Brain arteriovenous malformations and seizures: an Italian study.

OBJECTIVE: To evaluate seizures as first clinical manifestation of brain arteriovenous malformations (AVMs), in relation to angioarchitectural features of these vascular anomalies. METHODS: We performed a prospective observational study, collecting records of patients with AVMs consecutively admitted to the Neurological and Neurosurgery Units of Perugia University and to the Neurosurgery Unit of Terni Hospital, during a 10-year period (1 January 2002 to 1 June 2012). Two groups of patients, with or without seizures as AVM first presentation, were analysed to identify differences in demographic and angiographic features. A multivariate logistic regression model was also developed. RESULTS: We examined 101 patients with AVMs, 55 male and 46 female. Seizures were the initial clinical manifestation in 31 (30.7%) patients. We found a significant difference (p<0.05) between two groups of patients, with or without seizures as AVM first presentation concerning location, side, topography and venous drainage. A multivariate logistic regression model showed that clinical presentation with seizures was correlated with a location in the temporal and frontal lobes, and with a superficial topography. The strongest association (OR 3.48; 95% CI 1.77 to 6.85) was observed between seizures and AVM location in the temporal lobe. CONCLUSIONS: Vascular remodelling and haemodynamic changes of AVMs might create conditions for epileptogenesis. However, here we show that malformations with specific angiographic characteristics are more likely to be associated with seizures as first clinical presentation. Location is the most important feature related to epilepsy and in particular the temporal lobe might play a crucial role in the occurrence of seizure.

Mn(II) oxidation is catalyzed by heme peroxidases in "Aurantimonas manganoxydans" strain SI85-9A1 and Erythrobacter sp. strain SD-21.

A new type of manganese-oxidizing enzyme has been identified in two alphaproteobacteria, "Aurantimonas manganoxydans" strain SI85-9A1 and Erythrobacter sp. strain SD-21. These proteins were identified by tandem mass spectrometry of manganese-oxidizing bands visualized by native polyacrylamide gel electrophoresis in-gel activity assays and fast protein liquid chromatography-purified proteins. Proteins of both alphaproteobacteria contain animal heme peroxidase and hemolysin-type calcium binding domains, with the 350-kDa active Mn-oxidizing protein of A. manganoxydans containing stainable heme. The addition of both Ca(2+) ions and H(2)O(2) to the enriched protein from Aurantimonas increased manganese oxidation activity 5.9-fold, and the highest activity recorded was 700 microM min(-1) mg(-1). Mn(II) is oxidized to Mn(IV) via an Mn(III) intermediate, which is consistent with known manganese peroxidase activity in fungi. The Mn-oxidizing protein in Erythrobacter sp. strain SD-21 is 225 kDa and contains only one peroxidase domain with strong homology to the first 2,000 amino acids of the peroxidase protein from A. manganoxydans. The heme peroxidase has tentatively been named MopA (manganese-oxidizing peroxidase) and sheds new light on the molecular mechanism of Mn oxidation in prokaryotes.

Evaluación del impacto del tratamiento de portadores sanos de staphylococcus aureus, sobre la incidencia de infecciones por este germen / Evaluation of the impact of treatment of carriers healthy of staphylococcus aureus, about the incidence of infections for this germ

