Impact of Resident Participation on Operative Time and Outcomes in Otologic Surgery

Objectives To describe the impact of resident involvement in tympanoplasty on operative time and surgical complication rates. Study Design Case series with chart review. Setting Tertiary medical center. Subjects and Methods Current Procedural Terminology codes were used to identify patients in the 2011-2014 public use files of the American College of Surgeons National Surgical Quality Improvement Program who underwent a tympanoplasty or tympanomastoidectomy. Cases were included if the database indicated whether the operating room was staffed with an attending alone or an attending with residents. Categorical and continuous variables were compared with chi-square, Fisher’s exact, and Mann-Whitney U tests. Generalized linear models with a log-link and gamma distribution were used to examine the factors affecting operative time. Results Overall, 1045 cases met our study criteria (tympanoplasty, n = 797; tympanomastoidectomy, n = 248). Resident involvement increased mean operative time for tympanoplasties by 46% (107 vs 73 minutes, P < .001) and tympanomastoidectomies by 49% (175 vs 117 minutes, P < .001). While controlling for confounding factors, the variable with the largest impact on operative time was resident involvement. There were no significant differences observed in the rate of surgical complications between attending-alone and attending-resident cases. Conclusion Resident involvement in tympanoplasty and tympanomastoidectomy did not affect the surgical complication rate. Resident involvement increased operative time for tympanoplasties and tympanomastoidectomies; however, the specific reasons for the increase are not explained by the available data.

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The impact of resident involvement in minimally-invasive urologic oncology procedures

Canadian Urological Association Journal ◽

10.5489/cuaj.2170 ◽

2014 ◽

Vol 8 (9-10) ◽

pp. 334 ◽

Cited By ~ 37

Author(s):

Nedim Ruhotina ◽

Julien Dagenais ◽

Giorgio Gandaglia ◽

Akshay Sood ◽

Firas Abdollah ◽

...

Keyword(s):

Length Of Stay ◽

Minimally Invasive ◽

Partial Nephrectomy ◽

Operative Time ◽

Readmission Rates ◽

Improvement Program ◽

Urologic Oncology ◽

Invasive Approach ◽

Resident Involvement ◽

The Impact

Introduction: Robotic and laparoscopic surgical training is an integral part of resident education in urology, yet the effect of resident involvement on outcomes of minimally-invasive urologic procedures remains largely unknown. We assess the impact of resident participation on surgical outcomes using a large multi-institutional prospective database.Methods: Relying on the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files (2005-2011), we abstracted the 3 most frequently performed minimally-invasive urologic oncology procedures. These included radical prostatectomy, radical nephrectomy and partial nephrectomy. Multivariable logistic regression models were constructed to assess the impact of trainee involvement (PGY 1-2: junior, PGY 3-4: senior, PGY ≥5: chief) versus attending-only on operative time, length-of-stay, 30-day complication, reoperation and readmission rates.Results: A total of 5459 minimally-invasive radical prostatectomies,1740 minimally-invasive radical nephrectomies and 786 minimally-invasive partial nephrectomies were performed during the study period, for which data on resident surgeon involvement was available. In multivariable analyses, resident involvement was not associated with increased odds of overall complications, reoperation, or readmission rates for minimally-invasive prostatectomy, radical and partial nephrectomy. However, operative time was prolonged when residents were involved irrespective of the type of procedure. Length-of-stay was decreased with senior resident involvement in minimally-invasive partial nephrectomies (odds ratio [OR] 0.49, p = 0.04) and prostatectomies (OR 0.68, p = 0.01). The major limitations of this study include its retrospective observational design, inability to adjust for the case complexity and surgeon/hospital characteristics, and the lack of information regarding the minimally-invasive approach utilized (whether robotic or laparoscopic).Conclusions: Resident involvement is associated with increased operative time in minimally-invasive urologic oncology procedures. However, it does not adversely affect the complication, reoperation or readmission rates, as well as length-of-stay.

