2257 MEDICAL EXPULSION THERAPY IS UNDERUTILIZED IN WOMEN PRESENTING TO AN EMERGENCY DEPARTMENT WITH ACUTE URINARY STONE DISEASE

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2256 MEDICAL EXPULSIVE THERAPY UTILIZATION IN PATIENTS PRESENTING WITH URETEROLITHIASIS Aaron Lay*, Jeffrey Leow, Boston, MA; Benjamin Chung, Stanford, CA; Steven Chang, Boston, MA

Source of Funding: None

2255 THE IMPACT OF FISH OIL SUPPLEMENTATION ON ENDOGENOUS OXALATE SYNTHESIS AND URINARY OXALATE EXCRETION Jessica Lange*, Patrick Mufarrij, Linda Easter, Winston-Salem, NC; John Knight, Ross Holmes, Dean Assimos, Birmingham, AL INTRODUCTION AND OBJECTIVES: It has been recently reported that the administration of fish oil supplements to non-hyperoxaluric, healthy adults consuming metabolic diets with normal oxalate and calcium content resulted in a significant reduction in urinary oxalate excretion. The mechanism of this response has not been defined, but we hypothesize that it is due to a reduction in endogenous oxalate synthesis via its anti-inflammatory and antioxidant properties. METHODS: Fifteen healthy, non-stone forming, non-hyperoxaluric adults participated (mean age 25.3 ⫾ 2.7 years, BMI ⬍ 30, 8 male, 7 female) in this study. First, subjects were asked to abstain from utilization of any supplements, vitamins, medications, or foods enriched in omega 3 fatty acids for thirty days. After this, they collected two random baseline 24 hour urine specimens while eating a self-selected diet. Next, the subjects consumed a controlled low oxalate diet for five days. This was intended to reflect baseline endogenous oxalate production. The diet contained 50 mg oxalate, 1000 mg calcium, 3500 mg sodium, 300 mg magnesium, 1500 mg phosphorus, 3000 mg potassium, 125 mg vitamin C, and 2.5 liters of fluid per day. Subjects collected three 24 hour urine specimens on days three through five of this controlled diet phase. Next, they began taking two fish oil supplement capsules twice daily for 30 days (2600 mg eicosapentaenoic acid and 1800 mg docosahexaenoic acid per day) while consuming selfselected diets for 25 days. On days 26-30, they continued on fish oil and consumed the aforementioned controlled low oxalate diet. They collected 24 hour urine specimens on days 28-30. Statistical analysis included repeated measures ANOVA and Student’s t test. RESULTS: Analysis of the 24 hour urine collection data revealed no significant differences in urine volume, creatinine, or calcium between the baseline and metabolic dietary phases without and with fish oil. ANOVA analysis of daily oxalate excretion was significant (p ⬍ 0.01). While the Student’s t test revealed a significant decrease in oxalate excretion between the self-selected diet and both controlled dietary phases (p ⬍ 0.01), there was no significant difference between the controlled diet phases without or with fish oil supplementation. CONCLUSIONS: These results suggest that fish oil supplementation does not impact endogenous oxalate synthesis in healthy adults without hyperoxaluria. Thus, the reduction previously reported in this cohort could be due to alterations in gastrointestinal or renal handling of oxalate. Source of Funding: Nordic Naturals NIH grant R01 DK62284

INTRODUCTION AND OBJECTIVES: Randomized controlled trials have demonstrated the efficacy of medical expulsive therapy (MET) for promoting passage of ureteral stones. Though this is well known among urologists, there has been concern regarding its utilization in the acute setting, when these patients may not be treated by urologists. We sought to measure utilization rates of MET in patients presenting with acute ureterolithiasis. METHODS: We captured all patients who had a primary diagnosis of ureterolithiasis between January 1, 2003, and December 31, 2010, based on ICD-9 code 592.1 from Premier Perspective Database (Premier Inc, Charlotte, NC), a nationally representative discharge database that covers 20% of US hospital discharges. Patients who carried diagnosis of ureterolithiasis but did not undergo a surgical procedure were included in the study. Patients who received tamsulosin, nifedipine, and/or predisone were identified by hospital charge billing descriptions. Statistical analyses were performed using STATA. All statistical testing was two-sided and a p-value⬍0.05 was considered statistically significant. RESULTS: There were 2916 patients who had a principal diagnosis of ureterolithiasis but did not undergo a surgical procedure. Patients received tamsulosin 12.4% of the time, while nifedipine use was 1.5% and steroid use was 2.8%. Tamsulosin was more likely used in men, in teaching hospitals, and in recent years. Tamsulosin was also more likely used in the Middle Atlantic States compared to other regions of the country. CONCLUSIONS: Even though there are randomized controlled trials that have demonstrated medical expulsive therapy to increase the likelihood of stone passage and faster time to stone passage, MET is underutilized. Our analysis suggests that MET is being used more frequently in recent years, but there is still underuse in the medical community. Source of Funding: None

