Individuals' leukocyte DNA double-strand break repair as an indicator of radiosurgery responses for cerebral arteriovenous malformations

To evaluate the feasibility of using radiosensitivity of peripheral leukocytes as a predictor of clinical therapeutic responses to radiosurgery in individuals with cerebral arteriovenous malformation (AVM), we enrolled 18 patients years after they had received Gamma Knife radiosurgery for their cerebral AVM. The AVMs were shown with different degrees of regression in size in posttherapeutic periods. The peripheral leukocytes of these patients were collected at the last neuroimaging follow-ups. The leukocytes, before and 1 and 2 h after 8 Gy external gamma-irradiation, were evaluated for the amounts of DNA double-strand breaks (DSB) in 50 randomly selected individual nuclei by the neutral single cell gel electrophoresis, or so-called comet analysis. After being adjusted for gender and age at radiosurgery, the individuals with less posttherapeutic regression in AMV sizes or relatively poor or inadequate responses to radiosurgery were shown to have significantly higher DSB repair capacity on their leukocytes by comet analysis. These results suggested that in vitro radiosensitivity of peripheral leukocytes may provide valuable information for predicting therapeutic response or for adjusting irradiation doses in AVM radiosurgery.     

Extra-anatomic bypass grafting for vascular occlusive disease in the upper and lower extremities

Twenty-four patients with poor risk factors underwent an extra-anatomic bypass operation for aortoiliac occlusive disease and subclavian steal syndrome. A femoro-femoral bypass was performed on 5 patients, an axillo-femoral bypass on 15, a subclavian-subclavian bypass on 2 and an ascending aorta-femoral bypass on 2. There was only one operative death and there were 2 late deaths (8.3%). The patients were 20 males and 4 females with a mean age of 69.3 years. Among risk factors, high age (70 year old) was present in half of the patients, ischemic heart disease in 9, and cerebral vascular disease in 8. Seventy-five percent of the patients were suffering from two or more dysfunctions. During the limited follow-up period from 8 to 94 months (mean 46.1 months) there was a 96% patency rate. We had good results using externally supported ring graft and by the administration of prostaglandin E1 and ticlopidine during the pre and postoperative period.     

Speech activation SPECT measurements in the determination of hemispheric dominance

Cognitive activity leads to an increased regional cerebral blood flow (rCBF) and energy metabolism in both cerebral hemispheres. In order to assess the reliability of rCBF-SPECT measurements in hemispheric dominance (Broca's area) speech activation SPECT studies were performed in nine patients. Patients (men, n = 6; women, n = 3, mean age: 33.8 +/- 13.8 years) with diagnosis of epilepsy (n = 7) and AVM (n = 2) participated in the preoperative study. Two SPECT studies were performed in each case, one in rest, and one during speech activation. 740 MBq of 99mTc-HMPAO/ECD was injected and stereo TCD monitoring was performed during the three minutes of speech activation. The acquisition was performed by a dual-head ADAC Solus Epic Atlas SPECT camera (ADAC Laboratories, Milpitas, USA). RCBF SPECT measurements were analyzed visually and by a special region-of-interest (ROI) program. The hemispheric dominance profiles were established on the basis of the respective blood flow velocity values obtained by fTCD and cortical hyperperfusion measured by SPECT. The neuropsychological test battery, used in the present study, was developed in our institute. The results of rCBF-SPECT studies highly correlated with the lateralization of hemispheric dominance measured by fTCD. There was a significant increase of rCBF in the inferior posterior frontal cortex (Broca's area, p < 0.0003). The non-invasive speech activation rCBF-SPECT measurement is a highly reliable and useful method in the determination of hemispheric dominance. SPECT studies are especially useful in cases where the performance of fTCD measurements are impossible due to the lack of temporal bone window or occlusive cerebral arterial disease.     