Introducción. Las infecciones nosocomiales (o infección hospitalaria) constituyen un serio problema sanitario que encarece los costos, incrementa la estancia hospitalaria y se constituye en una de las causas relevantes de morbimortalidad de los pacientes internados. Los gérmenes más comúnmente involucrados en las infecciones nosocomiales son los bacilos gramnegativos (Klebsiella, Enterobacter, Pseudomonas, Serratia, Proteus, E. coli y Acinetobacter), y los estafilococos aureus (SA), Enterococos y Candida. Objetivo. Conocer la incidencia de infecciones nosocomiales en las salas de cuidados críticos de nuestro hospital, en especial las debidas a estafilococos aureus meticilino resistente (SAMR); y establecer el grado de correlación entre dichas infecciones y la existencia de portadores sanos en el equipo de salud. Material y método. Se analizó la tasa de incidencia de infecciones por SA en un año calendario entre los pacientes adultos ingresados en las salas de Cuidados Intermedios e Intensivos de nuestro hospital general de agudos. El primer período de seis meses fue tomado como grupo control y se comparó dicha tasa, con el segundo período después de identificar, tratar y negativizar a los portadores sanos del germen que estaban en contacto con los pacientes. Resultados. Fueron evaluados 846 pacientes. La tasa de pacientes con infecciones fue de 9.33% del total de ingresados durante ambos períodos. Del total de pacientes con cultivos positivos, 28.46% desarrollaron SA. Las infecciones por SA fueron de 4,37 por cada 100 pacientes internados (11,30 por cada 1000 días de estada). A su vez, se encontró que el 54% de las cepas de SA resultaron meticilino resistente. De los agentes de salud, se halló que el 24.41% (11/45) eran portadores nasales de SA resultando sólo un caso (2.22%) (1/45) meticilino resistente. Todos los portadores sanos que quedaron en contacto con los pacientes en el segundo período, estaban negativizados luego del tratamiento. Se encontró una disminución en la incidencia de infecciones por SA del 27.13% después de eliminar el germen en los agentes de salud portadores sanos. Esa disminución, si bien no es estadísticamente significativa, fue más notoria cuando se evaluó el impacto de la medida sobre la tasa de incidencia de infecciones por SAMR. Conclusión. Para prevenir la diseminación del SA entre pacientes hospitalizados se recomienda realizar estudios epidemiológicos y tomar medidas de control, tales como el lavado cuidadoso y repetido de las manos, vigilancia del personal con cultivos y la erradicación del estado de portador nasal en los agentes de salud. Pareciera ser que una sola medida aislada, por si sola, no es suficiente para disminuir la tasa de incidencia de infecciones por SAMR. (AU)

Intravenous or intranasal administration of gliadin is able to down-regulate the specific immune response in mice.

The mucosal lesion in coeliac disease (CD) represents an immunologically mediated injury triggered by gliadin and is restricted by a particular assortment of major histocompatibility complex (MHC) class II genes. Therefore, immunomodulatory strategies to tolerize gliadin-specific, class II-restricted T-cell responses could represent an alternative to current treatments of CD, which are based on a gluten-free diet. In this study, BALB/c mice derived from a gluten-free diet colony were tolerized by either intranasal (i.n.) or intravenous (i.v.) administration of single or multiple doses of gliadin. While a single dose failed to induce tolerance, a significant decrease in gliadin-specific T-cell proliferation was detected (P < 0.001) after multiple i.n. or i.v. administrations. No significant difference in antibody titre was detected for antigen-specific immunoglobulin G (IgG) or the IgG1 subclass, but a lower IgG2a-specific titre was observed. Both interferon-gamma (IFN-gamma) and interleukin (IL)-2 expression, measured by enzyme-linked immunosorbent assay (ELISA) and reverse transcription-polymerase chain reaction (RT-PCR), were reduced on antigen administration, both i.v. and i.n. Neither regimen showed a regulatory effect on IL-4 production. As T helper 1 (Th1) cytokines seem to be important in the pathogenesis of CD, our data therefore highlight the potential of i.n. and i.v. routes for the design of useful immunomodulatory strategies for CD.

Cerebral tomographic findings in patients undergoing carotid endarterectomy for asymptomatic carotid stenosis: short-term and long-term implications.

PURPOSE: Preoperative cerebral imaging has been considered not to be cost-effective in carotid endarterectomy (CEA) for asymptomatic carotid stenosis. Yet, silent brain infarction (SBI) has been associated with the embolization potential of a severe carotid stenosis. Thus the presence of SBI may represent an additional indication for CEA in asymptomatic patients. We examined the predictive value of preoperatively detected silent cerebral lesions on early and late outcomes in patients undergoing CEA for asymptomatic carotid stenosis. METHODS: Preoperative cerebral tomographic (CT) scans performed on 301 asymptomatic patients undergoing 346 CEAs from 1986 to 1995 were reviewed by a single neuroradiologist blinded to patients' records. Mean follow-up was 67. 3 months (range, 24-130 months). The degree of internal carotid lumen reduction was measured bilaterally in all patients (602 carotid arteries); carotid stenosis of 60% or more was found in 399 carotid arteries. RESULTS: Of the 103 (34%) CT scans positive for cerebral lesions, 58% were lacunar. No significant association was observed between the side of the cerebral lesion on CT scan and the severity of the corresponding carotid stenosis; 38 silent lesions were detected in the 203 hemispheres ipsilateral to carotid stenoses that were less than 60% versus 95 SBIs in the 399 hemispheres ipsilateral to carotid stenoses that were 60% or more (19% vs 24%; P =.2). There were no significant differences in the perioperative stroke/death rate in patients with or without cerebral CT lesions (2% vs 1%; odds ratio, 1.94; P =.6). Mortality rate during follow-up was 22% in patients with preoperative SBI and 15% in patients without SBI (P =.1). However, actuarial survival at 10 years was shorter (P =.02) in patients with SBI. Late stroke occurred in 11% of patients with preoperative SBI and in 3% of patients without preoperative SBI (P =.006). Cox regression analysis showed that both preoperative lacunar and nonlacunar infarctions were independent predictors of late stroke (hazard ratio, 3.6; P =.04; and hazard ratio, 7.1; P =.001; respectively). CONCLUSION: In our experience, preoperative SBI did not occur more frequently in the hemisphere ipsilateral to asymptomatic severe carotid stenosis. Although our study lacks a medically treated control group, our data show that SBI is predictive of poor neurologic outcome in asymptomatic patients undergoing CEA. We conclude that CT before CEA, selectively applied, provides information on long-term neurologic prognosis and that a less aggressive attitude towards CEA in asymptomatic patients with SBI may be justified.

