Assessing, updating and utilising primary care smoking records for lung cancer screening.

BACKGROUND: Lung cancer screening with low-dose computed tomography for high-risk populations is being implemented in the UK. However, inclusive identification and invitation of the high-risk population is a major challenge for equitable lung screening implementation. Primary care electronic health records (EHRs) can be used to identify lung screening-eligible individuals based on age and smoking history, but the quality of EHR smoking data is limited. This study piloted a novel strategy for ascertaining smoking status in primary care and tested EHR search combinations to identify those potentially eligible for lung cancer screening. METHODS: Seven primary care General Practices in South Wales, UK were included. Practice-level data on missing tobacco codes in EHRs were obtained. To update patient EHRs with no tobacco code, we developed and tested an algorithm that sent a text message request to patients via their GP practice to update their smoking status. The patient's response automatically updated their EHR with the relevant tobacco code. Four search strategies using different combinations of tobacco codes for the age range 55-74+ 364 were tested to estimate the likely impact on the potential lung screening-eligible population in Wales. Search strategies included: BROAD (wide range of ever smoking codes); VOLUME (wide range of ever-smoking codes excluding "trivial" former smoking); FOCUSED (cigarette-related tobacco codes only), and RECENT (current smoking within the last 20 years). RESULTS: Tobacco codes were not recorded for 3.3% of patients (n = 724/21,956). Of those with no tobacco code and a validated mobile telephone number (n = 333), 55% (n = 183) responded via text message with their smoking status. Of the 183 patients who responded, 43.2% (n = 79) had a history of smoking and were potentially eligible for lung cancer screening. Applying the BROAD search strategy was projected to result in an additional 148,522 patients eligible to receive an invitation for lung cancer screening when compared to the RECENT strategy. CONCLUSION: An automated text message system could be used to improve the completeness of primary care EHR smoking data in preparation for rolling out a national lung cancer screening programme. Varying the search strategy for tobacco codes may have profound implications for the size of the population eligible for lung-screening invitation.

Defining the road map to a UK national lung cancer screening programme.

Lung cancer screening with low-dose CT was recommended by the UK National Screening Committee (UKNSC) in September, 2022, on the basis of data from trials showing a reduction in lung cancer mortality. These trials provide sufficient evidence to show clinical efficacy, but further work is needed to prove deliverability in preparation for a national roll-out of the first major targeted screening programme. The UK has been world leading in addressing logistical issues with lung cancer screening through clinical trials, implementation pilots, and the National Health Service (NHS) England Targeted Lung Health Check Programme. In this Policy Review, we describe the consensus reached by a multiprofessional group of experts in lung cancer screening on the key requirements and priorities for effective implementation of a programme. We summarise the output from a round-table meeting of clinicians, behavioural scientists, stakeholder organisations, and representatives from NHS England, the UKNSC, and the four UK nations. This Policy Review will be an important tool in the ongoing expansion and evolution of an already successful programme, and provides a summary of UK expert opinion for consideration by those organising and delivering lung cancer screenings in other countries.

CREWS: improving specificity whilst maintaining sensitivity of the National Early Warning Score in patients with chronic hypoxaemia.

BACKGROUND: The National Early Warning Score (NEWS) is being introduced across the UK, but there are concerns about its specificity in patients with chronic hypoxaemia, such as some patients with COPD. This could lead to frequent clinically insignificant triggers and alarm fatigue. AIMS OF STUDY: To investigate whether patients with chronic hypoxaemia trigger excessively with NEWS, and to design a simple variant of NEWS for patients with chronic hypoxaemia: a Chronic Respiratory Early Warning Score (CREWS). METHODS: Data was collected from respiratory wards at two hospitals in North Wales. Components of NEWS and frequency of trigger thresholds being reached were recorded. CREWS was applied retrospectively to patients' observations. RESULTS: 196 admissions were analysed, including 78 for patients with chronic hypoxaemia. Patients with chronic hypoxaemia frequently exceeded trigger thresholds using NEWS during periods of stability/at discharge. Using CREWS, triggers during stability/at discharge were reduced from 32% of observations to 14% using a trigger threshold of a score greater than 6, and from 50% to 18% using a score greater than 5. All patients with chronic hypoxaemia who died within 30 days still reached CREWS trigger thresholds, and the area under receiver operated curves for NEWS and CREWS was comparable. CONCLUSION: CREWS is a simple variant of NEWS for patients with chronic hypoxaemia that could reduce clinically insignificant triggers and alarm fatigue, whilst still identifying the sickest patients.

Ascending aortic aneurysm causing hoarse voice: a variant of Ortner's syndrome.

A 68-year-old man with a persistent hoarse voice was found to have a left vocal cord paralysis. Clinical examination revealed signs consistent with aortic regurgitation. Subsequent investigation revealed an ascending aortic aneurysm. He underwent aortic root and ascending aorta replacement and his hoarseness improved. Ortner's syndrome refers to hoarseness due to recurrent laryngeal nerve palsy secondary to a cardiovascular abnormality. Recurrent laryngeal nerve palsy due to aneurysmal dilation of the ascending aorta is extremely rare, with aneurysms of the aortic arch being a more common cause.

Ghrelin induces abdominal obesity via GHS-R-dependent lipid retention.

Circulating ghrelin elevates abdominal adiposity by a mechanism independent of its central orexigenic activity. In this study we tested the hypothesis that peripheral ghrelin induces a depot-specific increase in white adipose tissue (WAT) mass in vivo by GH secretagogue receptor (GHS-R(1a))-mediated lipolysis. Chronic iv infusion of acylated ghrelin increased retroperitoneal and inguinal WAT volume in rats without elevating superficial sc fat, food intake, or circulating lipids and glucose. Increased retroperitoneal WAT mass resulted from adipocyte enlargement probably due to reduced lipid export (ATP-binding cassette transporter G1 mRNA expression and circulating free fatty acids were halved by ghrelin infusion). In contrast, ghrelin treatment did not up-regulate biomarkers of adipogenesis (peroxisome proliferator-activated receptor-gamma2 or CCAAT/enhancer binding protein-alpha) or substrate uptake (glucose transporter 4, lipoprotein lipase, or CD36) and although ghrelin elevated sterol-regulatory element-binding protein 1c expression, WAT-specific mediators of lipogenesis (liver X receptor-alpha and fatty acid synthase) were unchanged. Adiposity was unaffected by infusion of unacylated ghrelin, and the effects of acylated ghrelin were abolished by transcriptional blockade of GHS-R(1a), but GHS-R(1a) mRNA expression was similar in responsive and unresponsive WAT. Microarray analysis suggested that depot-specific sensitivity to ghrelin may arise from differential fine tuning of signal transduction and/or lipid-handling mechanisms. Acylated ghrelin also induced hepatic steatosis, increasing lipid droplet number and triacylglycerol content by a GHS-R(1a)-dependent mechanism. Our data imply that, during periods of energy insufficiency, exposure to acylated ghrelin may limit energy utilization in specific WAT depots by GHS-R(1a)-dependent lipid retention.