Brain manganese deposition and blood levels in patients undergoing home parenteral nutrition

BACKGROUND: Extrapyramidal syndrome and alterations in brain magnetic resonance images are described in patients undergoing long-term home parenteral nutrition (HPN) and in cholestatic patients. These abnormalities have been correlated to basal ganglia manganese (Mn) accumulation. METHODS: A longitudinal 1-year study was conducted on 15 patients undergoing HPN (median duration, 3.8 years; range, 1.7-10; median Mn parenteral supplementation, 0.1 mg/d). Whole-blood, plasma, intra-erythrocytes, and urinary Mn concentrations were measured and brain magnetic resonance was performed at the beginning (time 0) and after 1 year of Mn intravenous supplementation withdrawal (time 1). No patients showed psychosis, extrapyramidal syndrome, or cholestasis. RESULTS: At time zero, 10 of 15 patients (67%) showed paramagnetic accumulation on cerebral magnetic resonance images; at time 1 there was a reduction of cerebral Mn accumulation. In all patients, blood-Mn levels were significantly reduced after 1 year of Mn intravenous supplementation withdrawal. CONCLUSIONS: Patients receiving long-term HPN showed an elevated incidence of alterations in brain magnetic resonance images with a median Mn intravenous supplementation of 0.1 mg/d. Mn supplementation withdrawal significantly decreased metal levels in blood and brain storage. We noticed that the intra-erythrocyte Mn level was a good index of Mn status.     

Intracranial arteriovenous malformations in pregnant women]

Three women, aged 27, 32 and 30 years, respectively, suffered from headache, nausea and neurological abnormalities and were found to have an intracranial arteriovenous malformation (AVM). One of them after diagnosis had two pregnancies, both ended by caesarean section with good results. Another woman was 32 weeks pregnant when the AVM manifested itself with a haemorrhage; she recovered well and was delivered by caesarean section. After the AVM proved radiologically to have been obliterated, she delivered after her subsequent pregnancy by the vaginal route with vacuum extraction. The third woman was 15 weeks pregnant when major abnormalities developed. There was a large intracerebral haematoma with break-through to the ventricular system; this patient died. Intracranial haemorrhage during pregnancy is rate. It can result in maternal and foetal morbidity and mortality. It appears that pregnancy does not increase the rate of first cerebral haemorrhage from an AVM. The management of AVM rupture during pregnancy should be based primarily on neurosurgical rather than on obstetric considerations. Close collaboration with a team of neurologists, neurosurgeons, obstetricians and anaesthesiologists is mandatory.     

Store-and-forward teleneurology in developing countries

We assessed the feasibility of a store-and-forward email teleneurology service between a UK neurologist and a rehabilitation hospital in Bangladesh. Over 12 months, email advice was requested for 12 patients (mean age 43 years, range 15-57 years). Each patient generated an average of 5.2 email messages. Eight cases were considered complicated by the neurologist, who would have preferred a video-link consultation for these. The referring doctor found the neurologist's advice beneficial in 75% of the complex cases and in all of the more straightforward cases. Patient care was changed in 50% of the cases as a result of the specialist advice and one patient transfer out of the country was avoided. Store-and-forward teleneurology is effective for delivering expert neurological advice.     

Good results after closure of a arterial septal defect during heart catheterisation instead of surgery

OBJECTIVE: Evaluation of the first results in the Netherlands of percutaneous and transvenous closure of an ASD II in children with an Amplatzer Septal Occluder (ASO). DESIGN: Prospective. METHOD: Data were collected from children with an ASD II prior to, during and up to 24 months after the insertion of an ASO during heart catheterisation in Leiden University Hospital, the Netherlands. RESULTS: Between 1 January 1998 and 29 February 2000, 28 patients (12 girls, 16 boys; mean age: 74 months (range: 15-198 months)) underwent heart catheterisation to close an ASD II with an ASO. In 26 patients an ASO could be placed without significant complications. The size of the device varied from 9-34 mm (median 16 mm). In one patient ASD closure was not attempted because of multiple ASDs. In another patient the procedure was stopped after air embolism into the coronary arteries had occurred during preparation of ASO implantation. In 23/26 patients with an implanted ASO, no residual shunt was present after 24 hours. One child, in whom the defect was found to be closed after 24 hours and after three weeks, returned abroad and was lost to follow-up. After one year all defects (n = 22) were completely closed. CONCLUSION: Percutaneous transvenous closure of an ASD II with an ASO was possible, was not associated with any significant complications and had a high success rate, even in relatively young children with large defects.     

