Ατομικισμός και μαζοκοινωνία: Από τον Αλέξις ντε Τοκβίλ στον 20ο αιώνα

Σκοπός της συγκεκριμένης διπλωματικής εργασίας είναι η ανάδειξη του έργου του Alexis de Tocqueville σχετικά με τα ζητήματα του ατομικισμού και της ανάδυσης της μαζικής κοινωνίας, ενώ ταυτόχρονα μέσω της εργασίας αναδεικνύεται η φιλοσοφικοπολιτική επιρροή του Tocqueville σε συγκεκριμένους σημαντικούς στοχαστές του 20ου αιώνα. Οι στοχαστές αυτοί είναι ο Gilles Lipovetsky, o Παναγιώτης Κονδύλης και ο Charles Taylor και η εργασία έχεις ως σκοπό να αναδείξει τις σχέσεις αυτών των τριών νεότερων φιλοσόφων με την τοκβιλιανή σκέψη γύρω από τα ζητήματα του ατομικισμού και της μαζικής κοινωνίας. Επιπρόσθετα, παρουσιάζονται γενικότερα οι θέσεις των τριών στοχαστών έτσι ώστε να γίνουν ξεκάθαρες στον αναγνώστη όχι μόνο οι ομοιότητες που αυτές έχουν με τον Tocqueville, αλλά και οι διαφορές τους. Τέλος, ο συγγραφέας της εργασίας επιθυμεί να επισημάνει την ολική ρήξη που χαρακτηρίζει την σχέση μεταξύ της νεωτερικότητας και της ύστερης φάσης της, δηλαδή της μετανεωτερικότητας, μιας εποχής που παρατηρείται μια νέα μορφή ατομικισμού η οποία αναπτύσσεται μέσα από τους θεσμούς και τις πολιτικές δομές που χαρακτηρίζουν την μαζική δημοκρατία. Στο πρώτο μέρος παρουσιάζονται οι χαρακτηριστικές θέσεις της πολιτικής σκέψης του Tocqueville. Στο πρώτο κεφάλαιο αναλύεται ο στοχασμός και η κοινωνιολογική έρευνα του Γάλλου στοχαστή για την αμερικανική δημοκρατία και τον τρόπο που αυτή προσπαθεί να συνδυάσει την ισότητα των συνθηκών και την ελευθερία. Διατυπώνονται οι σκέψεις του Tocqueville για την διαδικασία παίδευσης των αμερικάνων πολιτών στην πολιτική διαδικασία, τον σημαντικό ρόλο των συνενώσεων και των αμερικανικών θεσμών και τον τρόπο που όλα τα παραπάνω ως προϊόντα της αγγλοαμερικανικής πολιτικής παράδοσης ενδέχεται να καθυστερήσουν την ανάδυση των δεσποτικών τάσεων που χαρακτηρίζει την δημοκρατική πολιτεία. Στο δεύτερο κεφάλαιο, παρουσιάζονται οι θέσεις του Γάλλου φιλοσόφου σχετικά με το φαινόμενο του ατομικισμού και του διαβρωτικού και υπονομευτικού του χαρακτήρα. Ο Tocqueville ασχολείται με τον ατομικισμό, κατά κύριο λόγο, στο έργο του Democracy in America και, σε ορισμένα σημεία, στο έργο του Old regime. and revolution. Στην σκέψη του γύρω από τον ατομικισμό, ο Γάλλος στοχαστής, αναπτύσσει την αντίληψη του για την ελευθερία ως αρνητική (με την μπερλινιανή σημασία του όρου) και ως δυνατότητα συμμετοχής στις πολιτικές υποθέσεις. Σε αυτό το σημείο, διατυπώνει τον λόγο που ο ατομικισμός αποτελεί κίνδυνο για την υπονόμευση της ελευθερίας. Παράλληλα, ο Τοκβίλ επισημαίνει την τάση των Δεσποτών να επιθυμούν την επικράτηση του ατομικισμού από την μία, και την ταυτόχρονη κλίση των ατομικιστικών τάσεων να ενισχύουν τον δεσποτισμό. Στο τρίτο κεφάλαιο αναλύονται οι θέσεις του Tocqueville για την επανάσταση, το κοινωνικό πρόβλημα και την επίλυση του, και τον σοσιαλισμό. Ο Γάλλος στοχαστής κάνει σαφές ότι δεν εναντιώνεται στην επανάσταση κάθε αυτή, αλλά στο επαναστατικό πνεύμα που συγκροτείται με την ηθική των «απόλυτων σκοπών». Ο Γάλλος φιλόσοφος προβληματίζεται με το ζήτημα της ένδειας και της εξαθλίωσης και προσπαθεί να προτείνει λύσεις που δεν ταυτίζονται με τις σοσιαλιστικές θεωρίες της εποχής του, οι οποίες θεωρεί ότι ενδέχεται να οδηγήσουν σε αντιδημοκρατικές τάσεις και σε μεγαλύτερη όξυνση του κοινωνικού προβλήματος. Σε αυτό το σημείο, αναφέρεται στην σημασία της ιδιωτικής φιλανθρωπίας και της ηθικής της ανωτερότητας σε σχέση με την δημόσια φιλανθρωπία και τον θεσμό του κράτους πρόνοιας, ενώ παράλληλα προσπαθεί να αναδείξει την αβεβαιότητα που χαρακτηρίζει την ζωή των βιομηχανικών εργατών, λόγω της εγγενούς αστάθειας της βιομηχανίας σε αντίθεση με την οικονομική ενασχόληση αγροτικού τύπου. Για τον Tocqueville η κατοχή γης αποτελεί μια σημαντική παράμετρο για την αντιμετώπιση του ενδεχόμενου κινδύνου της εξαθλίωσης. Τέλος, αναφέρεται στην σημασία την αποταμίευσης και του κοινωνικού ρόλου που μπορούν να έχουν τα ταμιευτήρια στην αντιμετώπιση του κοινωνικού προβλήματος, αφού προηγουμένως έχει τονίσει την σημασία της πολιτικής συμμετοχής των ανθρωπίνων υποκειμένων στις υποθέσεις του δημόσιου πεδίου. Στο επόμενο κεφάλαιο, γίνεται παρουσίαση της ιστορικής μελέτης του Γάλλου στοχαστή για την γαλλική επανάσταση, τους λόγους της αποτυχίας της και της ιακωβινικής της κατάληξης και της έντονης διαφοροποίησης της με την αμερικανική επανάσταση και την πολιτική κατάσταση που αναδύθηκε στον νέο κόσμο. Αναγνωρίζοντας την σημασία της γαλλικής επανάστασης και του ρόλου της φιλοσοφίας του Διαφωτισμού σε αυτή, ο Tocqueville δείχνει την καταστροφική τάση του άθρησκου πνεύματος που αναπτύχθηκε στους κόλπους της επανάστασης. Παράλληλα, επιθυμεί να φωτίσει τον τρόπο με τον οποίο οι θεσμοί, οι δομές και το γενικότερο κοινωνικό φαντασιακό των τελευταίων χρόνων του Παλαιού Καθεστώτος διαδραμάτισαν καθοριστικό ρόλο για την συγκρότηση της μετεπαναστατικής κοινωνικοπολιτικής κατάστασης στην Γαλλία. Στο τέλος του πρώτου μέρους παρουσιάζεται η σχέση που έχει η τοκβιλιανή σκέψη με τον Montesquieu, τον Edmund Burke και τον John Stuart Mill. Αρχικά, αποτυπώνεται η κεντρική επιρροή των φιλοσοφικοπολιτικών ενδιαφερόντων του Montesquieu και η κοινωνιολογική