (RF) have been proposed to facilitate early detection of CA; however, large-scale studies validating these RF are lacking. Our study aims to validate a comprehensive group of clinically relevant RF in combination. Methods We conducted a retrospective analysis of all patients from our amyloidosis centre with known TTR gene status and a definite diagnosis or exclusion of CA in accordance with ESC guidelines. A holistic analysis of the available diagnostic data at the time of initial presentation was performed and included multidisciplinary clinical evaluation, ECG, laboratory tests, transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (CMR). Comparative analysis included CA and a control group (CG), comprising patients with CA exclusion exhibiting left ventricular hypertrophy (LVH). For each modality, sensitivities (SE), specificities (SP) and RF with the highest diagnostic effectiveness, defined as Youden’s index (YI), were determined. Results Of the 618 available patients, 554 (90%) were included. 347 (63%) patients had CA, with transthyretin CA being the most common form (94.8%). In 207 (37%) cases CA was excluded. Of these, 104 (50%) had LVH and comprised the CG. Patients in the CA group were 10 years older on average (79 vs. 69) and showed a higher proportion of men (88.2% vs 62.5%). Heart failure and conduction disorders were the most effective clinical RF (YI 52.6% and 43.7%, respectively), followed by polyneuropathy (YI 31.1%) and bilateral carpal tunnel syndrome (CTS, YI 22.2%). QT interval prolongation and atrial fibrillation achieved the highest YI among ECG RF (40.7% and 40.2%, respectively). Peripheral low voltage, although highly specific (94.6%), was found in only about one third (32%) of CA patients. NT-proBNP &amp;gt;1000ng/L (YI 58.8%) and high sensitivity Troponin T (hsTnT) levels ≥ 2 times upper limit of normal (ULN, YI 58.2%) were the most effective laboratory RF. The combination of hsTnT &amp;lt;14ng/L and NT-proBNP &amp;lt;180ng/L ruled out CA in 99.7% of cases. As a marker of the "apical sparing", Apical-to-Basal strain ratio ≥ 2.0 was the most effective echocardiographic parameter (YI 61.3%), followed by biatrial dilatation (YI 53.3%). Further effective TTE-RF included diastolic dysfunction II-III°, LV-strain reduction, and relative wall thickness (RWT) &amp;gt; 0.6 at YI of 47-48%. Typical LGE pattern on CMR and ECV ≥ 40% achieved the best YIs among all evaluated RF (YI 66.9% and 63.1%, respectively). Two clinical scenarios identified CA with approximately 80% sensitivity and specificity (Fig. 1). Conclusion CA is frequently associated with distinctive cardiac and extracardiac features, which allow for a robust suspicion in routine clinical practice (Fig. 2), facilitating early diagnosis and treatment.Two clinical scenarios suspicious for CA Diagnostic characteristics of CA-RF

Purpose–This study aims to analyze the influence of professional skepticism, and red flags on fraud detection with auditor experience serving as a moderating variable. The research highlights the critical importance or adopting professional skepticism, identifying red flags, and leveraging auditor experience to enhance the effectiveness of fraud detection. Design/methodology/approach–The research uses quantitative methods with a correlational approach. This study uses a questionnaire distributed to KAP and students who have taken audit courses. A total of 39 questionnaires were distributed through social media platforms, containing 39 statements that respondents had to answer. Of these, 39 responses were received, which came from 5 regions. To analyze the data and obtain results, the study used PLS-SEM Version 3.0. Findings–This study examines the impact of professional skepticism and red flags on fraud detection, with auditor experience as a moderating variable. Data were collected from 39 auditors and students with audit experience and analyzed using Partial Least Square (PLS) with Moderated Regression Analysis. The results how that professional skepticism positively and significantly influences fraud detection, while red flags have a positive but significant effect. Additionally, auditor experience does not strengthen the relationship between professional skepticism, red flags, and fraud detection. The findings suggest the need for ongoing auditor training and a stronger emphasis on skepticism in audit practices Research limitations/implication s–Lies in its focus understanding the relationship between professional skepticism and red flags on fraud detection, by considering the role of auditor experience as a moderating professional skepticism and identifying red flags in supporting the effectiveness on fraud detection, although the role of auditor experience as moderating does not provide significant results.

Screening for transthyretin amyloid cardiomyopathy in patients with musculoskeletal symptoms: Red flags in the rheumatology/orthopedics practice setting.

Physiotherapists must identify potential red flags that may impede recovery and function in individuals with low back pain (LBP) or put them at risk. This study aimed to (1) investigate physiotherapists' awareness and use of red flags for individuals with LBP in Saudi Arabia and (2) identify factors associated with their awareness and use of LBP red flags. This cross-sectional study collected data using an anonymous online questionnaire (February-July 2023). It included physiotherapists working in private/public hospitals in Saudi Arabia. The questionnaire asked about the participants' characteristics, their awareness of LBP red flags, and their use of red flags for LBP assessment. A total of 643 participating physiotherapists (26.2 ± 3.8 years), 63.8% of whom were females, completed the survey. Most participants (94.4%) had adequate awareness of LBP red flags, and more than half (61%) had good utilization of red flags when assessing individuals with LBP. There was a positive correlation between the physiotherapists' awareness and use of LBP red flags. The majority of the participating physiotherapists in Saudi Arabia were aware of LBP red flags, and many reported to have good use of red flags in clinical practice when assessing and managing individuals with LBP.