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Not all hip arthroplasties are created equal

The Bone & Joint Journal ◽

10.1302/0301-620x.101b6.bjj-2018-1427.r1 ◽

2019 ◽

Vol 101-B (6_Supple_B) ◽

pp. 84-90 ◽

Cited By ~ 11

Author(s):

R. S. Charette ◽

M. Sloan ◽

G-C. Lee

Keyword(s):

Operative Time ◽

Categorical Variables ◽

Complication Rates ◽

Continuous Variables ◽

Improvement Program ◽

Major Morbidity ◽

Fracture Care ◽

Displaced Femoral Neck Fractures ◽

Chi Squared ◽

Student’S T

Aims Total hip arthroplasty (THA) is gaining popularity as a treatment for displaced femoral neck fractures (FNFs), especially in physiologically younger patients. While THA for osteoarthritis (OA) has demonstrated low complication rates and increased quality of life, results of THA for acute FNF are not as clear. Currently, a THA performed for FNF is included in an institutional arthroplasty bundle without adequate risk adjustment, potentially placing centres participating in fracture care at financial disadvantage. The purpose of this study is to report on perioperative complication rates after THA for FNF compared with elective THA performed for OA of the hip. Patients and Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database between 2008 and 2016 was queried. Patients were identified using the THA Current Procedural Terminology (CPT) code and divided into groups by diagnosis: OA in one and FNF in another. Univariate statistics were performed. Continuous variables were compared between groups using Student’s t-test, and the chi-squared test was used to compare categorical variables. Multivariate and propensity-matched logistic regression analyses were performed to control for risk factors of interest. Results Analyses included 139 635 patients undergoing THA. OA was the indication in 135 013 cases and FNF in 4622 cases. After propensity matching, mortality within 30 days (1.8% vs 0.3%; p < 0.001) and major morbidity (24.2% vs 19%; p < 0.001) were significantly higher among FNF patients. Re-operation (3.7% vs 2.7%; p = 0.014) and re-admission (7.3% vs 5.5%; p = 0.002) were significantly higher among FNF patients. Hip fracture patients had significantly longer operative time and length of stay (LOS), and were significantly less likely to be discharged to their home. Multivariate analyses gave similar results. Conclusion This large database study showed a higher risk of postoperative complications including mortality, major morbidity, re-operation, re-admission, prolonged operative time, increased LOS, and decreased likelihood of discharge home in patients undergoing THA for FNF compared with OA. While THA is a good option for FNF patients, there are increased costs and financial risks to centres with a joint arthroplasty bundle programme participating in fracture care. Cite this article: Bone Joint J 2019;101-B(6 Supple B):84–90.

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The impact of surgeon experience on perioperative complications and operative measures following thoracolumbar 3-column osteotomy for adult spinal deformity: overcoming the learning curve

Journal of Neurosurgery Spine ◽

10.3171/2019.7.spine19656 ◽

2020 ◽

Vol 32 (2) ◽

pp. 207-220 ◽

Cited By ~ 4

Author(s):

Darryl Lau ◽

Vedat Deviren ◽

Christopher P. Ames

Keyword(s):

Blood Loss ◽

Operative Time ◽

Surgical Complication ◽

Perioperative Complications ◽

Adult Spinal Deformity ◽

Neurological Deficits ◽

Complication Rates ◽

Years Of Experience ◽

Surgeon Experience ◽

Operative Measures

OBJECTIVEPosterior-based thoracolumbar 3-column osteotomy (3CO) is a formidable surgical procedure. Surgeon experience and case volume are known factors that influence surgical complication rates, but these factors have not been studied well in cases of adult spinal deformity (ASD). This study examines how surgeon experience affects perioperative complications and operative measures following thoracolumbar 3CO in ASD.METHODSA retrospective study was performed of a consecutive cohort of thoracolumbar ASD patients who underwent 3CO performed by the senior authors from 2006 to 2018. Multivariate analysis was used to assess whether experience (years of experience and/or number of procedures) is associated with perioperative complications, operative duration, and blood loss.RESULTSA total of 362 patients underwent 66 vertebral column resections (VCRs) and 296 pedicle subtraction osteotomies (PSOs). The overall complication rate was 29.4%, and the surgical complication rate was 8.0%. The rate of postoperative neurological deficits was 6.2%. There was a trend toward lower overall complication rates with greater operative years of experience (from 44.4% to 28.0%) (p = 0.115). Years of operative experience was associated with a significantly lower rate of neurological deficits (p = 0.027); the incidence dropped from 22.2% to 4.0%. The mean operative time was 310.7 minutes overall. Both increased years of experience and higher case numbers were significantly associated with shorter operative times (p < 0.001 and p = 0.001, respectively). Only operative years of experience was independently associated with operative times (p < 0.001): 358.3 minutes from 2006 to 2008 to 275.5 minutes in 2018 (82.8 minutes shorter). Over time, there was less deviation and more consistency in operative times, despite the implementation of various interventions to promote fusion and prevent construct failure: utilization of multiple-rod constructs (standard, satellite, and nested rods), bone morphogenetic protein, vertebroplasty, and ligament augmentation. Of note, the use of tranexamic acid did not significantly lower blood loss.CONCLUSIONSSurgeon years of experience, rather than number of 3COs performed, was a significant factor in mitigating neurological complications and improving quality measures following thoracolumbar 3CO for ASD. The 3- to 5-year experience mark was when the senior surgeon overcame a learning curve and was able to minimize neurological complication rates. There was a continuous decrease in operative time as the surgeon’s experience increased; this was in concurrence with the implementation of additional preventative surgical interventions. Ongoing practice changes should be implemented and can be done safely, but it is imperative to self-assess the risks and benefits of those practice changes.

