[Key dental challenges during COVID-19 pandemic: oral health monitoring in patients with chronic oral mucosal diseases]. / Klyuchevye stomatologicheskie problemy perioda pandemii COVID-19: monitoring sostoyaniya stomatologicheskogo zdorov'ya u patsientov s khronicheskimi zabolevaniyami slizistoi obolochki polosti rta.

OBJECTIVE: To develop an effective system of an interactive dynamic telemonitoring of oral health in patients with oral lichen planus (LP) during the COVID-19 pandemic. MATERIAL AND METHODS: The observational longitudinal prospective cohort study (follow-up for 12 months) involved 53 patients (19 men and 34 women aged 49-65 years) with various forms of LP in persistent remission. During the entire observation period dentists carried out telemonitoring (through a Telegram group) of oral health of patients with LP registering the preservation/coming out from remission, as well as the causes of exacerbation of LP. RESULTS: The developed interactive monitoring system based on the use of available video feedback communication technologies (via Telegram, WhatsApp, Viber messengers) provided stable remission in 28.3% of patients with LP (mainly typical and hyperkeratotic forms) and effective relief of exacerbations (mainly erosive-ulcerative forms) associated with the new coronavirus infection COVID-19 in 35.8% of cases, exacerbation of concomitant systemic pathology (excluding COVID-19) in 16.9%, local traumatic risk factors in 15.1%, development of post-vaccination reactions in 3.9%. COVID-19-associated exacerbation of LP is a polymorphic symptom complex manifested by a change in classical clinical picture and heavier course of skin-mucosal dermatosis due to the addition of new, atypical for LP, manifested COVID-19-associated intraoral symptoms and generalization of skin lesions. Periods of exacerbation of LP in COVID-19 patients are significantly longer, with shorter remissions than in the prepandemic period. CONCLUSION: Interactive telemonitoring of oral health in patients with chronic oral mucosal diseases is a safe and effective tool for dispensary observation, management and maintenance of social communications during periods of social isolation.

[The content of vascular endothelial grow factor in saliva and serum in patients with periodontitis.]

To study the concentration of vasculoendothelial growth factor (VEGF) in mixed saliva and serum of patients in normal conditions and with generalized periodontitis. The main group (n = 42) was represented by patients with generalized periodontitis. The comparison group (n = 36) consisted of patients without periodontal tissue diseases. The concentration of VEFR was determined by the method of enzyme-linked immunosorbent assay (ELISA) using a commercial test-system "VEGF - IFA - BEST" (A-8784) ("Vector - Best", Russia). The median values VEFR in saliva were 5.49 times higher than the values for serum in the main group (p = 0.000000) and 7.01 times in the comparison group (p = 0.000000). The concentration of VEFR in the saliva of the examined main group exceeded the similar values of the comparison group (p = 0,014857); the median and interquartile range for the main group was 1098.45 (925.5; 1291) pg/ml, and for the comparison group 1360.5 (998.9; 2062) pg/ml. There were no differences in the serum VEFR concentration (p = 0.775124). No significant correlation was found between the serum VEFR content and the mixed saliva. The Spearman's rank correlation coefficient for the main group was R = 0,0184358, and for the comparison group, respectively, R = 0.188932. The source of VEFR in saliva are the glands and cells of the oral mucosa, and not the process of exudation from blood serum. The high content of VEFR in the saliva of healthy people and a decrease in its level during periodontitis indicates the important role of this protein in the processes of maintaining the normal state of periodontal tissues and reparation of tissues of the oral mucosa.

[The NT-proBNP in saliva and blood serum in norm and under periodontitis.]

The concentration of NT-proBNP in saliva and blood serum was studied. The study included 58 individuals divided in two groups. The main group (group I) included 34 patients with chronic generalized periodontitis. The control group (group II), comparable in age and gender, included 24 examined individuals without signs of inflammatory diseases of oral cavity. The concentration of NT-proBNP in saliva and blood serum was detected by technique of solid-phase enzyme immunoassay using the test-system "NT-proBNP-ELISABEST" (Vector-Best, Russia). The concentration of NT-proBNP in saliva of patients of main group reliably exceeded its concentration in saliva of the examined from control group. The median and interquartile range made up to correspondingly 178.5 (128-253) pg / ml in main group and 105 (72.5 - 144.5) pg, respectively / ml in control group (p = 0.02). The comparison of concentration of NT-proBNP in blood serum samples established no reliable differences (p = 0,27). The evaluation of the relationship between content of NT-proBNP in saliva and blood serum demonstrated absence of close linear correlation dependence between the concentration of this compound in blood serum and saliva both in the main group (R = 0.143, p = 0.419) and the control group (R = 0.178; p = 0.405), and for all the examined as well (R = 0.252, p = 0.056). The higher concentration of NT-proBNP in saliva in comparison with blood serum can be explained by formation of proteolysis products cross-reacting in the used system.

Impact of diagnosis-related groups' prospective payment on utilization of medical intensive care.