Increased concentrations of eosinophilic cationic protein in whole-gut lavage fluid from children with inflammatory bowel disease.

BACKGROUND: Eosinophils may be involved in the pathogenesis of inflammation in inflammatory bowel disease. The purpose of this study was to verify whether concentrations of eosinophilic cationic protein in gut lavage fluid from children with inflammatory bowel disease correlate with clinical and laboratory indexes of disease activity. METHODS: Twenty-three children with Crohn's disease, 14 with ulcerative colitis, and 22 age-matched control subjects entered the study. Radioimmunoassay and sandwich enzyme-linked immunosorbent assay techniques were used to measure eosinophilic cationic protein, total immunoglobulin G and interleukin-1beta, respectively. RESULTS: Gut lavage eosinophilic cationic protein levels were significantly (p < 0.005) higher in patients with Crohn's disease and ulcerative colitis than in control subjects. Intestinal eosinophilic cationic protein levels decreased in three of four children with Crohn's disease who were fed an elemental diet. There was a significant (p < 0.001) correlation between eosinophilic cationic protein concentrations and immunoglobulin G and interleukin-1beta levels in gut lavage fluid. CONCLUSIONS: Elevated intestinal eosinophilic cationic protein levels in inflammatory bowel disease suggest that eosinophils are involved in the gastrointestinal inflammation in this disease. Intestinal eosinophilic cationic protein concentration is another marker with which to discriminate between active and inactive inflammatory bowel disease.

Gut lavage IgG and interleukin 1 receptor antagonist:interleukin 1 beta ratio as markers of intestinal inflammation in children with inflammatory bowel disease.

BACKGROUND: Whole gut lavage is currently used as preparation before radiological or endoscopic examination of the large bowel. AIM: To validate the gut lavage technique for the assessment of mucosal inflammation, by measuring intestinal IgG and interleukin 1 beta (IL-1 beta) in the fluid obtained. PATIENTS: Sixteen children with Crohn's disease (CD), 14 with ulcerative colitis (UC), and 22 age matched controls. METHODS: Isotonic, non-absorbable polyethylene glycol based lavage solution was given orally or by nasogastric tube. Clear fluid was collected, filtered, and treated with protease inhibitors. IgG, IL-1 beta and IL-1-receptor antagonist (IL-1-ra) were measured by sandwich enzyme linked immunosorbent assay (ELISA). RESULTS: In patients with UC and CD, IgG and IL-1 beta levels were significantly (p < 0.001) higher than in controls. A positive correlation (p < 0.05) was found with disease activity scores. IL-1-ra levels were not significantly different in UC and CD, when compared with controls, but the IL-1-ra:IL-1 beta ratio was significantly (p < 0.01) lower in patients with UC and CD, and negatively (p < 0.001) correlated with IgG levels in lavage fluid. CONCLUSIONS: Gut lavage fluid IgG and IL-1 beta levels and IL-1-ra:IL-1 beta ratio may provide objective discrimination between active and inactive disease in children with inflammatory bowel disease.

Diagnosing Alzheimer's disease in very elderly patients. Relevance of some functional and psychobehavioral aspects assessed by the Gottfries-Bråne-Steen Rating Scale for Dementia. Study Group on Brain Aging, Italian Society of Gerontology and Geriatrics.

