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BACKGROUND Although numerous studies have demonstrated the feasibility of cardiac surgery for blood refusal patients, few studies match to controls, and fewer examine cost. This historical cohort study aims to compare costs and outcomes after cardiac surgery in Jehovah's Witness patients who refuse blood transfusion with a group of matched patients accepting transfusion. STUDY DESIGN AND METHODS A retrospective database review was performed to find all patients having cardiac surgery who refused blood products from January 2005 to July 2012 at Duke University Medical Center. These 45 patients were closely matched 1:2 with controls who accepted transfusion based on characteristics likely to influence transfusion. Cost from day of surgery to hospital discharge and other outcome data (length of stay [LOS], discharge hemoglobin [Hb], acute kidney injury) were analyzed retrospectively. RESULTS Forty-five Witnesses having cardiac surgery were temporally matched to two controls having the same surgery. Median euroSCORE was the same in both groups (6.0, p = 0.9981). In the matched-pairs comparison of cost, there was no significant difference in total cost for Witnesses and controls. There was no difference in intensive care unit LOS (median, 1 day, both groups) or total LOS (median, 9 days for Witnesses vs. 7 days for controls). Mean Hb at discharge was higher in Witnesses than in controls (11.7 g/dL vs. 9.8 g/dL, p

Background Based on biblical doctrines, patients of the Jehovah's Witness faith refuse allogeneic blood transfusion. Cardiac surgery carries a high risk of blood transfusion, but has been performed in Jehovah's Witnesses for many years. The literature contains information on the outcomes of this cohort, but does not detail the perioperative care of these patients. This article describes a single institution's experience in perioperative care of Jehovah's Witnesses undergoing cardiac surgery. Study Design and Methods A chart review of adult Jehovah's Witness patients undergoing cardiac surgery at Duke University between January 2005 and June 2012 was completed. Institutional protocols regarding preoperative erythropoietin (EPO) therapy and intraoperative isovolemic hemodilution are detailed. Patient demographics and use of various blood conservation techniques are described. Hemoglobin (Hb) at various points throughout the perioperative management, hospital length of stay, and mortality are reviewed as indicators of outcome. Results Forty-five Jehovah's Witness patients underwent cardiac surgery at Duke University Medical Center. Preoperative EPO increased the mean Hb by 1.2 g/dL before surgery. Intraoperative normovolemic hemodilution was used in 37 patients with intraoperative mean nadir Hb of 10.3 g/dL. Antifibrinolytics and desmopressin were commonly used as coagulation adjuncts. Mean cardiopulmonary bypass time was 137 minutes, with mean nadir temperature of 30.5°C. The mean length of hospital stay was 6.2 days, with mean intensive care unit stay of 1.7 days. This cohort had zero 90-day mortality in the perioperative period. Conclusions This case series demonstrates that bloodless cardiac surgery can be performed in select patients refusing allogeneic blood transfusion.

Blood conservation techniques are used to reduce the need for allogeneic blood transfusion. One of the most important blood conservation techniques is the optimization of blood counts prior to invasive procedures with anticipated blood loss. Infusion nurses need to understand the importance of treating patients who require the use of parenteral iron to attempt to optimize their blood counts before procedures. Infusion nurses provide a vital link to patient safety and treatment. This article will also discuss other methods of blood conservation frequently used to protect a scarce resource and reduce inappropriate transfusions.

