The Role of Electronic Medical Records in Reducing Unwarranted Clinical Variation in Acute Health Care: Systematic Review

Background The use of electronic medical records (EMRs)/electronic health records (EHRs) provides potential to reduce unwarranted clinical variation and thereby improve patient health care outcomes. Minimization of unwarranted clinical variation may raise and refine the standard of patient care provided and satisfy the quadruple aim of health care. Objective A systematic review of the impact of EMRs and specific subcomponents (PowerPlans/SmartSets) on variation in clinical care processes in hospital settings was undertaken to summarize the existing literature on the effects of EMRs on clinical variation and patient outcomes. Methods Articles from January 2000 to November 2020 were identified through a comprehensive search that examined EMRs/EHRs and clinical variation or PowerPlans/SmartSets. Thirty-six articles met the inclusion criteria. Articles were examined for evidence for EMR-induced changes in variation and effects on health care outcomes and mapped to the quadruple aim of health care. Results Most of the studies reported positive effects of EMR-related interventions (30/36, 83%). All of the 36 included studies discussed clinical variation, but only half measured it (18/36, 50%). Those studies that measured variation generally examined how changes to variation affected individual patient care (11/36, 31%) or costs (9/36, 25%), while other outcomes (population health and clinician experience) were seldom studied. High-quality study designs were rare. Conclusions The literature provides some evidence that EMRs can help reduce unwarranted clinical variation and thereby improve health care outcomes. However, the evidence is surprisingly thin because of insufficient attention to the measurement of clinical variation, and to the chain of evidence from EMRs to variation in clinical practices to health care outcomes.

EP.FRI.132 Current practice in the investigation and management of post-operative ileus

Post-operative ileus is non-obstructive impairment of gastrointestinal motility after surgery. Treatment involves nil-by-mouth, correction of electrolytes and stopping aggravating medications. There is no national/trust guideline for investigation and management of post-operative ileus. Aim To assess current practice in investigation and management of post-operative ileus. Method All patients with a diagnosis of post-operative ileus on surgical wards at a London hospital between November - December 2020 were identified using clinical coding. Their clinical notes were reviewed and common themes explored. Results 16 patients were diagnosed with post-operative ileus. 12 (75%) patients were male, with a median age of 60 (IQR: 28). 10 (63%) were open procedures, majority being colorectal (10; 63%), cardiothoracic (3; 19%), urological (2; 13%), vascular (1; 6%) operations. Average time between operation and diagnosis was 5.2 (range: 2-14) days. Only 2 (12.5%) patients had documented auscultation of bowel sounds at initial assessment. 8 (50%) patients had imaging to confirm diagnosis (AXR; 5, CT scan; 4). Majority (15; 94%) of patients had serum magnesium and potassium checked at diagnosis. Patients with serum potassium <4.0mmol/L (5) and magnesium <0.7mmol/L (2) had intravenous supplementation. 14 (88%) were administered Hartmann’s solution. 10 (63%) patients were made nil-by-mouth and 15 (94%) had a Ryles tube inserted. 2 (12.5%) patients were prescribed a prokinetic, and only 2 had either opioids or laxatives stopped. No patients were offered gum. Conclusion There is apparent clinical variation in investigation and management of post-operative ileus. We plan to develop an evidence-based trust guideline to reduce unwarranted clinical variation.

Genetically diverse mouse models of SARS-CoV-2 infection model clinical variation and cytokine responses in COVID-19

Host genetics are a significant determinant of coronavirus disease 2019 (COVID-19). Animal models that reflect genetic diversity and a range of clinical outcomes observed in human populations are needed to understand mechanisms of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection dynamics and disease. Here, we report a mouse panel comprising the diverse genetic backgrounds of the Collaborative Cross (CC) founder strains crossed to C57BL/6J mice expressing the K18-hACE2 transgene3 that enables infection by SARS-CoV-2. Infection of CCxK18-hACE2 F1 progeny resulted in a spectrum of weight loss, survival, viral replication kinetics, histopathology, and cytokine profiles, some of which were sex-specific. Importantly, survival was closely associated with early type I interferon expression and a phased proinflammatory response distinct from mice with severe disease. Thus, dynamics of inflammatory responses observed in COVID-19 can be modeled in diverse mice that provide a genetically tractable platform for understanding antiviral immunity and evaluating countermeasures.

Dermatophytosis - A clinico-mycological profile in patients attending to tertiary healthcare centre- An observational study, Dewas, Madhya Pradesh

Dermatophytosis disease was found most common disease worldwide which showed a wide prevalence in tropical country as India and it is a wide importance to know their disease etiology and their clinical presentation. Study objective approaches to determine the clinical variation in Dermatophytosis and the species of fungus isolates which responsible for the infection in this area. In our study 1520 specimens were taken from infected skin, hair and nail screened by 10%-20% KOH mount examination and used Sabouraud’s Dextrose Agar (SDA) medium and Sabouraud’s Dextrose Chloramphenicol and Cycloheximide (SCCA) & Dermatophyte Test Medium (DTM) for culture and incubated at 27°C. Further identification done by slide culture method and lactophenol cotton blue mount. Out of 1520 samples taken, 981(64.54%) were found KOH mount positive for fungal elements and 1076 (70.79%) were found culture positive. (21.64%) was found predominantly among other isolated species. Study was found Tinea corporis (50.39%) as common clinically. The study was highlighted with Tinea corporis being the commonest infection type with variable fungal agents and out of other fungal isolates was found a most common isolate in various clinical conditions.

