Utilisation and impact of predict prostate on decision-making among clinicians and patients in a specialist tertiary referral centre: A retrospective cohort study.

Background: Patients with intermediate-risk prostate cancer are faced with the decision of whether to undergo radical treatment. Decision-making aids, such as Predict Prostate, can empower both clinicians and patients to make treatment decisions with personalised information, but their impact on multi-disciplinary team (MDT) decision-making and uptake of radical treatment remains unknown. Objective: The objective of this study is to assess the utilisation and utility of Predict Prostate in informing treatment decisions for patients with intermediate-risk prostate cancer. Patients and Methods: A retrospective cohort study was conducted in Cambridge University Hospitals (CUH) of patients referred to the prostate cancer specialist multi-disciplinary team (pcSMDT) and robotic prostatectomy clinic (ROPD) between September 2019 and August 2021 for consideration of radical prostatectomy (RARP). Data on patient characteristics, use of PredictProstate and management decisions were collected from the Epic electronic medical record (EMR) of 839 patients, of whom 386 had intermediate-risk prostate cancer. Results: The use of Predict Prostate at the pcSMDT increased in the second half of the study period (34.5% vs. 23.8%, p < 0.001). The use of Predict Prostate was associated with an increased likelihood of attending ROPD for men with CPG2 prostate cancer (OR = 2.155, 95% CI = 1.158-4.013, p = 0.015) but a reduced likelihood of proceeding with RARP for men with CPG2 (OR = 0.397, 95% CI = 0.209-0.753, p = 0.005) and CPG3 (OR = 0.305, 95% CI = 0.108-0.861, p = 0.025) prostate cancer. Conclusion: Our study showed that the use of Predict Prostate for patients with intermediate-risk prostate cancer is associated with increased attendance at specialist surgical clinic and a reduced chance of undergoing radical prostate surgery.

Pragmatic Trial of Messaging to Providers About Treatment of Hyperlipidemia (PROMPT-LIPID): A Randomized Clinical Trial.

BACKGROUND: Lipid-lowering therapy (LLT) is underutilized for very high-risk atherosclerotic cardiovascular disease. PROMPT-LIPID (PRagmatic Trial of Messaging to Providers about Treatment of HyperLIPIDemia) sought to determine whether electronic health record (EHR) alerts improve 90-day LLT intensification in patients with very high-risk atherosclerotic cardiovascular disease. METHODS: PROMPT-LIPID was a pragmatic trial in which cardiovascular and internal medicine clinicians within Yale New Haven Health (New Haven, CT) were cluster-randomized to receive an EHR alert with individualized LLT recommendations or no alert for outpatients with very high-risk atherosclerotic cardiovascular disease and LDL-C (low-density lipoprotein cholesterol), ≥70 mg/dL. The primary outcome was 90-day LLT intensification (change to high-intensity statin and addition of ezetimibe or PCSK9i [proprotein subtilisin/kexin type 9 inhibitors]). Secondary outcomes included LDL-C level, proportion of patients with LDL-C of <70 or < 55 mg/dL, rate of major adverse cardiovascular events, ED visit incidence, and 6-month mortality. Results were analyzed using logistic and linear regression clustered at the provider level. RESULTS: The no-alert group included 47 clinicians and 1370 patients (median age, 71 years; 50.1% female, median LDL-C, 93 mg/dL); the alert group included 49 clinicians and 1130 patients (median age, 72 years; 47% female, median LDL-C 91, mg/dL). The primary outcome was observed in 14.1% of patients in the alert group as compared with 10.4% in the no-alert group. There were no differences in any secondary outcomes at 6 months. Among 542 patients whose clinicians (n=46) did not dismiss the EHR alert recommendations, LLT intensification was significantly greater (21.2% versus 10.4%, odds ratio, 2.33 [95% CI, 1.48-3.66]). CONCLUSIONS: With a real-time, targeted, individualized EHR alert as compared with usual care, the proportion of patients with atherosclerotic cardiovascular disease with LLT intensification was numerically higher but not statistically significant. Among clinicians who did not dismiss the alert, there was a > 2-fold increase in LLT intensification. EHR alerts, coupled with strategies to reduce clinician dismissal, may help address persistent gaps in LDL-C management. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04394715, https://www.clinicaltrials.gov/ct2/show/study/NCT04394715.

