Long-term survival and quality of life in Jehovah's witnesses after cardiac surgery: a case control study.

BACKGROUND: We previously analyzed morbidity and mortality in Jehovah's Witnesses patients after cardiac surgery compared to control population patients. Patients who were Jehovah's Witnesses were operated in accordance with their philosophical convictions and in respect of their refusal of transfusions. We propose to assess long-term survival and quality of life in the patients of this preliminary study. METHODS: We contacted 31 adult Jehovah's Witnesses patients who underwent heart surgery at the Brugmann hospital between 1991 and 2012 and compared them to a control population of 62 patients that had no transfusion restriction, and matched them for sex, age at the time of intervention and the type of surgery performed. We compared long-term quality of life in both populations through the MacNew software, a validated instrument to assess quality of life of patients with cardiovascular disease. The long-term survival of patients was analyzed by Kaplan Meier curves. RESULTS: Long-term quality of life and survival do not appear different between the two groups. Patient evaluation by MacNew software shows comparable physical (p = 0.54), emotional (p = 0.12), social (p = 0.21) and global (p = 0.25) scores between the two populations. The analysis of the actuarial survival curves shows no differences in terms of long-term survival of these patients (p = 0.37). CONCLUSIONS: Cardiac surgery in Jehovah's Witnesses can be performed with identical long-term quality of life and survival compared to surgery without blood transfusion restriction, if one follows rigorous blood conserving strategies. TRIAL REGISTRATION: NCT03348072 . Retrospectively registered 16 November 2017.

Avoiding allogenic blood transfusions in endoscopic angiofibroma surgery.

BACKGROUND: Surgical approaches for many tumours are often limited by blood loss, exposure and risk to vital anatomical structures. Therefore, the standard of care for certain skull base tumours has become endoscopic transnasal resection. Other surgical disciplines often use cell salvage techniques, but review of the otolaryngology literature revealed very few case reports. This study investigated the value and safety of salvage-type autologous blood transfusion during the endoscopic resection of juvenile nasopharyngeal angiofibromas (JNA). METHODS: JNA is a rare vascular nasal tumour and the study extended over a 3-year period to obtain adequate patient numbers. All patients undergoing endoscopic resection during this period were included in the population sample. Ten patients with JNA were identified and underwent embolization prior to the endoscopic resection. In all cases the intraoperative blood salvage apparatus was used. Close post-operative monitoring was performed. RESULTS: Homologous blood transfusion could be avoided in all cases. Postoperative monitoring revealed transient bacteraemia in two cases where the leukocyte filter was not used, but no evidence of septicaemia. CONCLUSIONS: Perioperative cell saver and autologous blood transfusion in endonasal JNA surgery is safe. Homologous blood transfusion can be avoided by using this technique. The use of cell salvage allows for single stage surgery without the need to abandon surgery due to excessive blood loss and its future use is promising.

Strategic and operational aspects of a transfusion-free neonatal arterial switch operation.

Blood transfusion-free complex congenital cardiac surgery in a neonate remains a challenge for multidisciplinary cardiac teams. At our institution, a 3.5 kg neonate, born to a family of Jehovah's Witnesses and postnatally diagnosed with dextro-transposition of the great arteries (d-TGA) and a small muscular ventricular septal defect, underwent a successful arterial switch operation without blood or platelet transfusion. Key points that contributed to success were optimal preoperative haematopoetic conditioning using erythropoietin and iron, a miniaturized cardiopulmonary bypass circuit including a low prime volume oxygenator and crystalloid cardioplegia, and a well-coordinated multidisciplinary team. We report an overview of the literature regarding blood transfusion-free complex congenital cardiac surgery.

South African Deaf education and the Deaf community.

In a special section of the american Annals of the Deaf, Deaf education and the Deaf community in South Africa are discussed. The special section is organized into 7 segments: a historical overview to establish context, the educational context, educators and learners, postgraduate education and employment, perspectives of Deaf children and their parents, sport and the arts, and spiritual lives and mental health. Throughout the entire section, however, the central focus is on the overall foundation (or lack thereof) of education for Deaf learners in South Africa.

Recombinant human erythropoietin in severe anaemia: issues of dosing and duration.

The majority of Jehovah's Witnesses refuse blood product transfusion, even when it can be lifesaving. Treatment with recombinant human erythropoietin (RHuEPO) is a valuable adjunct in Jehovah's Witness patients undergoing surgery. A number of additional strategies, including acute normovolaemic haemodilution, intra-operative blood salvage and reinfusion, iron and folate supplementation are also utilized to avoid blood transfusion. Critically ill patients have blunted erythropoietin production and decreased endogenous iron availability. This case report reviews the treatment of anaemia in critically ill Jehovah's Witness patients after surgery and discusses the potential need for higher RHuEPO dosing strategies and longer duration of therapy.

