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

Asymptotic equivalence between Cournot–Nash and Walras equilibria in exchange economies with atoms and an atomless part

In this paper, we consider an exchange economy à la Shitovitz (Econometrica 41:467–501, 1973), with atoms and an atomless set. We associate with it a strategic market game of the kind first proposed by Lloyd S. Shapley, known as the Shapley window model. We analyze the relationship between the set of the Cournot–Nash allocations of the strategic market game and the Walras allocations of the exchange economy with which it is associated. We show, with an example, that even when atoms are countably infinite, any Cournot–Nash allocation of the game is not a Walras allocation of the underlying exchange economy. Accordingly, in the original spirit of Cournot (Recherches sur les principes mathématiques de la théorie des richesses. Hachette, Paris, 1838), we partially replicate the mixed exchange economy by increasing the number of atoms, without affecting the atomless part, and ensuring that the measure space of agents remains finite. Our main theorem shows that any sequence of Cournot–Nash allocations of the strategic market games associated with the partial replications of the exchange economy has a limit point for each trader and that the assignment determined by these limit points is a Walrasian allocation of the original economy

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 : 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

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.

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

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

The quality of Pachino tomato. The soilless tomato cultivation with salty water

openIl pomodoro è una delle coltivazioni più consumate e commerciate al mondo. Questo è dovuto alla sua alta produttività e la sua composizione ricca di nutrienti, in particolare antiossidanti. Tra questi, i più presenti sono polifenoli e carotenoidi, principalmente licopene e β-carotene, provitamina della vitamina A. La produzione di pomodoro è diffusa in tutto il mondo, tuttavia può avere delle criticità, tra cui acidità e alcalinità del suolo. Il pH rappresenta una delle caratteristiche più importanti del suolo per tutte le coltivazioni e può influenzare l’assorbimento di ioni e l’equilibrio osmotico della pianta inducendo stress idrico, stress ossidativo e altri problemi che diminuiscono la resa di produzione della pianta. In particolare l’alcalinizzazione del suolo è un problema in diffusione che influisce su sempre più suolo terrestre. In questo studio sono stati analizzati due genotipi di pomodoro con opposta risposta al pH alcalino: il genotipo Moresco, sensibile al pH alcalino, e il genotipo Blue, naturalmente resistente al pH alcalino. Entrambi i genotipi sono cresciuti con tecnica idroponica in differenti condizioni di pH, da ottimale (pH 5.2) a maggiormente alcalino (pH 7.2, pH 8.2, pH 9.2). Lo scopo di questo studio è di investigare sulle conseguenze dell’alcalinità nella coltivazione dei due genotipi, analizzando la loro composizione e cercando i meccanismi di risposta usati dalla pianta per affrontare lo stress alcalino. La coltivazione è durata otto giorni, dopo i quali sono stati analizzati i contenuti di prolina, polifenoli, flavonoli, tannini condensati, clorofilla e carotenoidi da campioni fogliari prelevati. I risultati hanno mostrato che i contenuti dell’aminoacido prolina, di polifenoli e di flavonoli sono influenzati dal pH basico solo nel genotipo Blue, nel quale sono aumentati in relazione all’innalzamento del pH; il contenuto di tannini condensati non è influenzato dal pH per nessuno dei due genotipi; il contenuto di pigmenti fogliari, cioè clorofilla e carotenoidi, varia a seconda del genotipo, infatti era più alto nel genotipo Moresco, ma non è influenzato dal pH. L’incremento in prolina e antiossidanti polifenoli e flavonoli, può indicare che il genotipo Blue ha sviluppato meccanismi di risposta allo stress che permettono alla pianta di resistere. Infatti, prolina, polifenoli e flavonoli, sono coinvolti in meccanismi di segnalazione e risposta allo stress nel pomodoro. Queste informazioni hanno importanti implicazioni per la coltivazione in ambienti alcalini e possono risultare utili per studi sull’uso dello stress nel miglioramento della qualità nutrizionale delle coltivazioni.Tomato is one of the most consumed and traded crops in the world. This is due to its high productivity and its composition rich of nutrient, in particular antioxidants. Among these, the most present are polyphenols and carotenoids, mainly lycopene and β-carotene, vitamin A provitamin. The production of tomato is widespread almost all over the world, however it may have some critical issues, which include soil acidity and alkalinity. The pH represents one of the main soil characteristics for all crops and can affect the absorption of ions and the osmotic balance of the plant inducing water stress, oxidative stress and other problems that decrease plant production yield. Soil alkalinization is a spreading problem affecting more and more planet cultivation soil. In this study, two tomato genotypes with opposing responses to alkaline pH were analyzed: the Moresco genotype, sensitive to alkaline pH, and the Blue genotype, naturally tolerant to alkaline pH. Both genotypes were grown with hydroponic technique under different pH conditions, from optimal (pH 5.2) to more alkaline (pH 7.2, 8.2, and 9.2). The aim of this study was to investigate the consequences of alkalinity in the cultivation of the two genotypes, analyzing their composition and evaluating the response mechanisms used by the plant to deal with alkaline stress. The cultivation lasted eight days, after which leaf samples were taken and the content of proline, polyphenols, flavonols, condensed tannins, chlorophyll and carotenoids were analyzed. The results showed that the contents of the amino acid proline, polyphenols and flavonols compounds are influenced by elevated pH only in the Blue genotype, in which they increased in relation to the increase in pH; the content of condensed tannins is not affected by pH for either genotypes; the content of leaf pigments, that means chlorophyll and carotenoids, varies depending on the genotype, in fact it was higher in the Moresco genotype, but was not affected by pH. The increase in proline and antioxidants polyphenols and flavonols, may indicate that the Blue genotype develops a mechanism of response to the stress that makes the plant more tolerant. In fact, proline, polifenols and flavonols, are involved in signaling and response pathways of tomato against stress. This information has important implications for cultivation in alkaline environments and may be useful for studies about the use of stress in improving nutritional quality of crops

European Guidelines for Obesity Management in Adults

Obesity is a chronic metabolic disease characterised by an increase of body fat stores. It is a gateway to ill health, and it has become one of the leading causes of disability and death, affecting not only adults but also children and adolescents worldwide. In clinical practice, the body fatness is estimated by BMI, and the accumulation of intra-abdominal fat (marker for higher metabolic and cardiovascular disease risk) can be assessed by waist circumference. Complex interactions between biological, behavioural, social and environmental factors are involved in regulation of energy balance and fat stores. A comprehensive history, physical examination and laboratory assessment relevant to the patient's obesity should be obtained. Appropriate goals of weight management emphasise realistic weight loss to achieve a reduction in health risks and should include promotion of weight loss, maintenance and prevention of weight regain. Management of co-morbidities and improving quality of life of obese patients are also included in treatment aims. Balanced hypocaloric diets result in clinically meaningful weight loss regardless of which macronutrients they emphasise. Aerobic training is the optimal mode of exercise for reducing fat mass while a programme including resistance training is needed for increasing lean mass in middle-aged and overweight/obese individuals. Cognitive behavioural therapy directly addresses behaviours that require change for successful weight loss and weight loss maintenance. Pharmacotherapy can help patients to maintain compliance and ameliorate obesity-related health risks. Surgery is the most effective treatment for morbid obesity in terms of long-term weight loss. A comprehensive obesity management can only be accomplished by a multidisciplinary obesity management team. We conclude that physicians have a responsibility to recognise obesity as a disease and help obese patients with appropriate prevention and treatment. Treatment should be based on good clinical care, and evidence-based interventions; should focus on realistic goals and lifelong multidisciplinary management. (C) 2015 S. Karger GmbH, Freibur