2257 MEDICAL EXPULSION THERAPY IS UNDERUTILIZED IN WOMEN PRESENTING TO AN EMERGENCY DEPARTMENT WITH ACUTE URINARY STONE DISEASE Herman Bagga*, Ayesha Appa, Ralph Wang, Thomas Chi, Joe Miller, Jersey Neilson, Rebecca Smith-Bindman, Marshall Stoller, San Francisco, CA INTRODUCTION AND OBJECTIVES: Medical expulsion therapy (MET) with alpha-adrenergic blockade (AB) is an established treatment option for the management of ureteral stones. Multiple studies have noted low utilization of MET in the Emergency Department (ED), however specific reasons for this phenomenon remain largely unknown. Given that AB agents are most typically associated with male urologic conditions such as benign prostatic hyperplasia (BPH), we hypothesized that the underutilization of MET would be most pronounced in women as AB medications are typically used for men with BPH. METHODS: Retrospective chart review of patients with an ED diagnosis of urinary stone disease between 2006-2012 was undertaken to identify patient variables related to presentation, history, management, and disposition. We excluded patients with incomplete medical records or a known diagnosis of stone disease within the previous month. RESULTS: Between 2006-2012, 729 patients presented to an ED with acute renal colic and were diagnosed with urinary stone disease. 92.9% (677) of all patients were discharged from the ED. Amongst discharged patients, 60.3% (408) were prescribed AB (commonly tamsulosin). 5.5% (40) were discharged with steroids for MET,

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with 90% (36) of these patients also receiving AB. 36.9% (269) of patients were discharged without any MET. Of those discharged without MET, 34.4% (84 patients) had CT or ultrasound imaging evidence of a ureteral stone. 38% (277) of all patients were female. When considering gender, 48.8% of women (120) were discharged without MET compared to 39.2% (177) of men (p ⬍ 0.05). Variables predictive of discharge without MET included female gender (OR 1.8, 95% CI 1.3-2.5, p ⬍ 0.05) and clinical diagnosis without use of imaging studies (OR 1.95, 95% CI 1.25-3.06, p ⬍ 0.05). Neither age nor a history of stone disease were significantly associated with likelihood of discharge with MET. CONCLUSIONS: MET was utilized in only 60% of patients diagnosed with an acute urinary stone in a tertiary care ED, despite a significant portion of patients demonstrating the presence of ureteral stone(s) on imaging. Women were nearly half as likely to receive MET compared to men. We propose that this may be due to providers’ perception that AB agents are drugs for male urologic conditions such as BPH. Increased awareness of the underutilization of MET, particularly in women, may help to promote its appropriate use amongst emergency department physicians and other allied health care providers. Source of Funding: None

2258 INDWELLING DOUBLE J URETERAL STENT AFTER URETEROSCOPY AND ROLE OF COMBINATION OF ANTICHOLINERGICS (TOLTERODINE) AND SELECTIVE ALPHABLOCKER (TAMSULOSIN) TO IMPROVE THE URINARY SYMPTOMS ASSOCIATED WITH DOUBLE J URETERAL STENT Ahmed Shelbaia*, Ahmed Shelbaia, Cairo, Egypt; ahmed Elnashar, Suez Canal, Egypt; Hosni Khairy, Cairo, Egypt INTRODUCTION AND OBJECTIVES: We conduct a prospective placebo controlled study comparing the effect of selective alphablocker( tamsulosin), anticholinergics( tolterodine) or combination of both drugs versus placebo in improving the urinary symptoms associated with indwelling double J ureteral stent after ureteroscopy. METHODS: 80 patients (who underwent ureteral stent placement) with a mean age 33.4⫹9.9 years were enrolled prospectively into 4 groups. Group A (n⫽20), patients received 0.4 mg tamsulosin once per day. Group B (n⫽20), patients received 4mg tolterodine once per day. Group C (n⫽20), patients received tamsulosin 0.4 mg ⫹tolterodine 4 mg once per day. Group D (n⫽20), patients received analgesics on demand (controlled group). For all patients, storage symptoms; voiding symptoms and international prostatic symptoms scores (IPSS) were compared at base line (day 1), day 7 and day 14, and the results were compared between the four groups. RESULTS: We found that the baseline scores for, storage; voiding and IPSS did not differ significantly in the 4 groups (p⬎0.05). At day 7, the same scores were significantly lower in group A, B and C in comparison to group D (placebo). The improvement in the symptoms was better in group C in comparison to group A or B alone. At day 14, only the storage symptoms and IPSS were still significantly lower in group A,B,C than placebo, and the effect was evident in group C in comparison to A or B alone. No significant difference was noted between group A, B at day 7 or day 14. CONCLUSIONS: The results of this study suggest that combination of alpha blockers (tamsulosin) and anticholinergics (tolterodine) has positive effect in improving the urinary symptoms associated with indwelling double J ureteral stent. The combination of both drugs is better than either drug alone. Source of Funding: None

