IntroductionLung cancer is the leading cause of cancer death in Australia and has the highest cancer burden. Numerous reports describe variations in lung cancer care and outcomes across Australia. There are no data assessing compliance with treatment guidelines and little is known about lung cancer multidisciplinary team (MDT) infrastructure around Australia.MethodsClinicians from institutions treating lung cancer were invited to complete an online survey regarding the local infrastructure for lung cancer care and contemporary issues affecting lung cancer.ResultsResponses from 79 separate institutions were obtained representing 72% of all known institutions treating lung cancer in Australia. Most (93.6%) held a regular MDT meeting although recommended core membership was only achieved for 42/73 (57.5%) sites. There was no thoracic surgery representation in 17/73 (23.3%) of MDTs and surgery was less represented in regional and low case volume centres. Specialist nurses were present in just 37/79 (46.8%) of all sites. Access to diagnostic and treatment facilities was limited for some institutions. IT infrastructure was variable and most sites (69%) do not perform regular audits against guidelines. The COVID-19 pandemic has driven most sites to incorporate virtual MDT meetings, with variable impact around the country. Clinician support for a national data-driven approach to improving lung cancer care was unanimous.DiscussionThis survey demonstrates variations in infrastructure support, provision and membership of lung cancer MDTs, in particular thoracic surgery and specialist lung cancer nurses. This heterogeneity may contribute to some of the well-documented variations in lung cancer outcomes in Australia.

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Introduction Benign variants or incidental findings are often identified on routine polysomnography. One such variant is 14-and-6 hertz positive spikes, first described on EEG in 1951; however, the significance of 14-and-6 positive spikes found on polysomnography has not been previously described. Methods We conducted a retrospective review of patients with 14-and-6 Hz spikes on polysomnography and compared clinical findings on polysomnography with age and sex-matched controls. Results Mean age was 8.6 years (range 2–16). Sleep indices did not differ between cases and controls. Patients with 14-and-6 Hz spikes had lower obstructive apnea-hypopnea index and were less likely to be diagnosed with obstructive sleep apnea. Patients with 14-and-6 Hz spikes did not differ from controls in frequency of formal neurology evaluation, whether a full EEG was obtained, or neurologic diagnoses. Patients with 14-and-6 Hz spikes were less likely to be diagnosed with behavioral or developmental disorders. Conclusion 14-and-6 Hz spikes can be seen in children of all ages and does not seem to be associated with any sleep, neurologic, or developmental disorders. Support (if any):

In the US the prevalence of obesity has risen to 39.8% and affected about 93.3 million of US adults in 2015. Morbidly obese patients are increasingly pursuing bariatric surgery. While the benefits of bariatric surgery are numerous, it is important to recognize and understand the short term and long term postoperative complications. Hyperammonemic syndrome is an uncommon but severe complication of gastric bypass surgery. CASE PRESENTATION:A 43 year old woman with history of non-alcoholic fatty liver disease and history of prior gastric sleeve which was followed by Roux-en-Y Gastric Bypass (RYGB) surgery was admitted for shortness of breath and altered mental status. On hospital day number 10 patient was transferred to ICU for altered mental status, worsening hypoxia, retroperitoneal bleed and septic shock. Patient was subsequently intubated, given transfusions, placed on vasopressors, and given broad-spectrum antibiotics. After 72 hours her overall shock resolved and her ventilator requirements were minimal, but she remained in a comatose state. Initial workup including CT head and brain MRI were unremarkable. Initial routine EEG was consistent with low voltage delta frequencies which could be seen in the setting of severe encephalopathy. Ammonia level had risen to 169 umol/L, which was significantly elevated from prior level of 81 umol/L on admission (Table 1). In addition to aggressive treatment with lactulose and rifaximin, multiple supplements were added, including: Zinc, multivitamin, and L-carnitine. Subsequent EEG on ICU revealed myoclonic status epilepticus for which antiepileptic drugs were given. Repeat MRI of the brain revealed increased diffusion-weighted signal intensity within the cortex and subcortical white matter of suggesting hypoxic and anoxic brain injury.DISCUSSION: Hyperammonemic syndrome related to bariatric surgery is characterized by hyperammonemia, elevated plasma glutamine, hypoalbuminemia, reactive hypoglycemia, nutritional deficiencies of essential amino acids, and low zinc levels, in the absence of overt liver fibrosis or evidence of significant hepatocellular injury (1). The mortality rate approaches 50% and it tends to occur at a high rate in women (1). Patients may present with irritability, vomiting, ataxia, mental retardation, lethargy, and eventually alteration in consciousness and coma (1). There are multiple genetic and nongenetic hypothesized mechanisms (Table 2). Treatment strategies for hyperammonemia include: lactulose, rifaximin, repletion of deficient amino acids, zinc, micro nutrients, and prevention of seizures and cerebral edema (2). CONCLUSIONS:It is important to consider hyperammonemia related to bypass as a potential etiology for neurologic changes in patients with prior bypass, especially in the ICU setting where multiple etiologies can cause encephalopathy and hyperammonemia.