Health policy analysis on barriers and facilitators for better oral health in German care homes: a qualitative study

OBJECTIVES

To assess possible health policy interventions derived from the theoretical domains framework (TDF) by studying barriers and facilitators on the delivery of oral healthcare and oral hygiene in German care homes using a behavioural change framework.

DESIGN

Qualitative correlational study to evaluate a national intervention programme.

SETTING

Primary healthcare in two care homes in rural Germany.

PARTICIPANTS

Eleven stakeholders participating in the delivery of oral healthcare (hygiene, treatment) to older people, including two care home managers, four section managers, two nurses/carers and three dentists.

INTERVENTIONS

Semistructured interviews conducted in person in the care homes or by phone. A questionnaire developed along the domains of the TDF and the Capabilities, Opportunities and Motivations influencing Behaviours model was used to guide the interviews. Interviews were transcribed and systematised using Mayring's content analysis along the TDF.

RESULTS

860 statements were collected. We identified 19 barriers, facilitators and conflicting themes related to capabilities, 34 to opportunities and 24 to motivation. The lack of access to professional dental care was confirmed by all stakeholders as a major limitation hampering better oral health.

PRIMARY OUTCOME

A range of interventions can be discussed with the methodology we utilised. In our interviews, lack of dentists willing to treat patients at these facilities was the most discussed barrier for improving oral health of nursing home residents.

SECONDARY OUTCOMES

Dentists highlighted the need for better incentives and facilities to deliver oral healthcare in these institutions. Differences with urban settings regarding access to healthcare were frequently discussed by our study participants.

CONCLUSIONS

Within our sample, greater capacitation of care home staff, better financial incentives for dentists and increased cooperation between the two stakeholders should be considered when designing interventions to tackle oral health of care home residents in Germany.

Beitrag zum Problem der „Blutgerinnung bei Schnecken“

Um eine Wunde in der Körperwand von Aplysia zu schließen, genügt die Muskelkontraktion nicht; es muß vielmehr ein die feinsten Spaltöffnungen verstopfender Mechanismus hinzukommen. Bei Störung dieses Mechanismus durch beträchtliche Veränderung des inneren Milieus verblutet Aplysia bei kontrahierter Muskulatur. Trotz seiner niedrigen Viskosität (Abb. 1) und sonstigen Ähnlichkeit mit Meerwasser (Tab. 1) hat das Blut in seinem äußerst geringen Gehalt an amöboiden Zellen und freiem Eiweiß sehr wirksame Verstopfungsmittel, die in Filterversuchen eingehender untersucht werden. Die Auslösung dieses Mechanismus, der in seiner biologischen Bedeutung an die Blutgerinnung der Wirbeltiere erinnert, wird diskutiert und die Beteiligung sehr großer Hämocyanin- oder ähnlicher Eiweiß-Moleküle vermutet.

Über nervenphysiologische Resonanz im Acusticus-System des Wellensittichs (Melopsittacus undulatus Shaw)

Mittels Mikroelektroden wird die Tätigkeit einzelner Zellen und Fasern von Hörnerv und Medulla des Wellensittichs bei akustischer Reizung untersucht. Klick-Signale rufen rhythmische Entladungen hervor, deren Periode der Tonfrequenz entspricht, die für das gleiche nervöse Element die größte Reizwirksamkeit aufweist. Der zugrundeliegende Mechanismus wird als „physiologische Resonanz“ bezeichnet; er ist in den Zellen des I. akustischen Ganglions zu lokalisieren. Es wird vermutet, daß es sich um ein allgemeines Mittel der Klanganalyse bei niederen Wirbeltieren handelt.

[HLA matching in keratoplasty: lessons learned from lamellar techniques]

BACKGROUND

The immunological mechanisms of graft rejections after penetrating keratoplasty are largely investigated in rodent models. Here, antigens are predominantly processed by host antigen presenting cells (APCs). For this reason, graft rejections are not primarily triggered by mismatches in the major histocompatibility complex (MHC). Consequently, MHC matching (equivalent of HLA matching) does not robustly prevent immunological graft rejections in mice. This, however, may not apply to humans because anatomy and the clinical picture of immune reactions differ vastly.

METHODS

Immunological experiments are not feasible in humans for ethical reasons. However, the recent surgical modifications in keratoplasty inadvertently gave rise to several interesting immunological field experiments. We herein discuss the potential insight into human graft rejections from selected clinical observations. On this basis, we have evaluated HLA matching for keratoplasty techniques.

RESULTS

Several clinical observations hint towards an active role of donor-derived APCs in graft rejections after human keratoplasty. Additionally, donor-specific anti-HLA antibodies may play a significant role. On this basis we suggest that HLA matching is potentially beneficial in human keratoplasty in contrast to the situation in mice.

CONCLUSIONS

Graft rejections are rarely observed after Descemet membrane keratoplasty (DMEK). For this reason, we do not recommend HLA matching here. The same is true for deep anterior lamellar keratoplasty, where graft rejections can usually be treated well. However, HLA matching is a viable option in penetrating keratoplasty. This is especially true for high-risk eyes.

Regeneration of corneal endothelium following complete endothelial cell loss in rat keratoplasty

PURPOSE

Corneal endothelial cells (EC) are crucial for maintaining corneal clarity before and after keratoplasty. Since it is thought that corneal graft rejection leads to irreversible EC loss and transplant failure, we quantified immune mediated EC loss in the rat keratoplasty model and analyzed whether the EC layer would then regenerate.