του μέθοδος στο μετέπειτα έργο του Tocqueville. Έπειτα, γίνεται αναφορά στην σύγκρουση με τον Burke σχετικά με την σημασία της γαλλικής επανάστασης και τον ιστορικό της ρόλο, καθώς και της πορείας που μπορεί να έχει η ευρωπαϊκή κοινωνία μετά την πτώση της societas civilis και του Παλαιού Καθεστώτος. Παρόλα αυτά, ο Burke και ο Tocqueville συγκλίνουν σε ζητήματα φιλοσοφικής ανθρωπολογίας, στην σημασία των ενδιάμεσων σωμάτων για τον περιορισμό της εξουσίας και σε θέματα που αφορούν τον κοινωνικό ρόλο της θρησκείας. Κλείνοντας, επισημαίνεται η επιρροή του Mill από το έργο του Γάλλου στοχαστή σχετικά με την κοινωνιολογική μεθοδολογία που υιοθετεί, τη σύνθεση φιλελευθερισμού και δημοκρατίας και την κριτική της κλασικής πολιτικής οικονομίας. Τέλος, παρουσιάζεται η κριτική στάση του Mill στο έργο του Tocqueville γύρω από την ταύτιση των δεινών της δημοκρατίας και της εκβιομηχάνισης. Στο δεύτερο μέρος της διπλωματικής εργασίας γίνεται παρουσίαση των θέσεων των Lipovetsky, Kονδύλη και Taylor γύρω από τα ζητήματα του ατομικισμού και της μαζικής κοινωνίας. Η προβληματική για την μαζική κοινωνία συναντάται σε πρώιμη μορφή στο Democracy in America, στο δεύτερο τόμο του έργου, ως το αποτέλεσμα της μαζικής χαύνωσης που χαρακτηρίζει τις νεωτερικές ατομικιστικές και εκδημοκρατισμένες κοινωνίες. Στις αρχές του 20ου αιώνα ένας στοχαστής που ασχολήθηκε με το φαινόμενο των μαζών και της εξέγερσης τους ήταν ο José Ortega y Gasset στο διάσημο έργο του The revolt of masses που παρατηρεί την όλο και μεγαλύτερη επιρροή των μαζών, δηλαδή του μέσου αδιαφοροποίητου ατόμου. Αυτό το υποκείμενο, σύμφωνα με τον Gasset, συναντάται εντόνως στην Αμερική. Παράλληλα, ο Ισπανός στοχαστής παρατηρεί ότι ο έλεγχος και η διαχείριση υποθέσεων που τα παλιότερα χρόνια αναλάμβαναν τα μεμονωμένα άτομα, γίνεται πεδίο ενασχόλησης για τις μάζες. Αρχικά, στο κεφάλαιο σχετικά με τον νεο-ατομικισμό και τη μετανεωτερικότητα, αναλύονται οι θέσεις του Gilles Lipovetsky για τον νέο ατομικισμό και τον τρόπο που αυτό το νέο είδος ατομικισμού γίνεται ακόμα πιο έντονο μέσα στην κοινωνία και τείνει να γίνει ένας απόλυτος ατομικισμός. Ο Lipovetsky επηρεασμένος από την αμερικανική κοινωνιολογία και τον Christopher Lasch διατυπώνει ότι ο νεο-ατομικισμός χαρακτηρίζεται από έντονα στοιχεία ναρκισσισμού. Ο Lipovetsky αναδεικνύει τις σημαντικές διαφορές που παρατηρούνται μεταξύ νεωτερικής πειθαρχικής κοινωνίας και μετανεωτερικής κοινωνίας που είναι στραμμένη προς την επιθυμία και την πληροφορία. Αυτή η νέα μετανεωτερική συνθήκη οδηγεί τον Γάλλο φιλόσοφο και κοινωνιολόγο να ασχοληθεί με τις θέσεις του Tocqueville περί ατομικισμού, αλλά να τις εξελίξει ως απόρροια του γεγονότος ότι ο ατομικισμός της μετανεωτερικής περιόδου είναι απόλυτος και εντονότερος. Στο επόμενο κεφάλαιο, γίνεται αναφορά στις θέσεις του Κονδύλη για την μαζική κοινωνία και το πολιτικό σύστημα που τη χαρακτηρίζει, δηλαδή τη μαζική δημοκρατία. Ο Έλληνας στοχαστής παρατηρεί ότι η μαζική κοινωνία αναδύεται με την κατάτμηση της κοινωνίας σε άτομα και με τη ρήξη των ανθρωπίνων υποκειμένων με την αγροτο-κοινοτική συνθήκη και με την ταυτόχρονη μετατροπή του συνθετικού-εναρμονιστικού (synthetic-harmonizing) τρόπου σκέψης σε αναλυτικό-συνδυαστικό (analytic-combinatory) τρόπο σκέψης. Στη συγκεκριμένη προβληματική περί μαζικής κοινωνίας και δημοκρατίας ο Κονδύλης φαίνεται να συμφωνεί με τις πρώιμες αναλύσεις του Tocqueville, καθώς διακρίνει τον κομβικό ρόλο της κατάτμησης της κοινωνίας σε άτομα για την ανάδυση της μαζικής κοινωνίας. Παράλληλα, σημαντικό στοιχείο είναι η ανάδειξη της σχέσης του Κονδύλη με τον Γάλλο στοχαστή σχετικά με το ζήτημα της μεθερμηνείας του φιλελευθερισμού, δηλαδή με τη μετατροπή του laissez-faire φιλελευθερισμού σε έναν μετα-αστικό εκδημοκρατισμένο φιλελευθερισμό. Επιπρόσθετα, το επόμενο κεφάλαιο παρουσιάζει τις σκέψεις του Lipovetsky για την σχέση του ατομικισμού με την βιαιότητα και το πως αυτή εξελίχθηκε από τις πρωτόγονες κοινωνίες μέχρι την διαμόρφωση του κράτους. Από τις αναλύσεις του Γάλλου στοχαστή συμπεραίνεται ο θετικός ρόλος του ατομικισμού στην άμβλυνση της ωμότητας και της βίας. Από το μέσο αυτού του κεφαλαίου, αναπτύσσεται η προβληματική των Lipovetsky και Κονδύλης για τις επαναστατικές εντάσεις του Μάιου του 68’ και την πολιτισμική επανάσταση των δεκαετιών του 60΄και του 70’. Οι δυο στοχαστές καταλήγουν ότι αυτή η «πολιτισμική επανάσταση» χαρακτηρίζεται από έντονη αμφιθυμία και αποτελούταν από ετερόκλητα ιδεολογικά και θεωρητικά στοιχεία. Παρόλα αυτά θεωρούν ότι η βασική τάση αυτής της «επανάστασης» στηριζόταν στη θεωρητική υπεράσπιση της επιθυμίας και του ηδονισμού και υπήρξε ως προς αυτό, το κοσμοϊστορικό γεγονός που σηματοδότησε το πέρασμα στη μετανεωτερικότητα και την ολική επικράτηση της μαζικοδημοκρατικής συνθήκης. Τέλος, προβάλλεται η σκέψη του Charles Taylor για την ατομικότητα, την αυθεντικότητα και τη σχέση που έχει με τον στοχασμό του Tocqueville για τη διάσωση της ατομικότητας. Ο Taylor παρουσιάζεται από την πλειοψηφία της βιβλιογραφίας ως ένας κοινοτιστής θεωρητικός που εναντιώνεται στον φιλελευθερισμό. Ο φιλελευθερισμός στον οποίο εναντιώνεται ο Taylor είναι ο «φιλελευθερισμός της ουδετερότητας» του John Rawls και η