[Jehovah's Witnesses refusal of blood: religious, legal and ethical aspects and considerations for anesthetic management]. / Fundamentos del rechazo a la transfusión sanguínea por los Testigos de Jehová. Aspectos etico-legales y consideraciones anestésicas en su tratamiento.

The refusal of Jehovah's Witnesses to agree to blood or blood product transfusion based on religious beliefs is one of the most challenging conflictive issues health care givers have to face today. Such conflict is a by product of the ideological and religious diversity in society today. The perioperative care of such patients constitutes a genuine challenge for anesthesiologists and surgeons from technical, scientific, ethical, and legal perspectives. We review the reasons why Jehovah's Witnesses refuse transfusion and discuss the ethical, legal, and anesthetic aspects of their care. The literature up to August 2005 was reviewed by MEDLINE search. The following search terms were used: Jehovah's Witnesses, anesthesia (and anaesthesia), legislation and jurisprudence, ethics, blood transfusion, alternatives, anemia (and anaemia), erythropoietin, trigger, and critical care. To further cover ethical and legal aspects, we reviewed current laws in Spain and similar practice settings.

Fundamentos del rechazo a la transfusión sanguínea por los Testigos de Jehová. Aspectos ético-legales y consideraciones anestésicas en su tratamiento / Jehovah's Witnesses refusal of blood: religious, legal and ethical aspects and considerations for anesthetic management

Uno de los conflictos asistenciales que la medicinaactual afronta, consecuencia de la pluralidad ideológicay religiosa de nuestra sociedad, es el rechazo a la transfusiónde sangre y derivados sanguíneos por los Testigosde Jehová a causa de sus creencias religiosas. El tratamientoperioperatorio de estos pacientes supone un retopara anestesiólogos y cirujanos, tanto desde el punto devista técnico y científico, como ético y legal. Revisamoslos fundamentos del rechazo a la transfusión sanguíneapor los Testigos de Jehová, así como los aspectos éticos,legales y consideraciones anestésicas en su tratamientoPara ello hemos revisado la literatura médica existentehasta agosto de 2005 mediante búsqueda en MEDLINE,utilizando los términos de búsqueda "Jehovah’s Witnesses,anaesthesia, legislation and jurisprudence, ethics,blood transfusion, alternatives, anaemia, erythropoietin,trigger, critical care". Para cubrir los aspectos éticos ylegales se ha revisado la legislación vigente en España yen otros países de nuestro entorno

The refusal of Jehovah's Witnesses to agree to bloodor blood product transfusion based on religious beliefs isone of the most challenging conflictive issues health caregivers have to face today. Such conflict is a by product ofthe ideological and religious diversity in society today.The perioperative care of such patients constitutes agenuine challenge for anesthesiologists and surgeonsfrom technical, scientific, ethical, and legal perspectives.We review the reasons why Jehovah's Witnesses refusetransfusion and discuss the ethical, legal, and anestheticaspects of their care. The literature up to August 2005was reviewed by MEDLINE search. The followingsearch terms were used: Jehovah's Witnesses, anesthesia(and anaesthesia), legislation and jurisprudence, ethics,blood transfusion, alternatives, anemia (and anaemia),erythropoietin, trigger, and critical care. To furthercover ethical and legal aspects, we reviewed current lawsin Spain and similar practice settings

Leukocyte filtration and miniature perfusion during arrested heart CABG on a Jehovah's Witness patient.

Bloodless surgery and a reduction in the use of allogeneic blood products has long been the standard of care in medicine. Many individuals in our communities have demanded this form of surgical treatment for personal and religious reasons. On 6 December 2002, a 72-year-old male patient was admitted to our institution as a critical air flight transfer. The patient's height was 190.5 cm and weight was 59.3 kg (body surface area 1.83 m2). His preliminary diagnosis was chest pain with myocardial infarction as evidenced by elevated blood cardiac isoenzymes. His principle diagnosis was subendocardial infarction with paroxysmal ventricular tachycardia. Cardiac catheterization was performed and demonstrated severe triple vessel disease with an ejection fraction of 30%. He was evaluated and accepted as a candidate for coronary artery bypass grafting. Multidisciplinary consultation concluded that a safe and effective method of perioperative treatment would involve the use of arrested heart support with cold blood cardioplegia using a low prime miniature perfusion circuit as no blood products would be considered for use. Additionally, the combined modalities of perfusion interventions to minimize hemodilution consisted of intraoperative autologous blood collection totaling 500 mL and rapid autologous priming of the miniature perfusion circuit. The miniature perfusion system was a low prime Cardiovention (Santa Clara, CA) CORx device which includes a hollow-fiber oxygenator and integral centrifugal pump with a surface area of 1.2 m2. This system also incorporates an air sensing solenoid which triggers rapid air evacuation in a bolus range of 1 mL or greater. Kinetic venous drainage is another feature of this device as the centrifugal pump is integrated into the oxygenator. We believed that a miniature extracorporeal circuit would enhance the desired clinical outcome as opposed to the risk of: (1) off-pump coronary artery bypass (OPCAB) approach and the concern of emergent transition to an on-pump procedure and (2) use of larger surface area with conventional systems that impose a greater hemodilutional effect. Leukocyte filtration was employed as the patient had a significant past medical history of chronic obstructive pulmonary disease. We herein report our clinical experience with this method of treatment on a patient who refused the use of blood products in his surgical treatment. It is our belief that the multiple modalities utilized in combination during this procedure resulted in positive clinical outcomes as demonstrated by an intubation time of 8 hours 35 min with a discharge on the fifth postoperative day.

