Last Follow-up In May Research Articles

Motivational Interviewing for Enhancing Self-care in Patients With Heart Failure: Protocol for a Randomized Controlled Trial.

Heart failure (HF) is characterized by an increasing prevalence, representing a public health problem and a significant cause of morbidity and mortality. Self-care is a cornerstone approach for optimizing therapy for patients with HF. Patients play a crucial role in managing their condition, given that several adverse health outcomes might be avoided with adequate self-care. In this regard, the literature describes motivational interviewing (MI) as highly favorable for treating chronic diseases, with promising results supporting its efficacy in enhancing self-care. Moreover, caregivers' availability constitutes a fundamental supporting factor among the strategies to improve self-care behaviors in people with HF. The primary study aim is to test the efficacy of a structured program, including scheduled MI interventions, in improving self-care maintenance in the 3-month follow-up from the enrollment. Secondary aims comprehend the assessment of the effectiveness of the above intervention on secondary outcomes (eg, self-care monitoring, quality of life, sleep disturbance) and the corroboration of the superiority of caregivers' participation to the intervention over the program administrated only to individual patients in enhancing self-care behaviors and other outcomes at 3, 6, 9, and 12 months from the enrollment. This study protocol designed a prospective, parallel-arm, open-label, 3-arm, controlled trial. The MI intervention will be administered by nurses trained in HF self-care and MI; the education program will be provided to nurses by an expert psychologist. Analyses will be performed within the framework of intention-to-treat analysis. Comparisons between groups will be based on an alpha of 5% and 2-tailed null hypotheses. In the case of missingness, analyzing the extent of the missingness and identifying underlying mechanisms and patterns will guide imputation methods. The data collection was started in May 2017. We completed the data collection with the last follow-up in May 2021. We plan to perform data analysis by December 2022. We plan to publish the study results within March 2023. MI enhances potential self-care practices in patients with HF and their caregivers. Although MI is effectively largely employed either alone or combined with other treatments and is administered in different settings and ways, face-to-face interventions seem to be more effective. Dyads with higher shared HF knowledge are more efficient in promoting self-care adherence behaviors. Moreover, patients and caregivers may perceive proximity with health care professionals, resulting in a better ability to follow the received health professionals' directions. The scheduled in-person meetings with patients and caregivers will be exploited to administer MI, respecting all the safety regulations for infection containment. The conduction of this study may support changes in clinical practice to include MI to improve self-care for patients with HF. ClinicalTrials.gov NCT05595655; https://clinicaltrials.gov/ct2/show/NCT05595655. DERR1-10.2196/44629.

Concomitant systemic lupus erythematosus and HIV infection

Rationale:Coexisting systemic lupus erythematosus (SLE) and human immunodeficiency virus (HIV) infection cases are rare worldwide. Great challenges are posed on the diagnosis and treatment of such concurrent cases.Patient concern:We report the case of a 44-year-old Chinese man with edema, hematuria, and fever who presented at West China Hospital, Sichuan University, Chengdu, Sichuan, China, in 2013.Diagnoses:An initial diagnosis of SLE was made from the clinical manifestations and laboratory findings based on the Systemic Lupus International Collaborating Clinics classification criteria. Immunosuppressant therapy relieved him of the edema and hematuria, but he regained the symptoms after a cold. Workup, including electrochemiluminescence immunoassay, western blot, and polymerase chain reaction analysis, revealed that he was concurrently infected with HIV after hospitalization.Interventions:The treatment plan included methylprednisolone and cyclophosphamide, with gastroprotective and hepatoprotective agents, simultaneously aiming to reduce urinary protein. After HIV infection confirmed, cyclophosphamide was stopped. He was referred to the local Centers for Disease Control and Prevention for combination antiretroviral therapy (ART). He was suggested to continue monitoring CD4 T-cell count for an appropriate dose of immunosuppressive drugs.Outcomes:In the last follow-up in May 2017, he had been stable in terms of both SLE and HIV infection.Lessons:The case highlights the presence of concurrent SLE and HIV infection. Laboratory technicians and clinicians should be cautious on diagnosis, especially in eliminating the false-positive results. Attention should be paid to the dose of immunosuppressants and the ART procedure.