ελευθεριστική θεωρία του Robert Nozick. Ο Καναδός στοχαστής, ωστόσο, έχει επηρεαστεί από τον Wilhelm Humboldt και τον φιλελευθερισμού του 19ου αιώνα. Σε αυτό το πλαίσιο φαίνεται η επιρροή που του έχει ασκήσει ο Tocqueville περί ατομικότητας, ενώ παράλληλα διαφαίνεται η προβληματική που θέτει ο Taylor για τον «ήπιο δεσποτισμό» ως αποτέλεσμα της γενικευμένης πολιτικής απάθειας, κάτι που είχε διαμορφωθεί θεωρητικά από τον Tocqueville τον 19ο αιώνα.The purpose of this thesis is to present the work of Alexis de Tocqueville on the issues of individualism and the emergence of mass society and, at the same time, the philosophical and political influence of Tocqueville on certain important thinkers of the 20th century is highlighted. These thinkers are Gilles Lipovetsky, Panagiotis Kondylis and Charles Taylor and this paper aims to highlight the relationship of these three modern philosophers with Tocquevillian thought around the issues of individualism and mass society. In addition, the positions of the three thinkers are presented more generally so that not only their similarities with Tocqueville but also their differences are made comprehensible to the reader. Finally, the author of this paper aspires to indicate the absolute rupture that characterizes the relationship between modernity and its late phase, namely postmodernity, an era in which a new form of individualism is observed which emerges through the institutions and political structures that characterize mass democracy. The first part presents the characteristic positions of Tocqueville's political thought. The first section refers to the French thinker's reflection and sociological research on American democracy and the way it attempts to combine equality of conditions and freedom. Tocqueville's thoughts on the process of entraining American citizens in the political process, the important role of associations and American institutions, and how all of the above as products of the Anglo-American political tradition may retard the emergence of the despotic tendencies that lie within the democratic system are articulated. In the second chapter, the French philosopher's views on the phenomenon of individualism and its corrosive and undermining nature are presented. Tocqueville approaches individualism, primarily, in his book Democracy in America and, at certain points, in his other work Old regime and revolution. In his contemplation around individualism, the French thinker develops his conception of freedom as negative (in the berlinian sense of the term) and as opportunity of participation in political affairs. At this point, he argues the reason why individualism is a danger to the undermining of freedom. In addition to that, Tocqueville indicates the tendency of the Despots to desire the prevalence of individualism and the simultaneous individualistic tendencies to reinforce despotism. Chapter three discusses Tocqueville's views on revolution, the social problem and its solution, and socialism. The French thinker clarifies that he is not opposed to revolution in itself, but to the revolutionary spirit constituted by the ethics of "ultimate ends". The French philosopher is concerned with the issue of poverty and misery and attempts to propose solutions that do not correspond to the socialist theories of his time, which he believes may lead to undemocratic tendencies and a greater aggravation of the social problem. In this respect, he refers to the importance of private philanthropy and its moral superiority in relation to public philanthropy and the institution of the welfare state, while highlighting the uncertainty that characterizes the life of industrial workers, due to the inherent instability of industry as opposed to the economic activity of an agrarian type. For Tocqueville, land tenure is a major parameter in addressing the potential danger of impoverishment. Finally, he refers to the importance of savings and the social role that savings banks can play in addressing the social problem, having previously stressed the importance of the political participation of human subjects in the affairs of the public sphere. The next chapter presents the French thinker's historical study of the French Revolution, the reasons for its failure and its Jacobin ending, and its 'sharp differentiation with the American Revolution and the political situation that emerged in the new world. Recognizing the importance of the French Revolution and the role of Enlightenment philosophy in it, Tocqueville mentions the destructive tendency of the irreligious spirit that developed within the revolution. Furthermore, he endeavors to shed light on the way in which the institutions, structures and the general social imaginary of the last years of the Old Regime played a decisive role in the constitution of the post-revolutionary socio-political situation in France. At the end of the first part, the relationship between Tocquevillian thought and Montesquieu, Edmund Burke and John Stuart Mill is presented. Firstly, the central influence of Montesquieu's philosophical-political interests and his sociological method on Tocqueville's