Immediate Postpartum IUD Training Within a Regional Network of Family Medicine Residencies.

BACKGROUND AND OBJECTIVE: Immediate postpartum placement of intrauterine devices (PPIUD) offers important benefits to patients. Little is known about PPIUD training or knowledge within family medicine residency programs. We evaluated PPIUD experience and prior training among family medicine residents and faculty. METHODS: We conducted a cross-sectional survey of residents and faculty in 24 regional family medicine residency programs in 2018. Survey questions focused on reception of PPIUD training and experience with PPIUD counseling and placement. RESULTS: The final survey sample included 203 residents and 100 faculty with an overall response rate of 39%. About 26% (n=79) of all participants reported receiving prior training for counseling and placement of PPIUDs, while 16% (n=48) of participants had ever placed a PPIUD. Twenty-six percent (n=78) of participants reported that their residency programs offered PPIUD training. Residents and faculty who reported past PPIUD training and/or placement experience were more likely to have ever counseled patients about PPIUD (P<.001) and report that their primary training hospital offered PPIUD to patients (P<.001) and their residency programs offered PPIUD training (P<.001). CONCLUSIONS: Few programs offer routine PPIUD training opportunities for family medicine residents and faculty, which may contribute to limited availability of PPIUD to patients. There is a need to improve PPIUD training and placement opportunities for both family medicine residents and faculty.

Ureteral stenting and retrograde pyelography in the office: clinical outcomes, cost effectiveness, and time savings.

OBJECTIVES: To examine the clinical outcomes and cost-effectiveness of endourologic procedures performed in the office using standard fluoroscopy and topical anesthesia. METHODS: We performed a retrospective review of all patients who underwent primary ureteral stent placement, ureteral stent exchange, or ureteral catheterization with retrograde pyeolography or Bacillus Calmette-Guerin (BCG) instillation under fluoroscopic guidance in the office. For an evaluation of potential time savings, we compared this to a cohort of similar procedures performed in the operating room during the same time period. RESULTS: Procedures were attempted in 65 renal units in 38 patients (13 male, 25 female) with a mean age of 62.2 years (range 29.1-95.4 years). Primary ureteral stent placement was successful in 23/24 (95.8%) renal units. Ureteral stent exchange was successful in 19/22 (86.4%) renal units. Ureteral catheterization with retrograde pyelography or BCG instillation was successful in 19/19 (100%) renal units. The total cost savings for the 38 patients in this study, including excess cost from failure in the office, was approximately $91,496, with an average cost savings of $1,551 per procedure. Office-based procedures were associated with a nearly three-fold reduction in total hospital time as a result of reduced periprocedure waiting times. CONCLUSIONS: Ureteral stent placement, ureteral stent exchange, and ureteral catheterization can be performed safely and effectively in the office in both men and women. This avoids general anesthesia and provides significant savings of time and cost for both patients and the health care system.

High dietary magnesium intake decreases hyperoxaluria in patients with nephrolithiasis.

OBJECTIVE: To examine the relationship between urine magnesium and hyperoxaluria in a cohort of patients with recurrent stone formation. METHODS: A total of 311 patients with nephrolithaisis were evaluated. The patients were divided into quintiles of urine magnesium excretion, an accepted surrogate of dietary magnesium intake. Multivariate analysis was used to examine the relationship between magnesium and hyperoxaluria. RESULTS: The mean patient age was 50.0 ± 14.9 years, the body mass index was 28.0 ± 5.9 kg/m(2), and 130 were women and 181 were men. The mean urine magnesium excretion was 100.8 ± 42.0 mg/d (range 17.8-224.8). On multivariate analysis, an increasing quintile of urine magnesium was associated with decreasing hyperoxaluria (ß = -0.37, 95% confidence interval -0.6 to -0.14, P < .05 for trend). When analyzed as separate quintiles with the lowest quintile of magnesium as the referent, only the greatest quintile demonstrated a statistically significant decrease in hyperoxaluria (ß = -1.7, 95% confidence interval -2.7 to -0.7, P < .05 for trend). CONCLUSION: Increasing magnesium intake was associated with decreasing hyperoxaluria in this population of patients with stone formation. Our findings showed that high magnesium intake might be required to observe clinically significant effects from magnesium.

