EBV-related lymphoproliferative disease in Wiskott-Aldrich Syndrome patient

Case: Wiskott-Aldrich Syndrome (WAS) is a rare X-linked inborn error of immunity caused by mutations in the WAS gene. It is classically characterized by immunodeficiency, eczema, and micro-thrombocytopenia. It has been known since the 1960s that patients with WAS have an increased risk of lymphoproliferative disease though the exact incidence remains unknown in the American population. Limited case reports have discussed EBV-related lymphoproliferative disease in patients with WAS. We present a case of a 9-year-old boy with known WAS complicated by eczematous rash, thrombocytopenia, recurrent ear infections, and monoclonal gammopathy who was found to have submandibular EBV-associated lymphoid hyperplasia with associated lung and retroperitoneal lymphadenopathy. Family had been offered treatment with hematopoietic stem cell transplant but declined multiple times in the past. Earlier in the year, he presented with possible MIS-C with negative SARS-CoV-2 PCR. He presented to our hospital with mastoiditis and lymphadenopathy. Physical examination showed severe eczema on hands and tender right mastoid. Laboratory evaluation showed thrombocytopenia, elevated IgG of 6290, IgA of 744, IgE of 827, low IgM of 41, and 14% response to pneumococcal titers. He was empirically treated with intravenous antibiotics. ENT performed right postauricular incision and drainage and the culture grew Hemophilus influenza. Throughout his hospital stay, his submandibular lymphadenopathy became more prominent despite treatment. Core needle biopsy of right submandibular lymph node was suggestive of EBV-associated lymphoid hyperplasia. EBV PCR and antibodies were both positive. CT chest, abdomen, and pelvis revealed multifocal pulmonary lymphadenopathy and a diffuse, bilateral nodularity as well as retroperitoneal and mesenteric lymphadenopathy. He was given four doses of weekly Rituximab, which successfully decreased EBV viremia below linear detectability. Immunoglobulin replacement therapy (IgRT) was initiated. Bronchoalveolar lavage and lung biopsy were performed and are results are currently pending. Discussion(s): We present a case of a 9-year-old boy with known WAS awaiting transplant who was found to have submandibular EBV-associated lymphoid hyperplasia with associated lung and retroperitoneal lymphadenopathy. While lymphoproliferative disease is a known complication of WAS, EBV-related lymphoproliferative disease in WAS patients has only been reported as case reports and remains a rare but known complication of patient with WAS.Copyright © 2023 Elsevier Inc.

An Evaluation of the Impact of 0.05% Chlorhexidine on the Prevalence of Surgical Site Infections in Aesthetic Breast Surgery

Purpose of Study Surgical site infections (SSI) burden U.S. hospitals with around $1.5 billion annually. To reduce SSI, irrigating the incision with an antimicrobial solution before closure is recommended. Hence, we evaluate the impact of Irrisept, a form of diluted chlorohexidine 0.05%, on reducing the prevalence of SSI in a high-risk breast cosmetic surgery population. Methods Used We conducted a retrospective cohort study using data in the electronic medical record for breast implant exchange patients in one practice and analyzed infection rates between 42 patients from July 2018-June 2019 that did not receive Irrisept irrigation (control group) with 16 patients from July 2019-July2020 that received Irrisept irrigation (experimental group;significantly less due to Covid-19). We executed descriptive analyses, independent T test, ANOVA (for 3 types of incision location), and Chi-squared to assess comorbidities and intraoperative factors. Summary of Results Among the control group (n=42), 4 patients had a postoperative infection;in the experimental group (n=16), 0 had an infection (9.52% vs. 0%;p=0.04) suggesting the use of Irrisept significantly decreases SSI. The p values from the T test and ANOVA (p<0.05=significant) showed no significant differences in breast cancer (0.84), previous radiation (0.32), history of chemotherapy (0.57), obesity (0.40), renal failure (0.32), smoker/previous smoker (0.41), type of implant (0.32), incision location (0.68), acellular dermal matrix use (0.32), or drain use (0.58) between two groups. The only significant comorbidity was diabetes (p=0.04) with 9.52% (control) vs. 0% (experimental). However, greater percentage of experimental group were obese (25% vs.14.29%) and had a history of smoking (25% vs. 9.52%). Conclusions A concern regarding the implementation of Irrisept irrigation is associated costs. However, the results show the use of Irrisept decreases the infection rates, ultimately relieving the financial burden of postoperative infections. Therefore, we recommend irrigating the incisions of breast surgery patients with Irrisept as both a preventative and economic measure.