Factors associated with reporting left ventricular ejection fraction with 3D echocardiography in real-world practice.

BACKGROUND: Guidelines recommend 3D echocardiography (3DE) to assess left ventricular ejection fraction (LVEF) on transthoracic echocardiogram (TTE) when possible, but it is unclear which factors are most strongly associated with reporting 3DE LVEF in real-world practice. METHODS: We evaluated 3DE LVEF reporting by age, sex, BMI, TTE location and variation in reporting by sonographer and reader. All TTEs were performed without contrast enhancement agent at a large medical center from 9/2015 to 12/2020 using ultrasound machines capable of 3DE. We used multivariable logistic regression to assess which factors were most associated with reporting 3DE LVEF. RESULTS: Among 35 641 TTEs included in this study, 57.4% were performed on women. 3DE LVEF was reported on 18 391 TTEs (51.6% of cohort; 50.5% for women and 52.4% for men). Portable inpatient TTEs (n = 5569) had the lowest rates of 3DE LVEF reporting (30.9%), while general outpatient TTEs (n = 15 933) had greater reporting (56.9%). Outpatient TTEs with an indication for chemotherapy (n = 3244) had the highest rates of 3DE LVEF (87.2%). The median (IQR) percentage of TTEs reporting 3D LVEF was 52.7% (43.1%-68.1%) among sonographers and 51.6% (46.5%-59.6%) among readers. Among 20082 (56.3%) TTEs with 3DE LVEF measured by sonographers, 91.6% were included by readers in the final report. After adjustment, performing sonographer in the highest reporting quartile was most strongly associated with reporting 3DE LVEF (OR 7.04, 95% CI 6.55-7.56), while an inpatient portable study had the strongest negative association for reporting (OR .38, 95% CI .35-.40). CONCLUSIONS: Use of 3DE LVEF in real-world practice varies substantially based on performing sonographer and is low for hospitalized patients, but can be frequently used for chemotherapy. Initiatives are needed to increase sonographer 3DE acquisition in most clinical settings.

Increasing trends in the use of the Precivia® intravitreal injection assist device across the UK.

BACKGROUND: Intravitreal anti-VEGF injections are the most frequently performed outpatient procedure in the UK, the need for which continues to rise. To meet this demand, injection assist devices such as Precivia® are increasingly adopted to aid in their prompt and safe delivery. We present data on the usage of Precivia® intravitreal injection assist device across two district general hospitals and its distribution across the UK over five years. METHODS: A retrospective review was undertaken of all Precivia® assisted intravitreal injections delivered at Great Western Hospitals NHS Trust (GWH), and Gloucestershire and Cheltenham Hospitals NHS Trust (GCH) between 2015-2020. Data were also obtained from the Precivia® device UK distributor; Veni Vidi Medical. RESULTS: In GCH, 47,968 intravitreal injections were administered with Precivia®: 5947 in year 1; 7058 in year 2; 9893 in year 3; 11,503 in year 4 and 13,567 injections in year 5, observing a 128.13% increase in the use of Precivia® over the five-year-period. In GWH, 26,923 injections were administered with Precivia®: 4232 in year 1; 5117 in year 2; 5437 in year 3; 5878 in year 4 and 6259 in year 5, observing a 47.89% increase in Precivia® injections over a five-year study period. The number of Precivia® devices distributed across the UK similarly increased including 42,150 devices sold in 2015; 68,125 in 2016; 72,575 in 2017; 88,325 in 2018; 112,850 in 2019 and 115,125 in 2020 observing a 173.31% increase in five years. CONCLUSION: An increasing trend in the use of the Precivia® intravitreal injection assist device was observed across the UK.

Non-IG::MYC in diffuse large B-cell lymphoma confers variable genomic configurations and MYC transactivation potential.

