Balance training program is highly effective in improving functional status and reducing the risk of falls in elderly women with osteoporosis: a randomized controlled trial

Introduction The purpose of this study was to investigate the effect of a 12-month Balance Training Program on balance, mobility and falling frequency in women with osteoporosis. Methods Sixty-six consecutive elderly women were selected from the Osteometabolic Disease Outpatient Clinic and randomized into 2 groups: the ‘Intervention’, submitted for balance training; and the ‘Control’, without intervention. Balance, mobility and falling frequency were evaluated before and at the end of the trial, using the Berg Balance Scale (BBS), the Clinical Test Sensory Interaction Balance (CTSIB) and the Timed “Up & Go” Test (TUGT). Intervention used techniques to improve balance consisting of a 1-hour session each week and a home-based exercise program. Results Sixty women completed the study and were analyzed. The BBS difference was significant higher in the Intervention group compared to Control (5.5 ± 5.67 vs −0.5 ± 4.88 score, p < 0.001). Similarly, the number of patients in the Intervention group presented improvement in two conditions of CTSIB compared to Control (eyes closed and unstable surface condition: 13 vs one patient, p < 0.001 and eyes open, visual conflict and unstable surface condition: 12 vs one patient, p < 0.001). Additionally, the differences between the TUGT were reduced in the Intervention group compared to Control (−3.65 ± 3.61 vs 2.27 ± 7.18 seconds, p< 0.001). Notably, this improvement was paralleled by a reduction in the number of falls/patient in the Intervention group compared to Control (−0.77 ± 1.76 vs 0.33 ± 0.96, p = 0.018). Conclusion This longitudinal prospective study demonstrated that an intervention using balance training is effective in improving functional and static balance, mobility and falling frequency in elderly women with osteoporosis.     

Insulin clearance in obesity

Insulin uptake and degradation is a complex and not yet completely understood process involving not only insulin sensitive tissues. The most important degradative system is insulin degrading enzyme which is a highly conserved metalloendopeptidase requiring Zn(++) for its proteolytic action, although protein disulfide isomerase and cathepsin D are also involved in insulin metabolism. The liver and the kidney are the principal sites for insulin clearance. In obese subjects with hyperinsulinemia and high levels of free fatty acids, insulin hepatic clearance is impaired, while the glomerular filtration rate, renal plasma flow and albumin excretion are increased, suggesting a state of renal vasodilatation leading to an abnormally transmitted arterial pressure to the glomerular capillaries through a dilated afferent arteriole. Insulin can be cleared also by muscle, adipocytes, gastrointestinal cells, fibroblasts, monocytes and lymphocytes which contain insulin receptors and internalization and regulation mechanism for insulin metabolism.     

Inguinal hernioplasty: the gold standard of hernia repair

On the basis of a critical review of 936 inguinal hernioplasties performed in 8 years, the authors present their good long-term results with tension-free techniques including the original Lichtenstein technique, Lichtenstein with a sutured mesh and annulorrhaphy of the deep inguinal ring, and Lichtenstein with plug. The only two recurrences in this case series occurred with the original technique. Suturing of the mesh and deep inguinal ring annulorrhaphy proved to be reliable and inexpensive. Results were equivalent with the use of the plug, despite the presence of an additional foreign body. In conclusion, the results obtained with the three variants are practically equivalent, and the choice of technique may depend on the preference and experience of the surgeon. Electronic Publication     

Therapeutic strategies in neoplasms of the distal bile duct and the Vater's ampulla

Malignant periampullary and ampullary tumors represent an anatomic and clinical entity of complex surgical approach due to the difficulty in setting out an early diagnosis, for the back of symptoms at early stages. The Authors at the Department of Surgery and Medical Technology Applications "F. Durante", University of Rome "La Sapienza", since 1990 to 2001 observed 19 cases. The results of surgical treatment of these tumors are here reported. By the analysis of the cases it is evident that long-term survival if mainly conditioned by prompt diagnosis stage of the tumor, and patient status before the operation.     

Assessment of macular function by focal electroretinogram and pattern electroretinogram before and after epimacular membrane surgery