Idiopathic anomalous congenital band causing small intestinal obstruction in a 5-month-old dog

A 5-month-old, intact male, yellow Labrador retriever was presented with a 24-hour history of anorexia and vomiting. Abdominal imaging revealed the presence of a mechanical obstruction in the jejunum and peritoneal effusion. Cytologic evaluation and culture of the effusion prior to surgery identified a suppurative exudate with bacteria consistent with septic peritonitis and suspected to be related to the intestinal lesion. An exploratory laparotomy was performed, and a segment of jejunum was circumferentially severely constricted by an off-white, fibrous band of tissue. Resection and anastomosis of the strangulated segment of jejunum and excision of the constricting band provided resolution of the clinical signs. The dog made a complete recovery. Histologic evaluation revealed the band to be composed of fibrovascular and smooth muscle tissue, consistent with an idiopathic anomalous congenital band. No other gastrointestinal lesions were observed, either grossly at surgery or histologically in the resected segment of intestine. To our knowledge, a similar structure has not been reported in the veterinary literature.Copyright © 2022 Canadian Veterinary Medical Association. All rights reserved.

Comparative study of early versus delayed presentation of lens induced glaucoma: A retrospective study conducted among population in remote hilly areas of Uttarakhand

Aim: To compare the causes and visual outcome of lens induced glaucoma amongst those presenting early (within 7 days) with those presenting late (after 7 days). Materials and Methods: This was a retrospective study which included a total of 50 cases diagnosed as lens induced glaucoma. Patients were divided into two groups-group A presenting within 7 days and group B presenting after 7 days. All the patients underwent manual small incision cataract surgery with PMMA lens implantation. Visual outcome and intraocular pressure in both the groups preoperatively and on postoperative day 30 were compared. Results: Majority of patients were females and in the age group of 61-70 years. Phacomorphic glaucoma was the main cause of lens induced glaucoma accounting for 64% of the cases. Good vision in the other eye was the most common reason of delay in seeking medical aid (45.45%). Postoperative day 30 assessment of visual outcome showed that majority of group A patients had a visual acuity of 6/6 to 6/12. Group B patients showed majority with visual acuity of 6/18 to 6/60. Postoperative IOP of 74% patients was well controlled below 21 mm Hg at 1 month. Conclusion: The final BCVA in our study was found to be better in those who presented early, highlighting the importance of early diagnosis and efficient management. © 2023 Innovative Publication, All rights reserved.

Detection of Breast Milk and Amniotic Fluid in Late Pregnant Women with Asymptomatic Infection of Coronavirus Disease 2019: Case Report

It was to explore the clinical characteristics of late pregnant women with asymptomatic infection of coronavirus disease 2019 (COVID-19) and the risk of intrauterine vertical transmission and breastfeeding transmission. The clinical data of a late pregnant woman with COVID-19 were retrospectively analyzed. The patient (singleton, cephalic) was admitted to the hospital on April 3, 2022. The patient had a dramatic increase in C-reactive protein after delivery, other blood routine tests were unremarkable, and the result of nucleic acid test was positive. On April 13, 2022, due to oligohydramnios, under measures such as positive pressure headgear and protective clothing in negative pressure operating room, second cesarean section combined with hysterorrhaphy (emergency) was performed to terminate the pregnancy, and the mother and baby were in good condition. Postpartum amniotic fluid, milk, and neonatal nucleic acid tests were negative. Corresponding treatment was given after cesarean section, and the patient was continuously monitored for nucleic acid detection to meet the discharge criteria of the COVID-19 and discharged and isolated. After discharge, the patient was followed up for 1 month. The newborn's spirit, diet, and development were normal. The maternal cesarean section incision recovered well. Patient with COVID-19 in the third trimester has prolonged hospital stays and are difficult to treat. However, the virus was not found in amniotic fluid, breast milk, and newborn, for which COVID-19 does not lead to intrauterine vertical transmission and breastfeeding transmission in the third trimester.Copyright © 2023 by the authors.

The effect of COVID-19 outbreak on hospital admissions for dental infections

Cervicofacial infections of dental origin can cause life threatening emergency and we were anticipating that the prevalence of hospital admissions for this reason between the 26 th of March 2020 until the 8 th of June 2020 that the dental practices were closed would increase. We conducted a retrospective analysis of the hospital admissions for cervicfacial infections of dental origin during this period and the results were compared with the admissions the same period last year. Surprisingly there were less admissions in 2020 compared to 2019 which can be attributed to the government guidance to ''Stay at home", "Save lives", "Protect the NHS'' and the treatment provided by the Urgent Dental Care Centers that reduced the pressure on the country's health care system. Proportionately more admissions in 2020 were attributed to dental abscess from mandibular teeth compared to 2019 but there was a small decrease in the incision and drainage under general anesthetic and a small increase in the length of the hospital stay in 2020.Copyright © 2021

Transjugular Approach for Recurrent Intracranial Glomus Vagale Tumors: An Ideal Approach to Preserve Hearing and Facial Nerve Function

