Implementation of a pharmacist-delivered Medicare counseling service in a rural community health center.

OBJECTIVE: To describe a pharmacist-delivered Medicare counseling service in a rural community health center for providing patients and community members with information and resources to facilitate informed Medicare plan selection(s). SETTING: Federally-qualified health center. PRACTICE INNOVATION: Health center patients and community members met with a pharmacist for individual Medicare counseling. The appointments provided an opportunity to educate clients on Original Medicare and private plan options for supplemental medical and drug coverage, compare specific plans, and assess eligibility for financial assistance programs. EVALUATION: Data were collected from client contact forms completed for individuals counseled between July 1, 2015 and June 30, 2018. Data were then summarized with descriptive statistics and analyzed with Fisher exact tests. RESULTS: A total of 47 appointments were completed with 31 unique clients. They were mostly women (n = 18, 58.1%) and aged 65 years or more (n = 17; 54.8%) but evenly divided between patients established with the health center (n = 15; 48.4%) and community members (n = 16; 51.6%). During appointments, the most common topic was an explanation of medical or drug benefits (n = 40; 85.1%) followed by comparison of specific plans (n = 25; 53.2%) and then screening individuals for Original Medicare or private plan eligibility (n = 27; 57.4%). There were no statistically significant differences when comparing topics discussed for current versus new Medicare beneficiaries. During follow-up visits, patients were less likely to be screened for Original Medicare or private plan eligibility (74.2% vs. 25%; P = 0.002), financial assistance programs (77.4% vs. 37.5%; P = 0.011), or have specific plans compared (71.0% vs. 37.5%; P = 0.034). CONCLUSION: A pharmacist-provided Medicare counseling service in a rural community health center was used by both patients and community members. This may be an effective strategy to improve beneficiary understanding of Medicare benefits and enable the selection of better insurance plans in underserved populations. Further research is needed to assess individual-level outcomes and scalability to other settings.

Pax4 is not essential for beta-cell differentiation in zebrafish embryos but modulates alpha-cell generation by repressing arx gene expression.

BACKGROUND: Genetic studies in mouse have demonstrated the crucial function of PAX4 in pancreatic cell differentiation. This transcription factor specifies ß- and δ-cell fate at the expense of α-cell identity by repressing Arx gene expression and ectopic expression of PAX4 in α-cells is sufficient to convert them into ß-cells. Surprisingly, no Pax4 orthologous gene can be found in chicken and Xenopus tropicalis raising the question of the function of pax4 gene in lower vertebrates such as in fish. In the present study, we have analyzed the expression and the function of the orthologous pax4 gene in zebrafish. RESULTS: pax4 gene is transiently expressed in the pancreas of zebrafish embryos and is mostly restricted to endocrine precursors as well as to some differentiating δ- and ε-cells but was not detected in differentiating ß-cells. pax4 knock-down in zebrafish embryos caused a significant increase in α-cells number while having no apparent effect on ß- and δ-cell differentiation. This rise of α-cells is due to an up-regulation of the Arx transcription factor. Conversely, knock-down of arx caused to a complete loss of α-cells and a concomitant increase of pax4 expression but had no effect on the number of ß- and δ-cells. In addition to the mutual repression between Arx and Pax4, these two transcription factors negatively regulate the transcription of their own gene. Interestingly, disruption of pax4 RNA splicing or of arx RNA splicing by morpholinos targeting exon-intron junction sites caused a blockage of the altered transcripts in cell nuclei allowing an easy characterization of the arx- and pax4-deficient cells. Such analyses demonstrated that arx knock-down in zebrafish does not lead to a switch of cell fate, as reported in mouse, but rather blocks the cells in their differentiation process towards α-cells. CONCLUSIONS: In zebrafish, pax4 is not required for the generation of the first ß- and δ-cells deriving from the dorsal pancreatic bud, unlike its crucial role in the differentiation of these cell types in mouse. On the other hand, the mutual repression between Arx and Pax4 is observed in both mouse and zebrafish. These data suggests that the main original function of Pax4 during vertebrate evolution was to modulate the number of pancreatic α-cells and its role in ß-cells differentiation appeared later in vertebrate evolution.