Background Estimates of blood loss in the operating room are typically performed as a visual assessment by providers, despite multiple studies showing this to be inaccurate. Use of a less subjective measurement of blood loss such as direct measurement of the hemoglobin (Hb) mass lost from the surgical field may better quantify surgical bleeding. The objective of this investigation was to compare anesthesiologist estimates of intraoperative blood loss with measured Hb loss. Study Design and Methods Sixty patients undergoing posterior spine surgery were enrolled in a prospective, randomized trial comparing intraoperative blood loss using unipolar cautery alone or with use of a bipolar tissue sealant device. Hb concentration and fluid volume were measured from all surgical sponges, suction canisters, and the cell salvage device. Using the volume and concentration of Hb from each solution allowed calculation of Hb mass, which was converted into volume of blood lost and compared with estimates of blood loss documented by the anesthesia team. A single-sample t test of no difference was used to compare estimated with measured blood loss. Results Mean estimated blood loss exceeded measured blood loss by 246 mL (860 mL vs. 614 mL, p

BACKGROUND: Traditional techniques for obtaining hemostasis during orthopedic surgery, such as conventional electrocautery and sealants, have limited clinical effectiveness in reducing hemoglobin (Hb) loss and requirement for transfusion. The bipolar tissue sealant device studied in this trial combines radiofrequency energy with saline irrigation to hemostatically seal both cut bone and soft tissue, potentially aiding hemostasis. STUDY DESIGN AND METHODS: Sixty patients undergoing multilevel posterior lumbar instrumentation and fusion were randomly assigned to unipolar cautery alone (control group) or unipolar cautery plus use of the bipolar tissue sealant device (treatment group). Hb loss from the surgical field was measured (rather than estimated) and compared between the two groups. The primary hypothesis was that the treatment group would lose significantly less Hb than the control group. RESULTS: The control group experienced a mean Hb loss of 102.4 g while the treatment group showed a significantly lower mean Hb loss of 66.2 g (p = 0.0004). No significant difference was found between groups with respect to secondary endpoints including length of surgery, number of red blood cell units transfused, number of total blood component units transfused, transfusion avoidance, length of stay, or serious adverse events. CONCLUSION: Use of a bipolar tissue sealant device in addition to unipolar cautery significantly decreased Hb loss during multilevel, posterior lumbar spinal instrumentation and fusion when compared with unipolar cautery alone.

OBJECTIVE. The purpose of this study was to determine whether the rate of polyp detection and the quality of air-contrast barium enema (ACBE) procedures performed by technologists differ from those performed by radiologists. CONCLUSION. Our results showed that well-trained certified technologists can perform ACBE similar in overall quality and accuracy to ACBE performed by attending physicians and residents. Training technologists to perform ACBE may help to alleviate the radiology staffing shortage in the United States.

Although numerous studies have demonstrated the feasibility of cardiac surgery for blood refusal patients, few studies match to controls, and fewer examine cost. This historical cohort study aims to compare costs and outcomes after cardiac surgery in Jehovah's Witness patients who refuse blood transfusion with a group of matched patients accepting transfusion.A retrospective database review was performed to find all patients having cardiac surgery who refused blood products from January 2005 to July 2012 at Duke University Medical Center. These 45 patients were closely matched 1:2 with controls who accepted transfusion based on characteristics likely to influence transfusion. Cost from day of surgery to hospital discharge and other outcome data (length of stay [LOS], discharge hemoglobin [Hb], acute kidney injury) were analyzed retrospectively.Forty-five Witnesses having cardiac surgery were temporally matched to two controls having the same surgery. Median euroSCORE was the same in both groups (6.0, p = 0.9981). In the matched-pairs comparison of cost, there was no significant difference in total cost for Witnesses and controls. There was no difference in intensive care unit LOS (median, 1 day, both groups) or total LOS (median, 9 days for Witnesses vs. 7 days for controls). Mean Hb at discharge was higher in Witnesses than in controls (11.7 g/dL vs. 9.8 g/dL, p 0.001). Thirty-day mortality was zero in both groups.Utilizing applicable blood conservation measures, cardiac surgery may be performed with similar outcomes and cost from day of surgery to discharge compared to controls in select patients without blood transfusion.

