Society of Critical Care Medicine and American Society of Health-System Pharmacists Guideline for the Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults.

RATIONALE: Critically ill adults can develop stress-related mucosal damage from gastrointestinal hypoperfusion and reperfusion injury, predisposing them to clinically important stress-related upper gastrointestinal bleeding (UGIB). OBJECTIVES: The objective of this guideline was to develop evidence-based recommendations for the prevention of UGIB in adults in the ICU. DESIGN: A multiprofessional panel of 18 international experts from dietetics, critical care medicine, nursing, and pharmacy, and two methodologists developed evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guideline development including task force selection and voting. METHODS: The panel members identified and formulated 13 Population, Intervention, Comparison, and Outcome questions. We conducted a systematic review for each question to identify the best available evidence, statistically analyzed the evidence, and then assessed the certainty of the evidence using the GRADE approach. We used the evidence-to-decision framework to formulate the recommendations. Good practice statements were included to provide additional guidance. RESULTS: The panel generated nine conditional recommendations and made four good practice statements. Factors that likely increase the risk for clinically important stress-related UGIB in critically ill adults include coagulopathy, shock, and chronic liver disease. There is no firm evidence for mechanical ventilation alone being a risk factor. Enteral nutrition probably reduces UGIB risk. All critically ill adults with factors that likely increase the risk for stress-related UGIB should receive either proton pump inhibitors or histamine-2 receptor antagonists, at low dosage regimens, to prevent UGIB. Prophylaxis should be discontinued when critical illness is no longer evident or the risk factor(s) is no longer present despite ongoing critical illness. Discontinuation of stress ulcer prophylaxis before transfer out of the ICU is necessary to prevent inappropriate prescribing. CONCLUSIONS: The guideline panel achieved consensus regarding the recommendations for the prevention of stress-related UGIB. These recommendations are intended for consideration along with the patient's existing clinical status.

Identification of the nuclear localization signal in the Saccharomyces cerevisiae Pif1 DNA helicase.

Saccharomyces cerevisiae Pif1 is a multi-functional DNA helicase that plays diverse roles in the maintenance of the nuclear and mitochondrial genomes. Two isoforms of Pif1 are generated from a single open reading frame by the use of alternative translational start sites. The Mitochondrial Targeting Signal (MTS) of Pif1 is located between the two start sites, but a Nuclear Localization Signal (NLS) has not been identified. Here we used sequence and functional analysis to identify an NLS element. A mutant allele of PIF1 (pif1-NLSΔ) that lacks four basic amino acids (781KKRK784) in the carboxyl-terminal domain of the 859 amino acid Pif1 was expressed at wild type levels and retained wild type mitochondrial function. However, pif1-NLSΔ cells were defective in four tests for nuclear function: telomere length maintenance, Okazaki fragment processing, break-induced replication (BIR), and binding to nuclear target sites. Fusing the NLS from the simian virus 40 (SV40) T-antigen to the Pif1-NLSΔ protein reduced the nuclear defects of pif1-NLSΔ cells. Thus, four basic amino acids near the carboxyl end of Pif1 are required for the vast majority of nuclear Pif1 function. Our study also reveals phenotypic differences between the previously described loss of function pif1-m2 allele and three other pif1 mutant alleles generated in this work, which will be useful to study nuclear Pif1 functions.

Tracking break-induced replication shows that it stalls at roadblocks.

Break-induced replication (BIR) repairs one-ended double-strand breaks in DNA similar to those formed by replication collapse or telomere erosion, and it has been implicated in the initiation of genome instability in cancer and other human diseases1,2. Previous studies have defined the enzymes that are required for BIR1-5; however, understanding of initial and extended BIR synthesis, and of how the migrating D-loop proceeds through known replication roadblocks, has been precluded by technical limitations. Here we use a newly developed assay to show that BIR synthesis initiates soon after strand invasion and proceeds more slowly than S-phase replication. Without primase, leading strand synthesis is initiated efficiently, but is unable to proceed beyond 30 kilobases, suggesting that primase is needed for stabilization of the nascent leading strand. DNA synthesis can initiate in the absence of Pif1 or Pol32, but does not proceed efficiently. Interstitial telomeric DNA disrupts and terminates BIR progression, and BIR initiation is suppressed by transcription proportionally to the transcription level. Collisions between BIR and transcription lead to mutagenesis and chromosome rearrangements at levels that exceed instabilities induced by transcription during normal replication. Together, these results provide fundamental insights into the mechanism of BIR and how BIR contributes to genome instability.

Intra-abdominal Hypertension and the Open Abdomen: Nursing Guidelines From the Abdominal Compartment Society.

Intra-abdominal hypertension has been identified as an independent risk factor for death in critically ill patients. Known risk factors for intra-abdominal hypertension indicate that intra-abdominal pressures should be measured and monitored. The Abdominal Compartment Society has identified medical and surgical interventions to relieve intra-abdominal hypertension or to manage the open abdomen if abdominal compartment syndrome occurs. The purpose of this article is to describe assessments and interventions for managing intra-abdominal hypertension and open abdomen that are within the scope of practice for direct-care nurses. These guidelines provide direction to critical care nurses caring for these patients.

MI: Not a Heart Attack but a Gut Attack.

