Bone regeneration with hydroxyapatite particles loaded in photo-cross-linkable hydrogel: An experimental study.

This study explores the use of in situ cross-linked hyaluronic acid methacryloyl (HAMA) and hydroxyapatite particles (HAP) for bone defect repair. Human periodontal ligament stem cells (PDLSCs) were isolated and co-cultured with the HAMA-HAP composite. Osteogenic differentiation was evaluated using Alizarin Red staining, alkaline phosphatase activity quantification, and polymerase chain reaction (PCR). A cranial defect was induced in Sprague-Dawley rats. This defect was then filled with the HAMA-HAP composite and cross-linked using UV light exposure. Bone formation was assessed through radiographic and histological analyses. The HAMA-HAP composite was found to promote cell viability similarly to pure HAP. It also enhanced gene expression of ALP, OPN, and Runx2, and increased ALP activity and mineralized nodule formation in vitro. Micro-CT scans showed defect restoration in the HAMA-HAP and HAP groups compared to the control group. The HAMA-HAP group exhibited higher Tb.N, Tb.Sp, Tb.Th, and BV/TV. Masson staining showed the HAMA-HAP composite restored the defect site, with new bone formation thicker than in the HAP group. The HAMA-HAP composite showed excellent biocompatibility and promoted osteogenic differentiation of PDLSCs. It effectively repaired cranial defects, indicating its potential for clinical use in bone defect repair.

Evaluation of a chat GPT generated patient information leaflet about laparoscopic cholecystectomy.

BACKGROUND: Artificial intelligence is increasingly being used in all aspects of life in information compilation and writing, and this includes healthcare. This study aimed to evaluate a Chat GPT generated patient information leaflet (PIL) against a surgeon generated version, in order to explore a potential application of this artificial intelligence language processing model. METHODS: Cross-sectional study, undertaken May to June 2023, asking two cohorts (patients and doctors) to complete a questionnaire evaluating a Chat GPT generated PIL and a surgeon generated PIL about laparoscopic cholecystectomy. The patients were having laparoscopic cholecystectomy at large private Hospital in Melbourne, Australia, and doctors were recruited from this hospital and a public quaternary hospital in Melbourne, Australia. The study included a convenience sample of 28 patients and 16 doctors. The main outcome measure was a questionnaire (maximum score out of 8) based on validated evaluation instrument for PILs. RESULTS: The study recruited 28 patients and 15 doctors to complete the questionnaire. The Chat GPT and surgeon generated PILs were scored similarly by patients (median 8 for both PIL; mean 7.5 for Chat GPT PIL vs. 7.1 for surgeon PIL). Doctors also scored both versions similarly, with slightly higher scores for Chat GPT over surgeon version (median 7 vs. 6; mean 6.7 vs. 5.6, respectively). CONCLUSIONS: The Chat GPT generated PIL was assessed as being as good or slightly better than the surgeon generated version. This study shows that PIL are a feasible application of AI language processing models.

The safety and efficacy of laparoscopic retrograde appendicectomy, base-to-tip approach.

Background: Laparoscopic appendicectomy is one of the most frequently performed surgical procedures worldwide. There is limited evidence evaluating the role and safety of laparoscopic retrograde appendicectomy (LRA), base to tip approach, compared to standard laparoscopic antegrade appendicectomy (LAA), tip to base approach. This study aims to assess the safety of LRA compared to LAA in terms of intra-abdominal collection (IAC) rate and using Sunshine Appendicitis Grading System (SAGS). Methods: Records of two-hundred and seventy-three patients undergoing laparoscopic appendicectomy by LAA and LRA approaches were analysed. The severity of appendicitis was rated using a standardised Sunshine Appendicitis Grading System (SAGS) score intra-operatively. The primary outcome measure was the occurrence of an intra-abdominal collection, and secondary measures were procedure time, post-operative length of stay and other complications. Results: Of the two-hundred and seventy-three patients, there were two patients who developed an intra-abdominal collection. Both patients were in the LAA group with SAGS IV scores. Between SAGS IV patients, Chi-squared p value of 0.6691. Therefore, there was no statically significant difference in the intra-abdominal collection (IAC) rate between LAA and LRA groups from this study. Conclusions: The current study has shown that laparoscopic retrograde appendicectomy (LRA) does not increase risk of intra-abdominal collection compared to laparoscopic antegrade appendicectomy (LAA) within the limit of this study.