MYC translocation occurs in 8-14% of diffuse large B-cell lymphoma (DLBCL), and may concur with BCL2 and/or BCL6 translocation, known as double-hit (DH) or triple-hit (TH). DLBCL-MYC/BCL2-DH/TH are largely germinal centre B-cell like subtype, but show variable clinical outcome, with IG::MYC fusion significantly associated with inferior survival. While DLBCL-MYC/BCL6-DH are variable in their cell-of-origin subtypes and clinical outcome. Intriguingly, only 40-50% of DLBCL with MYC translocation show high MYC protein expression (>70%). We studied 186 DLBCLs with MYC translocation including 32 MYC/BCL2/BCL6-TH, 75 MYC/BCL2-DH and 26 MYC/BCL6-DH. FISH revealed a MYC/BCL6 fusion in 59% of DLBCL-MYC/BCL2/BCL6-TH and 27% of DLBCL-MYC/BCL6-DH. Targeted NGS showed a similar mutation profile and LymphGen genetic subtype between DLBCL-MYC/BCL2/BCL6-TH and DLBCL-MYC/BCL2-DH, but variable LymphGen subtypes among DLBCL-MYC/BCL6-DH. MYC protein expression is uniformly high in DLBCL with IG::MYC, but variable in those with non-IG::MYC including MYC/BCL6-fusion. Translocation breakpoint analyses of 8 cases by TLC-based NGS showed no obvious genomic configuration that enables MYC transactivation in 3 of the 4 cases with non-IG::MYC, while a typical promoter substitution or IGH super enhancer juxtaposition in the remaining cases. The findings potentially explain variable MYC expression in DLBCL with MYC translocation, and also bear practical implications in its routine assessment.

Impact of positron emission tomography - computed tomography status on progression-free survival for relapsed follicular lymphoma patients undergoing autologous stem cell transplantation.

The optimum management approach for patients with relapsed or refractory follicular lymphoma remains uncertain. Autologous stem cell transplantation (autoSCT) is considered a standard option in suitable, younger patients with relapsed follicular lymphoma. AutoSCT is associated with very durable remissions in a minority of subjects, but also with significant, well-established toxicities. Although positron emission tomography (PET) status prior to autoSCT is an established prognostic factor in diffuse large B-cell lymphoma and Hodgkin lymphoma, no data exist in follicular lymphoma. We describe survival outcomes according to pre-transplant PET status, classified by the Lugano criteria into complete metabolic remission (CMR) versus non-CMR, in 172 patients with relapsed or refractory follicular lymphoma within a national, multicenter, retrospective British Society of Blood and Marrow Transplantation and Cellular Therapy registry study. The median number of lines of therapy prior to SCT was three (range, 1-6). The median follow-up after SCT was 27 months (range, 3-70). The median progression-free survival for all patients after autoSCT was 28 months (interquartile range, 23- 36). There was no interaction between age at transplantation, sex, number of months since last relapse, Karnofsky performance status or comorbidity index and achieving CMR prior to autoSCT. Superior progression-free survival was observed in 115 (67%) patients obtaining CMR versus 57 (33%) non-CMR patients (3-year progression-free survival 50% vs. 22%, P=0.011) and by pre-SCT Deauville score (continuous variable 1-5, hazard ratio [HR]=1.32, P=0.049). PET status was independently associated with progression-free status (non-CMR HR=2.02, P=0.003), overall survival (non-CMR HR=3.08, P=0.010) and risk of relapse (non-CMR HR=1.64, P=0.046) after autoSCT by multivariable analysis. Our data suggest that pre- SCT PET status is of clear prognostic value and may help to improve the selection of patients for autoSCT.

Rationale and design of a pragmatic trial aimed at improving treatment of hyperlipidemia in outpatients with very high risk atherosclerotic cardiovascular disease: A pragmatic trial of messaging to providers about treatment of hyperlipidemia (PROMPT-LIPID).