Abstract 18649: Long-term Outcome and the Mechanisms of Pulmonary Antrum Radial-linear Ablation in Patients With Paroxysmal Atrial Fibrillation

Objectives: The aim of this study was to determine the mechanisms and effectiveness of pulmonary antrum radial-linear (PAR) ablation in comparison with pulmonary vein isolation (PVI) in patients with paroxysmal atrial fibrillation (AF) after a long-term follow-up. Background: The one-year follow up data suggested that PAR ablation appeared to have a better outcome over the conventional PVI for paroxysmal AF. Methods: The enrollment occurred between March, 2011, and August, 2011, with the last follow-up in May, 2014. A total of 133 patients with documented paroxysmal AF were enrolled from 5 centers and randomized to PAR group or PVI group. Event ECG recorder and Holter monitoring were conductedduring the follow-up for all patients. Results: The average procedure time was 151±23 min in PAR group and 178±43 min in PVI group ( P <0.001). The average fluoroscopy time was 21±7 min in PAR group and 27±11 min in PVI group ( P= 0.002). AF triggering foci were eliminated in 59 patients (89.4%) in PAR group, whereas, only 4 patients (6.0%) in PVI group (P<0.001).At median 36 (37-35) months of follow-up after single ablation procedure, 43 of 66 patients in PAR group (65%) and 28 of 67 patients in PVI group (42%) had no recurrence of AF off antiarrhythmic drug (AAD) (P=0.007); and 47 of 66 patients in PAR group (71%) and 32 of 67 patients in PVI group (48%) had no recurrence of AF with AAD (P=0.006). At the last follow-up, the burden of AF was significantly lower in PAR group than in PVI group (0.9% ± 2.3% vs 4.9% ± 9.9%;90th percentile, 5.5% vs 19.6%; P=0.008). No major adverse event (death, stroke, PV stenosis) was observed in all the patients except one case of pericardial tamponade. Conclusions: PAR ablation is a simple, safe, and effective strategy for the treatment of paroxysmal AF with better long-term outcome than PVI. PAR ablation might exhibit the beneficial effect on AF management through multiple mechanisms. Registration: ChiCTR-TRC-11001191

Effect of a balloon-expandable intracranial stent vs medical therapy on risk of stroke in patients with symptomatic intracranial stenosis: the VISSIT randomized clinical trial.