OBJECTIVES: To describe the Gottfries-Bråne-Steen (GBS) Rating Scale more fully with instruments commonly used for the diagnostic assessment of older patients with cognitive disturbances--the Mini Mental State Examination (MMSE), Hamilton Depression Rating Scale (HDRS), and Global Deterioration Scale (GDS)--and to characterize the specific diagnostic value of the GBS. DESIGN: A multicenter study including patients diagnosed with senile dementia of the Alzheimer type (SDAT; age at onset: > 75 years) and age-matched non-demented subjects. SUBJECTS: One hundred thirty-eight consecutively referred SDAT patients and 116 non-demented age-matched healthy subjects selected from among relatives of the patients. METHODS: The MMSE, GBS and HDRS were used for assessing patients and controls. The GDS was utilized for dementia staging. FINDINGS: Principal component analysis carried out on GBS scores yielded three factors explaining 74% of variance: factor 1, general functioning; factor 2, depression, and factor 3, restlessness. The actual composition of these factors was analyzed after computing factor scores for each subject by means of forward selection regressions, each using the MMSE, GDS and HDRS as predictors of scores on a given factor. The best predictors were MMSE and GDS scores for factor 1; HDRS for factor 2, and MMSE for factor 3. A GBS cutoff of 8 (obtained after a quality receiver operating characteristic analysis) best discriminated between demented and non-demented subjects (positive-predictive value: 0.88; negative-predictive value: 0.90). CONCLUSIONS: The GBS Rating Scale for dementia can be a useful tool in routine clinical assessment of older subjects with cognitive impairment and distinguishes between demented and non-demented subjects; it gives comprehensive information on functional and psychobehavioral characteristics of demented patients, being composed of factors related to the MMSE and HDRS.

Latent and potential coeliac disease.

Under the umbrella of coeliac disease (CD), or gluten-sensitive enteropathy, the concepts of silent, latent and potential CD have recently been introduced. While silent CD is marked by severe damage to the jejunal mucosa in the absence of clinical symptoms, both latent and potential CD are characterized by jejunal mucosa that would be reported as normal by most clinical pathologists in an individual on a gluten-containing diet. As opposed to potential coeliac patients, latent subjects sometimes in their life have had a flat jejunal biopsy which recovered on a gluten-free diet. Latent coeliac patients are often symptomatic; neither high titres of gliadin antibodies nor mucosal changes (including raised intraepithelial lymphocyte counts) are obligate features of latent CD, although the presence of elevated endomysial antibodies is probably the best predictor of progression towards villous atrophy. The term potential CD has been proposed for those subjects who do not have, and have never had, a jejunal biopsy consistent with overt CD, and yet have immunological abnormalities similar to those found in coeliac patients. Good markers of potential CD include the presence of serum endomysial antibodies, a high count of intraepithelial lymphocytes and subtle pathological alteration such as increased density of intraepithelial lymphocytes expressing gamma delta T cell receptor, signs of activated mucosal cell-mediated immunity, coeliac-like intestinal antibody pattern, and positive rectal gluten challenge.

Cerebral dural arteriovenous fistulas: percutaneous transvenous embolization.

PURPOSE: To evaluate angiographic and clinical results in patients with a dural arteriovenous fistula (AVF) who underwent percutaneous transvenous embolization. MATERIALS AND METHODS: Retrospective chart analysis and radiologic studies were performed in 24 patients (aged 20-87 years) with a dural AVF treated with percutaneous transvenous embolization. Lesions were located in the transverse and/or sigmoid or superior sagittal sinus. Clinical follow-up was 3-44 (mean, 10.8) months. RESULTS: After percutaneous transvenous embolization of 24 dural AVFs, there was complete occlusion in 17 patients, important flow reduction in three, and moderate flow reduction in four. Twenty patients were clinically cured, 17 with complete occlusion and three with important flow reduction. In patients with moderate flow reduction, clinical improvement was good in two and moderate in one. One patient remained clinically unchanged. A transient complication was seen in one patient, and a permanent complication was seen in one patient. One patient, whose preexisting clinical status was poor, died. During long-term follow-up, the condition of two patients worsened. CONCLUSION: Percutaneous transvenous embolization appears to be effective in the treatment of dural AVFs. More experience is needed to evaluate long-term results.

Defective 'gut processing' of gliadin in mice with graft-versus-host enteropathy.