Lateral skull base paragangliomas (glomus tumors) are rare skull base tumors arising from neuroendocrine cells. These benign tumors can be locally aggressive with potential for intracranial extension and significant morbidity as they compromise cranial nerve structures. Treatment is highly patient dependent. Herein, we present a case of recurrent glomus vagale paraganglioma requiring a multidisciplinary transjugular and transcervical approach for complete resection. A 64-year-old male was referred to the neurotology clinic in 2019 for a left skull base tumor causing progressive dysphonia and dysphagia. Exam revealed left true vocal fold weakness and no other abnormalities. Hearing was normal on the left. Magnetic resonance imaging (MRI) revealed a large hyperintense lesion of the left jugular foramen with intracranial cerebellopontine angle extension and normal flow through the sigmoid sinus and jugular vein. The patient elected for surgical removal and near-total resection was achieved via retrosigmoid craniotomy. A small portion was intentionally left in the jugular foramen to preserve the intact eleventh cranial nerve, internal jugular vein, and sigmoid sinus. Surgical pathology confirmed glomus paraganglioma. Postoperative radiation was strongly recommended, but the patient was lost to follow-up due to the COVID-19 pandemic. The patient re-presented in late 2021 with worsened dysphonia and dysphagia. Exam confirmed left true vocal fold immobility consistent with vagal nerve paralysis and a new finding of left tongue weakness consistent with hypoglossal nerve injury. MRI revealed recurrence of the lesion to dimensions larger than original presentation and complete occlusion of the sigmoid-jugular system. Hearing and facial nerve function remained fully intact, thus a transjugular approach with hearing preservation and complete surgical resection was utilized. After combined retrosigmoid and transcervical incision, the transjugular approach was utilized to resect the sigmoid sinus, the tumor of the jugular foramen, and the intracranial extension. The ear canal and facial nerve canal were preserved. The sigmoid sinus was ligated with surgical clips and the jugular vein was ligated with suture thread. Intracranially, the hypoglossal nerve was identified and preserved, and the vagus nerve was seen eroded by tumor. Pathology confirmed recurrent paraganglioma. Postoperatively, the patient recovered well but continues to endorse persistent dysphonia. His treatment plan includes radiation and thyroplasty. Multiple surgical approaches for the treatment of skull base paragangliomas have been reported including infratemporal types A to D, among others. This report identifies a rare case of recurrent paraganglioma which necessitated removal via transjugular approach. While uncommon in skull base surgery, this approach allowed identification and preservation of important neck and skull base structures (e.g., facial nerve, ear canal, spinal accessory nerve) while achieving complete gross resection. Radiation techniques have become popular alternatives for treatment of glomus tumors of the skull base due to high levels of surgery-related adverse events. Thus, skull base surgeons should be aware of the utility of the transjugular surgical technique for patients with intact hearing and facial nerve function who seek removal of intracranial jugular foramen tumors.

First launch of 3D-printed high-fidelity hypospadias models, for hands-on training of standard hypospadias repairs

Introduction: Simulated training in Pediatric Surgery/Urology is gaining significance due to the following reasons: (a) being a specialty of rare diseases affects individual surgeon's exposure to index cases;(b) subspecialty areas are not universally accessible;and (c) Covid-19 affected elective surgery. Consequently, targeted training, via workshops and simulated models, is necessary. Hypospadias is the index case/operation in Pediatric Urology, requiring a spectrum of dissection and reconstruction skills. It is further challenging to revisit and redo, thus sound initial repair is crucial. To date, there has been no successfully utilizable 3D-printed hypospadias model. We hereby present our experience with silicone 3D-printed high-fidelity hypospadias models. Method(s): Overall, 27 trainees from different countries, under the supervision of 15 instructors, completed the training exercise. They were all given a seminar to show the relevant anatomy and eight key steps of the exercise. Each trainee filled a structured assessment form for the quality of the exercise and resemblance to live surgery. Each exercise was evaluated by a trainer on-site, who supervised the activity and two independent assessors through photographs of the cardinal steps. Result(s): In total, 11 (40.7%) trainees had 1-3 years of specialist training experience, 10 (37%) had 4-6 years, and 6 (22.2%) had beyond. Meanwhile, 2 (7.4%) trainees had no hypospadias experience, 16 (59.2%) assisted in procedures or performed steps, 5 (18.5%) performed whole procedures with guidance, and 4 (14.8%) without guidance. The trainees rated each step from unsatisfactory (1/5) to excellent (5/5) for each of the (1) degloving;(2) urethral marking;(3) incision;(4) tubularization;(5) glanuloplasty;(6) dartos layer preparation;(7) preputioplasty, and (8) skin closure. However, 20 (74%) trainees and 15 (100%) instructors judged the model to resemble the anomaly. Meanwhile, 17 (63%) trainees and 13 (86.6%) instructors rated needle penetrability of the material compared to human tissue >= 3/5. In total, 16 (59%) trainees and 13 (86.6%) instructors rated suture holding >= 3/5. Moreover, 11 (73.3%) and 13 (86.6%) instructors rated sutures' evenness and edge cooptation >= 3/5. Conclusion(s): Majority of instructors found this 3D-model able to mediate transferring skills. Trainees reported adequate skill acquisition.