Abnormalities of 24-hour urine composition in first-time and recurrent stone-formers.

OBJECTIVE: To examine differences in 24-hour urine composition between recurrent and first-time stone-formers. METHODS: A retrospective review of patients evaluated in 2 metabolic stone clinics was performed. Recurrent stone formation was defined as patients with a history of more than 1 stone episode and first-time stone-formers were those with a history of a single-stone episode. Frequencies of urine metabolic abnormalities were noted. Multivariate linear regression was performed to evaluate the likelihood of abnormalities of 24-hour urine composition. RESULTS: Three-hundred eleven patients met inclusion criteria: 71 (22.8%) were first-time stone-formers and 240 (77.1%) were recurrent stone-formers. On univariate analysis, the likelihood of having a single abnormality of 24-hour urine composition (ie, hypercalciuria, hyperoxaluria, hyperuricosuria, or hypocitraturia) was similar between the 2 groups (83.1% for first-time vs 88.8% for recurrent, P = NS). In addition, there were similar rates of hypercalciuria (39.4% vs 43.3%, P = NS), hyperoxaluria (32.4% vs 33.3%, P = NS), hyperuricosuria (29.6% vs 23.3%, P = NS), and hypocitraturia (45.0% vs 45.0%, P = NS). On multivariate logistic regression, there was no difference in detection of any urine abnormality (ie, hypercalciuria or hyperoxaluria or hypocitraturia or hyperuricosuria) between first-time (referent) or recurrent stone-formers (OR 1.68, 95% CI .8-3.5, P = .2). CONCLUSION: In this study, detection of urine abnormalities was similar in first-time and recurrent stone-formers. Given the strong patient preference for stone prevention and the high success of directed therapy in the literature, we believe it is not unreasonable to offer comprehensive metabolic evaluation to first-time stone-formers who express a desire to undergo evaluation.

Relationship between serum vitamin D and 24-hour urine calcium in patients with nephrolithiasis.

OBJECTIVE: To examine the relationship between serum 25-OH vitamin D and 24-hour urine calcium in patients with nephrolithiasis. METHODS: A retrospective review was performed. Patients evaluated in 2 metabolic stone clinics were included for analysis. Multivariate linear regression models were adjusted for known risk factors for stone disease (age, gender, body mass index, hypertension, diabetes mellitus, gout, relevant medications, and 24-hour urine composition). RESULTS: One-hundred sixty-nine patients were included in the study. Female to male ratio was 69:100, mean age was 50.9 years (SD 13.7), and mean body mass index was 27.4 (SD 6.4). Vitamin D deficiency (25-OH vitamin D <20 ng/mL) was present in 18.9% of patients, vitamin D insufficiency (>20, <30 ng/mL) was present in 34.9% of patients, and vitamin D was within normal limits (≥ 30 ng/mL) in 46.1% of patients. On age-adjusted and multivariate linear regression, serum 25-OH vitamin D was not related to 24-hour urine calcium (age adjusted ß = -0.31 m 95% CI -1.9 to 1.3; multivariate adjusted ß = 0.08, 95% CI -1.3 to 1.5). CONCLUSION: Although 25-OH vitamin D is involved in the body's calcium homeostasis, our study does not show a relationship between serum vitamin D level and 24-hour urine calcium excretion in stone-formers. This information may have implications regarding the safety of vitamin D repletion in patients with nephrolithiasis.

Relationship between glomerular filtration rate and 24-hour urine composition in patients with nephrolithiasis.

OBJECTIVE: To examine the relationship between GFR and 24-hour urine composition in patients with nephrolithiasis to understand how renal function may affect stone risk. Alterations in glomerular filtration rate (GFR) are associated with a number of physiological changes. METHODS: A retrospective, institutional review board-approved review of patients from 2 metabolic stone clinics was performed. One-way analysis of variance and multivariate linear regression models were used to evaluate the relationship between GFR quintile and 24-hour urine composition. RESULTS: A total of 403 patients (241 male, 162 female) with a mean age of 52.6 ± 14.2 years were included in the study. On univariate analysis, decreasing GFR by quintile was associated with significant reductions in urine calcium, citrate, supersaturation of calcium oxalate, and supersaturation of calcium phosphate (P < .05 for each). In multivariate linear regression models, decreasing GFR by quintile was associated with significant decreases in urine calcium (ß = -11.2, 95% CI = -18.3 to 4.01), urine citrate (ß = -32.4, 95% CI = -54.1 to 10.8), oxalate (ß = -1.83, 95% CI = -2.85 to 0.81), supersaturation of calcium oxalate (ß = -0.58, 95% CI = 0.84 to 0.33) and supersaturation of calcium phosphate (ß = -0.09, 95% CI = 0.17 to 0.02), as well as an increase in urine magnesium (ß = 3.40, 95% CI = 0.7 to 6.1). CONCLUSION: Reduction in GFR is associated with decreased urine calcium, oxalate, and citrate, and increased urine magnesium. These findings have implications for treatment of patients with stone disease and impaired renal function.

