GRANULOMATOUS-LYMPHOCYTIC INTERSTITIAL LUNG DISEASE AS THE NONINFECTIOUS COMPLICATION OF COMMON VARIABLE IMMUNODEFICIENCY

SESSION TITLE: Difficult Diffuse Lung Disease SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Common Variable Immunodeficiency (CVID) is one of the most common humoral immunodeficiency disorders and usually manifests as infectious complications. However, noninfectious complications such Granulomatous-Lymphocytic Interstitial Lung Disease (GLILD) can convey a much poorer prognosis in patients with CVID. In this case report, we present a patient with GLILD who presented with cough and shortness of breath. CASE PRESENTATION: A 66 year old female with past medical history of provoked DVT (off anticoagulation), cervical cancer (s/p resection) presented to pulmonology clinic with complaints of chronic cough and shortness of breath on exertion. She had a negative smoking history and no occupational exposures. She was up to date on vaccinations and COVID was negative. Vitals were stable and physical exam was normal including clear breath sounds. CXR revealed emphysema and hazy opacities in the lung bases. PFTs demonstrated moderate obstructive pattern with no response to bronchodilator, normal lung volumes, and DLCO of 76%. Due to lack of improvement in her cough, CT Chest was done which revealed diffuse pulmonary nodules, bronchiectasis with possible atelectasis or scarring in the RML and lingula, and a prominent subcarinal lymph node. EBUS TBNA of station 7 returned negative for malignancy. Culture showed polymicrobial growth with negative AFB and fungi. Patient was treated without antibiotics, but due to family history of immunodeficiency, immunoglobulin panel was sent which returned low IgG subclasses. She then received IVIG. However, given the centrilobular nodules and lack of response to IVIG, repeat bronchoscopy with TBBx and BAL was performed. BAL revealed lymphocytic predominance and tissue biopsy showed non-caseating granulomas and negative cultures. Eventually patient was diagnosed with GLILD and started on 6 weeks of prednisone 40 mg daily along with PJP prophylaxis. However, her symptoms remained same and rituximab was prescribed with improvement in the symptoms. DISCUSSION: Although recurrent sinopulmonary infections are common in CVID patients, if clinical response to IVIG is minimal to none, GLILD should be considered on the differential. Centrilobular nodules and ground glass opacities should raise suspicion of GLILD and tissue sample should be obtained in these patients to confirm the diagnosis. Appropriate treatment with prednisone or rituximab along with IVIG improves GLILD patient symptoms and yields better outcomes in terms of morbidity and quality of life. CONCLUSIONS: Appropriate treatment with prednisone or rituximab along with IVIG improves GLILD patient symptoms and yields better outcomes in terms of morbidity and quality of life. Reference #1: Hurst JR, Verma N, Lowe D, Baxendale HE, Jolles S, Kelleher P, et al. British lung foundation/United Kingdom primary immunodeficiency network consensus statement on the definition, diagnosis, and management of granulomatous-lymphocytic interstitial lung disease in common variable immunodeficiency disorders. J Allergy Clin Immunol Pract. (2017) 5:938– 45. doi: 10.1016/j.jaip.2017.01.021 DISCLOSURES: No relevant relationships by Benjamin Butler No relevant relationships by Abdulmetin Dursun No relevant relationships by Badri Giri No relevant relationships by Emily Smallwood

ESTABLISHING THE SAFETY OF OUTPATIENT RETROPERITONEAL SACROSPINOUS LIGAMENT FIXATION - A RETROSPECTIVE REVIEWAT A LARGE ACADEMIC HEALTHCARE CENTER

