Structure and biosynthesis of a pyruvate -dependent enzyme---phosphatidylserine decarboxylase from {\it Escherichia coli\/}

Phosphatidylserine decarboxylase of E. coli, a cytoplasmic membrane protein, catalyzes the formation of phosphatidylethanolamine, the principal phospholipid of the organism. The activity of the enzyme is dependent on a covalently bound pyruvate (Satre and Kennedy (1978) J. Biol. Chem. 253, 479-483). This study shows that the enzyme consists of two nonidentical subunits, $\alpha$ (Mr = 7,332) and $\beta$ (Mr = 28,579), with the pyruvate prosthetic group in amide linkage to the amino-terminus of the $\alpha$ subunit. Partial protein sequence and DNA sequence analysis reveal that the two subunits are derived from a proenzyme ($\pi$ subunit, Mr = 35,893) through a post-translational event. During the conversion of the proenzyme to the $\alpha$ and $\beta$ subunits, the peptide bond between Gly253-Ser254 is cleaved, and Ser254 is converted to the pyruvate prosthetic group at the amino-terminus of the $\alpha$ subunit (Li and Dowhan (1988) J. Biol. Chem. 263, 11516-11522).^ The proenzyme cannot be detected in cells carrying either single or multiple copies of the gene (psd), but can be observed in a T7 RNA polymerase/promoter and transcription-translation system. The cleavage of the wild-type proenzyme occurs rapidly with a half-time on the order of 2 min. Changing of the Ser254 to cysteine (S254C) or threonine (S254T) slows the cleavage rate dramatically and results in mutants with a half-time for processing of around 2-4 h. Change of the Ser254 to alanine (S254A) blocks the cleavage of the proenzyme. The reduced processing rate with the mutations of the proenzyme is consistent with less of the functional enzyme being made. Mutants S254C and S254T produce $\sim$15% and $\sim$1%, respectively, of the activity of the wild-type allele, but can still complement a temperature-sensitive mutant of the psd locus. Neither detectable activity nor complementation is observed by mutant S254A. These results are consistent with the hydroxyl-group of the Ser254 playing a critical role in the cleavage of the peptide bond Gly253-Ser254 of the pro-phosphatidylserine decarboxylase, and support the mechanism proposed by Snell and co-workers (Recsei and Snell (1984) Annu. Rev. Biochem. 53, 357-387) for the formation of the prosthetic group of pyruvate-dependent decarboxylases. ^

Physician coding for mental illness reimbursement and the need for mental health parity

Many patients with anxiety and depression initially seek treatment from their primary care physicians. Changes in insurance coverage and current mental parity laws, make reimbursement for services a problem. This has led to a coding dilemma for physicians seeking payment for their services. This study seeks to determine first the frequency at which primary care physicians use alternative coding, and secondly, if physicians would change their coding practices, provided reimbursement was assured through changes in mental parity laws. A mail survey was sent to 260 randomly selected primary care physicians, who are family practice, internal medicine, and general practice physicians, and members of the Harris County Medical Society. The survey evaluated the physicians' demographics, the number of patients with psychiatric disorders seen by primary care physicians, the frequency with which physicians used alternative coding, and if mental parity laws changed, the rate at which physicians would use a psychiatric illness diagnosis as the primary diagnostic code. The overall response rate was 23%. Only 47 of the 59 physicians, who responded, qualified for the study and of those 45% used a psychiatric disorder to diagnose patients with a primary psychiatric disorder, 47% used a somatic/symptom disorder, and 8% used a medical diagnosis. From the physicians who would not use a psychiatric diagnosis as a primary ICD-9 code, 88% were afraid of not being reimbursed and 12% were worried about stigma or jeopardizing insurability. If payment were assured using a psychiatric diagnostic code, 81% physicians would use a psychiatric diagnosis as the primary diagnostic code. However, 19% would use an alternative diagnostic code in fear of stigmatizing and/or jeopardizing patients' insurability. Although the sample size of the study design was adequate, our survey did not have an ideal response rate, and no significant correlation was observed. However, it is evident that reimbursement for mental illness continues to be a problem for primary care physicians. The reformation of mental parity laws is necessary to ensure that patients receive mental health services and that primary care physicians are reimbursed. Despite the possibility of improved mental parity legislation, some physicians are still hesitant to assign patients with a mental illness diagnosis, due to the associated stigma, which still plays a role in today's society. ^

HOUSE-TO-HOUSE SURVEY OF ACCESS TO AND USE OF PUBLIC HEALTH FACILITIES IN METROPOLITAN LAGOS, NIGERIA

One of the broad objectives of the Nigerian health service, vigorously being pursued at all levels of government, is to make comprehensive health care available and accessible to the population at the lowest possible cost, within available resources. Some state governments in the federation have already introduced free medical service as a practical way to remove financial barriers to access and in turn to encourage greater utilization of publicly funded care facilities.^ To aid health planners and decision makers in identifying a shorter corridor through which urban dwellers can gain access to comprehensive health care, a health interview survey of the metropolitan Lagos was undertaken. The primary purpose was to ascertain the magnitude of access problems which urban households face in seeking care from existing public facilities at the time of need. Six categories of illness chosen from the 1975 edition of the International Classification of Disease were used as indicators of health need.^ Choice of treatment facilities in response to illness episode was examined in relation to distance, travel time, time of use and transportation experiences. These were graphically described. The overall picture indicated that distance and travel time coexist with transportation problems in preventing a significant segment of those in need of health care from benefitting in the free medical service offered in public health facilities. Within this milieu, traditional medicine and its practitioners became the most preferred alternative. Recommendations were offered for action with regard to decentralization of general practitioner (GP) consultations in general hospitals and integration of traditional medicine and its practitioners into public health service. ^