Mesh herniorrhaphy during elective colorectal surgery.

The management of large ventral hernias in patients undergoing elective colorectal surgery is controversial considering the reluctance to use a mesh during a clean-contaminated case. We retrospectively reviewed the charts of all patients having undergone at our institution any colorectal surgery along with ventral hernia repair with mesh as identified by the ICD-9 codes between 1997 and 2003. Three patients underwent incisional mesh herniorrhaphy along with elective colorectal surgery, including a right hemicolectomy, a colostomy closure, and a diverting colostomy. Hernia size varied between 330 and 1,243 cm(2). All hernias were repaired using polypropylene mesh in an onlay fashion. Average operative time was 199 min. Two patients developed postoperative wound infection, one of them requiring incision and drainage of a part of the wound. One patient developed skin necrosis of the lower aspect of his incision requiring skin excision and open wound. All open wounds granulated well and healed by secondary intention despite presence of exposed mesh. Therefore prosthetic ventral hernia repair using polypropylene mesh can be performed concomitant to elective colorectal operations, thus avoiding another laparotomy. The incidence of wound complications is, however, high but does not usually require mesh excision.

Improving the pneumococcal immunization rate for patients with diabetes in a managed care population: a simple intervention with a rapid effect.

BACKGROUND: Pneumococcal disease kills more people in the United States than any other vaccine-preventable bacterial disease, and a national health objective for the year 2000 is that at least 60% of eligible persons be immunized with pneumococcal vaccine. METHODS: An electronic care monitoring system was used to track immunization of patients with diabetes in a managed care plan who were receiving their care through a staff-model primary care clinic in Guam. In November 1998 a letter was sent to all patients not known to be immunized. The letter invited these patients to attend immunization clinics and waived usual copayment. Standing orders were also created for the clinic nurses to administer pneumococcal vaccines. In addition, a diabetes care status report was placed on each patient's medical record. RESULTS: The immunization rate for the 1,278 actively enrolled patients with diagnosed diabetes increased from 42% in October 1998 to 62% in January 1999. Compared to November 1995, 1996, and 1997, the number of pneumococcal immunizations increased more than 15-fold in November 1998. DISCUSSION: The combined use of patient outreach letters, special immunization clinics, standing orders, and practitioner reminders on medical records resulted in a rapid, marked increase in the pneumococcal immunization rate for patients with diabetes. The electronic care monitoring system is being used to target get interventions for improvement opportunities for an array of diabetes care measures, including regular foot care and eye exams.

Hybrid (BDBB) interferon-alpha: preformulation studies.

A number of techniques, including RP-HPLC, HP-SEC and SDS-PAGE have been used in the delineation of degradative mechanisms of recombinant hybrid (BDBB) interferon-alpha (IFN-alpha) in the solution phase. Different degradation profiles are found according to medium pH. At pH 4.0 the major routes of degradation are via chemical transformation of the monomeric protein to a species which retains antiviral activity, and by self-proteolytic hydrolysis. At pH 7.6, methionine-oxidation is the major chemical degradative process. Protein aggregation is also a significant route of degradation at the higher pH. The results have assisted in a targeted preformulation screen of potentially stabilising excipients and possible parenteral solution dosage forms have been identified. Preliminary 'real-time' storage data confirm excellent chemical and physical stability of IFN-alpha in vehicles formulated at pH 7.6 or, especially, pH 4.0 under the proposed shelf conditions.

Synthesis, processing, and secretion of the Marek's disease herpesvirus A antigen glycoprotein.

The 57,000- to 65,000-dalton (Da) Marek's disease herpesvirus A (MDHV-A) antigen glycoprotein (gp57-65) has a 47,000-Da unglycosylated precursor polypeptide (pr47), as determined by immunological detection after cell-free translation of infected-cell mRNA. Cleavage of its signal peptide yielded a 44,000-Da precursor polypeptide molecule (pr44), detected both in vivo after tunicamycin inhibition of glycosylation and in vitro after dog pancreas microsome processing of pr47. High-resolution pulse-chase studies showed that pr44 was quickly glycosylated (within 1 min) to nearly full size, a rapid processing time consistent with a cotranslational mode of glycosylation. This major glycosylation intermediate was further modified 6 to 30 min postsynthesis (including the addition of sialic acid), and mature MDHV-A was secreted 30 to 120 min postsynthesis. Limited apparent secretion of pr44 occurred only in the first minute postsynthesis, in contrast to the later secretion of most of the MDHV-A polypeptide as the fully glycosylated form described above. In addition, in the presence of tunicamycin a small fraction of the newly synthesized MDHV-A protein appeared as a secreted, partially glycosylated, heterogeneously sized precursor larger than pr44. pr44 constituted the major fraction of the new MDHV-A made in the presence of the inhibitor but the precursor was smaller than mature MDHV-A. These data indicate that there is a minor glycosylation pathway not sensitive to tunicamycin and that "normal" glycosylation is not necessary for secretion. Collectively, the data demonstrate that the rapid release of most of the fully glycosylated form of MHDV-A from the cell shortly after synthesis is true secretion in a well-regulated and precisely programmed way and not the result of cell death and disruption.