Timing of bariatric surgery in people with obesity and diabetes

The use of bariatric surgery in the clinical management of type 2 diabetes in severely obese subjects has been included in the clinical practice recommendations released by the most influential diabetologic associations. However, the timing during the diabetic course in which this use may have the better benefit/risk ratio remains debated. Is it better to use surgery very early in the course of the disease in order to anticipate clinical deterioration, or we should favour a delayed approach in which we reserve the more risky surgery only to patients not adequately controlled with the maximal pharmacologic strategy? In this paper, past and recent evidences about the role of bariatric surgery in the different stages of the clinical course of type 2 diabetes have been revised, starting from pre-diabetes and ending to long-standing diabetic state with established or end-stage macro- and micro-vascular complications. Available evidences strongly advocate in favor of the application of bariatric surgery in the early phase of this course, possibly in the pre-diabetic or in very early diabetic stages. To reserve surgery to more advanced and complicated stages of the disease seems to confer less benefits for the clinical course of diabetes and exposes these more frail patients to the possible side effects of a rapid weight loss

Cournot-Walras Equilibrium as a Subgame Perfect Equilibrium

In this paper, we investigate the problem of the strategic foundation of the Cournot-Walras equilibrium approach. To this end, we respecify a'la Cournot-Walras the mixed version of a model of simultaneous, noncooperative exchange, originally proposed by Lloyd S.Shapley. We show, through an example, that the set of the Cournot-Walras equilibrium allocations of this respecification does not coincide with the set of the Cournot-Nash equilibrium allocations of the mixed version of the original Shapley's model. As the nonequivalence, in a one-stage setting, can be explained by the intrinsic two-stage nature of the Cournot-Walras equilibrium concept, we are led to consider a further reformulation of the Shapley's model as a two-stage game, where the atoms move in the first stage and the atomless sector moves in the second stage. Our main result shows that the set of the Cournot-Walras equilibrium allocations coincides with a specific set of subgame perfect equilibrium allocations of this two-stage game, which we call the set of the Pseudo-Markov perfect equilibrium allocations.

Noncooperative Oligopoly in Markets with a Continuum of Traders

In this paper, we study three prototypical models of noncooperative oligopoly in markets with a continuum of traders : the model of Cournot-Walras equilibrium of Codognato and Gabszewicz (1991), the model of Cournot-Nash equilibrium of Lloyd S. Shapley, and the model of Cournot-Walras equilibrium of Busetto et al. (2008). We argue that these models are all distinct and only the Shapley's model with a continuum of traders and atoms gives an endogenous explanation of the perfectly and imperfectly competitive behavior of agents in a one-stage setting. For this model, we prove a theorem of existence of a Cournot-Nash equilibrium.

Noncooperative oligopoly in markets with a continuum of traders : a limit theorem

In this paper, in an exchange economy with atoms and an atomless part, we analyze the relationship between the set of the Cournot-Nash equilibrium allocations of a strategic market game and the set of the Walras equilibrium allocations of the exchange economy with which it is associated. In an example, we show that, even when atoms are countably infinite, Cournot-Nash equilibria yield different allocations from the Walras equilibrium allocations of the underlying exchange economy. We partially replicate the exchange economy by increasing the number of atoms without affecting the atomless part while ensuring that the measure space of agents remains finite. We show that any sequence of Cournot-Nash equilibrium allocations of the strategic mar- ket game associated with the partially replicated exchange economies approximates a Walras equilibrium allocation of the original exchange econom

SGLT2 Inhibitors and the Diabetic Kidney

Diabetic nephropathy (DN) is the most common cause of end-stage renal disease worldwide. Blood glucose and blood pressure control reduce the risk of developing this complication; however, once DN is established, it is only possible to slow progression. Sodium-glucose cotransporter 2 (SGLT2) inhibitors, the most recent glucose-lowering oral agents, may have the potential to exert nephroprotection not only through improving glycemic control but also through glucose-independent effects, such as blood pressure-lowering and direct renal effects. It is important to consider, however, that in patients with impaired renal function, given their mode of action, SGLT2 inhibitors are less effective in lowering blood glucose. In patients with high cardiovascular risk, the SGLT2 inhibitor empagliflozin lowered the rate of cardiovascular events, especially cardiovascular death, and substantially reduced important renal outcomes. Such benefits on DN could derive from effects beyond glycemia. Glomerular hyperfiltration is a potential risk factor for DN. In addition to the activation of the renin-angiotensin-aldosterone system, renal tubular factors, including SGLT2, contribute to glomerular hyperfiltration in diabetes. SGLT2 inhibitors reduce sodium reabsorption in the proximal tubule, causing, through tubuloglomerular feedback, afferent arteriole vasoconstriction and reduction in hyperfiltration. Experimental studies showed that SGLT2 inhibitors reduced hyperfiltration and decreased inflammatory and fibrotic responses of proximal tubular cells. SGLT2 inhibitors reduced glomerular hyperfiltration in patients with type 1 diabetes, and in patients with type 2 diabetes, they caused transient acute reductions in glomerular filtration rate, followed by a progressive recovery and stabilization of renal function. Interestingly, recent studies consistently demonstrated a reduction in albuminuria. Although these data are promising, only dedicated renal outcome trials will clarify whether SGLT2 inhibitors, in addition to their glycemic and blood pressure benefits, may provide nephroprotective effects