Effect of socioeconomic status on 24-hour urine composition in patients with nephrolithiasis.

OBJECTIVE: To examine the relationship between the poverty and education levels and 24-hour urine composition in patients with nephrolithiasis because little is known about the relationship between socioeconomic status and kidney stone risk. METHODS: A retrospective review was performed of patients evaluated at 2 metabolic stone clinics. The poverty level (ie, percentage of those living below the poverty level) and education level (ie, percentage of those with a high school education or greater) for each postal code were determined from the U.S. Census Bureau data. Multivariate linear regression analysis was used to examine the relationship between the poverty and education levels and 24-hour urine composition. RESULTS: A total of 435 patients were included in the present study. Of the 435 patients, 173 were women and 262 were men (40% women), the mean age was 52.5 ± 14.4 years, and the mean body mass index was 28.6 ± 6.5 kg/m(2). The mean percentage of those below the poverty level was 8.2% ± 6.2%, and the mean percentage of those with a high school education or greater was 87.4% ± 7.4%. On multivariate linear regression analysis, an increasing local poverty level was associated with significant increases in urine calcium (ß = 1.51, 95% confidence interval [CI] 0.16-2.86). A decreasing local level of education (ie, decreasing percentage of those with a high school diploma or greater) was associated with significant increases in urine calcium (ß = 1.26, 95% CI 0.10-2.42), supersaturation of calcium oxalate (ß = 0.04, 95% CI 0.006-0.09), and supersaturation of calcium phosphate (ß = 0.013, 95% CI 0.0002-0.03). No other associations were found between the poverty and education levels and any urine constituents or supersaturations. CONCLUSION: In the present study of patients with stone formation, increasing poverty was associated with increased urine calcium, and increasing education appeared to be protective by decreasing urine calcium and the supersaturation of calcium oxalate and calcium phosphate. Additional studies are important to elucidate the mechanisms underlying these findings.

The effects of ambient temperature, humidity and season of year on urine composition in patients with nephrolithiasis.

UNLABELLED: Study Type--Prognosis (cohort series) Level of Evidence 2b. What's known on the subject? and What does the study add? Epidemiologic studies have shown that warmer climates are associated with increased incidence of nephrolithiasis. Many hypothesize that this is due to dehydration and lower urine volumes. The current study of stone formers reports that greater temperatures are associated with significant increases in urine calcium which may shed light on the mechanism underlying the increased stone incidence associated with increased ambient temperature. OBJECTIVE: • To understand the effects of temperature, humidity and season of year on 24-h urine composition in patients with nephrolithiasis. PATIENTS AND METHOD: • A retrospective review was performed of patients evaluated at four metabolic stone clinics. • Multivariate linear regression models examined the relationship between mean temperature, average humidity, season of year and 24-h urine composition. • Multivariate models adjusted for known risk factors for stone disease. • Mean temperature and average humidity data were obtained from http://www.weatherunderground.com based on patient-provided addresses. RESULTS: • A total of 599 patients were included in the study, comprising 239 women and 360 men with a mean age of 53.6 years (sd 15.0). • Mean temperature was 16.9 °C (sd 4.8, range -21.1 to 38.3 °C) and average humidity was 58.1% (sd 23.5, range 11-100%). • On multivariate linear regression, increasing temperature was associated with increasing urine calcium (ß = 11.3, 95% CI 2.2-20.0), super-saturation of calcium oxalate (ß = 0.6, 95% CI 0.2-0.9), super-saturation of calcium phosphate (ß = 0.14, 95% CI 0.03-0.2), and decreasing urine sodium (ß = -5.2, 95% CI -10.3 to -0.1). • As seasons become warmer (i.e. from winter to autumn to spring to summer), changes were increased urine volume (ß = 0.09, 95% CI 0.01-0.2) and decreased super-saturation of calcium phosphate (ß = -0.2, 95% CI -0.3 to -0.03). • There were no associations between quintile of humidity and any 24-h urine constituents. CONCLUSIONS: • Increasing temperature may increase stone risk by increasing urine excretion of calcium, and the super-saturation of calcium oxalate and calcium phosphate. • These findings were independent of humidity and of season of year. • This appears to be related to a physiological impact of temperature itself, rather than to geographic location.