Prognosis of infectious endocarditis

OBJECTIVE: To study clinical course and prognostic factors of infective endocarditis. PATIENT AND METHODS: Infective endocarditis was identified in 126 consecutive patients (criteria of DURACK). Of these, 73 were male, mean age was 29.9 + 15 years, 98 (77.7%) had past history of cardiac disease. The evolution has been marked by 38 deaths (30%) in spite of the recourse to surgery (69 patients). The mean follow-up period was 52 months, the event-free survival was 61% at 5 years. RESULTS: By univariate analysis the predictors of bad prognosis: Large vegetations > 10 mm, delay of apyrexia > 10 days presence of a neurological accident and the absence of surgical treatment. Multivariate analysis: Vegetation > 10 mm (OR 1.97, 1-4.1, p = 0.05), presence of a neurological accident (OR:2.76, 1.32-5.76, p = 0.007) and the absence of surgical treatment (OR: 5.03, 2-11.4, p < 0.001). CONCLUSION: Infective endocarditis remains a serious affection, identification of patients with poor prognosis should lead to early surgical referral: this attitude provides good immediate and long-term results.     

Neurological long term consequences of deep diving.

Forty commercial saturation divers, mean age 34.9 (range 24-49) years, were examined one to seven years after their last deep dive (190-500 metres of seawater). Four had by then lost their divers' licence because of neurological problems. Twenty seven (68%) had been selected by neurological examination and electroencephalography before the deep dives. The control group consisted of 100 men, mean age 34.0 (range 22-48) years. The divers reported significantly more symptoms from the nervous system. Concentration difficulties and paraesthesia in feet and hands were common. They had more abnormal neurological findings by neurological examination compatible with dysfunction in the lumbar spinal cord or roots. They also had a larger proportion of abnormal electroencephalograms than the controls. The neurological symptoms and findings were highly significantly correlated with exposure to deep diving (depth included), but even more significantly correlated to air and saturation diving and prevalence of decompression sickness. Visual evoked potentials, brainstem auditory evoked potentials, and magnetic resonance imaging of the brain did not show more abnormal findings in the divers. Four (10%) divers had had episodes of cerebral dysfunction during or after the dives; two had had seizures, one had had transitory cerebral ischaemia and one had had transitory global amnesia. It is concluded that deep diving may have a long term effect on the nervous system of the divers.     

Clinico-laboratory study of methylprednisolone and cyclophosphamide treatment in patients with multiple sclerosis relapse

INTRODUCTION: The effect of combined treatment (methylprednisolone and cyclophosphamide) of multiple sclerosis relapse within one year was investigated in an open clinical trial study of 70 patients. The sample comprised subjects shown to have clinically proven multiple sclerosis according to the criteria of C Poser and degree of neurological deficit according to EDSS rating from 2.5 to 6.0 points. MATERIAL AND METHODS: Methylprednisolone (200 mg, i.v., every other day, 10 doses, total course dose 2 g) was administered to 35 patients (mean age 31.34 +/- 1.53 years). Methylprednisolone using the same schedule and cyclophosphamide (200 mg, i.v.) given in the methylprednisolone-free day, 10 doses plus 200 mg i.v. once a month in the first three consecutive months (total course dose 2.6 g) were applied in another 35 patients (mean age 33.22 +/- 1.32 years). RESULTS AND DISCUSSION: The changes of EDSS ratings at the end of months 1 and 12, of the CD+ T-lymphocytes subpopulations and B-lymphocytes from peripheral blood--prior to treatment and between the 5th and 9th week of treatment were compared. The neurological deficit degree according to EDSS dropped significantly (P < 0.01; P < 0.001) after one month of treatment in both groups. At the end of month 12 this indicator reached its baseline value in the group treated only with methylprednisolone while remaining significantly lower in the combined therapy group (P < 0.01). After methylprednisolone and cyclophosphamide application the suppressor/inducer CD8+ T-cells increased significantly in percentage (P < 0.05), while the values of B-lymphocytes decrease significantly (P < 0.05), in contrast to the results from the methylprednisolone-only treatment. CONCLUSIONS: The results clearly indicate the greater efficaciousness of treatment by combining two immunosuppressive drugs.     