BACKGROUND: Despite guideline recommendations to optimize low-density lipoprotein cholesterol (LDL-C) reduction with intensification of lipid-lowering therapy (LLT) in patients with atherosclerotic cardiovascular disease (ASCVD), few of these patients achieve LDL-C < 70 mg/dL in practice. PURPOSE: We developed a real-time, targeted electronic health record (EHR) alert with embedded ordering capability to promote intensification of evidence based LLT in outpatients with very high risk ASCVD. METHODS: We designed a pragmatic, multicenter, single-blind, cluster randomized trial to test the effectiveness of an EHR-based LLT intensification alert. The study will enroll about 100 providers who will be randomized to either receive the alert or undergo usual care for outpatients with high risk ASCVD with LDL-C > 70 mg/dL. Total enrollment will include 2,500 patients. The primary outcome will be the proportion of patients with LLT intensification at 90 days. Secondary outcomes include achieved LDL-C at 6 months and the proportion of patients with LDL-C < 70 mg/dL or < 55 mg/dL at 6 months. RESULTS: Enrollment of 1,250 patients (50% of goal) was reached within 47 days (50% women, mean age 72, median LDL-C 91). At baseline, 71%, 9%, and 3% were on statins, ezetimibe, or proprotein convertase subtilisin/kexin type 9 inhibitors, respectively. CONCLUSIONS: PRagmatic Trial of Messaging to Providers about Treatment of HyperLIPIDemia has rapidly reached 50% enrollment of patients with very high risk ASCVD, demonstrating low baseline LLT utilization. This pragmatic, EHR-based trial will determine the effectiveness of a real-time, targeted EHR alert with embedded ordering capability to promote LLT intensification. Findings from this low-cost, widely scalable intervention to improve LDL-C may have important public health implications. TRIAL REGISTRATION: clinicaltrials.gov NCT04394715.

The provision of prostate cancer patient information leaflets on an electronic tablet: A further step to paperless health-care provision.

Introduction: The provision of patient information leaflets (PILs) for cancer treatment options is primarily via a paper format. PILs can now be provided on an electronic tablet with the added benefits of providing audio-visual information. Materials and Methods: Between February 2017 and August 2019, 112 patients with newly diagnosed prostate cancer (PCa) were enrolled into our prospective cohort study. The control group (n = 56) were all given PILs on a paper as the standard of care (SoC). The intervention (tablet) group (n = 56) were given the same paper PILs as that of the control group plus an electronic tablet computer with an application containing all SoC paper PILs in an electronic format and supplementary videos detailing treatments. Both groups were asked to complete a validated questionnaire (Telemedicine, Satisfaction and Usefulness questionnaire) with regard to satisfaction with care, provided information, and tablet usage. Results: The response rate for our study was 78/112 (70%). The control and tablet groups were highly satisfied with their care (91%-100% agreed or strongly agreed) and with the information they received (80%-100% agreed or strongly agreed). In the tablet group, 41/46 (89%) reported its utilization. Of those 41, 38 (92%) considered the tablet easy to use and 13 (32%) reported a preference for the paper format. Conclusions: The provision of electronic PILs in PCa treatment is an innovative method of providing oncological care, with positive feedback from our patients. With further development as a mobile application, electronic PILs may allow a more environmentally and fiscally advantageous method of providing PCa care.

Value of the capsular enhancement sign on dynamic contrast-enhanced prostate multiparametric MRI for the detection of extracapsular extension.

PURPOSE: To retrospectively determine the prevalence and diagnostic performance of the capsular enhancement sign (CES) on multiparametric (mp) MRI for the detection of prostate cancer (PCa) extracapsular extension (ECE). METHODS: This retrospective study included patients who underwent mpMRI prior to radical prostatectomy. CES was defined as an area of asymmetrical early hyperenhancement on DCE-MRI adjacent to a peripheral zone tumour, matched or exceeded the tumour circumferential diameter, and with persistent enhancement. Two uro-radiologists evaluated the presence of CES on mpMRI, independently and in consensus, with interobserver agreement calculated using bias and prevalence-adjusted kappa (PABAK). CES performance for predicting ECE was assessed using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: The study included 146 patients, with 91/146 (62%) having ECE on surgical pathology. Following initial review, Reader 1 identified 12/146 (8%) CES-positive cases, while Reader 2 reported 14/146 (10%) CES-positive cases, with 15/146 (10%) lesions determined as demonstrating the CES sign on consensus reading. PABAK for CES between the two readers was high at 0.90. All consensus determined CES-positive lesions represented pathological stage ≥ T3a disease, with the overall prevalence of CES among tumours with confirmed ECE being 15/91 (17%). The sign showed high specificity (100%) and PPV (100%) for ECE detection, but with low sensitivity, NPV, and accuracy at 16.5%, 41.3%, and 47.4%, respectively. CONCLUSIONS: CES was demonstrated to be a rare but highly specific ECE predictor on mpMRI that may improve local staging in the patients in whom it is demonstrated.