Improving Quality of Operation Notes in General Surgery - A complete audit cycle

Background: Good quality of operation notes are essential for good post-operative care, patient safety and medico-legal issues. RCSEng have guidelines on items that should be included in all operation notes. RCSEng Guidelines state: Ensure that there are clear (preferably typed) operative notes for every procedure. The notes should accompany the patient into recovery and to the ward and should give sufficient detail to enable continuity of care by another doctor. We re-audited the quality of operation notes in general surgery. Method(s): We re-audited and compared the results with the first cycle. Four months (1st August to 30th November 2021) period of consecutive operation notes were reviewed. Operation notes for endoscopy were excluded. Operations notes were analysed for documentation of the items as per RCSEng guidelines. There were less operations post COVID-19, hence longer study period. After first cycle, departmental presentation given for education and posters displayed in theatres as reminder. Initial plan for 2nd cycle in 2020 but it was not possible due to COVID-19. Problems/complications, extra procedures and prosthesis used were not included. Additional criteria reviewed was: Type of anaesthetic, patient position, indication for procedure and ASA grade. Result(s): A total of 239 operation notes were identified. 169 emergency and 70 elective cases. 193 were handwritten and 46 were typed.The results were compared to the first cycle: Conclusion(s): Higher proportion was ofemergency procedures during the 2nd cycle. Also, higher proportion of handwritten notes during 2nd cycle. There was improvement in documenting elective/emergency, time, type of anaesthesia, indication, position, operative findings/diagnosis, details of tissue removed/added/altered, blood loss, antibiotics, DVT prophylaxis. However, there was poorer documentation of date, name of assistant, incision, closure, signature remains. Ongoing education of the surgeons is vital to improve the quality of the operation notes. We suggest addition of further headings on the current op-note as aid-memoire and introduction of digital operation notes.

Laparoscopic Roux-en-Y cysto-jejunostomy in a complicated Pancreatic Pseudocyst following SARS-CoV-2 virus pancreatitis in a child

Background: Pancreatic pseudocyst (PPC) is the rare complication of pancreatitis. Unlike to adults, it is ensued due to malunion of pancreatic ducts, autoimmune or frequently post-traumatic. During follow up although it might resolve by conservative treatment, may necessitate interventional approaches. Even endoscopic or percutaneous treatments have been the first line treatment, surgery is inevitably necessary in case of complicated or>6 cm diameter. In this study laparoscopic Roux-en-Y cysto-jejunostomy (LRYCJ), to complicated PPC that did not respond to percutaneous drainage, has been presented. Method(s): A 15-year-old boy had been admitted to state hospital with the complains of vomiting, epigastric pain two weeks after SARSCoV- 2 (SARSC2) virus infection. He has been following due to Autism. Initially he had been treated conservatively due to pancreatitis. One month after, PPC (20 mm) distal to pancreas had been specified. He was referred to our department as the cyst got bigger (75 mm) with recurrent complains. No ductal connection was identified however thrombosis of splenic vein, dilated collateral and distal esophageal variceal veins was detected. Ultrasound guided percutaneous drainage has been performed however two weeks after, 95175 mm PPC at the same location was detected. LRYCJ was performed with four ports via suspending stomach and transvers colon. While Roux-en-Y has been performed through expanded umbilical incision cysto-jejunostomy was intracorporeally performed. Penrose drain was left close to cysto-jejunostomy. Oral feeding has begun on postoperative day 2, drain was removed on day 3. Fullfed and discharged on postoperative day 4. Patient did well after a follow up of 3 months. Conclusion(s): Consequently, our case is the first reported PPC following pancreatitis owing to SARSC2 virus infection. Even endoscopic or percutaneous drainage is the most preferred approach for PPC, in case of large cyst or complicated ones, cysto-jejunostomy could be applied by minimally invasive approach in children also.

Factors affecting surgically induced astigmatism in manual small-incision cataract surgery.

Cataract is the most common cause of avoidable blindness in the world. While cataract surgery is continually evolving, manual small-incision cataract surgery (MSICS) still remains highly relevant, especially with the threat of the coronavirus disease 2019 (COVID-19) still looming large over the world. MSICS today has a renewed significance, since it does not involve the use of any advanced machinery and relies mainly on easily sterilizable instruments, thereby making it a safe and inexpensive option. A self-sealing valvular tunnel entry forms the basis of MSICS, and proper positioning and construction of the tunnel is imperative to the success of the surgery. With more and more people demanding spectacle independence after surgery, it becomes important to have a thorough understanding of the factors that may influence surgically induced astigmatism in MSICS. These include the incision location, size and shape, configuration of the sclero-corneal tunnel, pre-existing ocular pathology, role of sutures, amongst others. With proper knowledge, many of these factors can be modulated to achieve best results.

