[Does the neurologic assessment have a decisive role in the early diagnosis of urinary disorders of uncertain etiology? A case of spinal chordoma]. / La valutazione neurourologica ha un ruolo decisivo nella diagnosi precoce delle disfunzioni minzionali a patogenesi incerta? Un caso di cordoma spinale.

The Authors report a rare case of detrusor areflexia due to a sacral column chordoma characterized as initial symptomatology, by dysuria and recurrent urinary tract infections. The patient was treated for a long time in a symptomatic way by her physicians. The Authors while discussing the case, underline the importance of an accurate differential diagnostical framing in patients with voiding and/or anorectal dysfunctions of uncertain nature. This framing must exclude those voiding pathologies of neurological origin which are frequently evinced merely by an aspecific voiding symptomatology of dysuric or irritative nature.

Early increase precedes a depletion of VIP and PGP-9.5 in the skin of insulin-dependent diabetics--correlation between quantitative immunohistochemistry and clinical assessment of peripheral neuropathy.

Diabetic neuropathy affects both sensory and autonomic peripheral nerve fibres. Vasoactive intestinal polypeptide (VIP) is present in autonomic fibres which modulate sweat secretion, while calcitonin gene-related peptide (CGRP) is localized to cutaneous sensory fibres. In this study, immunohistochemistry and image analysis were used to assess changes of VIP and CGRP, and of the pan-neuronal marker protein gene-product (PGP)-9.5, in skin biopsies of 18 patients affected by type 1 diabetes (age range 18-46 years) and from seven aged-matched controls. Patients were divided into three groups: group 1 (n = 6), with diabetes for 6 months to 3 years; group 2 (n = 5), with the disease for 5-10 years; and group 3 (n = 7), with diabetes for more than 10 years. VIP immunoreactivity (IR) and PGP-9.5-IR were significantly reduced around sweat glands (P < 0.005) in groups 2 and 3. Epidermal CGRP-IR and PGP-9.5-IR were significantly reduced in group 3 (P < 0.05). Twenty-eight per cent (5/18) of all patients showed high VIP-IR around sweat glands (> 95 per cent confidence limits of controls) and all of these patients had diabetes for less than 3 years. Conversely, 55 per cent (10/18) of patients had low VIP-IR (< 5 per cent confidence limit of controls). The latter, compared with the former, showed a significantly longer duration of diabetes (Fisher exact test P = 0.002), presence of clinical autonomic neuropathy (Fisher exact test P = 0.04), and a reduced sural nerve conduction velocity (Fisher exact test P = 0.04). These results suggest that quantitative immunohistochemical analysis of peptide-containing cutaneous nerves allows an objective evaluation of nerve fibre alterations at early stages of diabetes than is currently possible with neurophysiological functional tests.

[Radiculopathy and the organization of health services: applicability verification of a technic for analyzing time factors in diagnostic procedures]. / Le radicolopatie e l'organizzazione dei servizi sanitari: verifica dell'applicabilita' di una tecnica per l'analisi temporale dei processi diagnostici.

The PERT is a SPR (Reticular Programation System) based on statistic-mathematic models. Since some years they are applied to productive processes to increase the efficiency and effectiveness. They all have a same base structure which is the net that is composed by the logical succession of the event and the activity which has the part of the project. Determining the minimum time (to), the maximum one (tp) and the more frequent time (tm) of each activity and applying the statistic method PERT, one gets the probable duration (te) of every activity and the critical path of the net is placed in evidence. This is formed by the chain of those activities whose duration determines the total duration of the project. The Authors have desired to verify the applicability of SPR even to the "medical industry" and, more precisely, to the diagnostic process for the verification of radiculoneuropathy. Such pathology affects a large part of the active population. The diagnostic process in this case comprises besides an accurate neurological and clinical examination of the patient, also the x-ray exam, the electromyography, the Computed Tomography (CT) and the Magnetic Resonance Imaging (MR) exam. These last two investigations gives an increase of diagnostic accuracy. With the collaboration of the physicians of the diagnostic Service, the Authors have measured in every step of the diagnostic procedure the waiting time of 48 patients with low back pain. Applying the PERT method, it has been possible to put in evidence in the net the critical activities. They are such that their duration time determines the probable duration of the whole diagnostic process. Such duration in this case it corresponds to 91 days with a standard deviation of 33 days. The delay of any critical activity causes a lealy of the whole route. This delay influences negatively on the patient's health. Besides it determines an economic damage to the system because a relation cost/time exists. The systems of reticular programmation have as objective not only the one of improving the programmation and the control of the processes, but also the attainment of an optimum cost/time ratio, varying in a way that the total cost of the realization of the process is minimum. They represent a useful criterion to direct Quality Assurance (Q.A) in the local political sanitary context, within the bounds of organization of technical - scientific quality. An accurate application of the Q.A. should modify besides the duration of the critical activities.