Тарикъатлар хусусиетлери

В статье проанализированы в историко-хронологическом и диахроническом аспектах весьма важный социальный институт – суфийские братства и их деятельность. Работа посвящена по преимуществу особенностям и характерным чертам практического (прагматического, или рефлекторного) суфизма, который функционально осуществляется через братства, а не специфике суфизма интеллектуального, то есть не его религиозно-философским и этико-моральным доктринам и положениям

Clinical review: Post-extubation laryngeal edema and extubation failure in critically ill adult patients

Laryngeal edema is a frequent complication of intubation. It often presents shortly after extubation as post-extubation stridor and results from damage to the mucosa of the larynx. Mucosal damage is caused by pressure and ischemia resulting in an inflammatory response. Laryngeal edema may compromise the airway necessitating reintubation. Several studies show that a positive cuff leak test combined with the presence of risk factors can identify patients with increased risk for laryngeal edema. Meta-analyses show that pre-emptive administration of a multiple-dose regimen of glucocorticosteroids can reduce the incidence of laryngeal edema and subsequent reintubation. If post-extubation edema occurs this may necessitate medical intervention. Parenteral administration of corticosteroids, epinephrine nebulization and inhalation of a helium/oxygen mixture are potentially effective, although this has not been confirmed by randomized controlled trials. The use of non-invasive positive pressure ventilation is not indicated since this will delay reintubation. Reintubation should be considered early after onset of laryngeal edema to adequately secure an airway. Reintubation leads to increased cost, morbidity and mortality

Selective decontamination of the digestive tract (SDD) in critically ill patients: a narrative review

Selective decontamination of the digestive tract (SDD) is an infection prevention measure for intensive care unit (ICU) patients that was proposed more than 30 years ago, and that is currently considered standard of care in the Netherlands, but only used sporadically in ICUs in other countries. In this narrative review, we first describe the rationale of the individual components of SDD and then review the evidence base for patient-centered outcomes, where we distinguish ICUs with low prevalence of antibiotic resistance from ICUs with moderate-high prevalence of resistance. In settings with low prevalence of antibiotic resistance, SDD has been associated with improved patient outcome in three cluster-randomized studies. These benefits were not confirmed in a large international cluster-randomized study in settings with moderate-to-high prevalence of antibiotic resistance. There is no evidence that SDD increases antibiotic resistance. We end with future directions for research

Levofloxacin prophylaxis in patients with newly diagnosed myeloma (TEAMM): a multicentre, double-blind, placebo-controlled, randomised, phase 3 trial.

BACKGROUND: Myeloma causes profound immunodeficiency and recurrent, serious infections. Around 5500 new cases of myeloma are diagnosed per year in the UK, and a quarter of patients will have a serious infection within 3 months of diagnosis. We aimed to assess whether patients newly diagnosed with myeloma benefit from antibiotic prophylaxis to prevent infection, and to investigate the effect on antibiotic-resistant organism carriage and health care-associated infections in patients with newly diagnosed myeloma. METHODS: TEAMM was a prospective, multicentre, double-blind, placebo-controlled randomised trial in patients aged 21 years and older with newly diagnosed myeloma in 93 UK hospitals. All enrolled patients were within 14 days of starting active myeloma treatment. We randomly assigned patients (1:1) to levofloxacin or placebo with a computerised minimisation algorithm. Allocation was stratified by centre, estimated glomerular filtration rate, and intention to proceed to high-dose chemotherapy with autologous stem cell transplantation. All investigators, patients, laboratory, and trial co-ordination staff were masked to the treatment allocation. Patients were given 500 mg of levofloxacin (two 250 mg tablets), orally once daily for 12 weeks, or placebo tablets (two tablets, orally once daily for 12 weeks), with dose reduction according to estimated glomerular filtration rate every 4 weeks. Follow-up visits occurred every 4 weeks up to week 16, and at 1 year. The primary outcome was time to first febrile episode or death from all causes within the first 12 weeks of trial treatment. All randomised patients were included in an intention-to-treat analysis of the primary endpoint. This study is registered with the ISRCTN registry, number ISRCTN51731976, and the EU Clinical Trials Register, number 2011-000366-35. FINDINGS: Between Aug 15, 2012, and April 29, 2016, we enrolled and randomly assigned 977 patients to receive levofloxacin prophylaxis (489 patients) or placebo (488 patients). Median follow-up was 12 months (IQR 8-13). 95 (19%) first febrile episodes or deaths occurred in 489 patients in the levofloxacin group versus 134 (27%) in 488 patients in the placebo group (hazard ratio 0·66, 95% CI 0·51-0·86; p=0·0018. 597 serious adverse events were reported up to 16 weeks from the start of trial treatment (308 [52%] of which were in the levofloxacin group and 289 [48%] of which were in the placebo group). Serious adverse events were similar between the two groups except for five episodes (1%) of mostly reversible tendonitis in the levofloxacin group. INTERPRETATION: Addition of prophylactic levofloxacin to active myeloma treatment during the first 12 weeks of therapy significantly reduced febrile episodes and deaths compared with placebo without increasing health care-associated infections. These results suggest that prophylactic levofloxacin could be used for patients with newly diagnosed myeloma undergoing anti-myeloma therapy. FUNDING: UK National Institute for Health Research