Neurological long term consequences of deep diving

Forty commercial saturation divers, mean age 34.9 (range 24-49) years, were examined one to seven years after their last deep dive (190-500 metres of seawater). Four had by then lost their divers' licence because of neurological problems. Twenty seven (68%) had been selected by neurological examination and electroencephalography before the deep dives. The control group consisted of 100 men, mean age 34.0 (range 22-48) years. The divers reported significantly more symptoms from the nervous system. Concentration difficulties and paraesthesia in feet and hands were common. They had more abnormal neurological findings by neurological examination compatible with dysfunction in the lumbar spinal cord or roots. They also had a larger proportion of abnormal electroencephalograms than the controls. The neurological symptoms and findings were highly significantly correlated with exposure to deep diving (depth included), but even more significantly correlated to air and saturation diving and prevalence of decompression sickness. Visual evoked potentials, brainstem auditory evoked potentials, and magnetic resonance imaging of the brain did not show more abnormal findings in the divers. Four (10%) divers had had episodes of cerebral dysfunction during or after the dives; two had had seizures, one had had transitory cerebral ischaemia and one had had transitory global amnesia. It is concluded that deep diving may have a long term effect on the nervous system of the divers.     

Percutaneous endoscopic gastrostomy in 41 patients: indications and clinical outcome.

Percutaneous endoscopic gastrostomy, under local anaesthetic, was successfully used in 40 out of 41 patients referred for nutritional support. The indications were neurological disorders of swallowing in 32 patients, head and neck cancer in four patients and supplemental feeding in a miscellaneous group of five patients. The main complications of this procedure were one failed insertion and one peritubal infection. At prospective follow-up, the tube continued to function in 16 patients (seven at home) a mean of 184 days post-insertion (range 6-610 days). In 11 patients resumption of swallowing at a mean of 122 (20-390) days allowed tube removal. Thirteen patients died from their disease, a mean of 96 (12-320) days post-insertion. Patient tolerance and patient and carer satisfaction have been excellent and early results suggest that recovery of speech and swallowing in acute neurological disorders may be enhanced. Percutaneous endoscopic gastrostomy should be performed in all patients referred for a gastrostomy and should be considered in all patients requiring long-term tube feeding.     

Encephalopathy and polyneuropathy induced by organic solvents

Twenty-six patients with previous heavy exposure to organic solvents were admitted to a neurological department during a 1 1/2 year period. They were studied with a battery of tests, including general medical and neurological examinations, neuropsychological tests, electroencephalography (EEG) and neurography with electromyography (EMG), and cerebral computerized tomography (CT). The presenting complaints were compatible with encephalopathy and/or polyneuropathy. When patients with alternative diagnosis were excluded, 17 patients (65%) of the initial group were diagnosed as belonging to the organic solvent syndrome. These patients had a mean time of solvent exposure of 23.9 years, ranging from one to 45 years. EEG and cerebral CT showed minor deviations only as did the neurological examination. These methods proved nevertheless of importance in excluding alternative etiologies. Neuropsychological test performances were markedly reduced, especially short-term memory. All patients were injured by occupational exposure to organic solvents, most often from painting and lacquering. Encephalopathy was a more frequent finding than polyneuropathy, and most often classified as slight or marked, whereas severe encephalopathy was not found in the present group.     