PURPOSE Investigators have noted that primary open-angle glaucoma (POAG) in West Africa has an earlier age of onset and appears to be more clinically severe than in the United States and Europe. Primary open-angle glaucoma patients with mutations in myocilin have a similar phenotype. Therefore, we investigated the role of mutations in myocilin in patients with POAG in a West African population. MATERIALS AND METHODS Patients seen at the Emmanuel Eye Clinic in Accra, Ghana, were recruited for this study. Informed consent was obtained from all study patients. Glaucoma specialists from the sponsoring institution (PC, LWH, or RRA) ascertained all POAG and control patients. Age-matched unaffected controls were obtained in patients with an IOP < 22 mm Hg and normal-appearing optic nerves. PCR amplification of each of the three myocilin exons was performed. Denaturing high-performance liquid chromatography (Transgenomics Corp.) was used to detect allelic differences and samples demonstrating a mobility shift were sequenced in both directions. RESULTS Ninety unrelated affecteds with POAG and 76 control patients were recruited. Four individuals with severe POAG were found to have novel missense mutations in exon 3. Two exhibit an Asp380Asn mutation and two an Arg342Lys mutation. These changes were not detected in 152 ethnically matched control chromosomes. Fourteen affected individuals and eight controls exhibit a translationally silent polymorphism in codon 325 (Thr325Thr). CONCLUSIONS A total of 4.4% of patients with POAG have novel disease-associated mutations in myocilin. Mutations in myocilin appear to play a limited role in the pathogenesis of POAG in this region of West Africa.

PURPOSE: To report the various types of glaucoma among West African patients presenting to an eye clinic in Ghana. METHODS: A complete evaluation was performed in 198 consecutive Ghanaian glaucoma patients. Main outcome measures included intraocular pressure, visual acuity, gonioscopy findings, visual field, and total number of glaucoma medications. RESULTS: The most common form of glaucoma was primary open-angle glaucoma (44.2%). Open-angle glaucoma suspects also comprised a large percentage of the group (30.5%). Chronic angle-closure glaucoma was diagnosed in 6.6% of the patients. CONCLUSIONS: Primary open-angle glaucoma is the most common form of glaucoma being treated in this outpatient eye clinic in Ghana. Chronic angle-closure glaucoma was the second most common form of glaucoma in this series and was usually undiagnosed due to a lack of gonioscopic evaluation. Gonioscopy is an important diagnostic tool that should be promoted to guide more effective glaucoma treatment in this region. Pseudoexfoliation and pseudoexfoliation-associated glaucoma were not seen in this population.

Based on biblical doctrines, patients of the Jehovah's Witness faith refuse allogeneic blood transfusion. Cardiac surgery carries a high risk of blood transfusion, but has been performed in Jehovah's Witnesses for many years. The literature contains information on the outcomes of this cohort, but does not detail the perioperative care of these patients. This article describes a single institution's experience in perioperative care of Jehovah's Witnesses undergoing cardiac surgery.A chart review of adult Jehovah's Witness patients undergoing cardiac surgery at Duke University between January 2005 and June 2012 was completed. Institutional protocols regarding preoperative erythropoietin (EPO) therapy and intraoperative isovolemic hemodilution are detailed. Patient demographics and use of various blood conservation techniques are described. Hemoglobin (Hb) at various points throughout the perioperative management, hospital length of stay, and mortality are reviewed as indicators of outcome.Forty-five Jehovah's Witness patients underwent cardiac surgery at Duke University Medical Center. Preoperative EPO increased the mean Hb by 1.2 g/dL before surgery. Intraoperative normovolemic hemodilution was used in 37 patients with intraoperative mean nadir Hb of 10.3 g/dL. Antifibrinolytics and desmopressin were commonly used as coagulation adjuncts. Mean cardiopulmonary bypass time was 137 minutes, with mean nadir temperature of 30.5°C. The mean length of hospital stay was 6.2 days, with mean intensive care unit stay of 1.7 days. This cohort had zero 90-day mortality in the perioperative period.This case series demonstrates that bloodless cardiac surgery can be performed in select patients refusing allogeneic blood transfusion.

