Acute lung injury after allogeneic stem cell transplantation: is the lung a target of acute graft-versus-host disease?

Allogeneic hematopoietic stem cell transplantation (SCT) is an important therapeutic option for a number of malignant and nonmalignant conditions but the broader application of this treatment strategy is limited by several side effects. In particular, diffuse lung injury is a major complication of SCT that responds poorly to standard therapeutic approaches and significantly contributes to transplant-related morbidity and mortality. Historically, approximately 50% of all pneumonias seen after SCT have been secondary to infection, but the judicious use of broad-spectrum antimicrobial prophylaxis in recent years has tipped the balance of pulmonary complications from infectious to noninfectious causes. This mini review will discuss the definition, risk factors and pathogeneses of noninfectious lung injury that occurs early after allogeneic SCT.     

A comparison of the psychosocial functioning of children with drug-versus alcohol-dependent fathers

The present study compared the psychosocial functioning of children whose fathers primarily abused illicit drugs other than alcohol (n = 51 ) to children from a demographically matched sample of families whose fathers abused alcohol (n = 51). Children with drug-abusing (DA) fathers exhibited significantly more negative child behaviors on a standardized child-rating scale than did children from homes with alcohol-abusing fathers. In addition, a significantly greater proportion of children with DA fathers met clinical cutoffs indicative of psychosocial impairment (n = 23: 45%) than did children whose fathers abused alcohol (n = 5; 10%). Mediation analyses indicated that severity of drug, legal, medical, employment, and family problems partially mediated the relationship between type of family (i.e., families with fathers who had an alcohol problem versus families with fathers who had a drug problem) and children's psychosocial adjustment.     

Clinical audits to improve critical care: Part 2: Analyse,benchmark and feedback

Clinical audits are an essential part of the cycle designed to ensure that patients receive the best quality of care. By measuring the care delivered against established best practice standards, it becomes possible to identify shortcomings and to plan targeted strategies and processes for continuous improvement. The success of a clinical audit depends upon defined goals, motivation of stakeholders, appropriate tools and resources, and clear communication.In part 1 of this series, an overview of the structures and processes needed to prepare and collect data for clinical audits in the critical care setting was provided [A.J. Ullman, G. Ray-Barruel, C.M. Rickard, M. Cooke, Clinical audits to improve critical care: Part 1 Prepare and collect data, Aust Crit Care, 2017, in press]. In part 2, we discuss how to analyse the collected audit data, benchmark findings with internal and external data sets, and feedback audit results to critical care clinicians to promote evidence-based practice and improve patient outcomes.     

Disparate results of ACE inhibitor dosage on exercise capacity in heart failure: a reappraisal of vasodilator therapy and study design

Despite manifest benefits of angiotensin converting enzyme (ACE) inhibitors on the prognosis of patients with heart failure, there is a lack of consistency in the results of trials investigating the effects of ACE inhibitors on exercise capacity. The inconsistencies cannot be readily explained by variations in effects on known neurohumoral or conventional haemodynamic factors. Drawing on insights from physiology of pump-load interactions, in a normal circulation there is an optimal extent of systemic vasodilation at which the delivery of hydraulic energy from the cardiac pump is maximal (the 'impedance matchpoint'). In heart failure, the vasoconstrictive effects shift the operating point towards mismatch at higher resistances, and optimal vasodilatory therapy would reshift the operating point to the matchpoint. Excessive dosage, however, would cause overvasodilatation leading to a reduction in cardiac power output and consequently compromising exercise ability. High levels of ACE inhibitors may not therefore improve exercise ability. Another potential reason for the observed inconsistencies is that the often used parallel-group study design (ideal for mortality studies) may not be suitable for investigating drug effects on exercise capacity because dropouts from such studies would introduce occult selection biases, thereby confounding treatment effects. In conclusion, this reappraisal of the conflicting observations reported on ACE inhibitor effects on exercise capacity has highlighted a proposition that there is an optimal dosage of ACE inhibitors which will most enhance exercise capacity, and this will require further well designed cross-over studies to elucidate.