Intracranial stenosis is one of the most common etiologies of stroke. To our knowledge, no randomized clinical trials have compared balloon-expandable stent treatment with medical therapy in symptomatic intracranial arterial stenosis. To evaluate the efficacy and safety of the balloon-expandable stent plus medical therapy vs medical therapy alone in patients with symptomatic intracranial stenosis (≥70%). VISSIT (the Vitesse Intracranial Stent Study for Ischemic Stroke Therapy) trial is an international, multicenter, 1:1 randomized, parallel group trial that enrolled patients from 27 sites (January 2009-June 2012) with last follow-up in May 2013. Patients (N = 112) were randomized to receive balloon-expandable stent plus medical therapy (stent group; n = 59) or medical therapy alone (medical group; n = 53). a composite of stroke in the same territory within 12 months of randomization or hard transient ischemic attack (TIA) in the same territory day 2 through month 12 postrandomization. A hard TIA was defined as a transient episode of neurological dysfunction caused by focal brain or retinal ischemia lasting at least 10 minutes but resolving within 24 hours. Primary safety measure: a composite of any stroke, death, or intracranial hemorrhage within 30 days of randomization and any hard TIA between days 2 and 30 of randomization. Disability was measured with the modified Rankin Scale and general health status with the EuroQol-5D, both through month 12. Enrollment was halted by the sponsor after negative results from another trial prompted an early analysis of outcomes, which suggested futility after 112 patients of a planned sample size of 250 were enrolled. The 30-day primary safety end point occurred in more patients in the stent group (14/58; 24.1% [95% CI, 13.9%-37.2%]) vs the medical group (5/53; 9.4% [95% CI, 3.1%-20.7%]) (P = .05). Intracranial hemorrhage within 30 days occurred in more patients in the stent group (5/58; 8.6% [95% CI, 2.9%-19.0%]) vs none in the medical group (95% CI, 0%-5.5%) (P = .06). The 1-year primary outcome of stroke or hard TIA occurred in more patients in the stent group (21/58; 36.2% [95% CI, 24.0-49.9]) vs the medical group (8/53; 15.1% [95% CI, 6.7-27.6]) (P = .02). Worsening of baseline disability score (modified Rankin Scale) occurred in more patients in the stent group (14/58; 24.1% [95% CI, 13.9%-37.2%]) vs the medical group (6/53; 11.3% [95% CI, 4.3%-23.0%]) (P = .09).The EuroQol-5D showed no difference in any of the 5 dimensions between groups at 12-month follow-up. Among patients with symptomatic intracranial arterial stenosis, the use of a balloon-expandable stent compared with medical therapy resulted in an increased 12-month risk of added stroke or TIA in the same territory, and increased 30-day risk of any stroke or TIA. These findings do not support the use of a balloon-expandable stent for patients with symptomatic intracranial arterial stenosis. clinicaltrials.gov Identifier: NCT00816166.

Acute fulminant endophthalmitis complicating traditional lens couching

A 76-year-old woman presented to the department of ophthalmology in February, 2014, with painful unilateral exophthalmos, 5 days after undergoing couching of the right cataractous lens by a traditional healer. The following day her eye had become red and painful with reduced vision. On examination visual acuity in the right eye was light perception, the intraocular pressure was high (45 mm Hg; normal 10–20 mm Hg), and there was proptosis and ophthalmoplegia. Biomicroscopic examination showed eyelid oedema, conjunctival injection, total chemosis, abundant purulent secretions, and a greenish hypopyon occupying the anterior chamber, typical of pseudomonas infection (figure). CT showed preseptal and retroseptal cellulitis, exophthalmos grade II, and a dislocated cataractous lens in the lower vitreous. We took vitreous and aqueous humour samples and gave one injection of intravitreal antibiotics (vancomycin 1 mg/0·1 mL and ceftazidime 2·25 mg/0·1 mL). We started systemic antibiotics (intravenous ceftriaxone 1 g twice daily and levofloxacin 500 mg twice daily) and a systemic hypotonic (oral acetazolamide 250 mg twice daily). 48 h later we gave a second dose of intravitreal antibiotics and started methylprednisolone 40 mg twice daily for 5 days to reduce the inflammation. Vitreous cultures grew Pseudomonas aeruginosa. By the seventh day the patient's pain, eyelid oedema, and proptosis had resolved (figure), but she had a persistent vitreous opacity. We did pars plana vitrectomy and iris-claw intraocular lens on the posterior side of the iris to compensate for the refractive disorder caused by absence of the crystalline lens. At last follow-up in May, 2014, her best corrected visual acuity was 6/60 in the right eye and intraocular pressure had returned to normal (16 mm Hg). Lens couching is the oldest technique of cataract surgery. It was first practised by the Assyrians of Hammurabi in the 17th century BC, and then by the Hindu surgeon Sushruta around 600 BC. It consists of traumatising the zonula through the sclera using a pen so the lens falls into the vitreous and releases the visual axis, allowing the patient to see the light. The visual outcome of this technique, unfortunately still prevalent in some parts of the world, is often poor. Its complications are retinal detachment, secondary glaucoma, hyphaema, uveitis, optic atrophy, and endophthalmitis. Contributors All authors cared for the patient and wrote the report. Consent to publication was obtained.