Integration of Prostate Biopsy Results with Pre-Biopsy Multiparametric Magnetic Resonance Imaging Findings Improves Local Staging of Prostate Cancer.

PURPOSE: To assess the added value of histological information for local staging of prostate cancer (PCa) by comparing the accuracy of multiparametric MRI alone (mpMRI) and mpMRI with biopsy Gleason grade (mpMRI+Bx). METHODS: 133 consecutive patients who underwent preoperative 3T-MRI and subsequent radical prostatectomy for PCa were included in this single-centre retrospective study. mpMRI imaging was reviewed independently by two uroradiologists for the presence of extracapsular extension (ECE) and seminal vesicle invasion (SVI) on a 5-point Likert scale. For second reads, the radiologists received results of targeted fused MR/US biopsy (mpMRI+Bx) prior to re-staging. RESULTS: The median patient age was 63 years (interquartile range (IQR) 58-67 years) and median PSA was 6.5 ng/mL (IQR 5.0-10.0 ng/mL). Extracapsular extension was present in 85/133 (63.9%) patients and SVI was present in 22/133 (16.5%) patients. For ECE prediction, mpMRI showed sensitivity and specificity of 63.5% and 81.3%, respectively, compared to 77.7% and 81.3% achieved by mpMRI+Bx. At an optimal cut-off value of Likert score ≥ 3, areas under the curves (AUCs) was .85 for mpMRI+Bx and .78 for mpMRI, P < .01. For SVI prediction, AUC was .95 for mpMRI+Bx compared to .92 for mpMRI; P = .20. Inter-reader agreement for ECE and SVI prediction was substantial for mpMRI (k range, .78-.79) and mpMRI+Bx (k range, .74-.79). CONCLUSIONS: MpMRI+Bx showed superior diagnostic performance with an increased sensitivity for ECE prediction but no significant difference for SVI prediction. Inter-reader agreement was substantial for both protocols. Integration of biopsy information adds value when staging prostate mpMRI.

Efficacy of botulinum toxin in masseter muscle hypertrophy for lower face contouring.

BACKGROUND: Masseter muscle hypertrophy (MMH) usually presents with cosmetic concerns as it may lead to widening of the lower face. Apart from the traditional surgical approaches, botulinum toxin type A (BTA) injection is a non-invasive treatment option available. There are no standard guidelines for this procedure. OBJECTIVES: To study the efficacy of botulinumtoxin A in MMH for lower face contouring. METHODOLOGY: The Cochrane Library, PubMed/MEDLINE, Google-scholar, Science-Direct database, and ResearchGate from inception until September 2021 were searched using the keywords "botulinumtoxin type A," "masseter muscle hypertrophy," "lower face contouring," and "masseter botox." All available retrospective and prospective studies, case-series, case-reports, and expert reviews were included with an emphasis on efficacy of BTA in MMH and units injected into the muscle, points of placement, adverse events, and the duration of its effect. Reference lists of the resultant articles, as well as relevant reviews, were also searched. RESULT: 40 articles were shortlisted for the review, of which 14 studies with sample-size ≥10 in accordance with the study requirements were summarized in a tabular form for analysis and easy comparison and reference. CONCLUSION: BTA injection is a non-invasive, safe, and effective treatment for MMH. The optimum number of BTA units could not be ascertained due to wide variability in the studies as well as ethnicity of patients and extent or some measurement of MMH. The points of placement of injection should be well within the boundaries of the masseter muscle. The maximum effect of BTA after a single injection session is usually seen in ~3 months, and the duration may last for 6-12 months. Multiple injection sessions may be required to maintain a long-term effect. Injection technique and total number of injection units of neuromodulator must be individualized for each patient.