Child welfare versus parental autonomy: medical ethics, the law, and faith-based healing.

Over the past three decades more than 200 children have died in the U.S. of treatable illnesses as a result of their parents relying on spiritual healing rather than conventional medical treatment. Thirty-nine states have laws that protect parents from criminal prosecution when their children die as a result of not receiving medical care. As physicians and citizens, we must choose between protecting the welfare of children and maintaining respect for the rights of parents to practice the religion of their choice and to make important decisions for their children. In order to make and defend such choices, it is essential that we as health care professionals understand the history and background of such practices and the legal aspects of previous cases, as well as formulate an ethical construct by which to begin a dialogue with the religious communities and others who share similar beliefs about spiritual healing. In this paper, we provide a framework for these requirements.

Treating Jehovah's Witnesses.

This article explores the beliefs of Jehovah's Witnesses, related to allogeneic blood transfusions. Paul Wade also describes how Witnesses contribute to healthcare planning through the completion of individual Advance Medical Directive/Release documents and by shared learning. The article addresses the reasons why Jehovah's Witnesses refuse allogeneic blood, and what resources are available.

Cardiopulmonary bypass in Jehovah's Witnesses.

Jehovah's Witnesses do not accept heterologous blood transfusion for religious reasons. Autologous transfusions are also rejected if there is no continuous contact between the circulation and the autologous blood. There is, therefore, the need to adopt methods which will avoid transfusion of heterologous blood in elective cases as far as Jehovah's Witnesses are concerned. We report two cases where pre-operatively administration of nutritional supplements, haematenics, erythropoietin, antimalarials and the modification of the extra-corporeal circulation bypass circuit allowed successful open-heart surgery using cardiopulmonary bypass.

Acute isovolaemic haemodilution in two Jehovah's Witnesses presenting for major intracranial surgery.

The Jehovah's Witnesses (JWS) is a religious sect with strong convictions against acceptance of blood and its products for medical care, including surgery. We present two cases of JWS, aged 24 and 19 years old, who had craniectomy for trauma and craniotomy for tumour excision, respectively. A team approach was employed in the care of both patients. During exhaustive preoperative discussions they re-affirmed their religious convictions but agreed to some modifications. Both patients accepted Acute Isovolaemic Haemodilution (AIH). However one of them insisted on non-discontinuation of the line used in collecting the blood from the vein, as that would constitute blood storage. The preoperative Packed Cell Volume (PCV) was 45% and 41% for the trauma and the tumour patients respectively. Two units of blood (1000 ml) were collected from each patient resulting in post donation PCV of 40% and 33%. The intraoperative blood loss was 300 ml and 2000 ml, respectively, and the units and crystalloid fluids were transfused for replacement. Postoperative PCV were 42% and 25%. The latter improved to 30% over the following two weeks with oral haematinics. The two cases are discussed in the light of the experience gained.

Use of desmopressin and erythropoietin in an anaemic Jehovah's Witness patient with severely impaired coagulation capacity undergoing stentless aortic valve replacement.

Cardiac surgery in Jehovah's Witness patients remains a challenge in the presence of concomitant congenital or acquired coagulation disorders and anaemia. We report a case of a 66-year-old female Jehovah's Witness suffering from severe calcified aortic valve stenosis requiring aortic valve replacement. The anaemic patient suffered from concomitant platelet dysfunction and deficiency of factors V and VII due to gammopathy of immunoglobulin G. The patient was preoperatively treated with recombinant erythropoietin in combination with folic acid and iron, which resulted in an increase of the haematocrit from 0.335 to 0.416 after 22 days of treatment. Haemostasis was improved by high dose aprotinin and additional desmopressin, which could be demonstrated to be effective by a preoperative test. The patients intra- and postoperative course was uneventful, her total chest tube loss was 130 ml, and she was able to be discharged without the need of any blood transfusions. The beneficial properties of erythropoietin and desmopressin in Jehovah's Witness patients are discussed.