[Chemosensitivity of Plasmodium falciparum in Sainte Marie island, east coast of Madagascar: in vivo and in vitro studies]. / Sensibilité de Plasmodium falciparum dans l'île de Sainte Marie, côte Est de Madagascar: études in vivo et in vitro.

In order to document the evolution of the chemoresistance of Plasmodium falciparum to chloroquine in Madagascar, a study was carried out in Sainte-Marie island located at 6 km on the eastern border of the country. Symptomatic malaria patients who satisfied criteria for resistance testing, were recruited by a process of passive case detection at two clinics. These patients were enrolled in a sensitivity 14-day in vivo test for uncomplicated P. falciparum malaria attacks. All subjects received a supervised therapeutic regimen of chloroquine (25 mg base/kg over 3 days). Parasitemia and symptoms were monitored for 14 days. 62 (93.9%) out of the 66 enrolled patients completed the 14-day follow-up. A total of 50 of 62 patients (80.6%) presented an adequate clinical response. Early and late treatment failures were observed in 3 (4.8%) and 9 (14.5%) patients respectively. Failure therapeutic treatments treated with sulfadoxine-pyrimethamine were successful. Chloroquine remains effective in the treatment of malaria due to P. falciparum and therefore its choice as a first line drug remains justified. Likewise, guidelines for the use of sulfadoxine-pyrimethamine as second line drug are adequate. In vitro, 4 resistances out of 27 successful tests to chloroquine (14.8%) and 1 resistance out of 25 successful tests to mefloquine (4%) were recorded. No resistance to quinine nor to amodiaquine were noticed. Alternative antimalarial drugs such as quinine, amodiaquine or mefloquine can be used in patients for whom the treatment with chloroquine is not possible. Nevertheless, the level of therapeutic failures to chloroquine detected in this study highlights the need and importance of drug sensitivity test for the development of a rational national antimalarial drug policy.

Piezoelectric lithotripsy of ureteral stones: influence of shockwave frequency on sedation and therapeutic efficiency.

OBJECTIVE: The aim of this randomized study was to assess the relation between shockwave frequency, sedation, and efficiency in piezoelectric extracorporeal shockwave lithotripsy (SWL) for ureteral calculi. METHODS: A random sample of 114 patients aged between 15 and 74 (mean 45) years were treated at the shockwave frequencies of 1 (N = 57) or 4 (N = 57) per second using the EDAP LT 02 lithotripter at maximum energy. The stones' largest diameter ranged from 5 to 18 mm (mean 7.6 mm). Lower ureteral stones were treated with the patient in the prone position and upper ureteral stones in supine position. The duration of SWL sessions and stone measurements were statistically similar for patients treated at low and high frequencies. The levels of required sedation (none, intramuscular analgesia, intravenous sedation-analgesia) and stone-free rates after one session were analyzed by Student's t-test or Fisher's exact test. RESULTS: Sedation did not differ statistically with SWL frequency for mid and lower ureteral calculi. However, the use of intravenous sedation-analgesia was less common for patients with upper ureteral stones treated at low rather than high frequency (19% and 100%, respectively; P < 0.0001). The success rate was significantly lower (P = 0.04) for lower ureteral calculi treated at low v high frequency (65 % and 89%, respectively) but was not statistically affected by frequency for upper ureteral stones. CONCLUSION: We recommend high frequency for piezoelectric SWL of lower ureteral calculi, especially for stones with a maximum diameter > or =8 mm. On the other hand, low-frequency SWL appears to be suitable for the treatment of upper ureteral stones.

[Urologic management of cystine lithiasis in the upper urinary tract. Modalities and indications]. / Prise en charge urologique de la lithiase cystinique du haut appareil urinaire. Modalités et indications.