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Decontamination strategies in ICU : a European perspective

Patients admitted to the intensive care unit (ICU) have an increased risk to develop infections due to their underlying illness and the ICU environment facilitates transmission of micro-organisms. Potential pathogenic micro-organisms (PPMO) colonizing the oropharynx and lower gastro-intestinal tract are the target of decontamination strategies that aim to prevent infections, such as selective digestive tract decontamination (SDD), selective oropharyngeal decontamination (SOD), which both consist of antibiotic prophylaxis applied to the gastro-enteral tract and chlorhexidine (CHX) mouthwash. The interdependence between rectal and respiratory tract colonization and infection was explored among 2066 ICU patients treated with SDD. Rectal colonization was an independent risk factor for both respiratory tract colonization (cause specific hazard ratio (CSHR) 2.93, 95% confidence interval (CI) 2.02-4.23) and new GNB infection (CSHR 3.04, 95% CI 1.99-4.65). The association between colonization of the rectum and bacteremia was stronger than the association between respiratory tract colonization and bacteremia, which provides evidence that the gut acts as an important reservoir for PPMO. SDD and SOD have been used as standard care for ICU patients in the Netherlands after studies showed improved survival and prevention of bloodstream infections among long-stay ICU patients. In this thesis we evaluated two aspect of SDD and SOD in the Dutch ICU setting. First, the long-term effects of SDD and SOD on tobramycin and colistin resistance were evaluated in five Dutch ICUs with an average follow-up of 7 years. Tobramycin resistance decreased during the follow-up period (rectal samples risk ratio RR (95% CI) 0.35 (0.23-0.53); respiratory samples RR 0.48 (0.32-0.73)), compared to baseline, and there was no difference in colistin resistance, indicating that long-term use is safe. Second, amphotericin B (commonly used in SDD and SOD) and nystatin (which is cheaper) were compared in their effectiveness against yeast colonization. Nystatin was associated with less rectal acquisition of Candida, compared to amphotericin B. Nystatin could therefore improve cost-effectiveness of SDD and SOD. Most previous studies on SDD and SOD with beneficial outcomes were performed in the Netherlands, with relatively low levels of antimicrobial resistance. Evidence for the effectiveness in settings with higher levels of antimicrobial resistance is lacking. Therefore, a cluster randomized study was initiated in 13 ICUs in 6 European countries. 8665 Patients were included. As opposed to previous Dutch studies, the use of SDD, SOD and CHX 1% mouthwash were, compared to standard care, not associated with reductions in rates of ICU-acquired bloodstream infection or mortality. Furthermore, initial use of CHX mouthwash in a 2% concentration was abandoned as it led to side-effects in 10% of patients, mainly consisting of reversible oral mucosal lesions. The unit-wide prevalence of HRMO carriage in respiratory tract and rectum remained stable during interventions. Moreover, GNB resistant to carbapenem and cephalosporins, that were present during initial ICU stay were more frequently eradicated in rectum samples during SDD compared to standard care. Also, for Enterobacteriaceae resistant to cephalosporins there was a tendency towards eradication in respiratory samples during SDD (CSHR 1.47 (95% CI 0.98-2.20)) and SOD (CSHR 1.38 (95% CI 0.92-2.06)), compared to standard care. This might prevent the occurrence of infections and cross-transmission of such bacteria