Traditional techniques for obtaining hemostasis during orthopedic surgery, such as conventional electrocautery and sealants, have limited clinical effectiveness in reducing hemoglobin (Hb) loss and requirement for transfusion. The bipolar tissue sealant device studied in this trial combines radiofrequency energy with saline irrigation to hemostatically seal both cut bone and soft tissue, potentially aiding hemostasis.Sixty patients undergoing multilevel posterior lumbar instrumentation and fusion were randomly assigned to unipolar cautery alone (control group) or unipolar cautery plus use of the bipolar tissue sealant device (treatment group). Hb loss from the surgical field was measured (rather than estimated) and compared between the two groups. The primary hypothesis was that the treatment group would lose significantly less Hb than the control group.The control group experienced a mean Hb loss of 102.4 g while the treatment group showed a significantly lower mean Hb loss of 66.2 g (p = 0.0004). No significant difference was found between groups with respect to secondary endpoints including length of surgery, number of red blood cell units transfused, number of total blood component units transfused, transfusion avoidance, length of stay, or serious adverse events.Use of a bipolar tissue sealant device in addition to unipolar cautery significantly decreased Hb loss during multilevel, posterior lumbar spinal instrumentation and fusion when compared with unipolar cautery alone.

To retrospectively determine the cause of errors in air-contrast barium enema (ACBE) examination for detection of polyps 6 mm or larger.The study had institutional review board approval. Informed consent was waived for this HIPAA-compliant study. ABCE findings in 41 subjects with 56 missed polyps were evaluated by two radiologists to determine if the cause of errors was perceptual or technical. A comparison was made between total number of polyps in the proximal and distal colon and those missed at each location (Fisher exact test). The 288 ACBE examinations were assessed on a scale of 0-4 (0, excellent; 4, very poor) for six colonic segments (paired t test).Of 17 polyps 1 cm or larger not detected in 15 subjects, 11 (65%) were missed because of technical errors and six (35%) because of perceptual errors. Eight (72%) technical and four (67%) perceptual errors occurred proximal to the splenic flexure. One 3.5-cm cecal carcinoma was not diagnosed prospectively (perceptual error). Of 39 6-9-mm polyps not detected in 26 subjects, 35 (90%) were missed because of technical errors and four (10%) because of perceptual errors. Eighty percent of technical and 75% of perceptual errors were in the proximal colon. When the proportion of polyps in the proximal and distal colon was compared, 22 (63%) of 35 polyps in the distal colon and 15 (26%) of 58 in the proximal colon were detected (P = .0009). There were no detectable differences in the quality of studies in subjects whose polyps were detected and subjects whose polyps were missed (P.05).Technical errors were more common than perceptual errors. The majority of missed polyps were in the proximal colon. Detection rates of polypoid lesions might increase if the quality of ACBE examination can be improved, especially in the proximal colon.

Adult onset primary open angle glaucoma is a leading cause of blindness throughout the world. The disease results in an apoptotic death of retinal ganglion cells that is usually associated with an elevation of intraocular pressure. Familial aggregation of the disorder provides evidence for strong genetic influences that are likely to be the result of multiple susceptibility genes. A two-stage genome scan to identify the genomic locations of glaucoma susceptibility genes was performed using an initial pedigree set of 113 affected sibpairs and a second pedigree set of 69 affected sibpairs. Linkage analysis was performed using both model-dependent (lod score) and model-independent affected relative pair and sibpair methods. Twenty-five regions identified by the initial scan were further investigated using the second pedigree set. In the combined data analysis, regions located on chromosomes 2, 6, 9, 11, 14, 17 and 19 continued to produce model-dependent lod scores and/or an MLS >1.0, while five regions (2, 14, 17p, 17q and 19) produced an MLS >2. 0. Multipoint analysis using ASPEX also showed significant results on chromosomes 2, 14, 17p, 17q and 19. These results are an important step towards the identification of genes responsible for the genetic susceptibility to this blinding condition.