Postauricular Incision Keloid: An Unintended Consequence of COVID-19 Mask Precautions

Introduction: Keloids of the head and neck can result in significant disfigurement and psychological stress. Here we report a novel case of keloid formation at a well-healed postauricular incision presenting after a year of daily ear loop mask use and discuss unique considerations for management. Method(s): This is a retrospective case review of a 35-year-old African American man with Klinefelter syndrome, type 2 diabetes mellitus, and a history of hypertrophic scar formation who presented to otology clinic in 2015 with chronic left otitis media and cholesteatoma. He underwent left tympanoplasty and mastoidectomy in 2016 through a postauricular incision 1 cm posterior to retroauricular sulcus in a standard fashion. In 2018, the patient was noted to have a hypertrophic scar without extension beyond the borders of the incision that was stable until 2021. Result(s): In 2021, the patient was noted to develop a 12A 7-cm postauricular keloid in the setting of mechanical irritation from his mask worn throughout the COVID-19 pandemic. Given the disfiguring cosmesis and resulting challenges securing an ear loop mask, he elected to undergo complete excision of the postauricular keloid with tension-free primary closure of the wound, intralesional corticosteroid injection (triamcinolone acetonide 40 mg/mL), and pressure dressing. The patient was counseled on options for mask wearing to avoid contact with the postauricular incision. Conclusion(s): When designing postauricular incisions in patients prone to hypertrophic scar or keloid formation, the point of postauricular contact of ear loop masks is a novel consideration to minimize risk of future pressure-related injury. Counseling on alternative face masks that tie behind the head or anchoring ear loops to buttons sewn onto a hat or headband are other preventative pressures.

Epiglottic Abscess in a Healthy but Unvaccinated Patient With COVID: Predilection for the Upper Airway?

Introduction: With new SARS-CoV-2 variants emerging such as Delta and Omicron, it is important to reevaluate patterns of presentation and affected patient characteristics. SARS-CoV-2 infection may be shifting from a primary insult of the lower airway to one primarily affecting the upper airway. Method(s): This is a report of a novel case of SARS-CoV-2 infection causing an epiglottic abscess during the peak of the Omicron wave. A literature review showed no previous reports of this specific entity. Result(s): An otherwise healthy, unvaccinated 25-year-old man presented with 3 days of throat pain and mild cough. He had no subjective or objective fevers, malaise, voice changes, or difficulty breathing. White blood cell count was normal. A computed tomography neck with intravenous (IV) contrast revealed edema and gas formation of the epiglottis with a small developing abscess. Flexible fiber-optic laryngoscopy showed an edematous epiglottis with prolapse posteriorly to the pharyngeal wall and mild arytenoid edema without involvement of the vocal folds. He was intubated in the operating room, and incision and drainage of the epiglottic abscess was performed. He was given steroids and broad-spectrum IV antibiotics and extubated without difficulty on postoperative day 2. Intraoperative cultures unfortunately did not speciate to guide antibiotic therapy. He continued to improve clinically and was discharged home on postoperative day 3 with a course of amoxicillin/clavulanate. Conclusion(s): This case highlights a unique presentation of COVID in a young, unvaccinated patient that was successfully managed with operative drainage. He was without any medical comorbidities or immunodeficiency. It is possible that current COVID variants have a predilection for the upper airway as evidenced by this case.

The Impact of COVID-19 Pandemic on Follow-up Refusal Rate in a Surgical Randomized Controlled Trial

Introduction: Refusal to follow-up may affect the course of the ongoing randomized controlled trials (RCT). The aim of this study was to evaluate the impact of COVID-19 pandemic on follow-up refusal rate in an ongoing surgical RCT. Method(s): The study group comprised 107 participants enrolled in an ongoing surgical RCT designed to compare mass with layered closure of transverse abdominal incisions with respect to incisional hernias. Study group was divided into patients who were scheduled to have follow-up visit before (pre-COVID) and after (post-COVID) April 1st 2020. Follow-up refusal rate was compared in both groups. Result(s): Follow-up refusal rate in pre-COVID group was 18.52% (10 out of 55 patients), whereas in post-COVID group it was 50% (26 out of 52 patients;p=0.0004). Median value of age during scheduled follow-up day was 60 years and the distance from patients place of living was 151 km. The pandemic particularly increased refusal rate in patients living >151km from hospital (p <0.0001), patients older than 60 years (p=0.006), and in female patients (p=0.005). Conclusion(s): COVID-19 pandemic leads to remarkable increase in follow-up refusal rate among participants enrolled in RCT's, particularly in females, older patients, and in those living in a long-distance from the centre. Copyright © 2022