Low-Dose Aspirin for Primary Prevention of Cardiovascular Events in Japanese Patients 60 Years or Older With Atherosclerotic Risk Factors

Prevention of atherosclerotic cardiovascular diseases is an important public health priority in Japan due to an aging population. To determine whether daily, low-dose aspirin reduces the incidence of cardiovascular events in older Japanese patients with multiple atherosclerotic risk factors. The Japanese Primary Prevention Project (JPPP) was a multicenter, open-label, randomized, parallel-group trial. Patients (N = 14,464) were aged 60 to 85 years, presenting with hypertension, dyslipidemia, or diabetes mellitus recruited by primary care physicians at 1007 clinics in Japan between March 2005 and June 2007, and were followed up for up to 6.5 years, with last follow-up in May 2012. A multidisciplinary expert panel (blinded to treatment assignments) adjudicated study outcomes. Patients were randomized 1:1 to enteric-coated aspirin 100 mg/d or no aspirin in addition to ongoing medications. Composite primary outcome was death from cardiovascular causes (myocardial infarction, stroke, and other cardiovascular causes), nonfatal stroke (ischemic or hemorrhagic, including undefined cerebrovascular events), and nonfatal myocardial infarction. Secondary outcomes included individual end points. The study was terminated early by the data monitoring committee after a median follow-up of 5.02 years (interquartile range, 4.55-5.33) based on likely futility. In both the aspirin and no aspirin groups, 56 fatal events occurred. Patients with an occurrence of nonfatal stroke totaled 114 in the aspirin group and 108 in the no aspirin group; of nonfatal myocardial infarction, 20 in the aspirin group and 38 in the no aspirin group; of undefined cerebrovascular events, 3 in the aspirin group and 5 in the no aspirin group. The 5-year cumulative primary outcome event rate was not significantly different between the groups (2.77% [95% CI, 2.40%-3.20%] for aspirin vs 2.96% [95% CI, 2.58%-3.40%] for no aspirin; hazard ratio [HR], 0.94 [95% CI, 0.77-1.15]; P = .54). Aspirin significantly reduced incidence of nonfatal myocardial infarction (0.30 [95% CI, 0.19-0.47] for aspirin vs 0.58 [95% CI, 0.42-0.81] for no aspirin; HR, 0.53 [95% CI, 0.31-0.91]; P = .02) and transient ischemic attack (0.26 [95% CI, 0.16-0.42] for aspirin vs 0.49 [95% CI, 0.35-0.69] for no aspirin; HR, 0.57 [95% CI, 0.32-0.99]; P = .04), and significantly increased the risk of extracranial hemorrhage requiring transfusion or hospitalization (0.86 [95% CI, 0.67-1.11] for aspirin vs 0.51 [95% CI, 0.37-0.72] for no aspirin; HR, 1.85 [95% CI, 1.22-2.81]; P = .004). Once-daily, low-dose aspirin did not significantly reduce the risk of the composite outcome of cardiovascular death, nonfatal stroke, and nonfatal myocardial infarction among Japanese patients 60 years or older with atherosclerotic risk factors. clinicaltrials.gov Identifier: NCT00225849.

Cerebral Metastases From Thyroid Carcinoma

Brain metastases arise in roughly 0.9% of all cases of differentiated thyroid cancer. The median survival of adult patients with thyroid carcinoma that has metastasized to the brain is less than one year. Radioactive iodine treatment is only rarely given because its efficacy is not documented. In children, the situation may be different. In 2005, a 15-year-old girl underwent thyroidectomy, and an oxyphilic variant of papillary thyroid carcinoma was found in ectopic thyroid tissue. The patient underwent oral, high-dose radioactive iodine treatment. The post-therapeutic I-131 whole-body scan revealed multiple metastases in the skeleton, lungs, and the soft tissues, along with physiological uptake of the residual thyroid tissue. Magnetic resonance imaging of the head revealed two brain metastases. When the initial treatment was completed, additional age-adapted high-dose radioactive iodine treatment was given, up to a total activity level of 35 GBq. There followed a complete remission of all metastases in the brain, bones, lungs, and soft tissues. Computed tomography of the chest revealed stable residuals. Over the ensuing 7.5 years of follow-up, the thyroglobulin values steadily declined to less than 2 ng/mL. The patient was asymptomatic at her last follow-up in May 2013. She did not develop any delayed reaction to high-dose radioactive iodine treatment (in particular, she did not develop leukemia or any other secondary malignancy). She remained fertile: after completion of the treatment, she had two healthy children. In this patient with multifocal thyroid carcinoma, a rare entity, radioactive iodine treatment was successful as the single treatment. This case illustrates the point that a given therapeutic modality might succeed in an individual case despite a total or near-total lack of efficacy for most patients in the same situation.