Relativistic plasmas in AGN jets - From synchrotron radiation to γ\gamma-ray emission

Relativistic jets of plasma are a key ingredient of many types of Active Galactic Nuclei (AGN). Today we know that AGNs are powered by the accretion of inter stellar material into the gravitational field of a Super Massive Black Hole and that this process can release as much power as a whole galaxy, like the Milky Way, from a region that is comparable to the Solar System in size. Depending on the properties of the central energy source, a large fraction of this power can be involved in the acceleration of magnetized plasmas at relativistic speeds, to form large scale jets. The presence of jets affects the spectrum of AGNs through the emission of synchrotron radiation and Inverse Compton scattering of low energy photons, thus leading to a prominent non-thermal spectrum, some times extending from radio frequencies all the way up to $\gamma$-ray energies. Here we review some characteristic processes of radiation emission in AGN jets, which lead to the emission of photons in the radio, optical, X-ray and $\gamma$-ray bands, and we present the results of a spectroscopic campaign of optical counterparts. We discuss our observations and their connection with $\gamma$-ray properties in a scenario that traces the role of relativistic jets in different classes of AGNs, detected both in the local as well as in the remote Universe.Comment: 11 pages, 5 figures (3 in color), proceedings of the XXVIII School on Physics of Ionized Gases (SPIG), accepted for publication on the European Journal of Physics

Effect of metabolic and antioxidant supplementation on sperm parameters in oligo-astheno-teratozoospermia, with and without varicocele: a double-blind placebo-controlled study

Since sperm require high energy levels to perform their specialised function, it is vital that essential nutrients are available for spermatozoa when they develop, capacitate and acquire motility. However, they are vulnerable to a lack of energy and excess amounts of reactive oxygen species, which can impair sperm function, lead to immotility, acrosomal reaction impairment, DNA fragmentation and cell death. This monocentric, randomised, double-blind, placebo-controlled trial investigated the effect of 6 months of supplementation with l-carnitine, acetyl-l-carnitine and other micronutrients on sperm quality in 104 subjects with oligo- and/or astheno- and/or teratozoospermia with or without varicocele. In 94 patients who completed the study, sperm concentration was significantly increased in supplemented patients compared to the placebo (p =.0186). Total sperm count also increased significantly (p =.0117) in the supplemented group as compared to the placebo group. Both, progressive and total motility were higher in supplemented patients (p =.0088 and p =.0120, respectively). Although pregnancy rate was not an endpoint of the study, of the 12 pregnancies that occurred during the follow-up, 10 were reported in the supplementation group. In general, all these changes were more evident in varicocele patients. In conclusion, supplementation with metabolic and antioxidant compounds could be efficacious when included in strategies to improve fertility

Trattamento chirurgico del varicocele nell'adolescente: due tecniche a confronto (delivered versus not delivered testis procedure). Studio prospettico su 70 casi.

Background e scopo dello studio Il varicocele è generalmente considerato la causa più comune di infertilità maschile. Negli adolescenti il dibattito è ancora aperto sulla gestione dopo una diagnosi di varicocele, in particolare per quanto riguarda l'aspetto della loro futura fertilità. La varicocelectomia negli adolescenti è ancora senza un metodo gold standard. La varicocelectomia microchirurgica sub-inguinale è la tecnica open più utilizzato nei bambini e negli adolescenti. Alcuni autori suggeriscono di includere nella varicocelectomia anche la manovra di "delivered" del testicolo per ottenere un migliore accesso a tutte le possibili vie di drenaggio venoso del testicolo, incluse le vene gubernacolari. Lo scopo del nostro studio è quello di confrontare due diverse procedure chirurgiche, la varicocelectomia microchirurgica inguinale con risparmio dei vasi linfatici e delle artere (LASMIV) senza delivery del testicolo e la LASMIV con delivery del testicolo e legatura di tutte le vene gubernacolari e collaterali. Materiali e metodi Lo studio analizza i dati di 70 adolescenti affetti da varicocele con riduzione del volume testicolare omolaterale superiore al 20%, operati dal 2008 al 2013. Essi sono stati divisi in due gruppi: Gruppo A (35 pazienti) trattati con LASMIV senza delivery del testicolo; Gruppo B (35 pazienti) trattati con LASMIV con delivery. Tutti i pazienti di entrambi i gruppi sono stati rivalutati sia clinicamente che mediante ecografia 6 e 12 mesi dopo l'intervento chirurgico per verificare la presenza di potenziali complicazioni (idrocele secondario o ricorrenza di varicocele) e per la misurazione del volume testicolare. I pazienti del gruppo B sono stati tutti sottoposti a biopsia testicolare. Risultati Il nostro studio mostra come nel Gruppo B il recupero di crescita di volume del testicolo è significativamente superiore a 6 (p = 0,008) e 12 mesi (p = 0,004) rispetto al gruppo A (pazienti trattati con LASMIV senza delivery). Il tasso di recidiva di varicocele nel Gruppo B è dello 0%. Nessuno dei pazienti di entrambi i gruppi hanno presentato idrocele secondario. Dall’analisi anatomopatologica è risultato che tutti i pazienti presentavano almeno due alterazioni istologiche. Discussione È importante effettuare la legatura di tutte le vene dilatate che drenano il testicolo associata al risparmio di arteriole e vasi linfatici per ottenere un basso tasso di recidiva o di fallimento terapeutico ed evitare complicazioni post-chirurgiche, come idrocele e atrofia testicolare. Inoltre è importante ottenere post-operativamente il recupero della discrepanza di volume dei testicoli, segno indiretto di recupero funzionale. Sulla base di studi di flebografia post-chirurgica si è visto che le recidive sono per lo più causate dalla persistenza di vene cremasteriche, gubernacolari o trans-scrotali dilatate. La recidiva di varicocele si verifica più comunemente con un approccio retroperitoneale che non permette la legatura delle vene cremasteriche, nonché con un approccio inguinale o sub-inguinale che non consente di legare le vene gubernacolari e le vene collaterali distali. La varicocelectomia microchirurgica inguinale con delivery del testicolo, invece, offre un accesso visivo diretto a tutte le vie di drenaggio venoso del testicolo e questo ha comportato una significativa riduzione dell'incidenza di recidive di varicocele. Infine, il delivery del testicolo facilita l’esecuzione della biopsia testicolare utile per ottenere informazioni sulla potenziale sterilità di questi adolescenti. Conclusioni Il nostro studio dimostra che la LASMIV con delivery del testicolo, rispetto alla LASMIV senza questa manovra, negli adolescenti affetti da varicocele, ha migliorato la crescita volumetrica del testicolo in modo statisticamente significativo ed ha ridotto l’incidenza di ricorrenze e di idrocele secondario