The gut mucosa plays an important role in the induction of oral tolerance. Extending previous observations, we have here shown that serum containing gut-absorbed gliadin induces suppression of the specific systemic immune response in recipient mice parenterally immunized with gliadin. Graft-versus-host reaction (GvHR) has profound effects on the gut mucosa, representing a model of immune-mediated enteropathy. The aim of our work was to investigate the gut handling and processing of gliadin in mice with GvHR. Binding to enterocytes, passage through the epithelium, and ability of the epithelium to convert this antigen into a tolerogenic form were assessed in BDF1 mice weaned on gluten-free diet, 2 weeks after the induction of a semiallogeneic GvHR. Binding of gliadin peptide B3144 to enterocytes was similar in controls and GvHR mice. After feed, serum levels of gliadin were comparable in the two groups of mice, but when serum collected from GvHR mice and containing gut-absorbed gliadin was transferred intraperitoneally into naive recipient mice, this did not induce suppression of the specific immune response. These experiments indicate that during GvHR enteropathy the ability of the intestine to convert gliadin into a tolerogenic form is lost. Defective antigen gut processing may contribute to the observed failure in oral tolerance induction.

Post-treatment management options for patients with lung cancer.

OBJECTIVES: The first objective was to identify variations in patient management practice patterns after potentially curative lung cancer surgery. Patient management practice patterns were expected to range from intensive follow-up to no active surveillance. The second objective was to measure whether intensity of follow-up was related to patient outcomes. METHODS: An 18-month retrospective analysis was conducted of 182 patients with low TNM stage (< or = IIIA) lung cancer who were surgically treated with curative intent over the 11-year period from 1982 through 1992 at the St. Louis Department of Veterans Affairs Medical Center. RESULTS: Patients were followed for a mean of 3.3 years, until death or the end of the study. Analyses of diagnostic test and outpatient visit frequency distributions and cluster analyses facilitated the identification of 62 nonintensively followed patients and 120 intensively followed patients. Both groups were comparable at baseline, and there were no significant differences in patient outcomes attributable to intensity of follow-up. Intensively followed patients did, however, live an average of 192 days longer than nonintensively followed patients. CONCLUSIONS: Significant variations in follow-up practice patterns can exist within a single health care facility. In this analysis, variations in test and visit frequency did not result in statistically significant differences in patient outcomes, though the survival difference between groups suggests that some benefit might exist. Only well-designed prospective trials are likely to answer the question of what constitutes optimal follow-up after potentially curative lung cancer treatment.

Cerebrotendinous xanthomatosis (van Bogaert-Scherer-Epstein disease): CT and MR findings.

PURPOSE: To describe the CT and MR findings in the brain and spinal cord of patients with cerebrotendinous xanthomatosis and to seek possible correlations between clinical, biochemical (cholestanol levels), and neuroimaging findings. METHODS: Ten patients with well-defined clinical and biochemical diagnoses of cerebrotendinous xanthomatosis were examined. Brain CT was performed in eight cases. In all patients MR was obtained using spin-echo and gradient-echo sequences. In eight patients spine MR was also performed. RESULTS: Neuroradiologic findings included diffuse cerebral and cerebellar atrophy. In half the cases, atrophy of the brain stem and corpus callosum was also found. In the majority of patients cerebellar bilateral focal lesions and mild white matter signal alterations were present. Spinal cord MR did not show signal abnormalities or atrophy. CONCLUSIONS: We found cranial alterations in patients with severe neurologic impairment, but there was no correlation with cholestanol plasma levels. No spinal cord abnormalities were present.

Effects of gluten enriched diet on the small intestinal mucosa of normal mice and mice with graft versus host reaction.

This study looked at the effect of extra dietary gluten on the intestinal architecture of both normal mice and those with an ongoing mucosal delayed hypersensitivity reaction. BDF1 normal mice and mice in which a graft v host reaction (GvHR) had been induced, both weaned on gluten free diet, were allocated for three weeks to three different dietary regimens: gluten free, 'normal' (3.6% gluten), and gluten enriched (15.8% gluten). In normal mice receiving the gluten containing diet, shorter villi, deeper crypts, and higher crypt cell production rate were noted when compared with those receiving gluten free diet: these changes were more pronounced in those receiving the gluten enriched diet. GvHR mice showed shorter villi and an increase in both crypt length and crypt cell production rate when compared with normal mice, but the presence of gluten in their diet did not produce additional damage. Both in normal and in GvHR mice receiving gluten containing diet there were no signs of systemic (cell mediated or humoral) or mucosal immune reactions (raised intraepithelial lymphocyte counts or enhanced epithelial Ia expression) to gliadin. In conclusion, increasing the dietary gluten content produces significant changes in the mucosal architecture of normal mice; mice with GvHR enteropathy do not show additional damage resulting from dietary gluten.