METHODS

Rats were subjected to orthotopic penetrating keratoplasty. We compared endothelial responses to immunological EC loss following allogeneic transplantations between Fisher and Lewis rats (group R) to those following mechanical EC removal in a syngeneic setting between Lewis rats (group S). Animals were followed clinically for corneal opacity for up to one year. Bulbi were excised and prepared for histological examination at different time points: ECs were defined and characterized using Alicarin red S/ DAPI staining on corneal flatmounts. Ki-67/ DAPI staining on flatmount preparations served to detect cell proliferation. Immunohistochemical staining of corneal cryosections was used to characterize infiltrating immune cells.

RESULTS

GROUP R: After about two weeks the allografts were completely opaque, which was accompanied by a massive leukocyte infiltration in conjunction with EC destruction, signifying rejection. EC loss without an immune reaction (group S) resulted only in medium opacity levels. In both groups, all grafts regained clarity in the following weeks to months, and a newly-formed endothelial cell layer with irregular and enlarged ECs became apparent on the formerly EC free grafts. Scattered Ki-67 positive cells within the endothelial cell layer were observed during re-endothelialization. In addition to re-endothelialization, the immunological infiltration seen in the allografts at the time of rejection had subsided after one year.

CONCLUSIONS

Re-endothelialization following keratoplasty takes place in the rat in vivo and restores graft clarity, following both immunological or surgical destruction of ECs. Following rejection, EC replacement is accompanied by a reduction of immune infiltrates. Peripheral recipient ECs are a sufficient source for graft re-endothelialization, as seen in rats following EC removal. Our results suggest that ECs both proliferate and enlarge during re-endothelialization in the rat keratoplasty model.

[Penetrating keratoplasty with intrastromal corneal ring. A prospective randomized study]

BACKGROUND

The purpose of the study was to evaluate the efficacy and safety of Krumeichs' intrastromal corneal ring following penetrating keratoplasty. Postoperative astigmatism and occurrence of complications were the main criteria of this study.

MATERIAL AND METHODS

A total of 20 patients were included in this prospectively randomized study (10 patients with and 10 patients without corneal ring). Follow-up examinations were performed 6 weeks, 4, 12, and 18 months postoperatively, including best corrected visual acuity and Orbscan corneal topography.

RESULTS

The mean follow-up time is currently 18.9+/-2.8 months. The mean astigmatism (Orbscan) is 3.9 D in the group with ring and 4.0 D in the group without a ring. Spontaneous suture rupture occurred in five patients with corneal ring.

CONCLUSIONS

The use of the intrastromal corneal ring following penetrating keratoplasty caused no reduction of postoperative astigmatism. The reason for the spontaneous suture ruptures is unclear.

[Basiliximab following penetrating risk-keratoplasty--a prospective randomized pilot study]

BACKGROUND

Until now cyclosporin A (CSA) and mycophenolate mofetil (MMF) are the only available systemic immunosuppressants for patients undergoing risk keratoplasty. Basiliximab is a chimeric monoclonal interleukin 2-receptor antibody, which inhibits T-cell proliferation. Basiliximab is approved for the treatment in patients after kidney transplantation. The aim of this study was to prove the efficacy and safety of Basiliximab after penetrating risk keratoplasty.

PATIENTS AND METHODS

20 patients undergoing risk keratoplasty received as postoperative medication fluocortolon 1 mg/kg/d (tapered off within three weeks) and prednisolone acetate eye-drops 5x/d (tapered off within five months). In addition, 10 patients received 20 mg basiliximab immediately following surgery and four days postoperatively. 10 patients in the control group received oral CSA adapted to the blood-trough level (120-150 ng/mL) for six months.

RESULTS

After a mean follow-up time of 477 +/- 263 days 4 patients of the basiliximab group showed corneal immune reactions (2 irreversible), while no side effects were observed. In the CSA group 2 immune reactions occurred (1 irreversible). In 2 CSA-treated patients the CSA administration had to be stopped due to side effects.

CONCLUSIONS

Basiliximab has a lower efficacy in preventing immune reactions after risk keratoplasty than CSA. However, the side effect profile of basiliximab is more favourable than that of CSA.

The new malononitrilamide immunosuppressant FK778 prolongs corneal allograft survival in the rat keratoplasty model

PURPOSE

Aim of this study was to prove the efficacy and safety of the new malononitrilamide immunosuppressive FK778 in prolonging clear graft survival following allogeneic orthotopic keratoplasty in rats.

METHODS

Sixty-seven penetrating keratoplasties were performed using Fisher and Lewis rats as donors and recipients, respectively: group 1 (n=11), allogeneic control without therapy; group 2 (n=12), syngeneic control; group 3 (n=11), mycophenolate mofetil (MMF) 40 mg/kg bodyweight; group 4 (n=12), FK778 5 mg/kg bodyweight; group 5 (n=12), FK778 10 mg/kg bodyweight; and group 6 (n=9), FK778 20 mg/kg bodyweight. Four animals in each group were killed for immunohistological evaluation on day 14. Therapy was administered orally for 18 days. The grafts were evaluated every three days by means of a scoring system including opacity, oedema, and vascularization. Time to rejection was analysed with the Kaplan-Meier survival analysis and compared with the log-rank test. The densities of infiltrating immune cells were compared statistically using the non-parametric Mann-Whitney test.

RESULTS

Mean rejection-free graft survival was 11.4 days in group 1 (allogeneic control), 100 days (total follow-up time) in group 2 (syngeneic control), 24.0 days in group 3 (MMF 40 mg/kg), 15.7 days in group 4 (FK778 5 mg/kg), 19.1 days in group 5 (FK778 10 mg/kg), and 25.4 days in group 6 (FK778 20 mg/kg) (P<0.005).

CONCLUSIONS

Systemic immunosuppression with FK778 prolongs graft survival in the rat keratoplasty model. FK778's efficacy is comparable with that of MMF in preventing immunologic graft rejection.