Consensus Report: 2nd European Workshop on Tobacco Use Prevention and Cessation for Oral Health Professionals

Tobacco use has been identified as a major risk factor for oral disorders such as cancer and periodontal disease. Tobacco use cessation (TUC) is associated with the potential for reversal of precancer, enhanced outcomes following periodontal treatment, and better periodontal status compared to patients who continue to smoke. Consequently, helping tobacco users to quit has become a part of both the responsibility of oral health professionals and the general practice of dentistry. TUC should consist of behavioural support, and if accompanied by pharmacotherapy, is more likely to be successful. It is widely accepted that appropriate compensation of TUC counselling would give oral health professionals greater incentives to provide these measures. Therefore, TUC-related compensation should be made accessible to all dental professionals and be in appropriate relation to other therapeutic interventions. International and national associations for oral health professionals are urged to act as advocates to promote population, community and individual initiatives in support of tobacco use prevention and cessation (TUPAC) counselling, including integration in undergraduate and graduate dental curricula. In order to facilitate the adoption of TUPAC strategies by oral health professionals, we propose a level of care model which includes 1) basic care: brief interventions for all patients in the dental practice to identify tobacco users, assess readiness to quit, and request permission to re-address at a subsequent visit, 2) intermediate care: interventions consisting of (brief) motivational interviewing sessions to build on readiness to quit, enlist resources to support change, and to include cessation medications, and 3) advanced care: intensive interventions to develop a detailed quit plan including the use of suitable pharmacotherapy. To ensure that the delivery of effective TUC becomes part of standard care, continuing education courses and updates should be implemented and offered to all oral health professionals on a regular basis.

Early non-invasive cardiac output monitoring in hemodynamically unstable intensive care patients: A multi-center randomized controlled trial

Introduction Acute hemodynamic instability increases morbidity and mortality. We investigated whether early non-invasive cardiac output monitoring enhances hemodynamic stabilization and improves outcome. Methods A multicenter, randomized controlled trial was conducted in three European university hospital intensive care units in 2006 and 2007. A total of 388 hemodynamically unstable patients identified during their first six hours in the intensive care unit (ICU) were randomized to receive either non-invasive cardiac output monitoring for 24 hrs (minimally invasive cardiac output/MICO group; n = 201) or usual care (control group; n = 187). The main outcome measure was the proportion of patients achieving hemodynamic stability within six hours of starting the study. Results The number of hemodynamic instability criteria at baseline (MICO group mean 2.0 (SD 1.0), control group 1.8 (1.0); P = .06) and severity of illness (SAPS II score; MICO group 48 (18), control group 48 (15); P = .86)) were similar. At 6 hrs, 45 patients (22%) in the MICO group and 52 patients (28%) in the control group were hemodynamically stable (mean difference 5%; 95% confidence interval of the difference -3 to 14%; P = .24). Hemodynamic support with fluids and vasoactive drugs, and pulmonary artery catheter use (MICO group: 19%, control group: 26%; P = .11) were similar in the two groups. The median length of ICU stay was 2.0 (interquartile range 1.2 to 4.6) days in the MICO group and 2.5 (1.1 to 5.0) days in the control group (P = .38). The hospital mortality was 26% in the MICO group and 21% in the control group (P = .34). Conclusions Minimally-invasive cardiac output monitoring added to usual care does not facilitate early hemodynamic stabilization in the ICU, nor does it alter the hemodynamic support or outcome. Our results emphasize the need to evaluate technologies used to measure stroke volume and cardiac output--especially their impact on the process of care--before any large-scale outcome studies are attempted.

Practical sources of error in measuring pulmonary artery occlusion pressure: a study in participants of a special intensivist training program of The Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI)

BACKGROUND: Physiological data obtained with the pulmonary artery catheter (PAC) are susceptible to errors in measurement and interpretation. Little attention has been paid to the relevance of errors in hemodynamic measurements performed in the intensive care unit (ICU). The aim of this study was to assess the errors related to the technical aspects (zeroing and reference level) and actual measurement (curve interpretation) of the pulmonary artery occlusion pressure (PAOP). METHODS: Forty-seven participants in a special ICU training program and 22 ICU nurses were tested without pre-announcement. All participants had previously been exposed to the clinical use of the method. The first task was to set up a pressure measurement system for PAC (zeroing and reference level) and the second to measure the PAOP. RESULTS: The median difference from the reference mid-axillary zero level was - 3 cm (-8 to + 9 cm) for physicians and -1 cm (-5 to + 1 cm) for nurses. The median difference from the reference PAOP was 0 mmHg (-3 to 5 mmHg) for physicians and 1 mmHg (-1 to 15 mmHg) for nurses. When PAOP values were adjusted for the differences from the reference transducer level, the median differences from the reference PAOP values were 2 mmHg (-6 to 9 mmHg) for physicians and 2 mmHg (-6 to 16 mmHg) for nurses. CONCLUSIONS: Measurement of the PAOP is susceptible to substantial error as a result of practical mistakes. Comparison of results between ICUs or practitioners is therefore not possible.