We examined the financial impact of diagnosis-related groups (DRGs) payment for Medicare patients receiving medical intensive care and looked for any change in the type of patients admitted to the medical intensive care unit (MICU) after one year's experience with DRGs. During 1984, payment for 267 Medicare patients receiving medical intensive care at a large, multispecialty referral hospital was calculated to be $2.6 million below cost, representing an average loss per discharge of $9,794. For those who died (42 percent), the average payment per case was $11,418 below the average per discharge cost. In 1985, 241 Medicare patients treated in the MICU showed an average loss per discharge of $14,113, which rose to $20,271 for those who expired (39.4 percent). There was no significant difference in mortality between the two groups and in type of patients per DRG assignment (p = 0.56 and p = 0.88, respectively) by Chi-squared test. Despite the 1984 DRG experience, there was no change in admission practices or utilization of MICU beds during 1985. Appropriate management responses are needed from both the Federal government and the medical profession for better utilization of MICU resources.

Management of ventilator dependency following heart surgery.

The foregoing discussion has reviewed the concept that postoperative ventilator dependency following heart surgery is due to a combination of risk factors, partly due to the nature of the patient population and partly to the process of patient care. Weaning from mechanical ventilation has been a controversial topic for decades, but the issue of rehabilitation before successful weaning has only recently achieved recognition. The fact that this process is often prolonged suggests that a certain logic must be used during the rehabilitation process. Appropriate minimization of risks with continued mechanical ventilation and concise protocols for gradually withdrawing support of mechanical ventilation may insure the quality of the patient care process. It should be understood by both the physician and patient that the ventilator for the patient population discussed previously acts merely as a "crutch" that will facilitate the process of rehabilitation.

Clinical measurement of extravascular lung water.

The thermal-dye technique for the measurement of ELW is available for clinical and experimental use. This method is safe and can be performed serially in an individual patient. Although it is invasive, it requires only a central venous catheter and an arterial catheter, which are often already in place for routine hemodynamic monitoring and management. The procedure is accurate under a variety of conditions. Two obstacles argue against its routine application. First, the reliability of this approach appears to be seriously compromised when there are areas of edematous lung with poor blood perfusion. This includes aspiration and perhaps other forms of acute lung injury. Second, it remains to be demonstrated how useful routine measurements of ETVL, even if accurate, are in clinical management. However, regardless of the accuracy of the various methods for determination of ELW, the process of their development has significantly enhanced our knowledge of pulmonary edema formation and fluid distribution. We are at a transition point of soon being able to determine ELW easily. Techniques of reducing ELW can now be assessed directly in patients with pulmonary edema. As these therapies are developed and understood, the demand for the measurement of ELW will become a greater part of clinical medicine, and may stimulate further refinement of methods for quantitating lung water.

Home care ventilation: the Cleveland Clinic experience from 1977 to 1985.

A need for long-term ventilation in the home has created a demand for home care services that has been a source of growth for an industry. Evaluation of the patient and family who will guarantee successful home care requires careful psychological and psychiatric evaluation. Beyond this evaluation, long-term success is possible if appropriate financial resources are available. The implementation of successful home care is best done by a team consisting of primary physician, primary ICU nurse, social worker, psychiatrist, and home care respiratory therapist. An appropriate classification of patients based on goals of care, as well as the study of the incidence and prevalence of associated disorders, will be helpful in the future allocation of resources.

Pulmonary mechanical ventilation at home: a reasonable and less expensive alternative.

The long-term care of ventilator-dependent patients often presents financial and moral burdens. During a 38-month period, January 1978 through February 1981, we provided home care for 10 ventilator-dependent patients, four of whom were completely ventilator-dependent, 24 hours a day, at the time of their discharge from the hospital. Four patients had amyotrophic lateral sclerosis, three had restrictive chest wall disease, and three had miscellaneous disorders (chronic polyneuropathy, multiple sclerosis, and alveolar hypoventilation). The length of their home care during our observation period ranged from 2 to 38 months. As our home care program evolved, our conception of home care ventilation expanded from its being a necessity for getting certain patients discharged from institutional care to its being an alternative to institutional care or death. A team approach by physician, psychiatrist, nurse, respiratory therapist, physical therapist, occupational therapist, and social worker facilitated home care. Home care proved to be less costly by far than institutional care; estimated savings during our observation period from the use of home care for these 10 patients was approximately $2.8 million. We learned that a long-term psychological evaluation process is vitally important to the success of a home care program. Further support for this type of health care by third-party payers and professional societies is necessary to establish criteria and standards for the provision of services and reimbursement for them.

Planning and management of long-standing tracheostomy.

Long-term effects of tracheostomy can include structural changes in the anterior tracheal wall and larynx as a result of pressure, friction, and deformation by the relationship between the curved cannula, the trachea, the larynx, and the upper border of the sternum. High-placed stoma, flexed cervical position, and short, obese necks are predisposing anatomic relationships. In some long-standing tracheostomies, progressive erosion of the upper anterior tracheal wall and cricoid arch is observed, often with secondary subglottic stenosis. No discussion of measures to prevent or correct these problems was found in a review of the literature. This article discusses surgical techniques to (1) prevent laryngotracheal erosion and (2) repair and reconstruct an airway that is already damaged. A superiorly based tracheostomy flap and a muscular sling are designed to buttress the tracheostomy. Results and follow-up are also reported.