Introduction: With the strain placed on the medical system by the ongoing surges of the Covid-19 pandemic, inpatient surgery is often suspended, and same day discharge rates are increasing. Sacrospinous ligament fixation (SSLF) is an apical suspension procedure performed retroperitoneally;retroperitoneal hemorrhage and nerve injury are potential severe complications. Given these risks, providers vary in their preference for same day discharge vs. routine overnight admission after this procedure. Objective: To establish the safety of outpatient SSLF and evaluate the frequency of complications identified during the hospital stay. Methods: This is a retrospective cohort study of women who underwent SSLF by Urogynecologists at our large, academic institution between March 2018 and October 2021. Patients were identified from the Gynecologic Enhanced Recovery Surgical database, which includes all surgical patients in the department of OBGYN. The data was collected from the electronic medical record (EMR) to track compliance and outcomes in real time for quality improvement purposes during implementation of our enhanced recovery protocol. Institutional IRB approval was obtained. Descriptive statistics were performed. Student's t-test and two-sample tests-of-proportions were used, with a p-value <0.05 denoting statistical significance. Results: A total of 165 patients underwent SSLF;23 were outpatient, and 142 were admitted for at least one night. Over 90% of patients in both groups identified as white, non-Hispanic, and English-speaking. The mean BMI for both groups was 28.8 kg/m2. The outpatient group was younger (57.9 years compared to 64.7 years;P = 0.0051);outpatients were more likely to have commercial insurance (P = 0.0143) and inpatients to have Medicare (P = 0.0282). Almost double the proportion of those in the inpatient group had anxiety and depression, but this did not achieve statistical significance. Outpatients were more likely to be never smokers (P = 0.0175) and use narcotics preoperatively (P = 0.0385). They had a lower mean ASA score (P = 0.0067), Charleston Comorbidity Index score (P = 0.0452), total length of surgery (P < 0.001), total length of anesthesia (P < 0.001), and estimated blood loss (P = 0.0142). Those who went home the same day were more likely to have been the first case (P = 0.0123), and same-day discharge rates increased significantly after the onset of the Covid-19 pandemic (P = 0.0039). Both complications that required operative intervention were identified in the post-anesthesia care unit on the day of surgery. Notably, 30-day post-operative complications were proportionally lower in the outpatient group, but this did not achieve significance. Most of the complications were urinary tract infections, including the sole complication identified in the outpatient group. Conclusions: With the ongoing Covid-19 pandemic and rapidly evolving practice patterns, it is important to establish the safety of outpatient surgery. Our study demonstrates that outpatient SSLF is safe for appropriately selected patients after routine post-operative monitoring including serial vital signs and assessment of neuropathic pain. Severe complications requiring reoperation can often be identified immediately after surgery. Thirty-day post-operative complication rates did not significantly differ between patients undergoing outpatient versus inpatient SSLF.

SAME DAY DISCHARGE AFTER MINIMALLY INVASIVE HYSTERECTOMY IN THE COVID-19 PANDEMIC

Introduction: While same day discharge after minimally invasive hysterectomy (MIH) has demonstrated efficacy, patient's and provider's comfort and safety concerns have limited the universal transition to outpatient MIH. Beginning in March 2020, the COVID-19 pandemic led to an increased demand for hospital beds and limited the capacity for overnight admissions. Additionally, concerns over infection exposure increased patient and provider interest in limiting patient time in the hospital system. Together, these factors increased pressure for same day discharge in MIH cases. Objective: To quantify the impact of COVID-19 pandemic on same day discharges for MIH and evaluate the effect on postoperative outcomes and health care utilization. Methods: This was a retrospective cohort study of women who underwent MIH at a single institution between March 2018 and October 2021. Women over age 18 who underwent laparoscopic, vaginal, or robotic assisted hysterectomy by any gynecologic surgeon were included. Cases that converted to laparotomy or where a gynecologic surgeon was not listed as the primary surgeon were excluded. The primary objective measure was rate of same day hospital discharge. Secondary measures included length of stay and 30-day postoperative complications, readmissions, reoperations, and mortality. Continuous variables were summarized using medians (quantiles) and assessed with Wilcoxon rank tests;Categorical variables were presented using frequencies (percentages) and assessed with χ2 tests. All analyses were conducted using R version 4.1. Results: A total of 1608 women were included: 896 in the pre-pandemic cohort and 712 in the post pandemic cohort. Demographics are summarized in Table 1. The pre-pandemic cohort was more likely to have an ASA class III or IV (P < 0.01) and more likely to have a diagnosis of diabetes (P < 0.01). Surgical characteristics are described in Table 1 and Figure 1. Breakdown of surgeon subspecialty was similar between groups, endoscopic procedures were more frequent in the post-pandemic cohort (p < 0.01), and the timing in the day of cases was not different between groups. Intraoperative complications were more frequent in the pre-pandemic cohort (2.8% vs. 1.0%, P < 0.01). The post-pandemic cohort was significantly more likely to discharge on postoperative day 0 (32% vs. 54%, P < 0.01). Rates of 30-day postoperative complications were not significantly different (16.4% vs. 15.4%, P = 0.60), and there were not significant differences in postoperative transfusion (0.6% vs 1.0%, P = 0.78), readmissions (3.5% vs. 2.5%, P = 0.28), reoperations (0.8% vs. 0.8%, P = 0.89), or mortality (1 vs. 0, P = 0.37). Thirty-day postoperative emergency department visits were more frequent in the post-pandemic cohort (0.1% vs. 1.3%, P < 0.01). Conclusions: The COVID-19 pandemic was associated with an increase in same day discharge without increase in 30-day postoperative complications, although there was a significant increase in postoperative emergency room visits. Our data suggests increased utilization of same day discharge is a safe strategy for management of capacity and hospital bed constraints caused by the COVID19 pandemic (Table Presented).