PURPOSE: To evaluate macular function before and after surgical peeling of idiopathic epimacular membrane (EMM). METHODS: Logarithm of the minimal angle of resolution visual acuity and results of focal (central 9 x 9 degrees) electroretinogram (fERG), pattern electroretinogram (pERG), and optical coherence tomography (OCT) assessment of macular volume were evaluated for 22 eyes of 22 patients (mean age +/- SD, 63.20 +/- 10.0 years) with EMM preoperatively (baseline) and 6 months after surgical peeling. Preoperative visual acuity and fERG and pERG amplitudes observed in EMM eyes were compared with those in 15 age-matched control eyes. RESULTS: In the preoperative evaluation, EMM eyes had a significant (P < 0.01; one-way analysis of variance) reduction in visual acuity and fERG and pERG amplitudes and an increase in OCT macular volume when compared with controls. In EMM eyes, the decrease in visual acuity was significantly correlated (P < 0.01, Pearson test) to the reduction in fERG and pERG amplitudes. At the postoperative evaluation, EMM eyes had a correlated significant (P < 0.01) increase in visual acuity, fERG amplitude, and pERG amplitude with respect to the preoperative values. All EMM eyes had a significant (P <0.01) reduction in macular volume, and retinal microanatomy was restored to normal conditions. CONCLUSION: In EMM eyes, the decrease in visual acuity is related to dysfunction of both preganglionic (abnormal fERG) and ganglionic (abnormal pERG) macular elements. Surgical removal of EMM may induce improvement of the function of both outer and innermost macular retinal layers, leading to a related increase in visual acuity.     

First-Phase Insulin Secretion Restoration and Differential Response to Glucose Load Depending on the Route of Administration in Type 2 Diabetic Subjects After Bariatric Surgery

OBJECTIVE—The purpose of this study was to elucidate the mechanisms of diabetes reversibility after malabsorptive bariatric surgery.RESEARCH DESIGN AND METHODS—Peripheral insulin sensitivity and β-cell function after either intravenous (IVGTT) or oral glucose tolerance (OGTT) tests and minimal model analysis were assessed in nine obese, type 2 diabetic subjects before and 1 month after biliopancreatic diversion and compared with those in six normal-weight control subjects. Insulin-dependent whole-body glucose disposal was measured by the euglycemic clamp, and glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) were also measured.RESULTS—The first phase of insulin secretion after the IVGTT was fully normalized after the operation. The disposition index from OGTT data was increased about 10-fold and became similar to the values found in control subjects, and the disposition index from IVGTT data increased about 3.5-fold, similarly to what happened after the euglycemic clamp. The area under the curve (AUC) for GIP decreased about four times (from 3,000 ± 816 to 577 ± 155 pmol · l⁻¹ · min, P < 0.05). On the contrary, the AUC for GLP1 almost tripled (from 150.4 ± 24.4 to 424.4 ± 64.3 pmol · l⁻¹ · min, P < 0.001). No significant correlation was found between GIP or GLP1 percent changes and modification of the sensitivity indexes independently of the route of glucose administration.CONCLUSIONS—Restoration of the first-phase insulin secretion and normalization of insulin sensitivity in type 2 diabetic subjects after malabsorptive bariatric surgery seem to be related to the reduction of the effect of some intestinal factor(s) resulting from intestinal bypass.In 1987, Pories et al. (1) published a stunning observation that 99% of morbidly obese patients with frank type 2 diabetes or impaired glucose tolerance who had undergone Roux-en-Y gastric bypass (RYGB) became and remained euglycemic after surgery. Most interestingly, these authors reported that the patients were converted to euglycemia within 10 days, even if they had required large doses of insulin.Subsequently, we (2,3) and other authors (4) have found that either restrictive or malabsorptive bariatric surgery is effective in improving/resolving type 2 diabetes. In particular, using the euglycemic hyperinsulinemic clamp we have demonstrated that insulin sensitivity was normalized after malabsorptive bariatric surgery in both obese type 2 diabetic (2) and obese normotolerant subjects.We theorized that the normalization of insulin sensitivity that occurs very early after biliopancreatic diversion (BPD) before a significant weight loss can occur (2) may be dependent on the hormonal changes related to the nutrient diversion from the duodenum, the entire jejunum, and the proximal portion of the ileum. In fact, the enteroendocrine cells are largely found in these tracts of the small intestine.Two main hypotheses have been advanced up to now to explain which part of the small intestine is implicated in the reversibility of diabetes. The first, known as the hindgut hypothesis (5), holds that diabetes control results from accelerated delivery of nutrients in the distal small intestine. The second, the so-called foregut hypothesis, states that the exclusion of duodenum and jejunum from nutrient transit might prevent the secretion of a putative signal that promotes insulin resistance (2,6). The balance between the stimulatory action on insulin secretion exerted by incretins and the anti-incretin effect might allow a finer control of the glucose disposal.To test the hypothesis that an imbalance in the release of intestinal hormone(s) can determine insulin resistance and that after BPD secretion of intestinal hormone(s) is reduced, allowing normalization of insulin sensitivity with subsequent β-cell glucose sensitivity improvement, we assessed peripheral insulin sensitivity and β-cell function after either an intravenous or oral glucose tolerance test in nine obese, type 2 diabetic subjects compared with those in six normal-weight age- and sex-matched control subjects. To further support our results, insulin-dependent whole-body glucose disposal was also measured by the euglycemic clamp.