Secret ingredients: who knows what's in your food?

British chef and food activist Jamie Oliver ignited a firestorm in January 2011 when he mentioned on the Late Show with David Letterman that castoreum, a substance used to augment some strawberry and vanilla flavorings, comes from what he described as “rendered beaver anal gland.”1 The next year, vegans were outraged to learn that Starbucks used cochineal extract, a color additive derived from insect shells, to dye their strawberry Frappuccino® drinks2 (eventually, the company decided to transition to lycopene, a pigment found in tomatoes3). Although substances like castoreum and cochineal extract may be long on the “yuck factor,”4 research has shown them to be perfectly safe for most people; strident opposition arose not from safety issues but from the ingredients’ origins. But these examples demonstrate that the public often lacks significant knowledge about the ingredients in foods and where they come from. This is not a new development; the public relationship to food additives has a long history of trust lost, regained, and in some cases lost again. The Federal Food, Drug, and Cosmetic (FD&C) Act of 19385 was passed shortly after the deaths of 100 people who took an untested new form of a popular drug, which contained what turned out to be a deadly additive.6 The new law was consumer oriented and intended to ensure that people knew what was in the products they bought, and that those products were safe. The law has been amended over the years in attempts to streamline and bring order to the sprawling task of assessing and categorizing the thousands of substances used in foods, drugs, and cosmetics. One result of this streamlining is that under current U.S. law, companies can add certain types of ingredients to foods without premarket approval from the thin-stretched Food and Drug Administration (FDA). In other words, there are substances in the food supply that are unknown to the FDA. In 2010 the Government Accountability Office (GAO) concluded that a “growing number of substances … may effectively be excluded from federal oversight.”7 Is this a problem? The answer depends on whom you ask.