TONOMETRY REVISITED: PERFUSION-RELATED, METABOLIC, AND RESPIRATORY COMPONENTS OF GASTRIC MUCOSAL ACIDOSIS IN ACUTE CARDIORESPIRATORY FAILURE

Mucosal pH (pHi) is influenced by local perfusion and metabolism (mucosal-arterial Pco2 gradient, DeltaPco2), systemic metabolic acidosis (arterial bicarbonate), and respiration (arterial Pco2). We determined these components of pHi and their relation to outcome during the first 24 h of intensive care. We studied 103 patients with acute respiratory or circulatory failure (age, 63 +/- 2 [mean +/- SEM]; Acute Physiology and Chronic Health Evaluation II score, 20 +/- 1; Sequential Organ Failure Assessment score, 8 +/- 0). pHi, and the effects of bicarbonate and arterial and mucosal Pco2 on pHi, were assessed at admission, 6, and 24 h. pHi was reduced (at admission, 7.27 +/- 0.01) due to low arterial bicarbonate and increased DeltaPco2. Low pHi (<7.32) at admission (n = 58; mortality, 29% vs. 13% in those with pHi >/=7.32 at admission; P = 0.061) was associated with an increased DeltaPco2 in 59% of patients (mortality, 47% vs. 4% for patients with low pHi and normal DeltaPco2; P = 0.0003). An increased versus normal DeltaPco2, regardless of pHi, was associated with increased mortality at admission (51% vs. 5%; P < 0.0001; n = 39) and at 6 h (34% vs. 13%; P = 0.016; n = 45). A delayed normalization or persistently low pHi (n = 47) or high DeltaPco2 (n = 25) was associated with high mortality (low pHi [34%] vs. high DeltaPco2 [60%]; P = 0.046). In nonsurvivors, hypocapnia increased pHi at baseline, 6, and 24 h (all P

Dexmedetomidine versus propofol/midazolam for long-term sedation during mechanical ventilation

PURPOSE: To compare dexmedetomidine (DEX) with standard care (SC, either propofol or midazolam) for long-term sedation in terms of maintaining target sedation and length of intensive care unit (ICU) stay. METHODS: A pilot, phase III, double-blind multicenter study in randomized medical and surgical patients (n = 85) within the first 72 h of ICU stay with an expected ICU stay of >or=48 h and sedation need for >or=24 h after randomization. Patients were assigned to either DEX (

Assessment of splanchnic blood flow using magnetic resonance imaging

BACKGROUND AND AIMS: The splanchnic circulation has an important function in the body under both physiological and pathophysiological conditions. Despite its importance, no reliable noninvasive procedures for estimating splanchnic circulation have been established. The aim of this study was to evaluate MRI as a tool for assessing intra-abdominal blood flows of the aorta, portal vein (VPO) and the major intestinal and hepatic vessels. METHODS: In nine healthy volunteers, the proximal aorta (AOP) and distal abdominal aorta (AOD), superior mesenteric artery (SAM), celiac trunk (CTR), hepatic arteries (common and proper hepatic arteries, AHC and AHP, respectively), and VPO were localized on contrast-enhanced magnetic resonance angiography images. Volumetric flow was measured using a two-dimensional cine echocardiogram-gated phase contrast technique. Measurements were taken before and 30 min after continuous intravenous infusion of somatostatin (250 microg/h) and were independently evaluated by two investigators. RESULTS: Blood flow measured by MRI in the VPO, SAM, AOP, AHP, and CTR significantly decreased after drug infusion. Flows in the AOD and AHC showed a tendency to decrease (P>0.05). Interrater agreement on flows in MRI was very good for large vessels (VPO, AOP, and AOD), with a concordance correlation coefficient of 0.94, as well as for smaller vessels such as the CTR, AHC, AHP, and SAM (concordance correlation coefficient =0.78). CONCLUSION: Somatostatin-induced blood flow changes in the splanchnic region were reliably detected by MRI. MRI may be useful for the noninvasive assessment of blood flow changes in the splanchnic region.