COVID-19-INDUCED IMMUNOSUPPRESSION LEADING TO SECONDARY INFECTION AS DISSEMINATED COCCIDIOIDOMYCOSIS

SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Coccidioidomycosis caused by the fungi C. immitis and C. Posadasii is well known to be endemic to the Southwest United States. Less than 1% of these infections will manifest as extrapulmonary symptoms and multiple sites causing dissemination fungemia [1]. Risk factors for disseminated infection include exogenous immunosuppression, immunodeficiency, pregnancy, and ethnic backgrounds of African and Filipino descent [2]. CASE PRESENTATION: A 39-year-old previously immunocompetent Congolese male with recent onset of recurrent skin abscess, and positive testing for COVID-19 three week prior (not treated with steroids). He presents with shortness of breath, back pain, fevers after recently migrating from the Southwest region to the Midwest. Upon admission imaging with Computed Tomography (CT) revealed extensive pulmonary infiltrates (Fig 1), intra-abdominal abscesses, and magnetic resonance imaging revealing (MRI) osteomyelitis of the thoracic (Fig 2) and lumbar spine (Fig 3). His work of breathing continued to worsen, requiring prompt intubation, and he was initiated on a broad-spectrum antimicrobial regimen, including fluconazole, voriconazole, cefepime and vancomycin. Immunoglobulins, HIV and oxidative burst testing was unremarkable. Cultures from image-guided aspiration of the psoas abscess, incision, and drainages of skin abscess and bronchoalveolar lavage fluid were all positive for coccidioidomycosis, transitioned to amphotericin B. Course complicated with the development of multidrug-resistance pseudomonas aerogenes VAP treated with inhaled tobramycin and meropenem. He developed progressive acute respiratory distress syndrome with refractory hypoxemia. After 3 weeks of antimicrobial and anti-fungal treatment, a decision was made to transfer the patient to a lung transplant center, however, due to ongoing fungemia, he was deemed to be not a candidate for extracorporeal membrane exchange and lung transplantation. About a month into his hospitalization, the family decided to withdraw care. DISCUSSION: Reactivation of latent coccidiomycosis has been largely studied in the immunosuppressed population that includes HIV, hematological malignancies, and diabetes mellitus, however little is known about this fungal infection in the immunosuppressed state in the setting of COVID-19. Thus far only two case reports have been reported of co-infection if COVID-19 and pulmonary coccidioidomycosis [3]. The days of the COVID-19 pandemic might contribute to further delays in diagnosing this fungal infection due to similarities of pulmonary manifestation. CONCLUSIONS: This case demonstrates a COVID-19 infection leading to an immunosuppressed status resulting in disseminated infection from reactivation of latent coccidiomycosis. As a result, physicians must maintain a high level of suspicion for superimposed fungal infections in those with even relative immunosuppression from a recent COVID infection. Reference #1: Odio CD, Marciano BE, Galgiani JN, Holland SM. Risk Factors for Disseminated Coccidioidomycosis, United States. Emerg Infect Dis. 2017;23(2):308-311. doi:10.3201/eid2302.160505 Reference #2: Hector RF, Laniado-Laborin R. Coccidioidomycosis–a fungal disease of the Americas. PLoS Med. 2005;2(1):e2. doi:10.1371/journal.pmed.0020002 Reference #3: Shah AS, Heidari A, Civelli VF, et al. The Coincidence of 2 Epidemics, Coccidioidomycosis and SARS-CoV-2: A Case Report. Journal of Investigative Medicine High Impact Case Reports. January 2020. doi:10.1177/2324709620930540 DISCLOSURES: No relevant relationships by Stephen Doyle No relevant relationships by Connor McCalmon No relevant relationships by John Parent No relevant relationships by Jay Patel No relevant relationships by Angela Peraino No relevant relationships by Keval Ray