Cystine urinary stones is a relatively rare hereditary disorder of dibasic amino acid transport characterized by frequent recurrences. The management of these stones remains problematical despite the remarkable progress in the urological treatment of upper urinary tract stones. Cystine stones are particularly refractory to extracorporeal shock waves and relatively inaccessible to dye pulsed laser (504 nm). Apart from this exception, endourological techniques often represent the most appropriate therapeutic solution, but they are associated with significant morbidity. The physicochemical characteristics of these stones also allow dissolution by urinary alkalinization or the formation of disulfide compounds. In parallel with oral treatments, which constitute the basis of prevention of recurrence, dissolution can be obtained by direct perfusion of the urinary tract. This approach often requires irrigation for several weeks with a risk of the specific complications of catheterization, especially percutaneous catheterization. Prophylaxis, essentially consisting of dilution and dissolution of urinary cystine, raises the problem of the potential adverse effects of drug treatment. Cystinuria is easily detectable and can be investigated either systematically or only in the families concerned. However, the incidence as well as the frequently benign nature of cystinuria tend to limit its value and its indications.

Piezoelectric extracorporeal shock-wave lithotripsy of lower pole nephrolithiasis.

OBJECTIVE: To evaluate the efficacy of the EDAP LT 02 lithotriptor for the treatment of lower pole nephrolithiasis. METHODS: From January 1994 to September 1995, 91 patients presenting with solitary radiopaque calculi of the lower pole calix were treated by piezoelectric extracorporeal shock-wave lithotripsy (ESWL) with the EDAP LT 02. Among them, 82 were available for follow-up. The stones' largest diameter of these patients varied from 5 to 15 mm (mean = 8.1). Indications for ESWL were pain in 63 (77%), hematuria in 5 (6%), associated infection in 6 (7.5%) and stone size in 8 (10%) asymptomatic patients. Stone localization was assessed as very easy in 74 cases (90%) and difficult in 8 cases (10%) but no intraoperative IVP was needed. ESWL sessions were performed with intravenous sedo-analgesia in 69 cases (80%) and general anesthesia in 17 cases (20%). After ESWL we advised patients to combine a diuresis with postural drainage. RESULTS: Most patients were treated with one session of ESWL: none required more that two (mean = 1.05). The mean hospital stay for one session was 1.2 +/- 0.7 days. Obstructive complication rate was 11% and auxiliary treatments were necessary in 6%. The stone-free rate of in situ piezoelectric ESWL monotherapy was overall 84%, and 95% of patients with pain were cured. CONCLUSION: In the absence of abnormality of the upper urinary tract, the vast majority of small lower pole caliceal stones can be completely removed by piezoelectric ESWL without recourse to more invasive methods.

[Piezoelectric extracorporeal lithotripsy of calculi of the median ureter (EDAP LT 02)]. / La lithotitrie extra-corporelle piézo-électrique des calculs de l'uretère moyen (EDAP LT 02).

OBJECTIVE: To evaluate the performance of in situ piezolectric extracorporeal shock-wave lithotripsy (ESWL) in the middle part of the ureter. MATERIAL AND METHODS: 36 consecutive patients presenting with stones of the middle part of the ureter were treated by in situ piezoelectric ESWL (EDAP LT 02). The maximal dimensions of the stones ranged from 5 to 14 mm (m = 7.8). Moderate or severe ureterohydronephrosis was present in 19 cases (53%) and a double J stent had been previously implanted in 6 cases (17%). The ESWL sessions were performed in the ventral supine position without any anaesthesia or systematic premedication, but an IM injection of 100 mg of pethidine was administered during poorly tolerated treatments. RESULTS: The stone was located easily in 23 cases (64%) and with greater difficulty in 13 cases (36%), as an intraoperative intravenous injection of contrast agent was performed in 6 cases (17%). The number of sessions per patient ranged from 1 to 2 (m = 1.16). The complete sucess rate was 75%, with a 64% success rate after a single ESWL session. The performances were statistically independent of stone dimensions and the degree of obstruction of the urinary tract. The complication rate was 5.5%, but no ancillary endoscopic or percutaneous treatment was required. CONCLUSION: In situ piezoelectric ESWL allows effective management of most stones of the middle part of the ureter. However, the treatment of stones with a maximal diameter < 5 mm, especially poorly radiopaque stones, can raise problems of localization. Very large or impacted stones, especially when complicated by urinary tract infection, should be preferably treated by first-line ureteroscopy.