Increased splanchnic oxygen extraction because of routine nursing procedures

OBJECTIVE: Multiple organ failure is a common complication of acute circulatory and respiratory failure. We hypothesized that therapeutic interventions used routinely in intensive care can interfere with the perfusion of the gut and the liver, and thereby increase the risk of mismatch between oxygen supply and demand. DESIGN: Prospective, observational study. SETTING: Interdisciplinary intensive care unit (ICU) of a university hospital. PATIENTS: Thirty-six patients on mechanical ventilation with acute respiratory or circulatory failure or severe infection were included. INTERVENTIONS: Insertion of a hepatic venous catheter. MEASUREMENTS AND MAIN RESULTS: Daily nursing procedures were recorded. A decrease of >or=5% in hepatic venous oxygen saturation (Sho2) was considered relevant. Observation time was 64 (29-104) hours (median [interquartile range]). The ICU stay was 11 (8-15) days, and hospital mortality was 35%. The number of periods with procedures/patient was 170 (98-268), the number of procedure-related decreases in Sho2 was 29 (13-41), and the number of decreases in Sho2 unrelated to procedures was 9 (4-19). Accordingly, procedure-related Sho2 decreases occurred 11 (7-17) times per day. Median Sho2 decrease during the procedures was 7 (5-10)%, and median increase in the gradient between mixed and hepatic venous oxygen saturation was 6 (4-9)%. Procedures that caused most Sho2 decreases were airway suctioning, assessment of level of sedation, and changing patients' position. Sho2 decreases were associated with small but significant increases in heart rate and intravascular pressures. Maximal Sequential Organ Failure Assessment scores in the ICU correlated with the number of Sho2 decreases (r: .56; p < 0.001) and with the number of procedure-related Sho2 decreases (r: .60; p < 0.001). CONCLUSIONS: Patients are exposed to repeated episodes of impaired splanchnic perfusion during routine nursing procedures. More research is needed to examine the correlation, if any, between nursing procedures and hepatic venous desaturation.

Cartas desde el Nuevo Mundo. Sobre La cité des rats de Copi

La novela epistolar La cité des rats comienza con una advertencia: el autor y el editor del texto invitan a los amantes de las normas consensuadas del "escribir bien" a abandonar el libro y regresar a sus lecturas favoritas. Esa nota inicial no sólo atañe a aspectos estilísticos, sino que tiene también, por supuesto, implicaciones ideológicas. En efecto, La ciudad de las ratas desafía la ética y la estética de los discursos humanistas mediante lo que César Aira ha denominado "antropología del continuo", rastreable, por ejemplo, en las condensaciones espacio-temporales o en la sistemática desarticulación de las analogías y las construcciones metafóricas. Mediante estos procedimientos, la novela transfigura el universo miniaturizado de las ratas, tierno y domesticado, en un nuevo mundo hecho de fronteras, umbrales, territorios liminares. Nos proponemos hacer una lectura de estos pasajes para analizar los modos en que la escritura de Copi hace emerger, en el espacio que une y separa el universo animal y el humano, la fuerza desestabilizadora de lo imaginario

La singularidad del proyecto poético de Sergio Chejfec : Análisis de Mis dos mundos

En After the End. Representations of Post-Apocalypse, James Berger (1999) estudia el posapocalipsis en Estados Unidos. Explica que cada tentativa de representar lo irrepresentable es incompleta por definición porque siempre deja residuos. Otra paradoja que plantea es que cuesta menos recordar un evento traumático en sí que captar aquello que ocurre después, sus efectos posteriores sobre un individuo o una colectividad, la presencia dolorosa de lo fantasmático. En su narrativa, Sergio Chejfec evoca este mundo en ruinas de la memoria heredada (postmemory según Marianne Hirsch), tanto en cuanto a su configuración espacial como en cuanto a sus pautas de sociabilidad. El proyecto poético formulado por Chejfec supone un desplazamiento en la novelística argentina posterior a la fase posdictatorial "alegórica" (Idelber Avelar en Alegorías de la derrota, 2000). En Mis dos mundos (2008), Chejfec relata una excursión por un parque urbano del sur de Brasil. La caminata emprendida por el protagonista, a punto de convertirse en cincuentón, le permite reflexionar acerca del legado de algunos antecesores, evocado a través de intertextos como los Cumpleaños de Fuentes y de Aira, y acerca de las aporías de la tradición literaria en general. A pesar de las afinidades adornianas que se perciben en Chejfec, se observa en este texto una impugnación a la categoría de obra de arte como forma autónoma y distanciada de lo real. El análisis de Mis dos mundos que nos proponemos llevar a cabo constituirá el punto de partida para una tentativa de definición de los "atributos" de esta literatura