Gender differences in subcutaneous and perirenal fat distribution.

PURPOSE: Body mass index (BMI) has been shown to influence the outcome of various surgical procedures. The purpose of this study is to assess the relationship between BMI, gender, and the distribution of subcutaneous and perirenal fat. METHODS: A retrospective review was performed for 123 patients who underwent radical or partial nephrectomy. Preoperative CT scans were reviewed by two independent observers. Subcutaneous fat was measured at three locations and perirenal fat was measured at six locations. Statistical analysis was performed using the Student's t test and the Pearson's correlation coefficient. RESULTS: Mean anterior subcutaneous fat was significantly greater in females than in males (2.54 vs. 1.78 cm, p < 0.001) as was mean right posterolateral subcutaneous fat (2.78 vs. 2.21 cm, p = 0.03). With regard to perirenal fat, men were greater than women for all perirenal locations around the left kidney. For the right kidney, men were greater than women for four out of six perirenal positions. In both men and women, BMI was strongly correlated with subcutaneous fat. However, BMI was weakly correlated with perirenal fat. CONCLUSIONS: Women exceed men in subcutaneous fat, while men exceed women in perirenal fat. Obese patients are very likely to have large amounts of subcutaneous fat, but will not necessarily have proportionally increased fat around their kidneys when compared to the patients with lower BMI. These differences may have important implications for surgical approaches to the kidney.

Ureteral stone location at emergency room presentation with colic.

PURPOSE: It is thought that the 3 narrowest points of the ureter are the ureteropelvic junction, the point where the ureter crosses anterior to the iliac vessels and the ureterovesical junction. Textbooks describe these 3 sites as the most likely places for ureteral stones to lodge. We defined the stone position in the ureter when patients first present to the emergency department with colic. MATERIALS AND METHODS: We retrospectively reviewed the records of 94 consecutive patients who presented to the emergency department with a chief complaint of colic and computerized tomography showing a single unilateral ureteral calculus. Axial, coronal and 3-dimensional reformatted computerized tomography scans were evaluated, and stone position and size (maximal axial and coronal diameters) were recorded, as were the position of the ureteropelvic junction, the iliac vessels (where the ureter crosses anterior to the iliac vessels) and the ureterovesical junction. Patients with a history of nephrolithiasis, shock wave lithotripsy, ureteroscopy or percutaneous nephrolithotripsy were excluded from study. Statistical analysis was performed using Student's t test and Pearson's correlation coefficient. RESULTS: At the time of emergency department presentation for colic ureteral stone position was the ureteropelvic junction in 10.6% cases, between the ureteropelvic junction and the iliac vessels in 23.4%, where the ureter crosses anterior to the iliac vessels in 1.1%, between the iliac vessels and the ureterovesical junction in 4.3% and at the ureterovesical junction in 60.6%. Proximal calculi had a greater axial diameter than distal calculi (mean 6.1 vs 4.0 mm) and a greater coronal diameter than distal calculi (6.8 vs 4.1 mm, each p <0.001). Axial and coronal diameters moderately correlated with stone position (r = -0.47 and -0.55, respectively, each p <0.001). CONCLUSIONS: Proximal ureteral stones were larger in axial and coronal diameter than distal ureteral stones. At emergency department presentation for colic most stones were at the ureterovesical junction and in the proximal ureter between the ureteropelvic junction and the iliac vessels. A few stones were at the ureteropelvic junction and only 1 lodged at the level where the ureter crosses anterior to the iliac vessels, despite the literature stating that these locations are 2 of the 3 most likely places for stones to become lodged.