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Complications and Revisions After Spine Surgery in Patients With Skeletal Dysplasia: Have We Improved?

Global Spine Journal ◽

10.1177/2192568221994786 ◽

2021 ◽

pp. 219256822199478

Author(s):

Karim Shafi ◽

Francis Lovecchio ◽

Maria Sava ◽

Michael Steinhaus ◽

Andre Samuel ◽

...

Keyword(s):

Spine Surgery ◽

Skeletal Dysplasia ◽

Spinal Surgery ◽

Cardiovascular Health ◽

Surgical Complication ◽

Case Series ◽

Neurologic Complication ◽

Complication Rates ◽

Retrospective Case ◽

Average Patient

Study Design: Retrospective case series. Objective: To report contemporary rates of complications and subsequent surgery after spinal surgery in patients with skeletal dysplasia. Methods: A case series of 25 consecutive patients who underwent spinal surgery between 2007 and 2017 were identified from a single institution’s skeletal dysplasia registry. Patient demographics, medical history, surgical indication, complications, and subsequent surgeries (revisions, extension to adjacent levels, or for pathology at a non-contiguous level) were collected. Charlson comorbidity indices were calculated as a composite measure of overall health. Results: Achondroplasia was the most common skeletal dysplasia (76%) followed by spondyloepiphyseal dysplasia (20%); 1 patient had diastrophic dysplasia (4%). Average patient age was 53.2 ± 14.7 years and most patients were in excellent cardiovascular health (88% Charlson Comorbidity Index 0-4). Mean follow up after the index procedure was 57.4 ± 39.2 months (range). Indications for surgery were mostly for neurologic symptoms. The most commonly performed surgery was a multilevel thoracolumbar decompression without fusion (57%). Complications included durotomy (36%), neurologic complication (12%), and infection requiring irrigation and debridement (8%). Nine patients (36%) underwent a subsequent surgery. Three patients (12%) underwent a procedure at a non-contiguous anatomic zone, 3 (12%) underwent a revision of the previous surgery, and another 3 (12%) required extension of their previous decompression or fusion. Conclusions: Surgical complication rates remain high after spine surgery in patients with skeletal dysplasia, likely attributable to inherent characteristics of the disease. Patients should be counseled on their risk for complication and subsequent surgery.

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The Compliance of Prescribed Activity Restriction in Women at High Risk for Preterm Birth

American Journal of Perinatology ◽

10.1055/s-0040-1714358 ◽

2020 ◽

Author(s):

Ghamar Bitar ◽

Anthony Sciscione

Keyword(s):

Preterm Birth ◽

High Risk ◽

Medical Center ◽

Compliance Rate ◽

Tertiary Care ◽

Prescribing Patterns ◽

Categorical Variables ◽

Continuous Variables ◽

Activity Restriction ◽

The Impact

Objective Despite lack of evidence to support efficacy, activity restriction is one of the most commonly prescribed interventions used for the prevention of preterm birth. We have a departmental policy against the use of activity restriction but many practitioners still prescribe it in an effort to prevent preterm birth. We sought to evaluate the rate and compliance of women who are prescribed activity restriction during pregnancy to prevent preterm birth. Study Design This was a single-site retrospective questionnaire study at a tertiary care, academic affiliated medical center. Women with a history of preterm delivery or short cervix were included. Once patients were identified, each patient was contacted and administered a questionnaire. We assessed the rates of activity restriction prescription and compliance. Secondary outcomes included details regarding activity restriction and treatment in pregnancy. Continuous variables were compared with t-test and categorical variables with Chi-square test. The value p < 0.05 was considered significant. Results Among the 52 women who responded to the questionnaire, 18 reported being placed on activity restriction by a physician, with 1 self-prescribing activity restriction, giving a rate of our primary outcome of 19 of 52 (36.5%). All women reported compliance with prescribed activity restriction (100%). Gestational age at delivery was not different in women placed on activity restriction. Conclusion This questionnaire suggests that approximately one in three high-risk women were placed on activity restriction during their pregnancy despite a departmental policy against its use. The 100% compliance rate in patients placed on activity restriction is a strong reminder of the impact prescribing patterns of physicians can have on patients. Key Points