Increased intestinal sugar permeability after challenge in children with cow's milk allergy or intolerance.

The diagnosis of cow's milk allergy or intolerance (CMAI) is based on clinical improvement on exclusion diet and relapse after challenge with milk. The aim of this work was to investigate the value of the cellobiose/mannitol (C/M) sugar permeability test, performed before and after cow's milk challenge, as a tool for the diagnosis of CMAI. Thirty-two patients underwent milk challenge at a median age of 13 months (range 3-84 months). A dual sugar (C/M) permeability test with an iso-osmolar solution was performed before and 24 h after challenge. Of the 10 patients who developed symptoms after challenge, nine showed increased postchallenge C/M ratio, whereas such an increase was observed in only one of the 22 nonrelapsed subjects. The postchallenge C/M ratio increase in relapsed subjects is to be attributed to both higher cellobiose and lower mannitol urinary excretion. These results suggest the use of the sugar permeability test, in addition to clinical observation, as an aid in the evaluation of provocation tests in infants with suspected CMAI.

Immunologic and intestinal permeability tests as predictors of relapse during gluten challenge in childhood coeliac disease.

Fifteen children with an initial diagnosis of coeliac disease underwent gluten challenge either because they had never had a jejunal biopsy or because they had had one during the first 2 years of life. The challenge was preceded by a biopsy; clinical symptoms, the cellobiose/mannitol permeability test, and gliadin and endomysial antibody measurement were used to determine the timing of the confirmatory biopsy: it was performed if one test result was repeatedly abnormal or two results were concomitantly abnormal. Gliadin antibodies increased early (already 7 days after the reintroduction of gluten to the diet), but in many cases they returned to normal values thereafter. Increased intestinal permeability to sugars and even more positivity of endomysial antibody were good predictors of histologic relapse. The sequential use of laboratory tests during gluten challenge may significantly shorten its duration.

[Voluntary dilating pneumosinus (secondary hernia)]. / Pneumosinus dilatans voluntario (hernia secundaria).

In the present work authors describe an unusual case of pneumosinus dilatans caused willingly by a patient himself operated on a frontal-ethmoidal mucocele. They take the opportunity to summarize what it is known about the etiopathogenesis and the form of display of this uncommon disease.

[Ureteral calculi: comparison of echographic and radiologic scanning]. / Calcolosi ureterale: sistemi di puntamento ecografico e radiologico a confronto.

The ureteral calculi can be treated, today in situ with extracorporeal shock wave lithotripsy. In our study we have used three different lithotriptors, two with fluoroscopic scanning, one with ultrasound scanning. The patients we have treated with ultrasound scanning lithotriptor Dornier MPL 9000 were 48 (22M-26F), while 210 patients were treated with fluoroscopic scanning lithotriptor, respectively 23 (15M-8F) with Direx Tripter XI and 187 with Dornier HM3. The ureteral calculi were so localized: among the patients treated with ultrasound scanning lithotriptor 16 presented calculi in the upper third ureter between GPU and L3, 9 in the middle third ureter between L3 and the superior border of sacroiliac articulation, 9 in pelvic tract above the spinoischiatic line, 6 between this line and juxtabladder ureter and 8 in juxtabladder ureter. Among the patients treated with fluoroscopic scanning lithotriptors all together 58 presented calculi in the upper third ureter between GPU and L3, 29 in the middle third ureter between L3 and the superior border of sacroiliac articulation, 13 in the iliac tract of the ureter, 41 in pelvic tract above the spino-ischiatic line, 27 between this line and juxtabladder ureter and 42 in juxtabladder ureter. For every treatment the number of shock waves was 2500 and the number of treatments for every patients was 1, 3. We report 82% of patients stone-free at a follow up of three months for the patients treated with the MPL 9000, 87% of patients stone-free for Direx Tripter XI and 85% of patients stone-free for Dornier HM3.(ABSTRACT TRUNCATED AT 250 WORDS)