Vol. 189, No. 4S, Supplement, Wednesday, May 8, 2013

2259 LONGER INTERVAL FROM STONE ANALYSIS TO URINALYSIS LEADS TO DIFFERENCES ON 24-HOUR URINE COLLECTIONS Justin Friedlander*, Daniel Moreira, Chris Hartman, Sammy Elsamra, Arthur Smith, Zeph Okeke, New Hyde Park, NY INTRODUCTION AND OBJECTIVES: Twenty four hour urine collections are routinely performed in patients with recurrent nephrolithiasis, as well as those at increased risk for further stone formation. At present there is no standard for timing of urine collection in relation to passage or surgical treatment of stones. We examined 24-hour urine composition in patients according to timing of stone analysis. METHODS: We performed a retrospective review of stone clinic patients with a stone composition analysis and 24-hour urinalysis (Litholink®). Univariable analysis comparing patients who had analyses ⬍6 months apart and patients who had ⱖ6 months difference was performed with the t-test. Multivariable linear regression models were adjusted for clinical and demographic factors, and 24-hour urine constituents. RESULTS: A total of 508 patients were included in the final analysis, 398 (78%) who had 24-hour urinalysis ⬍6 months from stone analysis and 110 (22%) who had ⱖ6 months difference between evaluations. Univariable analysis demonstrated significant differences for 24-hour mean urinary calcium, oxalate, citrate, uric acid, sodium, potassium, magnesium, sulfate, phosphate, creatinine, and supersaturation (SS) of calcium oxalate (CaOx) and calcium phosphate (CaP; Table 1). Adjusted multivariable analysis found that compared to patients who had analysis ⬍6 months apart, patients who had analysis ⱖ6 months apart had significantly higher 24-hour urinary calcium (mean difference⫽37.74mg, p⫽0.0017), magnesium (9.71mg, p⫽0.03), sulfate (3.24 mmol, p⫽0.02), creatinine (131.9 mg, p⬍0.001), SS CaOx (1.19, p⬍0.001), and SS CaP (0.303, p⫽0.001; Table 2). CONCLUSIONS: Our analysis demonstrated that urinary calcium, magnesium, sulfate, SS CaOX, and SS CaP are all higher with a longer interval between stone analysis and urine collection. These findings must be accounted for in patient counseling and treatment, and reinforce the necessity of close and careful follow-up for stone clinic patients. Table 1. Univariable analysis of 24-hour urine chemistry by time between studies ⬍ 6 months 肁 6 months p-value BMI 30.1(⫾7.6) 30.6(⫾7.7) 0.59 pH Calcium (mg)

5.97(⫾0.58)

6.04(⫾0.58)

0.30

189.7(⫾115.3)

246.0(⫾133.8)

⬍ 0.001

Oxalate (mg)

38.2(⫾15.2)

44.5(⫾19.9)

0.002

Citrate (mg)

482.0(⫾310.7)

559.9(⫾376.8)

0.049

Uric acid (g)

0.68(⫾0.25)

0.77(⫾0.26)

0.001

Sodium (mmol)

170.8(⫾77.8)

194.2(⫾70.4)

0.003

Potassium (mEq)

59.2(⫾29.0)

65.4(⫾22.8)

0.019

Magnesium (mg)

92.9(⫾45.4)

109.4(⫾48.9)

0.002

Sulfate (mmol)

40.9(⫾18.3)

48.8(⫾18.4)

⬍ 0.001

Phosphate (g)

0.92(⫾0.38)

1.06(⫾0.41)

0.002

1543(⫾534.2)

1720(⫾530.5)

0.002

Volume (L)

1.87(⫾0.82)

2.01(⫾0.80)

0.11

SS CaOx

6.69(⫾3.56)

7.86(⫾3.94)

0.006

SS CaP

0.98(⫾0.87)

1.29(⫾1.00)

0.001

SS UA

1.18(⫾0.95)

1.12(⫾0.95)

0.51

Creatinine (mg)

Table 2. Multivariable adjusted differences in 24-hour urine composition Parameter Difference Standard error p-value pH 0.058 0.056 0.30 Calcium (mg)

37.74

11.99

0.0017

Oxalate (mg)

49.97

33.82

0.14

Citrate (mg)

2.76

1.60

0.08

Uric acid (g)

0.032

0.02

0.11

Sodium (mmol)

7.39

6.27

0.24

Potassium (mEq)

1.72

2.52

0.49