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Impact of Moderate to Severe Renal Impairment on Mortality and Appropriate Shocks in Patients with Implantable Cardioverter Defibrillators

Cardiology Research and Practice ◽

10.4061/2010/150285 ◽

2010 ◽

Vol 2010 ◽

pp. 1-6 ◽

Cited By ~ 7

Author(s):

Venkata M. Alla ◽

Kishlay Anand ◽

Mandeep Hundal ◽

Aimin Chen ◽

Showri Karnam ◽

...

Keyword(s):

Linear Models ◽

Severe Renal Impairment ◽

Medical Center ◽

Implantable Cardioverter Defibrillators ◽

Free Survival ◽

Kaplan Meier ◽

Appropriate Shocks ◽

The Impact ◽

Cardioverter Defibrillators

Background. Due to underrepresentation of patients with chronic kidney disease (CKD) in large Implantable-Cardioverter Defibrillator (ICD) clinical trials, the impact of ICD remains uncertain in this population.Methods. Consecutive patients who received ICD at Creighton university medical center between years 2000–2004 were included in a retrospective cohort after excluding those on maintenance dialysis. Based on baseline Glomerular filtration rate (GFR), patients were classified as severe CKD: GFR < 30 mL/min; moderate CKD: GFR: 30–59 mL/min; and mild or no CKD: GFR ≥ 60 mL/min. The impact of GFR on appropriate shocks and survival was assessed using Kaplan-Meier method and Generalized Linear Models (GLM) with log-link function.Results. There were 509 patients with a mean follow-up of 3.0 + 1.3 years. Mortality risk was inversely proportional to the estimated GFR: 2 fold higher risk with GFR between 30–59 mL/min and 5 fold higher risk with GFR < 30 mL/min. One hundred and seventy-seven patients received appropriate shock(s); appropriate shock-free survival was lower in patients with severe CKD (GFR < 30) compared to mild or no CKD group (2.8 versus 4.2 yrs).Conclusion. Even moderate renal dysfunction increases all cause mortality in CKD patients with ICD. Severe but not moderate CKD is an independent predictor for time to first appropriate shock.

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Ultrasound-Guided Needle Biopsy for Diagnosis of Advanced-Stage Malignancies of the Upper Aerodigestive Tract

OTO Open ◽

10.1177/2473974x17690132 ◽

2017 ◽

Vol 1 (1) ◽

pp. 2473974X1769013

Author(s):

Aaron Smith ◽

Anthony Grady ◽

Francisco Vieira ◽

Merry Sebelik

Keyword(s):

Direct Laryngoscopy ◽

Needle Biopsy ◽

Medical Center ◽

Case Series ◽

Fisher Exact Test ◽

Diagnosis Delay ◽

Ultrasound Guided ◽

Initial Examination ◽

Tissue Diagnosis ◽

The Impact

Objective Traditionally, direct laryngoscopy confirms stage and tissue diagnosis prior to treatment planning. Patients who are frail or have tenuous airway anatomy may incur risks while undergoing anesthesia. Further, direct laryngoscopy is scheduled after initial examination, introducing diagnosis delay. This study investigates the impact of ultrasound examination with guided needle biopsy compared with traditional operative biopsy. Study Design Case series. Setting Tertiary head and neck clinic. Subjects and Methods The records of patients at the Veterans Affairs Medical Center Memphis and Regional One Health who had supraglottic, oropharyngeal, and hypopharyngeal cancer that was diagnosed by ultrasound needle biopsy were reviewed from 2011 to 2016. Demographics, stage, biopsy results, and treatment were abstracted. Results Seventeen patients who underwent ultrasound-guided needle biopsy of the primary site were included. Average age was 63 years old, and 65% of patients were stage T4 (11/17). Needle biopsy yielded malignant cells in 76% (13/17). Eleven patients were included in subsequent analysis because 6 patients underwent needle biopsy only. Fisher exact test showed no difference between the 2 methods ( P = .27). Sensitivity was 86% and specificity was 100%. Seven patients had a median potential delay in diagnosis of 10 days. Conclusions Ultrasound can be used effectively to obtain a tissue diagnosis, circumventing an operative biopsy. Moreover, ultrasound may provide additional imaging details to support accurate staging. This strategy may prove worthwhile to cut costs and reduce delay to staging, reduce risk for those with contraindications to anesthesia, and increase staging accuracy via enhanced imaging details.