Chronic bacterial prostatitis: efficacy of short-lasting antibiotic therapy with prulifloxacin (Unidrox®) in association with saw palmetto extract, lactobacillus sporogens and arbutin (Lactorepens®)

Bacterial prostatitis (BP) is a common condition accounting responsible for about 5-10% of all prostatitis cases; chronic bacterial prostatitis (CBP) classified as type II, are less common but is a condition that significantly hampers the quality of life, (QoL) because not only is it a physical condition but also a psychological distress. Commonly patients are treated with antibiotics alone, and in particular fluoroquinolones are suggested by the European Urology guidelines. This approach, although recommended, may not be enough. Thus, a multimodal approach to the prolonged antibiotic therapy may be helpful.210 patients affected by chronic bacterial prostatitis were enrolled in the study. All patients were positive to Meares-Stamey test and symptoms duration was > 3 months. The purpose of the study was to evaluate the efficacy of a long lasting therapy with a fluoroquinolone in association with a nutraceutical supplement (prulifloxacin 600 mg for 21 days and an association of Serenoa repens 320 mg, Lactobacillus Sporogens 200 mg, Arbutin 100 mg for 30 days). Patients were randomized in two groups (A and B) receiving respectively antibiotic alone and an association of antibiotic plus supplement.Biological recurrence at 2 months in Group A was observed in 21 patients (27.6%) and in Group B in 6 patients (7.8%). Uropathogens found at the first follow-up were for the majority Gram - (E. coli and Enterobacter spp.). A statistically significant difference was found at the time of the follow-up between Group A and B in the NIH-CPSI questionnaire score, symptoms evidence and serum PSA.Broad band, short-lasting antibiotic therapy in association with a nutritional supplement (serenoa repens, lactobacillus sporogens and arbutin) show better control and recurrence rate on patients affected by chronic bacterial prostatitits in comparison with antibiotic treatment alone.NCT02130713Date of trial Registration: 30/04/2014

Body mass index and age correlate with antioxidant supplementation effects on sperm quality: Post hoc analyses from a double-blind placebo-controlled trial

Spermatozoa are vulnerable to lack of energy and oxidative stress as a result of elevated levels of reactive oxygen species. Therefore, it is essential that appropriate nutrients are available during maturation. This randomised, double-blind, placebo-controlled trial investigated the effect of 6-month supplementation with carnitines and other micronutrients on sperm quality in 104 subjects with oligo- and/or astheno- and/or teratozoospermia with or without varicocele. Semen analyses were done at the beginning and end of the treatment. In addition to main analyses, post hoc analyses for age and body mass index (BMI) were carried out. Results were interpreted by dividing the population into two age and BMI classes. In 94 patients who completed the study, all sperm parameters increased in supplemented patients compared to the placebo group. A significant (p = .0272) difference in supplementation efficacy was observed for total motility on patients with varicocele and BMI < 25. In the same group, also the progressive motility was significantly superior (p = .0159). For Responder analysis, total motility results were confirmed in both the cited group (p = .0066) and in the varicocele group with BMI < 25 and age < 35 (p = .0078). This study suggests that supplementation is more effective in subjects with varicocele younger than 35 years with BMI < 25