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Litigation in Mississippi required the Department of Corrections to ameliorate substandard conditions at the supermaximum Unit 32 of Mississippi State Penitentiary at Parchman, remove prisoners with serious mental illness from administrative segregation and provide them with adequate treatment, and reexamine the entire classification system. Pursuant to two federal consent decrees, the Department of Corrections greatly reduced the population in administrative segregation and established a step-down mental health treatment unit for the prisoners excluded from administrative segregation. This article describes and discusses not only the process of enacting the changes but also the outcomes, including the large reductions in rates of misconduct, violence, and use of force. Keywords: supermaximum security; administrative segregation; classification; use of force; mental health step-down unit

Byline: Kim Nagel, RN, BHSc N (McMaster Children's Hospital, Hamilton, Ontario, nagel@hhsc.ca); Michael Neal, MSc (Center for Reproductive Care, Hamilton Health Sciences, Hamilton, Ontario) Keywords: Key words: nurse; discussions; sperm [...]

Central venous access device (CVAD) insertion is one of the most common procedures performed on paediatric haemophilia patients. There are no clear guidelines outlining the optimal dosing schedule of factor VIII (FVIII) and duration of treatment required to achieve adequate haemostasis during and after surgery. In this article, we describe the experience at McMaster Children's Hospital using FVIII replacement therapy in 15 children with severe haemophilia A during the course of 7 years. This is a retrospective institutional chart review. Patients between 0 and 18 years of age with severe haemophilia A that underwent CVAD insertion at McMaster Children's Hospital in Hamilton, Ontario, from 2004 to 2010, were identified and charts were reviewed. A total of 15 CVAD insertion surgeries were reviewed. The total average preoperative dose of FVIII was 93.5 IU/kg (range: 53.7–145.4 IU/kg). The total average postoperative dose was 818.7 IU/kg (range: 441–1258 IU/kg). The total perioperative dose was 912.2 IU/kg (range: 495.2–1349 IU/kg). The current study attempts to describe the experience at McMaster Children's Hospital for CVAD insertion surgeries, the average factor dose administered has decreased during the years. These results may be of help in the development of optimal treatment schedules.

Thrombotic occlusion of central venous catheters (CVCs) is a common problem in newborns. There is no guideline that systematically addresses the diagnosis, management, and prevention of this complication. The objective of this review is to establish evidence-based guidance for the management of CVC-related thrombosis. A comprehensive search of the scientific literature was conducted from 1948 to 2012. Twenty-six articles fulfilling four criteria – humans, neonates aged below 28 days, CVC insertion, and English language – were included for analysis. The incidence of thrombosis was 9.2 (3083332). Singly inserted umbilical venous catheters (UVCs) and peripherally inserted central catheters accounted for over 80 of all CVCs. Frequently reported thrombotic sites were the hepatic vein, right atrium, and inferior vena cava. Symptoms included distal swelling of affected areas and thrombocytopenia. Increased length of catheter stay, infusion of blood products and malpositioned UVCs were identified as risk factors. The commonest diagnostic investigations to confirm thrombosis were echocardiography and ultrasonography. Spontaneous resolution may occur in UVC-related thrombosis, but this warrants close monitoring. Thrombolysis with urokinase alone or combined with low-molecular-weight heparin might be effective and well tolerated as treatment strategies. Prophylactic heparin increases the duration of catheter usability (P<0.005, 95 confidence interval 0.35–0.81), decreases catheter occlusion, but may not uniformly prevent thrombosis. CVL-related thrombosis is an underreported complication because events in the majority occur silently. Currently, solid evidence-based recommendations for diagnosis and treatment are not possible. Well designed prospective studies are urgently required to establish a concrete investigational approach to CVC-related thrombosis and to institute safe therapeutic modalities.

Neonatal spontaneous arterial thromboembolism is a rare phenomenon with a high risk of morbidity and mortality. Currently, there is little information regarding common risk factors, diagnostic strategies, therapeutic interventions, and outcomes of this condition. The objective was to nucleate the best evidence regarding the disorder in order to facilitate early detection and treatment recommendations and document adverse outcomes. Web of Science, PubMed, Medline, CINAHL, Cochrane Databases, DARE, and OVIDdatabases were searched using the following keywords: ‘arterial’ AND ‘thrombus’ OR ‘thrombosis’ OR ‘thromboembolism’ OR ‘embolism’ AND ‘spontaneous’ AND ‘at birth’ OR ‘newborn’ OR ‘neonatal’ OR ‘fetal’ AND ‘umbilical cord’ OR ‘umbilical wall necrosis’ AND ‘coagulation abnormality’ OR ‘placenta bits’ OR ‘ischemic limbs’. The search yielded 172 articles, all of which were case series or single case descriptions. Twenty-seven met inclusion criteria, with a total of 53 newborns and 30 newborn pathology reports. Ultrasound was the preferred method of diagnosis and thromboembolic locations varied with the most common site being umbilical, resulting in embolism and vascular compromise. Treatment interventions and drug dosages were not standardized and ranged from use of anticoagulants to surgery and hyperbaric oxygen. The reported mortality rate was 32.8. Recurring etiological features facilitated identification of possible sequences of events contributing to the disorder. The literature lacks empirical evidence to affirm causes and predisposing risk factors for timely diagnosis and effective treatment of spontaneous neonatal arterial thromboembolism. Further research is needed to clearly establish the causes and the efficacy of specific treatment options.

Intracranial hemorrhage (ICH) is a significant complication for children with hemophilia. Identifying risk factors may allow us to establish clinically relevant guidelines for the diagnosis and management of ICH. The purpose of this review is to nucleate evidence from the available literature on the incidence, risk factors, presentation, treatment, and outcomes of ICH that can be utilized to develop a clinically useful framework for the diagnosis and management of hemophiliac patients with the condition. An electronic MEDLINE and EMBASE literature search was undertaken using the key words ‘intracranial hemorrhage and hemophilia’ and setting limits as: Last 10 years and Review or Randomized Controlled Trial (RCT) or Clinical Trial, or Practice Guidelines. Following review of all articles using predetermined search words and criteria, 31 were retrieved with sufficient data to address our objectives. An algorithm is presented for the management of children (≥3 years–18 years) with hemophilia and suspected ICH. A standardized approach to ICH may reduce unnecessary exposure to radiation via computed tomography scan in a select group of children. Currently there is limited scientific evidence to recommend a diagnostic and therapeutic algorithm for neonates with hemophilia.

The purpose of this project was to obtain input from the families of survivors of childhood cancer regarding their needs surrounding the "coming off treatment" (COT) period. A questionnaire was developed to record their needs, their wishes, and their satisfaction surrounding this period of time. Closer examination of the time surrounding COT was undertaken in an attempt to enhance this area of service for patients and families in our clinic setting. Establishing a structured protocol is likely to alleviate some of the anxiety that surrounds this time for families and help us to provide better continuity of care. After identifying a cohort of patients and families, the reason for the survey was explained and they were asked to complete the questionnaire before they left the clinic setting. At the completion of the study, 82% of the cohort had been approached, and 100% of this group had completed the survey (n = 41). Less than 50% of participants felt they had had a formal "coming off treatment" review but, of that same group, 89% were satisfied with the process. Participants identified areas of importance and health care professionals who they would like involved in the COT process. After reviewing the responses to the questionnaires, the decision was made to proceed in preparing a COT protocol.

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