later work is illustrated. Secondly, the conflict with Burke over the significance of the French Revolution and its historical role, as well as the course that European society might take after the fall of the societas civilis and the Old Regime is discussed. In spite of their disagreements, Burke and Tocqueville converge on issues of philosophical anthropology, the importance of intermediate bodies in limiting power and issues concerning the social role of religion. Finally, Mill's influence of the French thinker's work is highlighted in terms of the sociological methodology he adopts, his synthesis of liberalism and democracy, and his critique of classical political economy. In addition, Mill's critical stance on Tocqueville's work around the identification of the evils of democracy and industrialization is presented. The second part of the thesis presents the positions of Lipovetsky, Kondylis and Taylor around the issues of individualism and mass society. The problematic of mass society is found in an early form in Democracy in America in the second volume of the work as the result of the mass chaos that characterizes modern individualistic and democratized societies. In the early 20th century, a thinker who approached the phenomenon of the masses and their revolt was José Ortega y Gasset in his famous work The revolt of masses which observes the increasing influence of the masses, i.e. the average undifferentiated individual. This subject, according to Gasset, is strongly found in America. At the same time, the Spanish thinker observes that the control and management of affairs that in earlier times were undertaken by individuals is becoming a field of preoccupation for the masses. In the chapter on neo-individualism and postmodernity, Gilles Lipovetsky's thesis on neo-individualism and the way this new type of individualism is becoming even more pronounced in society and tends to become an absolute individualism is analyzed. Influenced by American sociology and Christopher Lasch, Lipovetsky formulates that neo-individualism is characterized by strong elements of narcissism. Lipovetsky states the mentionable differences between a modern disciplinary society and a postmodern society that is oriented towards desire and information. This new postmodern condition leads the French philosopher and sociologist to engage with Tocqueville's theses on individualism, but to develop them as a consequence of the fact that the individualism of the postmodern period is absolute and intensified. In the next chapter, reference is made to Kondylis' thesis on mass society and the political system that distinguishes it, i.e. mass democracy. The Greek thinker observes that the mass society emerges with the segmentation of society into individuals and with the rupture of human subjects with the agro-communal condition and the simultaneous transformation of the synthetic-harmonizing mode of thinking into analytic-combinatory. In this particular problematic on mass society and democracy Kondylis seems to agree with Tocqueville's early analyses, as he discerns the pivotal role of the segmentation of society into individuals for the emergence of the mass society. At the same time, an important element is the association of Kondylis’ relationship with the French thinker on the issue of the interpretation of liberalism, i.e. the transformation of laissez-faire liberalism into a post-democratized liberalism. In addition, the next chapter presents Lipovetsky's thoughts on the relationship between individualism and brutality and how it evolved from primitive societies to the formation of the state. From the French thinker's analyses, the positive role of individualism in mitigating brutality and violence is inferred. In the second part of chapter, Lipovetsky and Kondylis' reflections on the revolutionary tensions of May ‘68 and the cultural revolution of the 1960s and 1970s are developed. The two thinkers conclude that this 'cultural revolution' was characterized by intense ambivalence and consisted of disparate ideological and theoretical elements. Nevertheless, they consider that the basic tendency of this 'revolution' was based on the theoretical defense of desire and hedonism and that it was as such the world-historical event that marked the passage to postmodernity and the total prevalence of the mass-democratic condition. Finally, Charles Taylor's thought on individuality, authenticity and its relation to Tocqueville's reflection on the salvation of individuality are highlighted. Taylor is presented by the majority of literature as a communitarian theorist opposed to liberalism. The liberalism Taylor opposes is John Rawls' "neutrality liberalism" and Robert Nozick's libertarian theory. The Canadian thinker, however, has been influenced by Wilhelm von Humboldt and 19th century liberalism. It is in this context that Tocqueville's influence on individualism can be seen, while also Taylor's problematic of "soft despotism" as a result of generalized political apathy, something that had been theorized by Tocqueville in the 19th century, argues to the influence of the former by Tocqueville

