Mycobacterial RNA polymerase requires a U-tract at intrinsic terminators and is aided by NusG at suboptimal terminators.

Intrinsic terminators, which encode GC-rich RNA hairpins followed immediately by a 7-to-9-nucleotide (nt) U-rich "U-tract," play principal roles of punctuating and regulating transcription in most bacteria. However, canonical intrinsic terminators with strong U-tracts are underrepresented in some bacterial lineages, notably mycobacteria, leading to proposals that their RNA polymerases stop at noncanonical intrinsic terminators encoding various RNA structures lacking U-tracts. We generated recombinant forms of mycobacterial RNA polymerase and its major elongation factors NusA and NusG to characterize mycobacterial intrinsic termination. Using in vitro transcription assays devoid of possible mycobacterial contaminants, we established that mycobacterial RNA polymerase terminates more efficiently than Escherichia coli RNA polymerase at canonical terminators with imperfect U-tracts but does not terminate at putative terminators lacking U-tracts even in the presence of mycobacterial NusA and NusG. However, mycobacterial NusG exhibits a novel termination-stimulating activity that may allow intrinsic terminators with suboptimal U-tracts to function efficiently. IMPORTANCE Bacteria rely on transcription termination to define and regulate units of gene expression. In most bacteria, precise termination and much regulation by attenuation are accomplished by intrinsic terminators that encode GC-rich hairpins and U-tracts necessary to disrupt stable transcription elongation complexes. Thus, the apparent dearth of canonical intrinsic terminators with recognizable U-tracts in mycobacteria is of significant interest both because noncanonical intrinsic terminators could reveal novel routes to destabilize transcription complexes and because accurate understanding of termination is crucial for strategies to combat mycobacterial diseases and for computational bioinformatics generally. Our finding that mycobacterial RNA polymerase requires U-tracts for intrinsic termination, which can be aided by NusG, will guide future study of mycobacterial transcription and aid improvement of predictive algorithms to annotate bacterial genome sequences.

Toward Continuous Primary Care in the United States: Differences in Patient Satisfaction Between First and Return Visits to Primary Care Physicians/Analysis of DrScore--The National e-Survey Data.

BACKGROUND: As stated by Donabedian, the father of quality assurance, satisfaction is an integral component of quality in medical care. Patient satisfaction is an important predictor of health-related behaviors, use of medical services, and health outcomes. Impressive literature exists in examining various aspects of patient satisfaction, however, no study thus far has examined differences in patient satisfaction between first and return visits to primary care physicians. OBJECTIVE: Our interest is to determine whether there are differences in patient satisfaction between first and return visits to primary care physicians, with the hypothesis that patients returning for their visits have a higher satisfaction level compared to their first initial visit. METHODS: The authors conducted a cross-sectional analysis of the national Web-based survey DrScore. Via DrScore, patients anonymously rated their physician on the basis of treatment satisfaction received from their most recent outpatient visit. The association between physician satisfaction and total care patient ratings of first and return visits was assessed via regression analysis. RESULTS: In total, 15,341 patients were included in this study. Our findings indicate that for a 1-unit change from first visit to return visits, the coefficient of patient satisfaction for the return visits is approximately 10 times higher compared to that of the first visit. Furthermore, the mean satisfaction score for the return visit group is higher than that for the first visit group, 80.28 versus 64.48, respectively (P < .05). CONCLUSION: Return visits to primary care physicians are associated with higher patient satisfaction compared to the first initial visit.

Enhancing the effectiveness of community stroke risk screening: a randomized controlled trial.

Stroke risk factors are routinely assessed in community screening programs; however, the rate of patient follow-up for health care once risk factors are identified is known to be low. This study was conducted to test the effectiveness of a brief behavioral telephonic intervention in an ongoing community stroke prevention screening program on health care seeking for stroke risk. A total of 227 participants with 2 or more stroke risk factors were randomly allocated to either an attention control arm or a behavioral intervention arm. The control group received standard information on risk and advice, whereas the intervention group received a brief Health Belief Model telephonic intervention designed to motivate care-seeking. The effect of treatment on the participants who completed a health care visit for stroke risk concerns was assessed using logistic regression. Cox survival analysis was used to compare time to physician visit between the 2 groups. Participants in the intervention arm were 1.85 times more likely to visit a primary care physician than controls. At 3 months, 69.2% of subjects in the intervention arm and 52.9% of those in the controls arm reported a new primary care visit after screening (P = .02), with 56.0% in the intervention arm and 38.4% in the control arm reporting a primary care visit specifically to discuss the stroke screening results (P < .01). Our data indicate that the brief, low-cost, motivational intervention effectively promoted adherence to screening advice and merits further testing.

Medicaid payment mechanisms: impact on medication adherence and health care service utilization in type 2 diabetes enrollees.

The purpose of this retrospective cohort study was to examine the impact of the type of health plan (capitated vs. fee for service [FFS]) on outcomes (medication adherence and health care service utilization) in type 2 diabetes Medicaid enrollees. Subjects were 8581 Medicaid enrollees with type 2 diabetes who newly started oral pharmacotherapy and were followed for 6 months before and 12 months after the index antidiabetic medication to collect data on medication adherence and health care service utilization. Multiple log-linear regression analysis was used to predict medication adherence while negative binomial regressions were used to examine health care service utilization. Medication adherence was found to be significantly lower for patients in capitated plans (5%, P < 0.05). Moreover, patients in capitated plans were associated with 14% more hospitalizations and 16% increased odds of emergency room visits, but 27% fewer outpatient visits compared to those in FFS plans (all P < 0.05). Although Medicaid programs use capitated managed care plans primarily as a cost-containment strategy, these plans may not be cost-effective for the long-term management of chronic conditions such as diabetes.

Psoriasis and its treatment with adalimumab.

IMPORTANCE OF THE FIELD: Psoriasis is an immune-mediated skin condition affecting 2 - 3% of world's population. It affects patients' health-related quality of life (HRQOL) and results in a significant financial burden. Adalimumab is the first fully human monoclonal antibody approved in the US and European countries for the treatment of psoriasis along with other immunomediated diseases. AREAS COVERED IN THIS REVIEW: We evaluate outcomes such as efficacy, safety, and quality of life associated with adalimumab in the treatment of psoriasis via a review of the published literature from the past 10 years. WHAT THE READER WILL GAIN: This review presents the effects, causes, types and treatment options for psoriasis with a focus on adalimumab with the goal of providing evidence-based guidance in choosing the appropriate therapy for the treatment of psoriasis. TAKE HOME MESSAGE: Adalimumab treatment in two forms 40 mg/every other week and 40 mg/week was reported to be effective and safe compared with placebo and methotrexate. Adalimumab significantly improved patients' HRQOL but some adverse events were reported, therefore vigilance is needed when using adalimumab. As the landscape of psoriasis treatments continues to evolve, adalimumab provides a highly effective and relatively safe treatment option for psoriasis patients.

Outcomes associated with pharmacologic treatments in Parkinson's disease: a review of recent literature.

Parkinson's disease (PD) affects nearly 1 million Americans with a mean onset age of 60 years. Its progressive, neurodegenerative nature, causing motor complications and affecting mood, has a considerable impact on a patient's health-related quality of life. Pharmacologic therapies are the most widely utilized treatment. The broad range of drugs for treating PD warrants an assessment of each medication's health-related outcomes, which includes consideration of clinical, economic and patient-centered outcomes. This review seeks to explore the outcomes associated with drugs frequently appearing in the literature of the past 5 years and to comment on the direction of pharmacologic research and management of PD pharmacotherapy in the future.