To evaluate ChatGPT's accuracy as information source for women and maternity-care workers on "nutrition" and "red flags" in pregnancy. Accuracy of ChatGPT-generated recommendations was assessed by a 5-point Likert scale by eight raters for ten indicators per topic in four languages (French, English, German and Dutch). Accuracy and interrater agreement were calculated per topic and language. For both topics, median accuracy scores of ChatGPT-generated recommendations were excellent (5.0; IQR 4-5) independently of language. Median accuracy scores varied with a maximum of 1 on a 5-point Likert-scare according to question's framing. Overall accuracy scores were 83-89% for 'nutrition in pregnancy' versus 96-98% for 'red flags in pregnancy'. Inter-rater agreement was good to excellent for both topics. Although ChatGPT generated accurate recommendations regarding the tested indicators for nutrition and red flags during pregnancy, women should be aware of ChatGPT's limitations such as inconsistencies according to formulation, language and the woman's personal context. Despite a growing interest in the potential use of artificial intelligence in healthcare, this is, to the best of our knowledge, the first study assessing potential limitations that may impact accuracy of ChatGPT-generated recommendations such as language and question-framing in key domains of perinatal health.

Pituitary metastases (PMs) are rare malignancy manifestations, generally deemed to have an extremely poor prognosis. Differential diagnosis from primary pituitary lesions is often difficult, as their features can mimic those of pituitary neuroendocrine tumours (PitNETs). This study aimed to report a single surgeon's experience in managing PMs and to gather the existing evidence on their clinical and neuroradiological presentation to build a model of 'red flags' that help raise the suspicion of PMs in the context of sellar lesions. We retrieved an original 10-year surgical series of patients undergoing endoscopic transsphenoidal (TNS) surgery for suspected PitNETs, and we additionally conducted a systematic review of case reports or series of patients with PMs. The local series consisted of n = 6 PMs. The literature review yielded n = 149 works reporting n = 340 PMs. Overall, the clinical presentation and neuroradiological features of n = 346 PMs were analysed and compared to data retrieved from n = 361 PitNETs from our original cohort. Primary features associated with PMs were: the presence of headaches (OR 1.24, p = 0.001), visual field deficits (OR 1.19, p = 0.02), extraocular nerve palsies (OR 1.23, p = 0.001), diabetes insipidus (OR 2.13, p < 0.001), MRI features of pituitary stalk/infundibular involvement (OR 1.98, p = 0.001), cavernous sinus invasion (OR 1.57, p = 0.004), and T2w flow voids (OR 1.13, p = 0.001). An incidental diagnosis (OR 0.49, p < 0.001) and cystic changes (OR 0.77, p = 0.02) were less common among PMs. Secondary features involved an acute onset of symptoms (OR 1.25, p = 0.001), the presence of oncological history (OR 1.89, p = 0.001), sellar walls erosion (OR 1.55, p = 0.002), and gross appearance of a firm (OR 2.01, p < 0.001) and easily bleeding lesion (OR 1.99, p < 0.001). Sellar enlargement predicted a lower risk of PMs (OR 0.54, p = 0.001). We have compiled a list of primary and secondary red flags, including clinical and neuroradiological features, to serve as a guiding tool for clinicians to raise suspicion of PMs and aid in the differential diagnosis of various lesions centered in the sella.

This project was designed as a retrospective service evaluation using audit to assess the identification and documentation of red flags in initial assessment of patients with low back pain. Firstly, the documentation of 11 predetermined red flags was assessed. Secondly, the documentation of relevant additional information was assessed and finally, compliance with local policy to highlight positive red flag findings in the designated area on the paper work was examined. The documentation for the majority of red flags was high, however, clear gaps were identified. Additionally, there was no evidence of further clinical consideration of positive red flags during the diagnostic process. Possible factors influencing red flag documentation are discussed and suggestions are provided to improve recording and response to clinical indicators of malignancy.

The Food and Drug Administration has recently highlighted an increase in reported complications associated with the use of transvaginal mesh. To describe the clinical outcomes, presentation, timing and management of mesh exposure/extrusion Retrospective study from December 2006 to March 2012. A total of 40 women had vaginal mesh exposure/extrusion secondary to prior transvaginal mesh (TVM) surgery. Descriptive statistics were used for demographics and pre-operative data. Paired-samples t-test was applied for comparison of pre- and postoperation. A P value of <0.05 was considered statistically significant. The mesh exposure/extrusion rate was noted to be 2.64% (17/642). Vaginal bleeding in 29 of 40 (72.5%) and hispareunia in 12 of 13 (92.3%) were identified as the most common symptoms for mesh exposure/extrusion. The onset of complications occurred in two peaks: between 3 and 4 months and after 1-year of follow-up. Initial conservative treatment was given for 12.5% (5/40) of women, while 87.5% (35/40) had undergone repair for mesh exposure/extrusion (21 outpatient and 14 inpatient cases). Among those who had conservative treatment, 80% (4/5) had persistent mesh exposure. Persistent or new-onset abnormal vaginal bleeding and hispareunia after TVM surgery should be considered as 'red flag' symptoms for mesh exposure/extrusion. Frequent follow-up from the first 3-4 months up to 1 year postoperative may identify complications. Utilisation of mesh excision or trimming as the initial means of treatment may yield a better outcome.