Development of a nurse led hepatology ambulatory review service

Background and aims: The Liver Unit in Oxford was significantly impacted by COVID-19-highlighting a need for a nurse-led Hepatology ambulatory review service to help minimise inpatient admissions and assess patients with newly diagnosed decompensated liver disease. The Hepatology DCU were providing a nurse led abdominal paracentesis clinic and between appointments the team were able to accommodate clinical reviews. The aims for this service were to reduce Emergency Department (ED) and hospital admissions, facilitate safe and early discharges, expedite care for long term management plans and to allow a single point of access for patients and their families. Method: Since its creation, the two founding Clinical Nurse Specialists (CNS) have collated key metrics pertaining to the patients treated by the service. These metrics included the route of referral, hospital details, date of referral, the reason for referral and whether they needed a hospital admission. Using this dataset, the effectiveness of the service has been critically assessed. Results: Between April 2020–September 2021 the Hepatology DCU reviewed a total of 407 patients. 210 patients were seen from April 2021-September 2021;a monthly average increase of 118%, when compared to the previous year. Not included in these figures, were patients reviewed by the hepatology medical team in ED and medical/surgical ambulatory units. Of the 210 patients reviewed in DCU since April 2021, 76 patients were hepatology ward discharges reviewed byeither CNS, hepatology specialist registrar or a consultant within 7–10 days of discharge. Furthermore, since starting the service just 3.9% of patients required admission from daycase. 224 (55%) of the patients seen in the ambulatory review service since April 2020 were for ascites/oedema review± diuretic management. The ambulatory reviews are in addition to the patients’ routine follow up appointments-aiding close management of their liver disease and expedition of the relevant investigations required for their long-term management, resulting in early interventions. Following completion of an Independent and Supplementary Prescribing module by the CNS, the ambulatory review service became nurse-led in September 2020.(Figure Presented) Conclusion: Although the service is in its infancy, the number of patients reviewed has doubled since starting the hepatology ambulatory reviewservice in April 2020. This has freed up outpatient clinic capacity and prevented delays to assessments. The Hepatology DCU currently provides a five-day service to help reduce ED attendances and reduce inpatient admissions;it is staffed by two full time band 7 CNS.

Determining the Impact of the COVID-19 Pandemic on Hand Surgery Fellowship Education

The purpose of this study is to report the impact of COVID-19 on hand surgery fellow learning and preparedness for practice. A multi-dimensional questionnaire was distributed to current hand fellows and fellowship directors across the United States. Survey questions included fellowship location, institutional response, impact on practice, education and job search. Thirty-two hand surgery fellows and 14 fellowship directors completed the survey. Of fellows, 59% reported a greater than 75% decrease in case volume. Mean hours worked per week per fellow decreased by 52%. All fellowship directors and 94% of fellows did not expect COVID-19 to impact their ability to graduate, and nearly all fellows felt prepared to start practice after fellowship training. However, many fellows expressed concern about job opportunities. The work hours and exposure of hand surgery fellows to elective surgical cases have been adversely impacted by COVID-19. Nevertheless, current hand fellows feel prepared to enter practice. (Journal of Surgical Orthopaedic Advances 31(1):048-052, 2022).

