A pilot study of changes in physician prescribing practices after Rural Mutual Health Care implementation in China

In 2002, the Chinese government renewed commitment to rural health. One experimental insurance program, Rural Mutual Health Care (RMHC), provides affordable coverage for rural residents where a previous insurance system, Cooperative Medical System (CMS), was poorly functioning. This study examined how RMHC affected physician prescribing in Fengshan Township, Guizhou Province, China. Six village doctors were chosen for study based on prior reviews showing high, average, or low rates of prescribing errors. 858 prescriptions with the single diagnosis of common cold were systematic sampled from insured and uninsured patient visits in March-May 2003 (under CMS) and 2004 (under RMHC). Peer physicians reviewed prescriptions for inappropriate prescribing. X2, Fishers exact, and two-tailed t-tests were used to explore demographic and prescription characteristics. Multiple linear and logistic regressions were used to model outcomes of: number of medications, cost, injection use, and inappropriate prescribing with covariates of: patient age and gender, prescribing doctor, year, insurance, and year-insurance interaction. Results show mean cost decreased from 13.09 yuan in 2003 to 7.22 yuan in 2004 (p\u3c0.001). Cost increased from 7.12 yuan for the uninsured to 11.19 yuan for the insured (p\u3c0.001). After adjusting for other covariates, RMHC had lower drug costs and fewer medications as compared to CMS (respectively, p=0.025 and p=0.001), but RMHC had no significant effect on injection use or inappropriate prescribing (respectively, p=0.641 and p=0.912). In conclusion, this study shows RMHC successfully controls medication costs, but likely has little effect on quality of care. A larger, more rigorous study is needed to assess RMHCs impact on quality of care

Receptor tyrosine phosphatase–dependent cytoskeletal remodeling by the hedgehog-responsive gene MIM/BEG4

During development, dynamic remodeling of the actin cytoskeleton allows the precise placement and morphology of tissues. Morphogens such as Sonic hedgehog (Shh) and local cues such as receptor protein tyrosine phosphatases (RPTPs) mediate this process, but how they regulate the cytoskeleton is poorly understood. We previously identified Basal cell carcinoma–enriched gene 4 (BEG4)/Missing in Metastasis (MIM), a Shh-inducible, Wiskott-Aldrich homology 2 domain–containing protein that potentiates Gli transcription (Callahan, C.A., T. Ofstad, L. Horng, J.K. Wang, H.H. Zhen, P.A. Coulombe, and A.E. Oro. 2004. Genes Dev. 18:2724–2729). Here, we show that endogenous MIM is induced in a patched1-dependent manner and regulates the actin cytoskeleton. MIM functions by bundling F-actin, a process that requires self-association but is independent of G-actin binding. Cytoskeletal remodeling requires an activation domain distinct from sequences required for bundling in vitro. This domain associates with RPTPδ and, in turn, enhances RPTPδ membrane localization. MIM-dependent cytoskeletal changes can be inhibited using a soluble RPTPδ-D2 domain. Our data suggest that the hedgehog-responsive gene MIM cooperates with RPTP to induce cytoskeletal changes

Environmental surveillance as a tool for identifying high-risk settings for typhoid transmission

Enteric fever remains a major cause of morbidity in developing countries with poor sanitation conditions that enable fecal contamination of water distribution systems. Historical evidence has shown that contamination of water systems used for household consumption or agriculture are key transmission routes for Salmonella Typhi and Salmonella Paratyphi A. The World Health Organization now recommends that typhoid conjugate vaccines (TCV) be used in settings with high typhoid incidence; consequently, governments face a challenge regarding how to prioritize typhoid against other emerging diseases. A key issue is the lack of typhoid burden data in many low- and middle-income countries where TCV could be deployed. Here we present an argument for utilizing environmental sampling for the surveillance of enteric fever organisms to provide data on community-level typhoid risk. Such an approach could complement traditional blood culture-based surveillance or even replace it in settings where population-based clinical surveillance is not feasible. We review historical studies characterizing the transmission of enteric fever organisms through sewage and water, discuss recent advances in the molecular detection of typhoidal Salmonella in the environment, and outline challenges and knowledge gaps that need to be addressed to establish environmental sampling as a tool for generating actionable data that can inform public health responses to enteric fever

