title: Nephrolithiasis, stone composition, meteorology, and seasons in Malta: Is there any connection?
abstract: BACKGROUND
  The effect of seasons and meteorology on the incidence of nephrolithiasis has been studied in various regions around the globe, but seldom in the Mediterranean.
  
  
  OBJECTIVE
  This retrospective analysis aims at investigating these putative effects in the Maltese Islands, whose climate is typically Mediterranean, followed by a systematic review of the literature.
  
  
  METHODS
  Submission rate and chemical composition of all kidney stones after spontaneous passage or surgical removal between January 2009 and December 2011 were analyzed according to seasons and corresponding meteorology.
  
  
  RESULTS
  A total of 389 stones were analyzed. A higher stone submission rate was observed in summer compared to winter (31.6% vs. 20.8%, P = 0.0008) and in the warm period compared to the cold period (57.1% vs. 42.9%, P = 0.0001). Significant correlation was established between the monthly number of stones and mean monthly maximum temperature (r = 0.50, P = 0.002), mean monthly temperature (r = 0.49, P = 0.003) and mean monthly Humidex (r = 0.49, P = 0.007). Humidex was found to be an independent predictor for stone submission (β = 0.49, P = 0.007). The majority of stones contained calcium (83.3%), combined with oxalate (77.6%), phosphate (14.7%), and carbonate (2.8%). Some stones (11.8%) contained a mixture of >1 negatively charged molecules. Urate (11.6%), cysteine (4.6%), and ammonium-magnesium-phosphate (0.5%) constituted the rest. There was no association between chemical composition and seasons. Literature review included 25 articles. Higher ambient temperature and warm seasons were the most commonly encountered risk factors for both presentation and etiology of nephrolithiasis.
  
  
  CONCLUSIONS
  A significant positive correlation was noted between ambient temperature and stone submission rate, which was significantly higher during the warm months in Malta.
authors.affiliation: Department of Nephrology, Mater Dei Hospital, L-Imsida, Malta.
authors.forename: Jesmar
authors.initials: J
authors.lastname: Buttigieg
authors.affiliation: Department of Nephrology, Mater Dei Hospital, L-Imsida, Malta.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Attard
authors.affiliation: Department of Urology, Mater Dei Hospital, L-Imsida, Malta.
authors.forename: Alexander
authors.initials: A
authors.lastname: Carachi
authors.affiliation: Department of Medicine, Mater Dei Hospital, L-Imsida, Malta.
authors.forename: Ruth
authors.initials: R
authors.lastname: Galea
authors.affiliation: Department of Medicine, Mater Dei Hospital, L-Imsida, Malta.
authors.forename: Stephen
authors.initials: S
authors.lastname: Fava
keywords: Ambient temperature; kidney stones/calculi; meteorology; nephrolithiasis; seasons