Heritage questing with Virginia Woolf: UCL Institute of Archaeology's 'spirit of place' and new pedagogies of the pandemic

This article charts a particular journey of discovery - that of 'heritage questing with Virginia Woolf. We explore how, against the backdrop of COVID-19, the Master's in Cultural Heritage Studies (MACHS) adopted and adapted Virginia Woolf as an efficacious 'ancestor figure' around which staff and students were able to grasp, engage with, articulate and try to understand the extraordinary experiences and challenges faced throughout the academic year. Woolf emerged as the shared conduit and portal by which MACHS in 'diaspora' could imaginatively connect with, collectively tap into and add new layers to the Institute of Archaeology (IoA)'s 'spirit of place' in Bloomsbury. In what follows, our article draws on a co-ethnography of these experiences which, in turn, we juxtapose alongside Virginia Woolf s own literary insights. Writ large, our journey sees us critically reflect upon attempts to navigate the unknown currents and trajectories of living, teaching and learning in times of coronavirus within which Woolf emerged as a lighthouse of sorts. Writ larger still, we see our quest as a means to grasp the 'new pedagogies of the pandemic' that materialised as an outcome of the impacts and experiences of coronavirus. Ultimately these were also seized upon as a means of taking forward the shared promise of fulfilment, in terms of shaping such quests into liveable presents and better futures as well as adding new layers to the IoA's stratigraphy.

Mechanical Thrombectomy for Treatment of Cerebral Venous Sinus Thrombosis in Vaccine-Induced Immune Thrombotic Thrombocytopenia.

Reports of a rare form of cerebral venous sinus thrombosis with profound thrombocytopenia have emerged following introduction of the adenovirus-vectored coronavirus disease 2019 (COVID-19) vaccines. Between March and June 2021, seven cases of refractory vaccine-induced immune thrombotic thrombocytopenia were referred to our institution for mechanical thrombectomy. The condition of 1 patient deteriorated during interhospital transfer, and the remaining 6 underwent successful recanalization. No procedure-related adverse events were reported. At the time of this writing, 3 patients have been discharged with a good functional outcome (mRS 0-1), one required rehabilitation for mild dysarthria and vocal cord palsy (mRS 3), and 2 have died due to severe mass effect. Our anecdotal experience suggests that endovascular therapy may be safe and effective in reducing thrombus burden in selected cases of postvaccination cerebral venous sinus thrombosis.

Capturing the Effects of Transportation on the Spread of COVID-19 with a Multi-Networked SEIR Model

In this paper we present a deterministic discrete-time networked SEIR model that includes a number of transportation networks, and present assumptions under which it is well defined. We analyze the limiting behavior of the model and present necessary and sufficient conditions for estimating the spreading parameters from data. We illustrate these results via simulation and with real COVID-19 data from the Northeast United States, integrating transportation data into the results.

Evolving Intelligent Reflector Surface Toward 6G for Public Health: Application in Airborne Virus Detection

While metasurface-based intelligent reflecting surfaces (IRS) are an important emerging technology for future generations of wireless connectivity in its own right, plans for the mass deployment of these surfaces motivate the question of their integration with other new and emerging technologies that would require such widespread deployment. This question of integration and the vision of future communication systems as an invaluable component for public health motivated our new concept of Intelligent Reflector-Viral Detectors (IR-VD). In this novel scheme, we propose deployment of intelligent reflectors with strips of receptor-based viral detectors placed between the reflective surface tiles. Our proposed approach encodes information of the presence of the virus by flicking the angle of the reflected beams, using time variations between the beam deviations to represent the messages. This information includes the presence of the virus, its location and load size. The article presents simulations to demonstrate the encoding process that represents the number of virus particles that have bound to the IR-VD. IEEE