The Impact of Extended Reality on Surgery: A Scoping Review

Aim: Extended reality (XR) is a spectrum of technologies encompassing augmented reality (AR), virtual reality (VR), augmented virtuality (AV), mixed reality (MR). This scoping review maps out current utilisation and future prospects of XR-assisted surgery. Method: A systematic search of PubMed, Scopus, Embase was performed. Primary studies describing surgical procedures on human subjects, dentistry, anaesthetic procedures for surgery were included. Non-surgical, rehabilitation, bedside, veterinary procedures, robotic surgery were excluded. Studies were classified into preoperative planning, intraoperative navigation/guidance, patient pain, patient anxiety, surgical training, surgeon confidence. Results: 213 studies were included for analysis. Thirty-six studies on pre-operative planning noted VR improved surgeon's understanding of anatomical sites, leading to reduced operating time and surgical trauma. Fifty-nine studies on intra-operative planning noted AR headsets highlight 'negative structures', reducing chance of accidental incision. Fourteen studies on patients' pain found VR-induced meditative state resulted in less analgesics for patient comfort. Twelve studies on patient anxiety found VR failed to change patients' physiological parameters such as arterial blood pressure, cortisol levels, heart rate. Sixty-eight studies explored surgical training, with VR being most cost-effective. Thirteen studies documented increased surgeon confidence. Conclusions: XR-assisted surgery's growth is fuelled by hardware and software innovations. Training and pre-operative planning are mostly achieved by VR;intraoperative guidance is mostly supplemented with AR. The other sections of XR spectrum, AV and MR, are underexplored. Working time restrictions during surgical training, COVID-19's impact on limiting physical presence and increasing complexity of surgical procedures means that XR-assisted surgery may assume a greater role in coming decades.

TELEMEDICINE IN POST-CIED CARE

Background: Previously, all patients post-CIED implant returned to the clinic to have wound assessment, reinforce device knowledge, and confirm remote connectivity. This did not offer any tailored options for patient follow-up. Narrative: At the onset of COVID-19, wound checks post-CIED implants were changed from in person visits to telemedicine. For the few patients who had wound healing/hematoma issues identified, the patient was asked to come to clinic for further assessment. The objective of the telemedicine visit was to assess incision healing post-CIED implant. The visit also allowed the provider to ensure remote connectivity and review expectations for establishing routine device follow up. Many patients preferred the convenience of the telemedicine as it reduced travel cost and hassle of getting to the clinic, making it a more time efficient visit. For those who scheduled for a telemedicine visit, expectations of the video visit is set at the time of discharge. We need to ask the patient if they are willing to take off the Steri-Strips at time of the telemedicine visit and send them home with the needed supplies for the telemedicine visit. If patient declined removing the Steri-Strips, they were instructed to let the bandage gradually come off. They were then instructed to notify clinic for any concerning signs/symptoms. Challenges with the video quality, at times, necessitated higher quality photos to be taken and sent in for better assessment of incision site. We identified specific patients, ie, patients taking anticoagulation medication or those who had a higher risk of infection, benefitted from an in clinic visit to allow a more accurate assessment of the pocket and incision line. Therefore, those patients were required to return to clinic. Conclusion: What started out as a pandemic necessity, expanded the opportunities for telemedicine assessments to evaluate wound healing and to provide education through a telemedicine format.

MINI OR RETROPUBIC SLING IN WOMEN WITH INTRINSIC SPHINCTER DEFICIENCYAT 6 MONTHS- AN RCT (MINI RISD)

Introduction: Intrinsic sphincter deficiency (ISD) is associated with a higher risk of sling failure and is difficult to treat. The retropubic (RP) sling and the “mini” single incision sling (SIS) are two treatment options. Comparison of the efficacy and safety for these procedures in an ISD population has not been determined. The RP sling has been shown to be superior to the obturator sling for the treatment of SUI associated with ISD1, however the RP sling is associated with more complications such as bleeding, bladder injury and voiding difficulty2,3. SISs provide a “hammock” support and are able to be placed under more tension than an obturator sling. It is plausible that SISs could be as effective as the retropubic sling but associated with less complications. Objective: To assess if the SIS is as efficacious as the RP sling for women with urodynamic stress incontinence (USI) and ISD and compare clinical outcomes. Methods: This was a multicenter randomized controlled trial involving women with SUI/ISD. Demographic data of eligible women and POPQ examination was collected. Randomization to SIS or RP occurred in equal probability. Concomitant prolapse operation was performed as required. Post-operative interview and examination were performed at 6 weeks and 6 months. Examination included uroflow, cough stress test and POPQ assessment. Standardized questionnaires were performed at 6 months. Primary outcome was to assess the objective cure rate (negative clinical cough stress test) of the SIS against the RP sling at 6 months post- surgery. Secondary outcomes included immediate and short term post-operative complications and patient reported outcomes. Categorical Outcomes were compared using the chi-squared test and continuous outcomes using the independent samples t-test for normally distributed data. Results: 112 women have been randomized and completed 6 month follow up. 54 women were randomized to SIS and 58 women to RP sling. Results were analyzed by at ITT analysis. No women crossed groups. We did not achieve our sample size of 132 due to a combination of factors including withdrawal of approval of the SIS from the local regulatory body, Covid restrictions on recruitment/surgery and women's reluctance to have mesh. Average age was 66 years and BMI 27. Table 1 shows results at 6 months. There was no difference in post-operative complications between the 2 groups however, one SIS was removed for groin pain. At 6 months, women who had no symptoms of SUI (72% RP group versus 72% SIS) and who had a negative cough stress test (87% RP versus 82% SIS) were similar. 78% in the RP group and 76% in the SIS group reported improvement as “very much better or much better” (RR 1.06 (95% CI 0.68-1.66), P = 0.79). 2 women had repeat surgery at 6 months. One in the RP group (1.7%) and one in the SIS group (1.9%). At 2 years, 4 women in the RP group (6.9%) had repeat surgery and 6 in the SIS group (11.1%). Conclusions: After six months, we are unable to show a difference in subjective or objective cure between groups. With time, more women had repeat surgery (Table Presented).