Resting energy expenditure and nutritional state in patients with liver cirrhosis before and after liver transplantation

Resting energy expenditure (REE), body composition, and the biochemical parameters of liver function were measured in 26 patients before and 432 days (range: 103-1022 days) after liver transplantation (LTX). PreLTX REE was variable (mean: 1638 +/- 308 kcal/day, range: 1220-2190 kcal/day or +10 +/- 11% of Harris Benedict = HB prediction, range: -19 - +33%) and was closely related to body cell mass (r = 0.66, p < 0.0003). PostLTX REE was variable (mean: 1612 +/- 358 kcal/day, range: 1010-2490 kcal/day or +5 +/- 15% of HB prediction, range: -20 - +37%) and was closely related to body cell mass (r = 0.65, p < 0.0006). When compared with preLTX values only small changes in mean REE (-71 +/- 43 kcal/day) and a close correlation between pre and postLTX REE (r = 0.82, p < 0.001) were observed. In contrast to REE, changes in body weight were highly variable (-16.5 - +32.7 kg/year). This variance was not explained by the number of postoperative complications, pre and postLTX liver function, possible graft rejection and/or hepatitis reinfection. Pre-operative hypermetabolism (i.e. REE >+20% of HB prediction) was associated with postoperative hypermetabolism and a reduced liver function before and after LTX. Hypermetabolic patients had a poorer nutritional outcome after LTX (weight change: 0 +/- 8.4 kg/year) when compared with normometabolic controls (weight change: +5.7 +/- 7.4 kg/year; p < 0.05). There was no significant association between deviations in pre and postLTX REE and changes in body weight. When corrected for changes in the nutritional state our data provide evidence for the persistence of resting energy expenditure in liver transplant patients.     

A study of a single high potency multivitamin preparation in the management of cystic fibrosis

Background: ADEKs® is a new multivitamin preparation formulated specifically for cystic fibrosis (CF) patients, containing all four fat-soluble vitamins. There is no data currently available on its use in CF. Method: We carried out a retrospective study to evaluate ADEKs® in 54 CF patients attending the specialist CF Unit at Nottingham City Hospital. Plasma vitamin A and E levels were collected from annual review reports when taking ADEKs® and a year previously when using other vitamin preparations. Dietary assessment data was available for 24 of these patients (11 children, 13 adults). Results: ADEKs® was taken for a median of 9.5 months by 19 children (mean age 11.3 years; range 7–15 years) and for 4 months by 35 adults (mean age 24 years; range 17–36 years). Median plasma vitamin A levels were significantly higher ( P <0.05) for all age groups (27% increase for 7–10 year olds, 48% increase for 11–15 year olds, 100% increase for 16+ year olds) following the change from other vitamin supplements to ADEKs®. Median plasma vitamin E levels were also significantly higher (59% increase for 7–10 year olds; 16% increase for 11–15 year olds; 26% increase for 16+ year olds). Fifteen (28%) and 9 (17%) patients went from below to within the normal plasma reference range for vitamins A and E, respectively, when changed onto ADEKs®. Four (7%) and 11 (20%) patients had values above the normal plasma range for vitamins A and E, respectively, whilst on ADEKs®. Conclusion: This study suggests that ADEKs® tablets are useful for CF patients aged over 10 years as plasma vitamin A and E levels were improved. The use of a single vitamin preparation such as ADEKs® is likely to improve compliance. We have reservations over its use amongst the 7–10 year olds because of high plasma vitamin A (3/9) and E (7/9) levels, although further research may ultimately endorse its future use within this group.     