Hyperpolarised 13C-MRI identifies the emergence of a glycolytic cell population within intermediate-risk human prostate cancer.

Hyperpolarised magnetic resonance imaging (HP 13C-MRI) is an emerging clinical technique to detect [1-13C]lactate production in prostate cancer (PCa) following intravenous injection of hyperpolarised [1-13C]pyruvate. Here we differentiate clinically significant PCa from indolent disease in a low/intermediate-risk population by correlating [1-13C]lactate labelling on MRI with the percentage of Gleason pattern 4 (%GP4) disease. Using immunohistochemistry and spatial transcriptomics, we show that HP 13C-MRI predominantly measures metabolism in the epithelial compartment of the tumour, rather than the stroma. MRI-derived tumour [1-13C]lactate labelling correlated with epithelial mRNA expression of the enzyme lactate dehydrogenase (LDHA and LDHB combined), and the ratio of lactate transporter expression between the epithelial and stromal compartments (epithelium-to-stroma MCT4). We observe similar changes in MCT4, LDHA, and LDHB between tumours with primary Gleason patterns 3 and 4 in an independent TCGA cohort. Therefore, HP 13C-MRI can metabolically phenotype clinically significant disease based on underlying metabolic differences in the epithelial and stromal tumour compartments.

Timing of high-dose methotrexate CNS prophylaxis in DLBCL: a multicenter international analysis of 1384 patients.

Prophylactic high-dose methotrexate (HD-MTX) is often used for diffuse large B-cell lymphoma (DLBCL) patients at high risk of central nervous system (CNS) relapse, despite limited evidence demonstrating efficacy or the optimal delivery method. We conducted a retrospective, international analysis of 1384 patients receiving HD-MTX CNS prophylaxis either intercalated (i-HD-MTX) (n = 749) or at the end (n = 635) of R-CHOP/R-CHOP-like therapy (EOT). There were 78 CNS relapses (3-year rate 5.7%), with no difference between i-HD-MTX and EOT: 5.7% vs 5.8%, P = .98; 3-year difference: 0.04% (-2.0% to 3.1%). Conclusions were unchanged on adjusting for baseline prognostic factors or on 6-month landmark analysis (n = 1253). In patients with a high CNS international prognostic index (n = 600), the 3-year CNS relapse rate was 9.1%, with no difference between i-HD-MTX and EOT. On multivariable analysis, increasing age and renal/adrenal involvement were the only independent risk factors for CNS relapse. Concurrent intrathecal prophylaxis was not associated with a reduction in CNS relapse. R-CHOP delays of ≥7 days were significantly increased with i-HD-MTX vs EOT, with 308 of 1573 (19.6%) i-HD-MTX treatments resulting in a delay to subsequent R-CHOP (median 8 days). Increased risk of delay occurred in older patients when delivery was later than day 10 in the R-CHOP cycle. In summary, we found no evidence that EOT delivery increases CNS relapse risk vs i-HD-MTX. Findings in high-risk subgroups were unchanged. Rates of CNS relapse in this HD-MTX-treated cohort were similar to comparable cohorts receiving infrequent CNS prophylaxis. If HD-MTX is still considered for certain high-risk patients, delivery could be deferred until R-CHOP completion.

Immediate post-operative PDE5i therapy improves early erectile function outcomes after robot assisted radical prostatectomy (RARP).

To assess whether the timing of post-operative Phosphodiesterase Inhibitor (PDE5i) therapy after Robot-Assisted Radical Prostatectomy (RARP) is associated with a change in early erectile function (EF) outcomes, continence or safety outcomes. Data were prospectively collected from a single surgeon in one tertiary centre. 158 patients were treated with PDE5i therapy post RARP over a 2-year period. PDE5i therapy was started: immediately (day 1-2) post-op in 29%, early (day 3-14) post-op in 37% and late (after day 14) post-op in 34%. EPIC-26 EF scores were collected pre-op and post-op. There were no significant differences in pre-operative characteristics between the therapy groups. Drop in EF scores and percentage return to baseline for unilateral nerve sparing was, respectively, 9 and 11.1% of immediate therapy, 7 and 14.8% of early therapy and 9.7 and 9.5% of late therapy (p = 0.9 and p = 0.6). For bilateral nerve sparing, this was, respectively, 3.5 and 42.9% immediate therapy, 5.5 and 35.5% early therapy and 7.3 and 25% late therapy (p = 0.017 and p = 0.045). Pad free and social continence were achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early therapy and 26% and 54% for late therapy. There were no differences in compliance, complication or readmission outcomes. In patients with bilateral nerve sparing RARP, immediate post-operative PDE5i therapy can protect EF and improve early continence outcomes. Therefore, immediate PDE5i therapy should be considered in patients following nerve sparing RARP to maximise functional outcomes.