The importance of colonization pressure in multiresistant Acinetobacter baumannii acquisition in a Greek intensive care unit

INTRODUCTION: We investigated the role of colonization pressure on multiresistant Acinetobacter baumannii acquisition and defined patient-related predictors for carriage at admission and acquisition during hospitalization in intensive care unit (ICU) patients. METHODS: This was a 12-month, prospective, cohort study of all patients admitted to a single ICU of a tertiary hospital. Screening samples were collected at ICU admission to identify imported carriers, and weekly during hospitalization to identify acquisition. Colonization pressure (carriers' patient-days × 100/all patients' patient-days) and the absolute number of carriers were calculated weekly, and the statistical correlation between these parameters and acquisition was explored. Multivariable analysis was performed to identify predictors for A. baumannii carriage at admission and acquisition during hospitalization. A. baumannii isolates were genotyped by repetitive-extragenic-palindromic polymerase chain reaction (PCR; rep-PCR). RESULTS: At ICU admission, 284 patients were screened for carriage. A. baumannii was imported in 16 patients (5.6%), and acquisition occurred in 32 patients (15.7%). Acquisition was significantly correlated to weekly colonization pressure (correlation coefficient, 0.379; P = 0.004) and to the number of carriers per week (correlation coefficient, 0.499; P <0.001). More than one carrier per week significantly increased acquisition risk (two to three carriers, odds ratio (OR), 12.66; P = 0.028; more than four carriers, OR, 25.33; P = 0.004). Predictors of carriage at admission were infection at admission (OR, 11.03; confidence interval (CI), 3.56 to 34.18; P < 0.01) and hospitalization days before ICU (OR, 1.09; CI, 1.01 to 1.16; P = 0.02). Predictors of acquisition were a medical reason for ICU admission (OR, 5.11; CI, 1.31 to 19.93; P = 0.02), duration of antibiotic administration in the unit (OR, 1.24; CI, 1.12 to 1.38; P < 0.001), and duration of mechanical ventilation (OR, 1.08; CI, 1.04 to 1.13; P = 0.001). All strains were multiresistant. Rep-PCR analysis showed one dominant cluster. CONCLUSIONS: Acquisition of multiresistant A. baumannii in ICU patients is strongly correlated to colonization pressure. High levels of colonization pressure and more than two carriers per week independently increase acquisition risk. Patient-related factors, such as infection at admission and long hospitalization before the ICU, can identify imported A. baumannii carriers. Medical patients with extended administration of antibiotics and long duration of mechanical ventilation in the ICU were the most vulnerable to acquisition