Pulmonary vest therapy in pediatric long-term care

OBJECTIVES: Pulmonary infections are common in children with quadriplegic cerebral palsy. High frequency chest wall oscillation with the vest therapy (VT) is used to promote pulmonary clearance and to prevent pneumonias in cystic fibrosis patients. The purpose of this study was to ascertain the effectiveness of VT in patients with quadriplegic cerebral palsy who reside in pediatric skilled nursing facilities. METHODS: Seven individuals with quadriplegic cerebral palsy, who had frequent pulmonary infections were identified (age range: 7-28 years; median 19 years; 2 females and 5 males). Five had a tracheostomy and three an active seizure disorder. Clinical data was collected for 12 months before starting VT and during 12 months of VT. RESULTS: The total number of pneumonias that required antibiotics decreased from 36 per year before VT, to 18 during the year of VT (P < 0.05). The number of hospitalizations due to pneumonia decreased from 9 to 3. With VT, the frequency of effective suctioning of pulmonary secretions was significantly increased (P < 0.01). In the patients with epilepsy, with VT, the average monthly frequency of seizures decreased from 4 to 1, from 9 to 2, and from 9 to 1. CONCLUSION: VT resulted in more effective suctioning of pulmonary secretions, reduced incidence of pneumonia, and reduced number of hospitalizations for pneumonia. In patients with epilepsy, VT resulted in reduced seizure frequency. VT was tolerated well, without complications or side effects. Further clinical investigations of the use of VT in cerebral palsy are indicated.     

An epidemiological study of rotavirus diarrhoea in a cohort of Nigerian infants: II. Incidence of diarrhoea in the first two years of life

In a community-based prospective study of diarrhoeal diseases carried out in Ibadan, 131 infants were selected at birth. The maximum possible length of follow-up ranged from 16 to 24 months. Weekly surveillance for diarrhoea was carried out at home by Primary Health Care workers. Each child was also required to attend a monthly clinic. Of the 131 babies, 95 (73%) completed at least one year of follow-up. All of these had at least one episode of diarrhoea within the first year of life. The incidence rate of diarrhoea in the first year of life was 3.2 cases/child/year. The mean duration of diarrhoea days in the first year of life was 16 per child per year (range 3-34 days). The peak incidence of diarrhoea and the greatest number of diarrhoea days were in the age interval 6-9 months. The mean duration of diarrhoea was five days per episode. Faecal samples for 280 diarrhoea episodes during the first year of life were examined for rotavirus using the ELISA technique: 22 (7.7%) were found to be positive. The mean duration of rotavirus diarrhoea episodes was eight days.     

Central nervous system tuberculosis in adult patients

Central nervous system tuberculosis is the fifth most frequent and at the same time most severe form of extrapulmonary tuberculosis diseases. It presents with no typical signs, thus early diagnosis and treatment is of high importance concerning the outcome. Authors present the characteristics, diagnostic and therapeutic alternatives of central nervous system tuberculosis through a case report and a retrospective study of 15 patients. Patients and methods: Authors performed a retrospective analysis of medical records of patients with central nervous system tuberculosis in an academic teaching hospital (Department of Neurology and Infectious Diseases, United Szent István-Szent László Hospital, Budapest, Hungary). Results: Median age of patients was 54.5 years, and 6 (40%) were females. Cerebrospinal fluid findings at admission showed elevated protein (1.54 g/l; 95% confidence interval (CI): 1.01-2.05), cell count (mean: 337/μl; CI: 171.9-502.5), and decreased glucose index (0.32; CI: 0.15-0.52). 14 patients (93.3%) had hyponatremia. Average duration of symptoms were 16.3 days (1-40). On physical examination meningeal irritation was absent in 9 patients (60%). On admission headache and altered consciousness was present in 53%, while headache, fever, nuchal rigidity was present in only 33.3%. Diagnosis was culture and/or PCR confirmed in 46.7% of the cases. Two third of patients were followed-up at least for one year, and nine patients presented neurological sequel. Authors found that patients with central nervous system tuberculosis present with unspecific symptoms, but later progressive disorientation, cranial nerve palsies and convulsions may develop. Headache and altered consciousness proved to be the leading symptoms among these patients. Even today, diagnostic gold standard procedure is cultivating M. tuberculosis on solid and liquid medium. The polymerase chain reaction, which is known to have sensitivity between 27% and 86%, was positive in two of eight samples. Revealing predisposing factors (immunodeficiency, HIV infection, previous tuberculosis exposure) promotes setting up early diagnosis. Co-administration of four antituberculotic drugs for 12 months cured all patients, but authors note that even in cases with early diagnosis and optimal treatment various neurological impairment and seldom death can occur. Conclusions: Central nervous system tuberculosis is a rare but regularly emerging disease with unspecific signs and symptoms. The diagnosis may be difficult. It should be considered as a differential diagnostic issue in patients with uncharacteristic subacute conditions with headache, disorientation, elevated protein and low glucose in cerebrospinal fluid.     