Challenges in managing upper gastrointestinal bleeding secondary to primary squamous cell carcinoma of the pancreas: a case report and literature review.

BACKGROUND: Primary pancreatic squamous cell carcinoma (SCC) is a rare type of pancreatic cancer, with an incidence of 5% of all pancreatic cancers. This condition is associated with a poor prognosis, and no optimal treatment has been established (Zhang et al. in Medicine (Baltim). 97:e12253, 2018). CASE PRESENTATION: A 56-year-old man presented to our hospital with upper gastrointestinal bleeding and new-onset diabetes mellitus. He had no other medical comorbidities, episodes of pancreatitis and symptoms secondary to pancreatic insufficiency. A computed tomography (CT) scan showed a 94 × 72 × 83 mm necrotic pancreatic body mass with gastric invasion and multiple liver metastases. Gastroscopy revealed deep ulcerations at the posterior wall of the stomach with an active slow ooze. Endoscopic ultrasound was performed with EUS guided biopsy, which confirmed poorly differentiated squamous carcinoma of the pancreas. The patient underwent palliative radiotherapy for recurrent upper gastrointestinal bleeding followed by palliative chemotherapy with gemcitabine and nab-paclitaxel. He was referred to dietitians and diabetes educators for the management of pancreatic exocrine and endocrine insufficiency before being referred to community palliative care upon discharge. CONCLUSIONS: This is the first reported Australian case of pancreatic SCC presenting with upper gastrointestinal bleeding and new-onset diabetes mellitus. Patients with unresectable disease require a multidisciplinary approach to manage complications and improve symptom control. However, there are no standard treatment guidelines and future research is needed in this regard.

Learning curve of laparoscopic inguinal hernia repair: systematic review, meta-analysis, and meta-regression.

BACKGROUND: Laparoscopic inguinal hernia repair has a long learning curve. It can be a technically challenging procedure and initially presents an unfamiliar view of inguinal anatomy. The aim of this review was to evaluate published literature relating to the learning curve of laparoscopic inguinal hernia repair and identify the number of cases required for proficiency. The secondary aim was to compare outcomes between surgeons before and after this learning curve threshold had been attained. METHODS: A systematic literature search was conducted in databases of PubMed, Medline, Embase, Web of Science, and Cochrane Library, to identify studies that evaluated the learning curve of laparoscopic inguinal hernia repair. A meta-regression analysis was undertaken to identify the number of cases to achieve surgical proficiency, and a meta-analysis was performed to compare outcomes between cases that were undertaken during a surgeon's learning phase and experienced phase of the curve. RESULTS: Twenty-two studies were included in this review, with 19 studies included in the meta-regression analysis, and 11 studies included in the meta-analysis. Mixed-effects Poisson regression demonstrated that there was a non-linear trend in the number of cases required to achieve surgical proficiency, with a 2.7% year-on-year decrease. The predicted number of cases to achieve surgical proficiency in 2020 was 32.5 (p < 0.01). The meta-analysis determined that surgeons in their learning phase may experience a higher rate of conversions to open (OR 4.43, 95% CI 1.65, 11.88), postoperative complications (OR 1.61, 95% CI 1.07, 2.42), and recurrences (OR 1.32, 95% CI 0.40, 4.30). CONCLUSION: Laparoscopic inguinal hernia repair has a well-defined learning curve. While learning surgeons demonstrated reasonable outcomes, supervision during this period may be appropriate given the increased risk of conversion to open surgery. These data may benefit learning surgeons in the skill development of minimally invasive inguinal hernia repairs.

Dantrolene Administration in the Management of the Prehospital Patient with Methylenedioxymethamphetamine Overdose: A Case Series and Literature Review.