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Morbidity of First Rib Resection in the Surgical Repair of Thoracic Outlet Syndrome

Hand ◽

10.1177/1558944718760037 ◽

2018 ◽

Vol 14 (5) ◽

pp. 636-640 ◽

Cited By ~ 2

Author(s):

Kevin T. Jubbal ◽

Dmitry Zavlin ◽

Joshua D. Harris ◽

Shari R. Liberman ◽

Anthony Echo

Keyword(s):

Thoracic Outlet Syndrome ◽

Operative Time ◽

Medical Complications ◽

Complication Rates ◽

Improvement Program ◽

Cervical Rib ◽

Rib Resection ◽

First Rib ◽

Increased Risk ◽

First Rib Resection

Background: Thoracic outlet syndrome (TOS) is a complex entity resulting in neurogenic or vascular manifestations. A wide array of procedures has evolved, each with its own benefits and drawbacks. The authors hypothesized that treatment of TOS with first rib resection (FRR) may lead to increased complication rates. Methods: A retrospective case control study was performed on the basis of the National Surgical Quality Improvement Program database from 2005 to 2014. All cases involving the operative treatment of TOS were extracted. Primary outcomes included surgical and medical complications. Analyses were primarily stratified by FRR and secondarily by other procedure types. Results: A total of 1853 patients met inclusion criteria. The most common procedures were FRR (64.0%), anterior scalenectomy with cervical rib resection (32.9%), brachial plexus decompression (27.2%), and anterior scalenectomy without cervical rib resection (AS, 8.9%). Factors associated with increased medical complications included American Society of Anesthesiologists (ASA) classification of 3 or greater and increased operative time. The presence or absence of FRR did not influence complication rates. Conclusions: FRR is not associated with an increased risk of medical or surgical complications. Medical complications are associated with increased ASA scores and longer operative time.

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Outcomes of Primary Tibiotalocalcaneal Nailing for Complicated Diabetic Ankle Fractures

Foot & Ankle International ◽

10.1177/1071100719869639 ◽

2019 ◽

Vol 40 (12) ◽

pp. 1382-1387 ◽

Cited By ~ 3

Author(s):

M. Pierce Ebaugh ◽

Benjamin Umbel ◽

David Goss ◽

Benjamin C. Taylor

Keyword(s):

Hospital Stay ◽

Limb Salvage ◽

Patient Population ◽

Surgical Complication ◽

Case Series ◽

Ankle Fractures ◽

Complication Rates ◽

Average Hospital ◽

The Mean

Background: Ankle fractures in patients with complicated diabetes have significantly increased the rates of complications and poorer functional outcomes when treated nonoperatively, and there have been only modest reductions when treated operatively. We hypothesized that the minimally invasive, robust construct that tibiotalocalcaneal fixation with an intramedullary nail offers would result in high rates of limb salvage, acceptable rates of complications, and less loss of function, in this difficult patient population. Methods: This was an institutional review board–approved retrospective study of 27 patients with complicated diabetes who underwent tibiotalocalcaneal nailing of their ankle fracture as a primary treatment without formal joint preparation. Patients with complicated diabetes were defined as having neuropathy, nephropathy, and/or peripheral vascular disease. The mean clinical follow-up was 888 days. Patients were screened for associated risk factors. Data were collected on surgical complications. The outcomes measured included length of hospital stay, loss of ambulatory level, amputation, and time to death. The mean age was 66 years with an average body mass index of 38 and hemoglobin A1c of 7.4. Six fractures were open. Results: The limb salvage rate was 96%. The average hospital stay was 6 days, and the mean time to weightbearing was 6.7 weeks. The fracture union rate was 88%. The surgical complication rate was 18.5%, with no instances of malunions, symptomatic nonunions, or Charcot arthropathy. Eight patients died by final follow-up (mean, 1048 days). An ambulatory level was maintained in 81% of the patients. Conclusion: With high limb salvage rates, relatively early weightbearing, maintained ambulatory level, and acceptable complication rates, we believe our technique can be considered an appropriate approach to increase the overall survivability of threatened limbs and lives in this patient population. Level of Evidence: Level IV, retrospective case series.