Mesenteric ischemia and infarction are infrequent but often deadly conditions in acute and critically ill patients. Mesenteric ischemia may be a primary admission diagnosis or may develop secondary to another diagnosis. Having a high index of suspicion for patients at risk of mesenteric ischemia and mesenteric infarction can alter a poor outcome. This article reviews the pathophysiology, risk factors, assessment, medical and nursing diagnoses, as well as collaborative management for mesenteric ischemia. Early identification of patients at risk and the appropriate diagnostic testing are stressed. Nurses armed with the knowledge of this condition are better able to provide safe care to their patients.

The effects of nursing activities on the intra-abdominal pressure of patients at risk for intra-abdominal hypertension.

BACKGROUND: Intra-abdominal hypertension (IAH) occurs frequently in critically ill patients, and adds to their morbidity and mortality. There is no published evidence on the effects of nursing activities on the intra-abdominal pressure (IAP) for patients at risk of IAH. The purpose of this study was to identify the effects of hygiene care on the IAP of patients at risk for IAH. METHODS: Hygiene care was provided to 34 at-risk patients. IAP was measured prior to initiating the hygiene care, immediately after and 10 minutes later. This was a quasi-experimental, pre-test/ post-test design. RESULTS: The 10 minute post-hygiene care measurement of the IAP was significantly lower than the pre or immediate post-measurement of the IAP. There were no significant changes in the mean arterial pressure (MAP) or the abdominal perfusion pressure (APP). CONCLUSIONS: It is safe and possibly therapeutic to provide hygiene care to patients at risk for IAH.

Moral distress among healthcare professionals at a health system.

Moral distress is increasingly recognized as a problem affecting healthcare professionals. If not addressed, it may create job dissatisfaction, withdrawal from the moral dimensions of patient care, or even leaving the profession. Using the 21-Moral Distress Scale-Revised to assess moral distress, 323 surveys were received from 5 healthcare disciplines. The overall results showed that all disciplines experienced moderate to high actual moral distress, related to similar and/or different patient care situations.

Intra-abdominal hypertension and abdominal compartment syndrome: a comprehensive overview.

Intra-abdominal hypertension has a prevalence of at least 50% in the critically ill population and has been identified as an independent risk factor for death. Yet, many of the members of the critical care team do not assess for intra-abdominal hypertension and are unaware of the consequences of untreated intra-abdominal hypertension. These consequences can be abdominal compartment syndrome, multisystem organ failure, and death. This article provides an overview of the pathophysiology of intra-abdominal hypertension and abdominal compartment syndrome. In addition, the evidence-based definitions, guidelines, and recommendations of the World Society of the Abdominal Compartment Syndrome are presented.

The San Francisco collaborative: an evaluation of a partnership between three schools of nursing and a public health department.

Many factors are contributing to a decline in the number of nurses who opt to choose public health nursing as a career option. One factor is the lack of preceptors in public health, which has led to the placement of nursing students in nontraditional clinical settings. Thus, many nursing students are not exposed to public health nursing while still in school. Graduating students may not have a clear idea of what a public health nurse is or does. The purpose of the study was to describe a collaborative project between three schools of nursing aimed at increasing interest in public health nursing among undergraduate nursing students. The study method involved analysis of student, faculty, and staff feedback received after an orientation to public health nursing. Nursing students found the experience valuable. Participation in the collaborative project has increased clinical experiences for nursing students in public health, increased exposure of nursing students to public health nursing, and has led to opportunities for both students and faculty within an urban public health department.

Upgrading the American Association of Critical-Care Nurses' evidence-leveling hierarchy.

In August 2008, the American Association of Critical-Care Nurses' (AACN's) Evidence-Based Practice Resource Work Group met to review current AACN Practice Alerts and to identify new Practice Alerts to be created. The work group was also tasked with reassessment of the grading system used by AACN that evaluates evidence associated with the Practice Alerts and other AACN resources. This article details the effort of this national volunteer work group, specifically highlighting the development of the new AACN evidence-leveling hierarchy system.

Assessment of a register-based rheumatic heart disease secondary prevention program in an Australian Aboriginal community.

OBJECTIVE: To assess specific performance indicators relating to a register-based acute rheumatic fever and rheumatic heart disease (ARF/RHD) prevention program in a remote Australian Aboriginal community in order to identify the most appropriate avenues for improvements in delivery of services. METHODS: Information kept on the central ARF/RHD register was compared with an amalgamated dataset from three other sources. The community clinic charts of identified patients were reviewed for information regarding accuracy of diagnosis and the number of doses of benzathine penicillin received in the last year. Specific follow-up arrangements were assessed and compared with practice guidelines. RESULTS: The central ARF/RHD register contained the names of 58 of the 72 (81%) people identified in the community as eligible for inclusion. Only 42% (22/52) of people receiving antibiotic prophylaxis had received 80% or more of the recommended doses in the previous year; service delivery was significantly better for females than males (p = 0.004). Individuals in priority category 1 (most severe disease) were found to be receiving follow-up and investigation according to guidelines. About half the people in categories 2 (moderate disease) and 3 (mild disease) had been inadequately investigated and/or missed out on follow-up appointments. CONCLUSIONS: The ARF/RHD prevention program in this large remote Aboriginal community is struggling to deliver services to a substantial proportion of people who require them. Specific interventions, especially those related to men's health, may be required to correct the problems.