Quality assessment in the medical intensive care unit: evolution of a data model.

Quality assessment and assurance in the intensive care unit require systematic monitoring and evaluation of patient care and its outcome. For analysis of these activities, data must be organized to reflect changes in such factors as patient types, ages, and lengths of stay. A model was developed to group data from the Cleveland Clinic Hospital medical intensive care unit into structural, process, and outcome categories. Development and application of the model are described.

Demographics of long-term ventilator-dependent patients outside the intensive care unit.

Continued management of clinically stable ventilator-dependent patients in the intensive care unit is controversial, given the expense and limitations of intensive care resources. A proposed alternative, which could reduce the cost of care, has been "noninvasive respiratory units." We review the management of 99 ventilator-dependent patients on routine nursing floors to define our case mix and the outcome of long-term care.

Management of hypoventilation in motor neuron disease presenting with respiratory insufficiency.

A 57-year-old man presented with a three-month history of somnolence, hypoventilation, cor pulmonale, and episodes of apnea during sleep. Neurological studies revealed motor neuron disease, mainly confined to the muscles of respiration, that was causing respiratory insufficiency in the supine position. Nighttime treatment of respiratory insufficiency has permitted independent activity during wakefulness.

Quality assessment in the medical intensive care unit. Continued evolution of a data model.

Quality assessment and assurance activities in the intensive care unit are complex processes that begin with the definition of the scope of services delivered in the unit with further identification of the important aspects of care. There is also a need to establish indicators of quality, gather data, and finally to organize the data into useful information. There are many approaches to these efforts ranging from establishment of indicators to data collection and analysis of patterns that lead to clarification of the indicators. We chose the latter pathway, specifically utilizing a previously described data model in which information was grouped according to structure, process, and outcome of patient care. In this paper, we focus on the application of the concept of patient days of service for quantification of the utilization of resources as an element of quality. Efficient utilization of resources cannot be effected until data on actual utilization are collected and analyzed.

Long-term management of respiratory failure in amyotrophic lateral sclerosis.

Present-day technology has made the in-home care of patients requiring prolonged mechanical ventilation increasingly common. When this technology is applied to the care of patients with amyotrophic lateral sclerosis, physiological, psychological, and ethical issues must be adequately addressed. Assessment of medical and social factors in six patients, four of whom are still living, indicates that in-hospital as well as follow-up evaluation should be carried out in an effort to anticipate the long-range problems, challenges, and limitations of home care ventilation. Because of increasing availability and simplicity of portable respiratory support devices, the implications of long-term ventilatory support for some patients with amyotrophic lateral sclerosis and similar illnesses will become more commonly considered in planning long-term home care.

Neuromuscular disease and hypoventilation.

Alveolar hypoventilation associated with neuromuscular disease can occur in acute and chronic forms. In the acute form, progressive weakness of respiratory muscles leads to rapid reduction in vital capacity followed by respiratory failure with hypoxemia and hypercarbia. Symptoms are those of acute respiratory failure, including dyspnea, tachypnea, and tachycardia. In the chronic form, impairment of the respiratory muscles affects mechanical properties of the lungs and chest wall, decreases the ability to clear secretions, and eventually may alter the function of the central respiratory centers. Symptoms include orthopnea, fatigue, disturbed sleep, and hypersomnolence. Treatment and outcome of the disease's chronic form are dependent on the underlying clinical cause of the alveolar hypoventilation. For chronic but stable diseases such as old polio, quadriplegia, or kyposcoliosis, mechanical support of minute ventilation can reverse symptoms. For chronic and progressive disease such as muscular dystrophy and amyotrophic lateral sclerosis, mechanical support of minute ventilation provides only symptomatic relief and is usually associated with deterioration to the point of complete ventilator dependency for survival. For the chronic progressive forms of alveolar hypoventilation, there is currently a need for quality randomized controlled clinical trials to define physiologic indicators and appropriate timing for mechanical support of minute ventilation.

Effect of pulmonary vascular engorgement on respiratory mechanics in the dog.

The immediate effects of pulmonary vascular engorgement (PVE) on lung and chest wall mechanics were studied in anesthetized, paralyzed dogs with the chest wall intact. A balloon-tipped catheter advanced retrograde into the left atrium was used to produce partial mitral valve obstruction and increases in pulmonary artery and left atrial preassures equal to 15 and 20 cm H2O, respectively. This increased pulmonary blood volume (PBV) by 50% and reduced dynamic lung ocmplicance 14%. With the airway occluded at different lung volumes, transient PVE produced a 6% decrease in compliance on the deflation limb of the pressure volume curve of the lung and a shift in the chest wall pressure-volume curve, which was consistent with an increase in chest wall volume equal to the increase in PBV. During apnea with the airway open, PVE reduced lung gas volume and increased chest wall recoil. We conclude that the changes in chest wall recoil associated with PVE are the result of an increase in total lung displacement volume.