Safety and efficacy of nurse led intravitreal injection service with Precivia® injection assist device.

INTRODUCTION: Intravitreal anti-VEGF injections are the most frequently performed outpatient procedure in the UK. Ophthalmic allied healthcare professionals are replacing medical professionals in delivering injections nationwide. The use of injection assist devices such as Precivia® has been well established and increasingly adopted to aid in their safe delivery. We present outcomes of nurse-led intravitreal injections using the Precivia® injection assist device over a five-year period in the UK. METHODS: A retrospective review was completed of all anti-VEGF intravitreal injections delivered at the Great Western Hospital between May 2015 and May 2020. RESULTS: Over the five-year study period, 2318 patients underwent a total of 26,923 intravitreal injections; 20,421 (75.8%) of which were delivered by appropriately trained ophthalmic nurses. The annual number of injections increased year-on-year from 2112 injections in 2015-2016 to 5410 injections in 2019-2020. The mean age of patients was 75.7±12.2 years with a female-to-male ratio was 1.17:1. Wet age-related macular degeneration represented the major indication for injections followed by retinal vein occlusion and diabetic maculopathy respectively. Three cases of post-injection endophthalmitis out of 20,421 (0.015%) injections in nurse injection group were identified during the study period. There were no cases of lens touch, retinal detachment or systemic thromboembolic events. CONCLUSION: Use of the Precivia® intravitreal injection assist device by trained ophthalmic allied health professionals is a safe and cost-effective way to deliver intravitreal injections service.

A High-Value Care Initiative to Reduce the Use of Intravenous Magnesium Sulfate Through an Electronic Indication-Based Order Set.

BACKGROUND: Intravenous (IV) magnesium sulfate (MgSO4) supplementation is common despite limited indications. Oral magnesium oxide (MgO) is an effective, lower-cost alternative. This project aimed to reduce IV MgSO4 use by 20% among the Internal Medicine (IM) service. METHODS: Electronic health record (EHR) orders for MgSO4 and MgO within the IM service were replaced with an indication-based EHR order panel. The project team educated clinicians regarding indications for IV MgSO4 and relative costs. The mean of daily 2 g MgSO4 administrations per week and the mean of weekly proportion of 2 g MgSO4 administrations nine months before and after intervention were compared between IM and Emergency Medicine (EM) (control group). Statistical process control analysis was used to assess for special cause variation in daily MgSO4 per week and weekly proportion of MgSO4 administrations. RESULTS: The mean of daily 2 g IV MgSO4 administrations per week decreased among IM (19.3 vs. 12.1, p < 0.0001) but not EM (3.1 vs. 4.8, p < 0.0001). The mean of weekly proportions of IV MgSO4 administrations decreased among both IM (83.6% vs. 60.7%, p < 0.0001) and EM (97.0% vs. 93.1%, p = 0.0004). For IM, the change in daily MgSO4 per week and weekly proportion of MgSO4 occurred as a discrete initial decline consistent with special cause variation; for EM, changes in both measures were not consistent with special cause variation. CONCLUSION: Replacing stand-alone IV MgSO4 orders with an indication-based order panel along with clinician education reduced IV MgSO4 administrations and may offer a significant opportunity to reduce low-value care.

Collateral Damage: Gun Violence-Induced STEMI.

A young man who presented with chest trauma from multiple gunshot wounds was found to have regional ST-segment elevations perioperatively. This case describes the rapid evaluation and clinical management by a multidisciplinary consultative team pursued for this unusual presentation of cardiac injury. (Level of Difficulty: Intermediate.).