The importance of colonization pressure in multiresistant Acinetobacter baumannii acquisition in a Greek intensive care unit

Introduction: We investigated the role of colonization pressure on multiresistant Acinetobacter baumannii acquisition and defined patient-related predictors for carriage at admission and acquisition during hospitalization in intensive care unit (ICU) patients. Methods: This was a 12-month, prospective, cohort study of all patients admitted to a single ICU of a tertiary hospital. Screening samples were collected at ICU admission to identify imported carriers, and weekly during hospitalization to identify acquisition. Colonization pressure (carriers’ patient-days × 100/all patients’ patient-days) and the absolute number of carriers were calculated weekly, and the statistical correlation between these parameters and acquisition was explored. Multivariable analysis was performed to identify predictors for A. baumannii carriage at admission and acquisition during hospitalization. A. baumannii isolates were genotyped by repetitive-extragenic-palindromic polymerase chain reaction (PCR; rep-PCR). Results: At ICU admission, 284 patients were screened for carriage. A. baumannii was imported in 16 patients (5.6%), and acquisition occurred in 32 patients (15.7%). Acquisition was significantly correlated to weekly colonization pressure (correlation coefficient, 0.379; P = 0.004) and to the number of carriers per week (correlation coefficient, 0.499;

Outcomes of ICU patients with and without perceptions of excessive care:a comparison between cancer and non-cancer patients