Recurrence of epidermoid cyst in the third ventricle. Case report

The authors present the case of a 34-year-old man. The patients was admitted for the second time in the clinic. A year before an epidermoid cyst of the third ventricle, obstructing the two foramen Monroe and causing acute hydrocephaly, was surgically removed. In the operative intervention a cerebral fenestration of the lateral cerebral ventricle was performed and the epidermoid cyst was totally extirpated through the right foramen Monroe under operative microscope. The patient was discharged in excellent state, without complaints and neurological symptoms. The patient received attacks of severe headaches, staggering gate and double vision two months before his second admission. The neurological examination revealed paresis of left nervus abducens, staggering gait and pronounced psychic symptoms. The computed tomography of the brain revealed cystic formation, 3.4 cm in diameter, in the front part of the third cerebral ventricle. The intervention was performed after preoperative management of the patient and a cystic tumor with the histologic characteristics of an epidermoid cyst was totally extirpated under operative microscope, using the same approach as in the first operation. The patient was discharged in good state without complaints and no abnormalities detected in the neurological status.     

Extracorporeal shock wave lithotripsy of pancreatic stones as a part of complex endoscopic therapy

INTRODUCTION: The authors report on ESWL treatment of 29 patients suffering from pancreatolithiasis. PATIENTS/METHODS: The mean age was 46.5 (23-76) years, there were 7 women and 22 men. The etiology of chronic calcifying pancreatitis was alcohol in 24 (82.7%) cases, idiopathic in 3 (10.3%) patients and there was one familiar and one pancreas divisum case. The indication of ESWL was abdominal pain in 27/29 (93.1%) cases. During ERCP pancreatic sphincterotomy was performed and a nasopancreatic catheter was placed for a continuous lavage with isotonic citrate at a rate of 0.5-1 ml/min for a mean of 6 days. The mean number of ESWLs was 2.2. RESULTS: Fragmentation was achieved in 28/29 (96.5%) patients. There were five (17.5%) complications, fever in three cases, one case of acute relapse of pancreatitis, and one hematuria. The mean number of therapeutic ERCPs was 2.32 (0-7). Overall a complete duct clearance was achieved in 62% (18/29) of the patients, partial clearance in 13.9% (4/29) but the ESWL was unsuccessful in 24.1% (7/29) of the cases. Early pain relief occurred in almost every case (28/29). Twenty four (82.7%) patients were followed for 18.7 (2-33) months. Each patient remained symptom free. The average weight gain was 7.6 kg. The exocrine pancreatic function determined by Lundh test in 7 patients had not improved (11.2 vs. 12.2 pathological value in average). Recurrence of pancreatic duct stones was revealed in four (22.2%) cases among the 18 successfully treated patients after 15 (7-22) months. CONCLUSION: The authors conclude that the ESWL treatment of pancreatic stones together with the endotherapy applied is an effective method for painful pancreatolithiasis.