Multi system Inflammatory Syndrome in Children (MIS-C) in a 17-year Old with Dendritic Cell Neoplasm Presenting as a Retropharyngeal Abscess

Introduction: Multisystem Inflammatory Syndrome in Children (MIS-C) is a constellation of symptoms involving fever, laboratory evidence of inflammation, and >/= 2 organ systems involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurologic) in a patient who is positive for current or recent COVID-19 infection by RT-PCR, serology or by antigen testing. The total number of cases reported in the United States with MIS-C is more than 3000 as of May 2021. We present a case of MIS-C presenting as a retropharyngeal abscess in a 17- year-old with dendritic cell neoplasm. Case Description: 17-yearold male with a past medical history of metastatic, recurrent, atypical dendritic tumor currently in remission presented with fever for 4 days, associated with headache, sore throat and dysphagia, with a normal examination except 3+ tonsils without midline shift. He had an asymptomatic COVID 19 infection 2 months prior to this presentation. On admit, labs revealed hyponatremic (129) dehydration and a CRP of 29. CT neck showed a well-defined retropharyngeal fluid collection. He was started on Vancomycin and Cefepime and was also given a dose of Dexamethasone. Due to clinical improvement on Day 3, the antibiotics were changed to Unasyn and Clindamycin for the presumed retropharyngeal abscess. He however became hemodynamically unstable and was taken for an emergent incision •drainage by ENT but there was no fluid to be drained. He remained intubated and admitted to the ICU. He required vasopressors because of his hemodynamic instability and broadspectrum antibiotics for concerns of sepsis. Further workup showed signs of end organ damage and inflammation including severe myocardial dysfunction (EF ∼ 20%) and a positive COVID 19 antibody. He was diagnosed with MIS-C and started on IVIG, steroids and Enoxaparin. He showed significant improvement in his clinical status, inflammatory markers and myocardial function over the next 24-48 hours following initiation of treatment. Discussion: MIS-C is believed to develop due to an abnormal immune response to the COVID 19 virus. There has only been a single case reported in a healthy individual presenting as a retropharyngeal abscess. Most of the cases of MIS-C are reported in primarily healthy children or with comorbidities like obesity and asthma but there have been very few cases reported in oncology patients possibly because of an inadequate immune response in these patients. Our case to the author's knowledge is the first case of MIS-C presenting as a retropharyngeal abscess in an oncology patient. Conclusion: It is important to identify the history of COVID 19 infection and have a high index of suspicion in unusual presentations so that early investigation and management is possible to prevent morbidity and mortality due to MIS-C.

Can we increase bladder outlet obstruction surgery day case rates to tackle the post-Covid Elective Recovery?

Introduction: There is growing recognition that bladder outlet obstruction (BOO) surgery can often be safely performed as a day case procedure. The BOO surgery day case rate (DCR) is a Getting It Right First Time (GIRFT) quality metric. Patients awaiting BOO surgery represent the largest group awaiting elective surgical treatment in urology. This unmet need has expanded considerably due to the Covid-19 pandemic. Patients and Methods: Model Hospital (MH) is a datadriven improvement tool for English NHS trusts, which utilises routinely collected national level data. MH describes performance metrics for transurethral resection of prostate, laser prostatectomy, prostatic urethral lift, and bladder neck incision. MH data were analysed for all 115 trusts performing BOO surgery over 12 months to October 2021. Associations between service delivery and outcome metrics were tested. Results: Table 1 shows national Trust-level metrics for DCR, length of stay (LOS), 30-day readmission rate (30D), annual centre volume (ACV), and waiting list time (WLT). Analysis indicated no significant association between any of the following;DCR and 30D (Spearman rank correlation coefficient (rs)=-0.085, p=0.37), ACV and 30D (rs=- 0.019, p=0.84), DCR and WLT (rs=0.16, p=0.096). Conclusion: There is wide variation in DCR and WLT nationally. The absence of association between DCR and 30D suggests that many trusts can safely increase DCR for BOO surgery. Optimising DCR could help to facilitate the post-Covid Elective Recovery for surgery. The lack of association between DCR and WLT, however, suggests that further resource constraints beyond elective inpatient bed availability influence the provision of BOO surgery.