Thrombocytopenia in a nutshell

In January, 2009, a 70 year old man was referred to us because a blood count done after a night of nausea, vomiting, and fever showed a platelet count of 32×109/L. He had no previous history of thrombocytopenia or haemorrhagic diathesis and did not take medications or quinine-containing beverages. 4 days later, the platelet count was normal, and we believed that the low platelet count might be a result of laboratory error. 8 months later, his symptoms recurred and, again, the platelet count (37×109/L) was low. Other blood values were normal and his platelet count returned to normal in a few days. At this time, our patient recalled eating walnuts before each thrombocytopenic episode, suggesting a possible connection between his complaints and the consumption of walnuts. To test this hypothesis, an in-hospital walnut challenge was undertaken. Our patient’s initial platelet count was 233×109/L. He ate 100 g of walnuts at 1700 h and after 4 h developed a fever (temperature 38·7°C), nausea, and vomiting. No other physical or systemic symptoms, such as rash, angio-oedema, or hypotension, occurred. The nausea and fever resolved during the next 8 h, but he bled from an existing small wound and developed large haematomas at venepuncture sites. His platelet count, measured 15 h after walnut ingestion, was 4×109/L; haemoglobin concentration and white cell count were normal. IgE antibodies specific for tree nuts were not detected. As in previous episodes of thrombocytopenia, the platelet count became normal within 4 days (figure). Figure Changes in platelet count after exposure to walnuts The rapid improvement in platelet count after each episode suggested that the thrombocytopenia might have been caused by a platelet-reactive antibody specific for a substance present in walnuts. We studied new blood samples collected when the platelet count was normal. Strong (titre 1 to 32) IgG antibodies were detected in our patient’s serum by flow cytometry;1 they reacted with platelets when a saline extract made from ground English walnuts(Juglans regia) was present. Similar activity was not detected in normal control serum samples. His antibody did not react with platelets from a patient with Glanzmann’s thrombasthenia lacking the platelet surface αIIb/βIIIa integrin. The findings provided strong evidence that our patient’s thrombocytopenic episodes were caused by an IgG antibody that reacted with αIIb/βIIIa integrin when a soluble substance from walnuts was present. He excluded nuts from his diet and at last follow-up in May 2010, he had had no further symptoms. Many medications are known to cause immune thrombocytopenia, but convincing reports of this complication triggered by foods and beverages are rare. Examples reported were associated with consumption of an African bean,2 sesame seeds,3 cranberry juice,4 cow’s milk, and Jui (a Chinese herbal medicine).5 To the best of our knowledge this is the first case in which a patient reported systemic symptoms and in which a platelet-reactive antibody specific for a substance present in the implicated food was identified. With these findings and the positive provocation test, our patient’s case met all criteria for establishing a causal association between exposure and thrombocytopenia:5 exposure to walnuts resulted in acute thrombocytopenia that rapidly recovered to normal; and no other cause for thrombocytopenia was identified. The provocation test led to profound thrombocytopenia, systemic symptoms, and bleeding, albeit followed by rapid recovery. In retrospect, we should have begun the challenge with a smaller dose of walnuts. Our patient’s case shows the clinical importance of product induced thrombocytopenia and its distinction from other more common causes.

Recurrent aspiration and upper lobe cavitation

In May, 2010, a 49-year-old woman presented to the outpatient clinic with a 4-month history of feeling generally unwell with night sweats and a persistent productive cough of green and yellow sputum. She described coughing when lying fl at, particularly in the early morning hours. Medical history included laparo scopic adjustable gastric banding fi tted in September, 2008, for class III obesity, when her body-mass index (BMI) was 45·4 kg/m². She had been referred to a weight management clinic in July, 2008, at age 49 (BMI 46·2 kg/m²), and subsequently qualifi ed for gastric banding. Her initial response to surgery was modest and she underwent further band fi lls in 2008 and 2009. She was a known asthmatic and had been treated by her general practitioner for exacerbation of her asthma but with no improvement. On examination, her BMI was 32·6 kg/m² and her observations were within normal limits. Blood tests showed a high concentration of C-reactive protein (81 mg/L) and a high ESR (96 mm/h). Chest radiograph showed left upper zone cavitation. Given the radiographic appearance and the presence of persistent night sweats, tuberculosis was suspected. She was referred to the tuberculosis clinic and a subsequent thoracic CT scan confi rmed the presence of a 3·2 cm × 2·8 cm irregular cavitating lesion within the apical segment of the left upper lobe (fi gure). A moderate dilatation of the oesophagus, but no signifi cant thoracic lymphadenopathy, was also seen. Subsequent early morning sputum samples for acid fast bacilli were persistently negative and sputum culture showed only normal respiratory fl ora. Aspergillus precipitins were negative and an autoimmune screen showed no abnormalities. A bronchoscopy and subsequent washings did not yield acid fast bacilli. At this point, the diagnosis of recurrent aspiration and cavitation secondary to a severe restriction from her gastric banding was suspected. She was allergic to penicillin, and therefore treated with metronidazole and doxycycline.Her symptoms persisted, and after 6 weeks of anti-biotics she had only had short-term symptom relief. Therefore, her gastric band was completely emptied, after which her symptoms quickly resolved. A subsequent barium meal showed resolution of her oesophageal dilatation. Based on chest radiographs, the lung cavitation had fully resolved, along with her symptoms. At last follow-up in May, 2011, her BMI was 34·8 kg/m² and her gastric band had been cautiously refi lled with no symptom recurrence.Laparoscopic adjustable gastric banding is regarded as the least invasive surgical option for morbid obesity. However, the procedure is associated with high frequency of late complications, with pouch expansion and band slippage or erosion being the most common.