El efecto Duchamp

En una literatura en la que ha desaparecido el valor y los fantasmas perdieron consistencia, el lenguaje es un ready made de clichés. Algunas novelas actuales, sin embargo, han merecido el epíteto de verdaderas" (Jarkowski 2008) o "auténticas" (Lemus 2004). La magia ha regresado, y los narradores, aunque sus relatos sean inconclusos, indiferentes e incluso frívolos, interpelan al lector como los grandes realistas (Lukács 1971) porque el efecto de los textos es indicial. Señalan -con brutalidad o con delicia- el desfasaje entre lo que se dice y lo que se hace o lo que se deja de hacer. Nombran así, con palabras comunes y sin ninguna distancia, deseos singulares: los suyos y los nuestros (Aira 1988: 59)

Escritores de marca : Voces argentinas en el catálogo de Anagrama

El interés de la industria editorial española por la literatura hispanoamericana resurge a partir de los años noventa del siglo XX, al tiempo que se fomentan otras relaciones culturales y económicas de diverso tipo. Por un lado, los grandes grupos apuestan con riesgos mínimos y controlados; por otro, editoriales independientes tienen por objetivo descubrir nuevas voces con talento y calidad literaria. En el caso de Anagrama se ha abierto el catálogo a escritores como Bolaño, Aira, Pitol, Neuman o Pauls, pero también se ha creado una especie de redil anagramático, en palabras de Herralde, y así un grupo de escritores "de marca" disfruta del capital simbólico de la editorial, al tiempo que lo incrementa con el suyo propio gracias a su notable producción y su proyección internacional

Belleza y Felicidad en la vorágine del 2001 : Algunas percepciones contemporáneas sobre las condiciones de un arte político

Muy discutida en su momento, la producción de Belleza y Felicidad, y especialmente los debates que generó en torno suyo, permite iluminar retrospectivamente los conceptos y valoraciones subyacentes en las discusiones sobre arte y poesía de fines de los noventa y principios de la década del dos mil. Este artículo recorre, desde esta premisa, tres textos críticos publicados en el período por Martín Prieto y Daniel García Helder, César Aira y Mario Ortiz, en los que a propósito de la lectura crítica de Belleza y Felicidad, se ordenan ciertos modos posibles de la vinculación entre poesía y política.

Teatroxlaidentidad : La puesta en escena de narrativas sobre la (des)responsabilidad por el terrorismo de Estado y la violencia política en el marco de la memoria social sobre el pasado reciente

El presente artículo analiza cómo se representan las figuras y los discursos de los apropiadores y (ex) agentes de las fuerzas militares y policiales, y cómo se vinculan con ciertas retóricas de la (des)responsabilidad y de la (des)agencia de los perpetradores, colaboradores y cómplices del accionar del terrorismo de Estado y la violencia política en los textos dramáticos pertenecientes a cuatro obras del primer ciclo de Teatroxlaidentidad del año 2001: A propósito de la duda de Patricia Zangaro, Esclava del alma de Amancay Espíndola y Método de Silvia Aira

El efecto Duchamp

En una literatura en la que ha desaparecido el valor y los fantasmas perdieron consistencia, el lenguaje es un ready made de clichés. Algunas novelas actuales, sin embargo, han merecido el epíteto de verdaderas" (Jarkowski 2008) o "auténticas" (Lemus 2004). La magia ha regresado, y los narradores, aunque sus relatos sean inconclusos, indiferentes e incluso frívolos, interpelan al lector como los grandes realistas (Lukács 1971) porque el efecto de los textos es indicial. Señalan -con brutalidad o con delicia- el desfasaje entre lo que se dice y lo que se hace o lo que se deja de hacer. Nombran así, con palabras comunes y sin ninguna distancia, deseos singulares: los suyos y los nuestros (Aira 1988: 59)

Escritores de marca : Voces argentinas en el catálogo de Anagrama

El interés de la industria editorial española por la literatura hispanoamericana resurge a partir de los años noventa del siglo XX, al tiempo que se fomentan otras relaciones culturales y económicas de diverso tipo. Por un lado, los grandes grupos apuestan con riesgos mínimos y controlados; por otro, editoriales independientes tienen por objetivo descubrir nuevas voces con talento y calidad literaria. En el caso de Anagrama se ha abierto el catálogo a escritores como Bolaño, Aira, Pitol, Neuman o Pauls, pero también se ha creado una especie de redil anagramático, en palabras de Herralde, y así un grupo de escritores "de marca" disfruta del capital simbólico de la editorial, al tiempo que lo incrementa con el suyo propio gracias a su notable producción y su proyección internacional