MIM/BEG4, a Sonic hedgehog-responsive gene that potentiates Gli-dependent transcription

Sonic hedgehog (Shh) signaling plays a critical role during development and carcinogenesis. While Gli family members govern the transcriptional output of Shh signaling, little is known how Gli-mediated transcriptional activity is regulated. Here we identify the actin-binding protein Missing in Metastasis (MIM) as a new Shh-responsive gene. Together, Gli1 and MIM recapitulate Shh-mediated epidermal proliferation and invasion in regenerated human skin. MIM is part of a Gli/Suppressor of Fused complex and potentiates Gli-dependent transcription using domains distinct from those used for monomeric actin binding. These data define MIM as both a Shh-responsive gene and a new member of the pathway that modulates Gli responses during growth and tumorigenesis

Feasibility and acceptability of a novel intervention to improve hand hygiene behavior in rural Liberian health facilities

Hand hygiene is central to the prevention of healthcare-associated infection. In low-income settings, barriers to health worker hand hygiene may include inconsistent availability of hand hygiene supplies at the point of care. However, there is a lack of knowledge of interventions to improve and sustain health worker hand hygiene in these settings. This pilot study evaluates acceptability and feasibility of a personally-worn hand hygiene holster device for improving point-of-care access to alcohol-based handrub (ABHR). Holsters were distributed to clinical staff at a hospital in Liberia in July–September 2021. Data collection included 2,066 structured observations of hand hygiene behavior, six spot checks of supply availability, and focus group discussions with 13 clinical staff. The Integrated Behavioral Model for Water, Sanitation, and Hygiene (IBM-WASH) provided a framework for study design and qualitative analysis. Acceptability of the intervention was high, with users reporting that holsters were comfortable, easy to use, and aligned with their professional identities. Feasibility depended on consistent ABHR availability, which may diminish sustainability of this intervention. The hand hygiene holster is a promising tool for improving health worker hand hygiene behavior, but solutions to ABHR supply chain and distribution constraints are necessary to support sustainability of this intervention. HIGHLIGHTS This pilot study evaluated the feasibility and acceptability of a hand hygiene holster device to improve access to point-of-care hand hygiene in Liberian health facilities.; Users reported satisfaction with holsters and many felt that this intervention made hand hygiene more accessible during patient care.; Further research should explore the impact of the holster intervention on health worker hand hygiene behavior.

Barriers and Opportunities for Sustainable Hand Hygiene Interventions in Rural Liberian Hospitals

Hand hygiene is central to hospital infection control. During the 2014–2016 West Africa Ebola virus disease epidemic in Liberia, gaps in hand hygiene infrastructure and health worker training contributed to hospital-based Ebola transmission. Hand hygiene interventions were undertaken post-Ebola, but many improvements were not sustainable. This study characterizes barriers to, and facilitators of, hand hygiene in rural Liberian hospitals and evaluates readiness for sustainable, locally derived interventions to improve hand hygiene. Research enumerators collected data at all hospitals in Bong and Lofa counties, Liberia, in the period March–May 2020. Enumerators performed standardized spot checks of hand hygiene infrastructure and supplies, structured observations of hand hygiene behavior, and semi-structured key informant interviews for thematic analysis. During spot checks, hospital staff reported that handwashing container water was always available in 89% (n = 42) of hospital wards, piped running water in 23% (n = 11), and soap in 62% (n = 29). Enumerators observed 5% of wall-mounted hand sanitizer dispensers (n = 8) and 95% of pocket-size dispensers (n = 53) to be working. In interviews, hospital staff described willingness to purchase personal hand sanitizer dispensers when hospital-provided supplies were unavailable. Low-cost, sustainable interventions should address supply and infrastructure-related obstacles to hospital hand hygiene improvement