Methylenedioxymethamphetamine (MDMA) is a psychoactive substance that is used commonly as a recreational drug at rave music festivals. MDMA intoxication can cause a myriad of symptoms and side effects including the manifestation of hyperpyrexia in patients. Hyperpyrexia can mimic a heat stroke and ultimately lead to various forms of end-organ damage. The most common methods used in treating MDMA-induced hyperpyrexia focus on the rapid reduction of core body temperature. Various off-label medications have also been used in combating MDMA-induced hyperpyrexia. Dantrolene is one such medication, although its role in the treatment of MDMA intoxication remains uncertain. This case series preliminarily examines the efficacy of dantrolene in mitigating MDMA-induced hyperpyrexia and potentially reducing the risk of end-organ damage in patients suffering from MDMA overdose. This study focuses on nine patients who presented after ingesting various forms of MDMA at "rave" music events. All patients were found to be hyperthermic in the field with a maximum core body temperature of 109 degrees Fahrenheit. All patients were immediately managed by cooling measures, and seven patients additionally received dantrolene in the field before being transferred to Arrowhead Regional Medical Center. Upon arrival to the hospital, nearly every patient was found to have significantly decreased body temperatures when compared to previously measured body temperatures out in the field. However, nearly all patients in the study were also noted to have laboratory abnormalities consistent with various forms of end-organ damage. The degree and severity of end-organ damage observed in MDMA-induced hyperpyrexia seem to be a function of initial core body temperature. Higher core body temperature tends to correlate with more forms of end-organ damage and a higher severity of end-organ damage. Intervention with dantrolene and cooling measures appeared to have no effect on reducing the risk of developing end-organ damage in this patient population.

Metal stents are safe and cost-effective for preoperative biliary drainage in resectable pancreaticobiliary tumours.

BACKGROUNDS: To compare the complication rates and overall costs of self-expandable metal stents (SEMS) and plastic stents (PS) in clinically indicated preoperative biliary drainage (PBD) prior to a pancreatoduodenectomy (PD). METHODS: We conducted an Australian multicentre retrospective cohort study using the databases of four tertiary hospitals. Adult patients who underwent clinically indicated endoscopic PBD prior to PD from 2010 to 2019 were included. Rates of complications attributable to PBD, surgical complications and pre-operative endoscopic re-intervention were calculated. Costing data were retrieved from our Financial department. RESULTS: Among the 157 included patients (mean age 66.6 ± 9.8 years, 45.2% male), 49 (31.2%) received SEMS and 108 received PS (68.8%). Baseline bilirubin was 187.5 ± 122.6 µmol/L. Resection histopathology showed mainly adenocarcinoma (93.0%). Overall SEMS was associated less complications (12.2% vs. 28.7%, p = 0.02) and a lower pre-operative endoscopic re-intervention rate (4.3 vs. 20.8%, p = 0.03) compared with PS. There was no difference in post-PD complication rates. On multivariate logistic regression analysis, stent type was an independent risk factor of PBD complication (OR of SEMS compared to PS 0.24, 95% CI 0.07-0.79, p = 0.02) but not for any secondary outcome measures. Upfront material costs were $56USD for PS and $1991USD for SEMS. Accounting for rates of complications, average costs were similar ($3110USD for PS and $3026USD for SEMS). CONCLUSION: In resectable pancreaticobiliary tumours, SEMS for PBD was associated with reduced risk of overall PBD-related complications and pre-surgical endoscopic reintervention rates and was comparable to PS in terms of overall cost.

Circulating tumor DNA dynamics and recurrence risk in patients undergoing curative intent resection of colorectal cancer liver metastases: A prospective cohort study.

