Meckel's diverticulum containing enterolith mimicking acute appendicitis.

INTRODUCTION: Meckel's diverticulum is a vestige of the vitello-intestinal duct. It is one of the most common congenital abnormality of the GI tract. CASE PRESENTATION: We present a case of a male patient who presented with pain in the peri-umbilical region and in right iliac fossa. A clinical diagnosis of acute appendicitis was made, but, interestingly it turned out to be a Meckel's diverticulum having enterolith intraoperatively. The patient underwent wedge resection and the post-operative course was uneventful. CONCLUSION: Meckel's diverticulum containing enterolith is rare. This can mimick as acute appendicitis and the surgeon needs to be wary of this.

T-Cell Response in a Cardiac Xenotransplant Model.

OBJECTIVES: Despite the advances in preclinical cardiac xenotransplantation, the immune reactions caused by species differences are not fully understood. Hyperacute rejection can now be avoided using genetically engineered donor organs, but cellmediated rejection by the adaptive immune response has not been addressed successfully. Here we investigated the initial human pan-T-cell reaction using a pig-human blood working heart model. MATERIALS AND METHODS: Porcine wild-type hearts (n = 7) were perfused with human blood in a biventricular working heart system for 3 hours. As control, blood from the same human donors was circulated without a pig heart. Pan-T cells were selectively extracted from blood taken before and at the end of the perfusion cycle. The relative mRNA expression of selected target genes (real-time quantitative polymerase chain reaction) and the expression of microRNAs were determined. RESULTS: After xenogeneic organ perfusion, there was a moderate upregulation of several CD4+ marker cytokines (interleukin 2, interleukin 4, interferon γ) compared with control. We found a distinct increase in the mRNA expression of granzyme B and perforin, key markers of cytotoxic T cells. No differences in the marker genes of regulatory T cells were evident. Levels of the anti-inflammatory microRNAs miR-16 and miR-93 were significantly higher in the xenoperfused group than in the control group. CONCLUSIONS: This study demonstrated that contact of human blood with pig endothelium activates cytotoxic T cells within the first few hours, indicating acute rejection processes. This is accompanied by upregulation of anti-inflammatory microRNAs, which may represent compensatory anti-inflammatory mechanisms.

Home Health Agency Performance in the United States: 2011-15.

OBJECTIVES: To evaluate home health agency quality performance. DESIGN: Observational study. SETTING: Home health agencies. PARTICIPANTS: All Medicare-certified agencies with at least 6 months of data from 2011 to 2015. MEASUREMENTS: Twenty-two quality indicators, five patient survey indicators, and their composite scores. RESULTS: The study included 11,462 Medicare-certified home health agencies that served 92.4% of all ZIP codes nationwide, accounting for 315.2 million people. The mean composite scores were 409.1 ± 22.7 out of 500 with the patient survey indicators and 492.3 ± 21.7 out of 600 without the patient survey indicators. Home health agency performance on 27 quality indicators varied, with the coefficients of dispersion ranging from 4.9 to 62.8. Categorization of agencies into performance quartiles revealed that 3,179 (27.7%) were in the low-performing group (below 25th percentile) at least one time during the period from 2011-12 to 2014-15 and that 493 were in the low-performing group throughout the study period. Geographic variation in agency performance was observed. Agencies with longer Medicare-certified years were more likely to have high-performing scores; agencies providing partial services, with proprietary ownership, and those with long travel distances to reach patients had lower performance. Agencies serving low-income counties and counties with lower proportions of women and senior residences and greater proportions of Hispanic residents were more likely to attain lower performance scores. CONCLUSION: Home health agency performance on several quality indicators varied, and many agencies were persistently in the lowest quartile of performance. Still, there is a need to improve the quality of care of all agencies. Many parts of the United States, particularly lower-income areas and areas with more Hispanic residents, are more likely to receive lower quality home health care.

Time of day influences the voluntary intake and behavioral response to methamphetamine and food reward.

The circadian timing system influences a vast array of behavioral responses. Substantial evidence indicates a role for the circadian system in regulating reward processing. Here we explore time of day effects on drug anticipation, locomotor activity, and voluntary methamphetamine (MA) and food intake in animals with ad libitum food access. We compared responses to drug versus a palatable treat during their normal sleep times in early day (zeitgeber time (ZT) 0400) or late day (ZT 1000). In the first study, using a between-subjects design, mice were given daily 1-h access to either peanut butter (PB-Alone) or to a low or high concentration of MA mixed in PB (MA+PB). In study 2, we repeated the experiment using a within-subjects design in which mice could choose between PB-Alone and MA+PB at either ZT 0400 or 1000. In study 3, the effects of MA-alone were investigated by evaluating anticipatory activity preceding exposure to nebulized MA at ZT 0400 vs. ZT 1000. Time of day effects were observed for both drug and palatable treat, such that in the between groups design, animals showed greater intake, anticipatory activity, and post-ingestional activity in the early day. Furthermore, there were differences among mice in the amount of MA ingested but individuals were self-consistent in their daily intake. The results for the within-subjects experiment also revealed robust individual differences in preference for MA+PB or PB-Alone. Interestingly, time of day effects on intake were observed only for the preferred substance. Anticipatory activity preceding administration of MA by nebulization was also greater at ZT 0400 than ZT 1000. Finally, pharmacokinetic response to MA administered intraperitoneally did not vary as a function of time of administration. The results indicate that time of day is an important variable mediating the voluntary intake and behavioral effects of reinforcers.