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Right-to-Left Shunts Are Unexpectedly Common in Adults with HbSS

Blood ◽

10.1182/blood.v128.22.3659.3659 ◽

2016 ◽

Vol 128 (22) ◽

pp. 3659-3659 ◽

Cited By ~ 1

Author(s):

Bryan Christopher Hambley ◽

Rania Abdul Rahman ◽

Mary Ann O'Riordan ◽

Nathan Langer ◽

Seth Rotz ◽

...

Keyword(s):

Sickle Cell ◽

Research Funding ◽

Medical Center ◽

Adult Population ◽

Laboratory Data ◽

Acute Chest Syndrome ◽

Compound Heterozygous ◽

Continuous Variables ◽

Cardiopulmonary Complications ◽

The Impact

Abstract INTRODUCTION: Patients with homozygous sickle cell anemia (SCA) have frequent cardiopulmonary complications. The clinical prevalence and consequences of intracardiac or intrapulmonary right-to-left shunts in SCA are unknown. Here we report a retrospective examination of this complication, and clinical and laboratory correlates at clinical baseline, in an adult population with SCA. These shunts may be of particular relevance, due to the susceptibility of these patients to thrombosis and the role that desaturated hemoglobin plays in the underlying pathophysiology of this disease. METHODS: This single-institution study included 153 patients with homozygous HbSS, who are followed at Case-UH Medical Center, Cleveland. Clinical and laboratory data were gathered on patients who underwent an echocardiogram with bubble contrast. Echocardiograms were reviewed to confirm the presence, characteristics, and degree of a right-to-left shunt. Immediate (intracardiac) or delayed (intrapulmonary) shunts were identified; the latter were quantitated as <5, 5-15, or >15 bubbles visualized in the left heart. Continuous variables were described, using mean ± standard deviation (SD) and nominal variables were described as N (%). The relationship between clinical characteristics and echo results was determined using linear regression. All analyses were undertaken using SAS v9.4 The SAS Institute, Cary, NC. n.b. Compound heterozygous sickle cell disease patients showed this complication rarely, and were not examined systematically. RESULTS: 82/153 (53.6%) of studied SCA patients were female. Mean (SD) age in years was 32.2 (11.8). 90 (58.8%) patients had an echo with bubble study. In our population, 27 (17.6%) patients had an intracardiac shunt, 41 (26.8%) had an intrapulmonary shunt, and 22 (14.4%) had no shunt present; 63 (41.2%) patients did not have a bubble study. Mean (SD) LDH was 523.3 (318.1) for those with intracardiac shunts and 570.5 (205.4) for those with intrapulmonary shunts. Mean (SD) LDH for all shunt patients combined was 551.3 (255.9). Mean LDH (SD) for patients either with no shunt or no contrast echocardiogram was 415.5 (193.0). In a combined analysis, patients with shunts (N=68) showed a statistically higher baseline mean LDH when compared to a mean LDH of patients with either a negative bubble study or no bubble study (N=85), (551.3 vs 415.5, p<0.001). No difference was seen in prevalence of clinical outcomes of acute chest syndrome or stroke between groups. Laboratory markers of disease activity, such as absolute reticulocyte count or baseline hemoglobin were not different in shunt versus non-shunt patients. 8 patients had <5 bubbles in the left atrium or ventricle, 7 had 5-15 and 25 >15 bubbles. There was no evidence that this had an effect at clinical baseline, but the impact of such shunts during crises or multi-organ failure has not yet been assessed. A small number of individuals with shunts showed significant oxygen desaturation with exercise, but these were not statistically distinct from other groups. CONCLUSIONS: 68 patients with HbSS, or almost half of the adult SCA population, had right-to-left shunting on echocardiograms, either intracardiac or intrapulmonary, when evaluated at clinical baseline. These patients had significantly higher LDH than did patients with no bubble study or a negative bubble study, when evaluated in a combined post hoc analysis. The pathophysiology of these shunts is not known, but these have the potential to delay reoxygenation of sickle hemoglobin at clinical baseline and to facilitate right-to-left passage of fat or thrombotic emboli during clinical exacerbation. We are currently evaluating the potential impact of these shunts in patients with HbSS prospectively, both at baseline and during clinical exacerbation. Disclosures Schilz: Genetech: Speakers Bureau; Bayer: Consultancy, Speakers Bureau; Gilead: Consultancy, Speakers Bureau; Actelion: Consultancy, Speakers Bureau; United Therapeutics: Consultancy, Research Funding; Merck: Research Funding; Arena: Research Funding; Eiger: Research Funding.

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