Recurrent catatonia treated with lithium and carbamazepine: a series of 2 cases.

Recurrent catatonia treated with lithium and carbamazepine: a series of 2 cases.

Benign intraspinal tumour misdiagnosed as mechanical low back pain

In December, 2001, a 71-year-old woman was referred to us with low back pain. She had had this pain since 1991, which her general practitioner initially attributed to a mechanical cause. She received conservative treatment and showed improvement, but after 5 years her pain worsened. Several other diagnoses were made, including arthritis, muscle strain, and pain of psychosomatic origin. In December, 2001, she experienced sudden onset of radicular pain around her right knee, associated with numbness and a decreased knee jerk. Neurological examination was otherwise normal and lumbar-spine radiography showed spondylolisthesis. Spinal MRI showed an intradural lesion attached to the L3 root (fi gure). Total resection of the neurofi broma was undertaken, and the patient had complete relief of symptoms on discharge at the end of December, which had been sustained when she was seen for last follow-up in May, 2006. The diagnostic approach to low back pain aims to identify red fl ags that raise suspicion of serious pathology, such as infection or tumour. Since the prevalence of spinal neoplasms in patients with low back pain is 1%, and these tumours present with a long history of non-specifi c symptoms, there is a low index of suspicion among nonspecialists; symptoms can be attributed to mechanical causes and the diagnosis can be delayed, leading to poor outcome. Low back pain is commonly treated in primaryhealth-care settings. The causes of pain are heterogeneous, so specifi c management protocols are diffi cult to formulate. Even though most patients seek initial evaluation by a primary-care physician, they are also managed by rheumatologists, neurologists, orthopaedic surgeons, and neurosurgeons, leading to much variation in assessment and treatment, and to diagnostic delays of less commonly encountered disorders. Because not every patient with low back pain can undergo exhaustive investigation, successful assessment relies on clinical history and examination, aiming to identify red fl ags, such as weight loss, history of cancer, age over 50 years, high ESR, or positive radiological fi ndings. Benign lumbar spinal tumours, however, tend to present without these warning signs. Physicians should therefore look for secondary symptoms that should also raise suspicion of potentially serious disease. Such patients generally present with a long history of increasing pain, not necessarily accompanied by neurological fi ndings, because of a slow growing tumour within the wide lumbar space. Pain can occur at night or when the patient lies down, due to stretching of spinal roots over the mass. Physical examination may show tenderness over the tumour site, stiff ness, abnormal gait, and antalgic scoliosis. These non-specifi c symptoms can be mis interpreted as mechanical or degenerative in nature. Neurological symptoms can present late because of the mobility of lumbar roots. As the tumour grows, it may compress parasympathetic fi bres to the bladder, bowel, or sexual organs, or compromise a single dorsal root. Therefore other diagnoses, including cystocele, prostatic hypertrophy, and atypical sciatica, are also made. Plain radiographs are generally required to ascertain a diagnosis for low back pain. However, the lumbar spine is a diffi cult location for radiological recognition of benign tumours, and plain radiographs can therefore be misleading. CT and MRI are preferable, especially in patients with low back pain and neurological symptoms. Early investigation should not be delayed by atypical features. Benign lumbar spine tumours should not be excluded from the diff erential diagnosis of persistent low back pain. Initial assessment should aim to identify patients at risk of serious causes of low back pain. A high index of suspicion is also required for patients with a confusing clinical presentation, who complain of trivial or atypical symptoms. In such cases, failure of conservative treatment after 3 months, should prompt advanced neurological imaging even if plain radiographs are normal. A high index of suspicion, detailed history and careful physical examination can help identify those high-risk candidates who will need early screening tests.