BACKGROUND: In patients with resectable colorectal liver metastases (CRLM), the role of pre- and postoperative systemic therapy continues to be debated. Previous studies have shown that circulating tumor DNA (ctDNA) analysis, as a marker of minimal residual disease, is a powerful prognostic factor in patients with nonmetastatic colorectal cancer (CRC). Serial analysis of ctDNA in patients with resectable CRLM could inform the optimal use of perioperative chemotherapy. Here, we performed a validation study to confirm the prognostic impact of postoperative ctDNA in resectable CRLM observed in a previous discovery study. METHODS AND FINDINGS: We prospectively collected plasma samples from patients with resectable CRLM, including presurgical and postsurgical samples, serial samples during any pre- or postoperative chemotherapy, and serial samples in follow-up. Via targeted sequencing of 15 genes commonly mutated in CRC, we identified at least 1 somatic mutation in each patient's tumor. We then designed a personalized assay to assess 1 mutation in plasma samples using the Safe-SeqS assay. A total of 380 plasma samples from 54 patients recruited from July 2011 to Dec 2014 were included in our analysis. Twenty-three (43%) patients received neoadjuvant chemotherapy, and 42 patients (78%) received adjuvant chemotherapy after surgery. Median follow-up was 51 months (interquartile range, 31 to 60 months). At least 1 somatic mutation was identified in all patients' tumor tissue. ctDNA was detectable in 46/54 (85%) patients prior to any treatment and 12/49 (24%) patients after surgery. There was a median 40.93-fold (19.10 to 87.73, P < 0.001) decrease in ctDNA mutant allele fraction with neoadjuvant chemotherapy, but ctDNA clearance during neoadjuvant chemotherapy was not associated with a better recurrence-free survival (RFS). Patients with detectable postoperative ctDNA experienced a significantly lower RFS (HR 6.3; 95% CI 2.58 to 15.2; P < 0.001) and overall survival (HR 4.2; 95% CI 1.5 to 11.8; P < 0.001) compared to patients with undetectable ctDNA. For the 11 patients with detectable postoperative ctDNA who had serial ctDNA sampling during adjuvant chemotherapy, ctDNA clearance was observed in 3 patients, 2 of whom remained disease-free. All 8 patients with persistently detectable ctDNA after adjuvant chemotherapy have recurred. End-of-treatment (surgery +/- adjuvant chemotherapy) ctDNA detection was associated with a 5-year RFS of 0% compared to 75.6% for patients with an undetectable end-of-treatment ctDNA (HR 14.9; 95% CI 4.94 to 44.7; P < 0.001). Key limitations of the study include the small sample size and the potential for false-positive findings with multiple hypothesis testing. CONCLUSIONS: We confirmed the prognostic impact of postsurgery and posttreatment ctDNA in patients with resected CRLM. The potential utility of serial ctDNA analysis during adjuvant chemotherapy as an early marker of treatment efficacy was also demonstrated. Further studies are required to define how to optimally integrate ctDNA analyses into decision-making regarding the use and timing of adjuvant therapy for resectable CRLM. TRIAL REGISTRATION: ACTRN12612000345886.

Evaluation of palliative treatments in unresectable pancreatic cancer.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) presents as unresectable disease in 80% of patients. Limited Australian data exists regarding management and outcome of palliative management for PDAC. This study aims to: (i) identify patients with PDAC being managed with palliative intent; (ii) assess the type of palliative management being used. METHODS: A prospectively maintained pancreatic database at Western Health (2015-2017) was used to identify patient demographics; stage and multidisciplinary decision regarding resectability and operative interventions; palliative care; use of chemotherapy, radiotherapy and; management of exocrine and endocrine insufficiency. Data on chemotherapy use, number of hospital admissions, emergency department attendances and intensive care unit admissions 30 days prior to death were recorded. RESULTS: One-hundred and eleven patients had diagnosis of PDAC, 15% with locally advanced and 45% with metastatic PDAC. Among the locally advanced and metastatic PDAC, 48% received biliary stent insertions, 93% had palliative care referral, 45% received palliative chemotherapy and 10% received radiotherapy. Dietitian referral occurred in 79% and 36% were prescribed with a pancreatic enzyme replacement therapy. Diabetes mellitus was present in 52% of which 31% was new onset. Within 30 days prior to death, 11% patients received palliative chemotherapy, 32% were hospitalized and 11% visited an emergency department more than once. Sixty-five percent died in hospital. CONCLUSION: A high proportion of patients diagnosed with locally advanced and metastatic PDAC received palliative care referrals and appropriate level of end-of-life care. Further prospective studies are necessary, examining the management and impacts of pancreatic insufficiency in this group.

An intraoperative diagnosis of sclerosing encapsulating peritonitis: a case report.

Primary sclerosing encapsulating peritonitis (SEP) is an idiopathic and rare condition characterized by chronic peritoneal inflammation. We describe the case of an intraoperative diagnosis of SEP, presenting as a mimicker of small bowel obstruction. The patient was a 59-year-old male with suspected small bowel obstruction. On exploratory laparotomy, it was noted that there was thick fibrous tissue involving the visceral and parietal peritoneum enveloping grossly dilated loops of small bowel. This case reports on the histopathological features of peritoneal biopsies as well as radiological findings. There is no consensus regarding the standard management for idiopathic SEP. The present case demonstrates a significant improvement in the patient's condition with conservative management alone. A critical teaching point is that in the absence of an obvious cause, SEP is a rare but important differential diagnosis for surgeons to consider in the context of recurrent bowel obstruction.

Retrograde jejunogastric intussusception presenting as haematemesis in a patient following pancreaticoduodenectomy.