Late-onset primary open-angle glaucoma (POAG) is a bilateral disease, which typically has its onset in the fifth or sixth decade of life. The clinical course usually consists of mild to moderately elevated intraocular pressure (IOP), although a significant number of patients may not have a measured IOP greater than the normal range [1]. Optic nerve damage and visual field loss, which may culminate in blindness, occur over many years, usually decades after onset of the disease. The mode of inheritance for late-onset POAG is not known. POAG is considered a complex trait that results from interaction of multiple genes in conjunction with environmental influences.

Primary open-angle glaucoma (POAG) is a complex inherited disorder. At least eight loci have been defined for POAG using family-based linkage studies and a small number of pedigrees (GLC1A-GLC1H) (Wirtz MK, et al. IOVS 1998;39: ARVO Abstract 512).1–3 Mutations in genes located in the GLC1A, GLC1E, and GLC1G loci have been identified in families with POAG. Mutations in MYOC (GLC1A) are associated with approximately 3% to 5% of adult-onset POAG and 10% to 20% of cases of the autosomal dominant juvenile-onset form of POAG.4 Mutations in OPTN (GLC1E) have been found in kindreds in which most family members have an autosomal dominant form of normal-tension glaucoma, a variant of POAG in which statistically elevated intraocular pressure (IOP) is not present.5 In a recent study, mutations in WDR36, a gene located on the long arm of chromosome 5 (GLC1G), have been reported to cause adult-onset POAG.6 Sequence variations of WDR36 were identified in approximately 5% of familial and sporadic cases of POAG. Additional regions of interest have emerged from genome-wide scans using nonparametric methods, completed for mainly white patients with POAG7 and African-Caribbean patients in Barbados.8 These studies have identified nine genomic regions that may harbor POAG-susceptibility genes. Two of these chromosomal regions, 14q11 and 15q11–13 have continued to show evidence of POAG-susceptibility loci after follow-up studies, using additional sibling pairs and additional makers in the regions of interest (Wiggs JL et al., manuscript in preparation). One method used to address genetic heterogeneity and strengthen linkage findings is to incorporate phenotypic subsetting of the data. Most phenotypic stratification approaches require that subsets be identified before linkage studies. An alternative to traditional stratification approaches for incorporating a trait-related covariate is ordered subset analysis (OSA).9 This method provides maximum evidence of linkage, by using the covariate without a priori specification of families to a subset. With this approach, families are ordered by a phenotypic variable (e.g., age of onset, cup-to-disc ratio, or IOP). Linkage analysis with a specific genetic marker set is performed on the first family in the list and then repeated, adding one family each time. In this way, the subset of families with the greatest evidence of linkage can be determined. The goal of OSA is to identify regions of increased linkage in a subset of families. By increasing genetic homogeneity, OSA can also reduce the linkage interval. Subsets with evidence of increased linkage can be used for candidate gene analysis. This approach has been successfully used to confirm and narrow the area of proposed linkage, as well as to define novel regions of linkage in several complex traits, including diabetes,10 Alzheimer disease,11 autism,12 and macular degeneration.13 The age of onset of POAG is difficult to determine because of the absence of symptoms in the early stages of the disease; however, it is well known that the prevalence of POAG is low in persons younger than 50 years and increases dramatically after age 70.14–16 There is some evidence that the age at diagnosis (AAD) has a genetic contribution in POAG. For example, POAG associated with myocilin mutations is frequently diagnosed between 20 and 40 years of age,17 whereas that associated with optineurin mutations is diagnosed at an average of 44 years of age.5 In this report we discuss the use of OSA using age at diagnosis as a covariate in a large POAG multiplex family dataset to identify linkage to a locus on the long arm of chromosome 15, region 11–13, originally identified in a genome-wide scan.7