Incidence and cost of potentially avoidable emergency department visits for urolithiasis.

OBJECTIVES: Urolithiasis represents a leading cause of emergency department (ED) presentation nationally, affecting approximately 10% of Americans. However, most patients require neither hospital admission nor surgical intervention. This study investigates patient and facility factors associated with potentially avoidable ED visits and their economic consequences. STUDY DESIGN: Retrospective analysis. METHODS: Patients presenting to the ED for index urolithiasis events were selected using Florida and New York all-payer data from the 2016 Healthcare Cost and Utilization Project state databases. Avoidable visits were defined as subsequent ED encounters following initial ED presentation that did not result in intervention, admission, or referral to an acute care facility. Utilizing multivariable logistic and linear regression, researchers discerned patient and facility factors predictive of avoidable ED presentations and associated costs. RESULTS: Of the 167,102 ED encounters for urolithiasis, 7.9% were potentially avoidable, totaling $94,702,972 in potential yearly cost savings. Mean encounter-level costs were higher for unavoidable vs avoidable visits ($5885 vs $2098). In contrast, mean episode-based costs were similar for avoidable and unavoidable episodes ($7200 vs $7284). Receiving care in small metropolitan (vs large metropolitan) communities was associated with potentially avoidable visits, whereas increased comorbidities and Hispanic ethnicity were protective against avoidable visits. CONCLUSIONS: The incidence of ED use for subsequent urolithiasis care reveals opportunity for enhanced outpatient availability to reduce hospital-based costs. Several nonclinical factors are associated with potentially avoidable ED visits for urolithiasis, which, if appropriately targeted, may represent an opportunity to reduce health care spending without compromising the quality of care delivery.

Regulation of IGF1R by MicroRNA-15b Contributes to the Anticancer Effects of Calorie Restriction in a Murine C3-TAg Model of Triple-Negative Breast Cancer.

Calorie restriction (CR) inhibits triple-negative breast cancer (TNBC) progression in several preclinical models in association with decreased insulin-like growth factor 1 (IGF1) signaling. To investigate the impact of CR on microRNAs (miRs) that target the IGF1/IGF1R pathway, we used the spontaneous murine model of TNBC, C3(1)/SV40 T-antigen (C3-TAg). In C3-TAg mice, CR reduced body weight, IGF1 levels, and TNBC progression. We evaluated the tumoral expression of 10 miRs. CR increased the expression of miR-199a-3p, miR-199a-5p, miR-486, and miR-15b. However, only miR-15b expression correlated with tumorigenicity in the M28, M6, and M6C C3-TAg cell lines of TNBC progression. Overexpressing miR-15b reduced the proliferation of mouse (M6) and human (MDA-MB-231) cell lines. Serum restriction alone or in combination with low levels of recombinant IGF1 significantly upregulated miR-15b expression and reduced Igf1r in M6 cells. These effects were reversed by the pharmacological inhibition of IGFR with BMS754807. In silico analysis using miR web tools predicted that miR-15b targets genes associated with IGF1/mTOR pathways and the cell cycle. Our findings suggest that CR in association with reduced IGF1 levels could upregulate miR-15b to downregulate Igf1r and contribute to the anticancer effects of CR. Thus, miR-15b may be a therapeutic target for mimicking the beneficial effects of CR against TNBC.

Influence of Clinical and Sociodemographic Factors on the Management, Costs and Outcomes of Acute Urinary Retention in the Acute Care Setting.

INTRODUCTION: We evaluated clinical and sociodemographic factors that influence care pathways following acute urinary retention with attention to subsequent bladder outlet procedures. METHODS: This was a retrospective cohort study examining patients who presented for emergent care with concomitant diagnoses of urinary retention and benign prostatic hyperplasia in New York and Florida in 2016. Using Healthcare Cost and Utilization Project data, patients were followed throughout a calendar year across subsequent encounters for recurrent urinary retention and bladder outlet procedures. Multivariable logistic and linear regression were utilized to identify factors associated with recurrent urinary retention, subsequent outlet procedures and the cost of retention-related encounters. RESULTS: Among 30,827 patients, 12,286 (39.9%) were ≥80 years of age. Though 5,409 (17.5%) experienced multiple retention-related encounters, only 1,987 (6.4%) received a bladder outlet procedure within the calendar year. Covariates associated with repeat urinary retention included older age (OR 1.31, p <0.001), Black race (OR 1.18, p=0.001), Medicare insurance (OR 1.16, p=0.005) and lower education level (OR 1.13, p=0.03). Age ≥80 years (OR 0.53, p <0.001), Elixhauser Comorbidity Index score ≥3 (OR 0.31, p <0.001), Medicaid status (OR 0.52, p <0.001) and lower education level were associated with lower odds of receiving a bladder outlet procedure. Episode-based costs favored single retention encounters vs repeat encounters ($15,285.96 vs $28,451.21, p <0.001) and undergoing an outlet procedure vs foregoing one ($16,223.38 vs $17,690.54, p=0.002). CONCLUSIONS: Sociodemographic factors are associated with recurrent retention episodes and the decision to undergo a bladder outlet procedure following an episode of urinary retention. Despite the cost benefits associated with preventing repeated episodes of urinary retention, merely 6.4% of patients presenting with acute urinary retention underwent a bladder outlet procedure during the study period. Our findings suggest that early intervention among individuals experiencing urinary retention may confer cost and duration of care benefits.

Management of internal bleeding piles by ligation and plication followed by Matra Basti - A case report.

Arsha (hemorrhoids) is engorgement of the hemorrhoidal venous plexus, characterized by bleeding per rectum, constipation, pain in ano, prolapse and discharge per anum. It is a primary disease, with impaired digestion as the underlying pathogenesis. It is manifested due to improper diet, prolonged standing and faulty habits of defecation causing derangement of Tridosha, mainly VataDosha. Vitiated Dosha localizes in Houstan's Valve, rectal arteries, fascia and vitiates Skin, muscles, adipose tissue and blood due to AnnavahaSrotodushti (vitiation of gastrointestinal tract). A 45-year-old male patient came to the OPD of Dr. Sarvepalli Radhakrishnan Rajasthan Ayurved University hospital, Jodhpur, Rajasthan, with complaints of prolapsing pile mass during defecation, pain per anum with erosion and bleeding per anum while passing stool. On proctoscopy, pile masses were seen at 11 and 3 O'clock positions and few erosions were seen near the 3 O'clock pile mass. The case was diagnosed as "Raktarsha"- later stage of 2nd degree internal hemorrhoids at 11 and 3 O'clock positions, deeply situated, projecting one and caused by Pitta and RaktaDosha; with bleeding tendency. Ligation of pile mass by surgical linen barbour thread number 20 on 11 O'clock positions and plication by absorbable chromic catgut on 3 O'clock positions of internal hemorrhoid were done under local anesthesia followed by Matra Basti (therapeutic oil enema) with Jatyadi oil. The pile mass and per rectal bleeding resolved in 10 days and the patient got relief from all the symptoms within 4 weeks. No complications were reported after the procedure. The patient was followed up regularly from the registered date onward till 3 months and proctoscopic examination did not revealed any evidence of recurrence of the hemorrhoids.