Intussusception is defined as the invagination of one part of the gastrointestinal tract into another. Jejunogastric intussusception is a rare phenomenon following major upper abdominal surgery, where its aetiology is not well understood. We describe a 68-year-old woman who presented with abdominal pain and haematemesis on the background of a previous pancreaticoduodenectomy (Whipple procedure) for pancreatic cancer. Gastroscopy demonstrated retrograde jejunogastric intussusception, where part of the efferent jejunal limb had prolapsed into the remnant stomach. As a consequence, this intussuscepted segment had become oedematous and ischaemic. The patient subsequently underwent a laparotomy, where the original gastrojejunostomy was resected, which showed the intussuscepted jejunum. The non-viable portion was removed and a Roux-en-Y anastomosis was created. This case highlights the need to 'think outside the box' with respect to differential diagnoses when a patient presents with abdominal pain on the background of previous complex abdominal surgery.

Splenic autotransplantation: a systematic review.

BACKGROUND: Splenectomy is a surgical procedure indicated in a variety of medical conditions including trauma. Post-operatively, there is a lifelong risk of developing overwhelming sepsis from encapsulated bacteria, most commonly due to Streptococcus pneumoniae. Splenic autotransplantation has been proposed as a method to recover splenic function in patients requiring splenectomy with otherwise normal spleens. This study aims to systematically review the literature to determine the efficacy of spleen autotransplantation. METHODS: MEDLINE, PubMed and the Cochrane Library were searched for all studies assessing splenic autotransplantation (January 1947 to July 2018). Data were extracted on study characteristics, outcomes assessed, including spleen scintigraphy results, blood film counts and serum immunoglobulin (Ig) levels. RESULTS: Data were obtained from 18 primary studies. All studies demonstrated return of regenerated spleen tissue in the majority of their patients (95.3%) on spleen scintigraphy. In 12 studies, 90.2% of patients had blood films return to normal following transplantation. Ig levels were shown to return to normal in all 12 studies where it was assessed. In 11 studies, 3.7% of patients had post-operative complications. In five studies, 1.3% of patients had post-operative infections in the follow-up period. CONCLUSION: Splenic autotransplantation is a safe procedure with minimal complications that can return splenic filtration function and Ig levels to normal ranges. It has not been confirmed whether autotransplantation provides meaningful protection against overwhelming post-splenectomy infections.

Laparoscopic EndoClose fixation of a peritoneal catheter reduces migration.

BACKGROUND: With the introduction of laparoscopic Tenckhoff catheter insertion in the early 1990s, catheter malposition resulting in malfunction remains a frequent complication, often requiring surgical or radiological intervention. In this pioneer study, we describe the technique of suturing the Tenckhoff catheter using an EndoClose (Medtronic, Macquarie Park, NSW, Australia) device to the anterior abdominal wall during laparoscopic insertion and compare its outcomes with those not sutured. METHODS: This is a retrospective study of all patients who underwent laparoscopic Tenckhoff catheter insertion at Western Health from January 2013 to June 2018. All procedures were undertaken or supervised by one surgeon. The primary outcome was catheter malposition requiring surgical revision. Secondary outcomes were time to malposition and complications. Peri- and post-operative factors were analysed to adjust for confounders using the Cochran-Mantel-Haenszel test. RESULTS: There were 82 patients in the sutured group and 63 patients in the non-sutured group. Catheter malposition occurred in 7.32% in the sutured group and 19.05% in the non-sutured group (P = 0.034; 95% confidence interval for the difference 0.007-0.237). There was an overall reduction in the odds of catheter malposition of 63% in favour of the sutured group. The median time-to-malposition was 128 and 182 days for the non-sutured and sutured group, respectively, but not statistically different. No differences were found for the number of post-operative complications. CONCLUSION: Suturing of Tenckhoff catheter with an EndoClose device to the anterior abdominal wall during laparoscopic insertion is a simple, safe and useful method of reducing catheter malposition.

A Delayed Diagnosis of Hemorrhagic Shock in a Patient with Alcoholic Cirrhosis and Ascites on Bedside Ultrasound.