TO STUDY THE MORBIDITY AND MORTALITY OF ACUTE PANCREATITIS

Background: Acute pancreatitis is a protean disease capable of wide clinical variation ranging from mild discomfort to apocalyptic prostration Methods: This study was conducted in the department of surgery, RNT Medical College and Maharana Bhupal Govt. Hospital, Udaipur. A total of 35 cases of acute pancreatitis were studied Results: Out of these 35 patients, 25(71.42%) had favourable outcome, while 4(15.4%) patient had complication (pancreatic pseudocyst in 3, and recurrence after 7 months in 1 patient), 3(8.57%) patient died and 3 (8.57%) patient could not be followed up due to non-compliance of patient. Conclusion: We concluded that history, clinical examination, radiological and blood investigations are helpful to come to a conclusive diagnosis and severity of acute pancreatitis and most of these cases can be managed conservatively and the use of Octreotide therapy helps in the favourable outcome. Keywords: Conservative, Pancreatitis, Outcome

Identification of Arhgef12 and Prkci as Genetic Modifiers of Retinal Dysplasia in the Crb1rd8 Mouse Model

Mutations in the apicobasal polarity gene CRB1 lead to diverse retinal diseases, such as Leber congenital amaurosis, cone-rod dystrophy, retinitis pigmentosa (with and without Coats-like vasculopathy), foveal retinoschisis, macular dystrophy, and pigmented paravenous chorioretinal atrophy. Limited correlation between disease phenotypes and CRB1 alleles, and evidence that patients sharing the same alleles often present with different disease features, suggest that genetic modifiers contribute to clinical variation. Similarly, the retinal phenotype of mice bearing the Crb1 retinal degeneration 8 (rd8) allele varies with genetic background. Here, we initiated a sensitized chemical mutagenesis screen in B6.Cg-Crb1rd8/Pjn, a strain with a mild clinical presentation, to identify genetic modifiers that cause a more severe disease phenotype. Two models from this screen, Tvrm266 and Tvrm323, exhibited increased retinal dysplasia. Genetic mapping with high-throughput exome and candidate-gene sequencing identified causative mutations in Arhgef12 and Prkci, respectively. Epistasis analysis of both strains indicated that the increased dysplastic phenotype required homozygosity of the Crb1rd8 allele. Retinal dysplastic lesions in Tvrm266 mice were smaller and caused less photoreceptor degeneration than those in Tvrm323 mice, which developed an early, large diffuse lesion phenotype. In both models at one month of age, Müller glia and microglia mislocalization at dysplastic lesions was similar to that in B6.Cg-Crb1rd8/Pjn mice, while photoreceptor cell mislocalization was more extensive. External limiting membrane disruption was comparable in Tvrm266 and B6.Cg- Crb1rd8/Pjn mice but milder in Tvrm323 mice. Immunohistological analysis of mice at postnatal day 0 indicated a normal distribution of mitotic cells in Tvrm266 and Tvrm323 mice, suggesting normal early development. Aberrant electroretinography responses were observed in both models but functional decline was significant only in Tvrm323 mice. These results identify Arhgef12 and Prkci as modifier genes that differentially shape Crb1-associated retinal disease, which may be relevant to understanding clinical variability and underlying disease mechanisms.

928 Current Practice in The Investigation and Management of Post-Operative Ileus

Introduction Post-operative ileus is non-obstructive impairment of gastrointestinal motility after surgery. Treatment involves nil-by-mouth, correction of electrolytes and stopping aggravating medications. There is no current national/trust guideline for investigation and management of post-operative ileus. Aim To assess current practice in investigation and management of post-operative ileus on surgical wards at St Thomas’s Hospital. Method All patients with a diagnosis of post-operative ileus on surgical wards between November - December 2020 were identified. Their clinical notes were reviewed, and common themes explored. Results 16 patients were diagnosed with post-operative ileus. 12 (75%) patients were male, with a median age of 60 (IQR: 28). 10 (63%) were open procedures, majority being colorectal (10; 63%), cardiothoracic (3; 19%), urological (2; 13%), vascular (1; 6%) operations. Average time between operation and diagnosis was 5.2 (range: 2-14) days. Bowel sounds were auscultated in only 2 (12.5%) patients at initial assessment. 8 (50%) patients had imaging to confirm diagnosis (AXR; 5, CT scan; 4). Majority (15; 94%) of patients had serum magnesium and potassium checked at diagnosis. All patients with serum potassium <4.0mmol/L (5) and magnesium <0.7mmol/L (2) had intravenous supplementation. 14 (88%) were administered Hartmann’s solution. 10 (63%) patients were made nil-by-mouth and 15 (94%) had a Ryles tube inserted. 2 (12.5%) patients were prescribed a prokinetic, and only 2 had either opioids or laxatives stopped. No patients were offered gum. Conclusions There is apparent clinical variation in investigation and management of post-operative ileus. We plan to develop an evidence-based trust guideline to reduce unwarranted clinical variation.