BACKGROUND: Whether Intensive Care Unit (ICU) clinicians display unconscious bias towards cancer patients is unknown. The aim of this study was to compare the outcomes of critically ill patients with and without perceptions of excessive care (PECs) by ICU clinicians in patients with and without cancer.METHODS: This study is a sub-analysis of the large multicentre DISPROPRICUS study. Clinicians of 56 ICUs in Europe and the United States completed a daily questionnaire about the appropriateness of care during a 28-day period. We compared the cumulative incidence of patients with concordant PECs, treatment limitation decisions (TLDs) and death between patients with uncontrolled and controlled cancer, and patients without cancer.RESULTS: Of the 1641 patients, 117 (7.1%) had uncontrolled cancer and 270 (16.4%) had controlled cancer. The cumulative incidence of concordant PECs in patients with uncontrolled and controlled cancer versus patients without cancer was 20.5%, 8.1%, and 9.1% (p &lt; 0.001 and p = 0.62, respectively). In patients with concordant PECs, we found no evidence for a difference in time from admission until death (HR 1.02, 95% CI 0.60-1.72 and HR 0.87, 95% CI 0.49-1.54) and TLDs (HR 0.81, 95% CI 0.33-1.99 and HR 0.70, 95% CI 0.27-1.81) across subgroups. In patients without concordant PECs, we found differences between the time from admission until death (HR 2.23, 95% CI 1.58-3.15 and 1.66, 95% CI 1.28-2.15), without a corresponding increase in time until TLDs (NA, p = 0.3 and 0.7) across subgroups.CONCLUSIONS: The absence of a difference in time from admission until TLDs and death in patients with concordant PECs makes bias by ICU clinicians towards cancer patients unlikely. However, the differences between the time from admission until death, without a corresponding increase in time until TLDs, suggest prognostic unawareness, uncertainty or optimism in ICU clinicians who did not provide PECs, more specifically in patients with uncontrolled cancer. This study highlights the need to improve intra- and interdisciplinary ethical reflection and subsequent decision-making at the ICU.</p

Outcomes of ICU patients with and without perceptions of excessive care:a comparison between cancer and non-cancer patients

BACKGROUND: Whether Intensive Care Unit (ICU) clinicians display unconscious bias towards cancer patients is unknown. The aim of this study was to compare the outcomes of critically ill patients with and without perceptions of excessive care (PECs) by ICU clinicians in patients with and without cancer.METHODS: This study is a sub-analysis of the large multicentre DISPROPRICUS study. Clinicians of 56 ICUs in Europe and the United States completed a daily questionnaire about the appropriateness of care during a 28-day period. We compared the cumulative incidence of patients with concordant PECs, treatment limitation decisions (TLDs) and death between patients with uncontrolled and controlled cancer, and patients without cancer.RESULTS: Of the 1641 patients, 117 (7.1%) had uncontrolled cancer and 270 (16.4%) had controlled cancer. The cumulative incidence of concordant PECs in patients with uncontrolled and controlled cancer versus patients without cancer was 20.5%, 8.1%, and 9.1% (p &lt; 0.001 and p = 0.62, respectively). In patients with concordant PECs, we found no evidence for a difference in time from admission until death (HR 1.02, 95% CI 0.60-1.72 and HR 0.87, 95% CI 0.49-1.54) and TLDs (HR 0.81, 95% CI 0.33-1.99 and HR 0.70, 95% CI 0.27-1.81) across subgroups. In patients without concordant PECs, we found differences between the time from admission until death (HR 2.23, 95% CI 1.58-3.15 and 1.66, 95% CI 1.28-2.15), without a corresponding increase in time until TLDs (NA, p = 0.3 and 0.7) across subgroups.CONCLUSIONS: The absence of a difference in time from admission until TLDs and death in patients with concordant PECs makes bias by ICU clinicians towards cancer patients unlikely. However, the differences between the time from admission until death, without a corresponding increase in time until TLDs, suggest prognostic unawareness, uncertainty or optimism in ICU clinicians who did not provide PECs, more specifically in patients with uncontrolled cancer. This study highlights the need to improve intra- and interdisciplinary ethical reflection and subsequent decision-making at the ICU.</p

Outcomes of ICU patients with and without perceptions of excessive care:a comparison between cancer and non-cancer patients