Undifferentiated shock is a common and challenging problem in critical care. We present a case of hemorrhagic shock due to splenic and hepatic lacerations diagnosed by bedside paracentesis, initially misclassified as septic shock due to suspected spontaneous bacterial peritonitis (SBP). Case. A 47-year old man with a history of reported alcoholic cirrhosis and ongoing heavy alcohol use was brought to the emergency room after a syncopal event. He was found to be anemic (hemoglobin 9.9 g/dl) and hypotensive with a blood pressure of 64/34. Despite crystalloid infusion he remained hypotensive and required vasopressor support with norepinephrine. Bedside ultrasound revealed moderate ascites and as there was no evidence of active bleeding, his shock was attributed to sepsis due to SBP. A bedside paracentesis was performed which revealed gross blood. A repeat hemoglobin returned at 4.4 g/dl. Massive transfusion protocol was initiated and interventional radiology was emergently consulted due to concerns for intraabdominal hemorrhage; general surgery deemed the patient too unstable for surgical intervention. Angiogram revealed a splenic laceration and possible hepatic laceration, both embolized successfully. Internal medicine practitioners should keep the differential of hemorrhagic shock due to intraabdominal organ injury in mind for patients with undifferentiated shock.

Progressive disseminated histoplasmosis with concomitant disseminated nontuberculous mycobacterial infection in a patient with AIDS from a nonendemic region (California).

BACKGROUND: Opportunistic infections, while well studied in the AIDS population, continue to have variable and surprising presentations. Here, we present a case of disseminated histoplasmosis with disseminated nontuberculous mycobacterial infection in a 50 year old man with long standing AIDS living in a non-endemic area. CASE PRESENTATION: Patient presented with a constellation of symptoms, and imaging of the chest showed a pulmonary mass with cavitation, multiple nodules, and ground glass opacities. Further investigations revealed granulomatous lung nodules and fungemia consistent with Histoplasma capsulatum, and coinfection with disseminated nontuberculous mycobateria in a nonendemic area. CONCLUSIONS: Immunocompromised patients risk co-inhabitation by multiple infectious organisms. Some of these organisms may preside in the host for years prior to reactivation. Clinicians in non endemic areas should therefore be careful to not overlook specific organisms based on a lack of a recent travel history. Physicians in nonendemic areas should become more familiar with the clinical findings and diagnostic approach of infectious such as Histoplasmosis, to ensure earlier recognition and treatment in immunocompromised individuals.

Paraneoplastic syndrome as the presentation of limited stage small cell carcinoma.

BACKGROUND: Small cell lung carcinoma (SCLC) is one of the deadliest forms of lung cancer due to its poor prognosis upon diagnosis, rapid doubling time, and affinity for metastasis. As 60-70% of patients with SCLC have disseminated disease upon presentation, it is imperative to determine the extent of disease burden for treatment. As a neuroendocrine carcinoma, clinicians must pay close attention to abnormal findings in a smoker that could lead to earlier diagnosis and better prognostication. CASE PRESENTATION: A 64 year-old 20-pack year smoker presented to the emergency department with nausea and vomiting for 3 days. No inciting events were elicited. History and review of symptoms were negative including symptoms most-commonly associated with malignancy such as fevers and weight loss. He also denied any pulmonary symptoms. Physical examination was benign except for right lung end-expiratory wheezing. Our patient was clinically euvolemic. Initial blood laboratories showed a sodium 110, serum osmolarity 227, and urine osmolarity of 579. Fluid restriction led to normalization of his sodium and resolution of nausea & vomiting. Chest radiography was obtained to follow-up on the wheezing, which was read as no acute cardiopulmonary disease by radiology. Due to high suspicion of SIADH from malignancy, a CT of the chest was performed which showed a conglomerate of nodules and opacities in the right upper lobe. Biopsy revealed SCLC. At outpatient follow-up, patient had a PET-CT showing one active mediastinal lymph node as the only site of metastasis. He received three round of chemotherapy, chest and prophylactic cranial radiation, and deemed in remission by oncology. DISCUSSION AND CONCLUSIONS: Due to its affinity for metastases, 70% of patients with SCLC present with symptoms related to the spread of cancer to affected organ systems. Given the aggressive nature of this disease, screening measures have been implemented to help diagnose limited stage SCLC. Unfortunately, in our patient and many others, screening guidelines may fail to identify appropriate patients to scan. It is therefore imperative to use our clinical index of suspicion and identify any early presentations (including paraneoplastic syndromes) which may tip off the beginning stages of SCLC. This could improve survival rates by up to 45%.