BACKGROUND: Whether Intensive Care Unit (ICU) clinicians display unconscious bias towards cancer patients is unknown. The aim of this study was to compare the outcomes of critically ill patients with and without perceptions of excessive care (PECs) by ICU clinicians in patients with and without cancer.METHODS: This study is a sub-analysis of the large multicentre DISPROPRICUS study. Clinicians of 56 ICUs in Europe and the United States completed a daily questionnaire about the appropriateness of care during a 28-day period. We compared the cumulative incidence of patients with concordant PECs, treatment limitation decisions (TLDs) and death between patients with uncontrolled and controlled cancer, and patients without cancer.RESULTS: Of the 1641 patients, 117 (7.1%) had uncontrolled cancer and 270 (16.4%) had controlled cancer. The cumulative incidence of concordant PECs in patients with uncontrolled and controlled cancer versus patients without cancer was 20.5%, 8.1%, and 9.1% (p &lt; 0.001 and p = 0.62, respectively). In patients with concordant PECs, we found no evidence for a difference in time from admission until death (HR 1.02, 95% CI 0.60-1.72 and HR 0.87, 95% CI 0.49-1.54) and TLDs (HR 0.81, 95% CI 0.33-1.99 and HR 0.70, 95% CI 0.27-1.81) across subgroups. In patients without concordant PECs, we found differences between the time from admission until death (HR 2.23, 95% CI 1.58-3.15 and 1.66, 95% CI 1.28-2.15), without a corresponding increase in time until TLDs (NA, p = 0.3 and 0.7) across subgroups.CONCLUSIONS: The absence of a difference in time from admission until TLDs and death in patients with concordant PECs makes bias by ICU clinicians towards cancer patients unlikely. However, the differences between the time from admission until death, without a corresponding increase in time until TLDs, suggest prognostic unawareness, uncertainty or optimism in ICU clinicians who did not provide PECs, more specifically in patients with uncontrolled cancer. This study highlights the need to improve intra- and interdisciplinary ethical reflection and subsequent decision-making at the ICU.</p

Impact of Reporting Bias in Network Meta-Analysis of Antidepressant Placebo-Controlled Trials

BACKGROUND: Indirect comparisons of competing treatments by network meta-analysis (NMA) are increasingly in use. Reporting bias has received little attention in this context. We aimed to assess the impact of such bias in NMAs. METHODS: We used data from 74 FDA-registered placebo-controlled trials of 12 antidepressants and their 51 matching publications. For each dataset, NMA was used to estimate the effect sizes for 66 possible pair-wise comparisons of these drugs, the probabilities of being the best drug and ranking the drugs. To assess the impact of reporting bias, we compared the NMA results for the 51 published trials and those for the 74 FDA-registered trials. To assess how reporting bias affecting only one drug may affect the ranking of all drugs, we performed 12 different NMAs for hypothetical analysis. For each of these NMAs, we used published data for one drug and FDA data for the 11 other drugs. FINDINGS: Pair-wise effect sizes for drugs derived from the NMA of published data and those from the NMA of FDA data differed in absolute value by at least 100% in 30 of 66 pair-wise comparisons (45%). Depending on the dataset used, the top 3 agents differed, in composition and order. When reporting bias hypothetically affected only one drug, the affected drug ranked first in 5 of the 12 NMAs but second (n = 2), fourth (n = 1) or eighth (n = 2) in the NMA of the complete FDA network. CONCLUSIONS: In this particular network, reporting bias biased NMA-based estimates of treatments efficacy and modified ranking. The reporting bias effect in NMAs may differ from that in classical meta-analyses in that reporting bias affecting only one drug may affect the ranking of all drugs

The Effects of Fructose Intake on Serum Uric Acid Vary among Controlled Dietary Trials1234

Hyperuricemia is linked to gout and features of metabolic syndrome. There is concern that dietary fructose may increase uric acid concentrations. To assess the effects of fructose on serum uric acid concentrations in people with and without diabetes, we conducted a systematic review and meta-analysis of controlled feeding trials. We searched MEDLINE, EMBASE, and the Cochrane Library for relevant trials (through August 19, 2011). Analyses included all controlled feeding trials ≥7 d investigating the effect of fructose feeding on uric acid under isocaloric conditions, where fructose was isocalorically exchanged with other carbohydrate, or hypercaloric conditions, and where a control diet was supplemented with excess energy from fructose. Data were aggregated by the generic inverse variance method using random effects models and expressed as mean difference (MD) with 95% CI. Heterogeneity was assessed by the Q statistic and quantified by I2. A total of 21 trials in 425 participants met the eligibility criteria. Isocaloric exchange of fructose for other carbohydrate did not affect serum uric acid in diabetic and nondiabetic participants [MD = 0.56 μmol/L (95% CI: −6.62, 7.74)], with no evidence of inter-study heterogeneity. Hypercaloric supplementation of control diets with fructose (+35% excess energy) at extreme doses (213–219 g/d) significantly increased serum uric acid compared with the control diets alone in nondiabetic participants [MD = 31.0 mmol/L (95% CI: 15.4, 46.5)] with no evidence of heterogeneity. Confounding from excess energy cannot be ruled out in the hypercaloric trials. These analyses do not support a uric acid-increasing effect of isocaloric fructose intake in nondiabetic and diabetic participants. Hypercaloric fructose intake may, however, increase uric acid concentrations. The effect of the interaction of energy and fructose remains unclear. Larger, well-designed trials of fructose feeding at “real world” doses are needed

Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

Purpose: Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown. Methods: In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis. Results: Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former. Conclusion: Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life