[What is new in 2014 for the specialist in hospital internal medicine? The point of view of university hospital chief residents]. / L'année 2014 mise en perspective par les internistes hospitaliers.

The year 2014 was rich in significant advances in all areas of internal medicine. Many of them have an impact on our daily practice and on the way we manage one problem or another. From the use of the ultrasound for the diagnosis of pneumonia to the choice of the site of venous access and the type of line, and the increasing complexity of choosing an oral anticoagulant agent, this selection offers to the readers a brief overview of the major advances. The chief residents in the Service of internal medicine of the Lausanne University hospital are pleased to share their readings.

Advanced anaerobic processes to enhance waste activated sludge stabilization.

The requirement for enhanced stabilization processes to obtain a more stable, pathogen-free sludge for agricultural use is an increasing challenge to comply with in the waste hierarchy. With this in mind, the Routes European project ('Novel processing routes for effective sewage sludge management') is addressed to assess innovative solutions with the aim of maximizing sludge quality and biological stability. In order to increase anaerobic stabilization performances, the sequential anerobic/aerobic process and the thermophilic digestion process, with or without integration of the thermal hydrolysis pre-treatment, were investigated as regards the effect on sludge stabilization, dewaterability and digestion performances. Thermal pre-treatment improved anaerobic digestion in terms of volatile solids reduction and biogas production, but digestate dewaterability worsened. Fluorescence in situ hybridization (FISH) quantification showed an increase of methanogens consistent with the increase of biogas produced. The aerobic post-treatment after mesophilic digestion had a beneficial effect on dewaterability and stability of the digested sludge even if was with a reduction of the potential energy recovery.

Integration of biocompatible hydrogen evolution catalyst developed from metal-mix solutions with microbial electrosynthesis.

Microbial conversion of CO2 to multi-carbon compounds such as acetate and butyrate is a promising valorisation technique. For those reactions, the electrochemical supply of hydrogen to the biocatalyst is a viable approach. Earlier we have shown that trace metals from microbial growth media spontaneously form in situ electro-catalysts for hydrogen evolution. Here, we show biocompatibility with the successful integration of such metal mix-based HER catalyst for immediate start-up of microbial acetogenesis (CO2 to acetate). Also, n-butyrate formation started fast (after twenty days). Hydrogen was always produced in excess, although productivity decreased over the 36 to 50 days, possibly due to metal leaching from the cathode. The HER catalyst boosted microbial productivity in a two-step microbial community bioprocess: acetogenesis by a BRH-c20a strain and acetate elongation to n-butyrate by Clostridium sensu stricto 12 (related) species. These findings provide new routes to integrate electro-catalysts and micro-organisms showing respectively bio and electrochemical compatibility.

Estrogens need insulin-like growth factor I cooperation to exert their neuroprotective effects in post-menopausal women.

BACKGROUND: The abrupt fall in estrogens levels during the menopausal transition may connote an hormonal state predisposing to neurodegenerative disorders, e.g. Alzheimer's disease (AD). Reportedly, the neurotrophic activity of estrogen involves an interaction with IGF-I. AIM: To evaluate the leukocyte gene expression of progesterone receptor (PR-A/B) and interleukin 6 (IL-6), two parameters under the control of estrogens and involved in the pathogenesis of AD. SUBJECTS: The study was conducted in non-demented women divided into two groups according to their pre- or post-menopausal state; each group being further divided into two subgroups based on their circulating levels of IGF-I (normal or low). An additional sample of AD-affected women served as a comparison group. RESULTS: Estrogens maintained their full activity only when IGF-I levels were in the range of normalcy. On the contrary, if the concentrations of one or both hormones were reduced, estrogens were not anymore capable to control the gene expression of PR-A/B or IL-6. CONCLUSIONS: Before administering hormone-based replacement therapy, characterization of the somatotropic function should be performed in the early phase of the menopause.

[What is new in 2012 for the specialist in hospital internal medicine?]. / L'année 2012 de la perspective de l'interniste hospitalier.

The knowledge in internal medicine is constantly and so rapidly evolving that practices have to be updated and adjusted to recent scientific rules, in order to improve quality and efficiency in the day to day activities. Residents in the Service of internal medicine of the Lausanne University present several relevant papers published in 2012, whose results are susceptible to change the daily hospital practices. From modest impacts to real revolution, a variety of subjects are discussed in the perspective of evidence based medicine.

[Hospital-based internal medicine: year 2011 in chief resident's perspective]. / Médecine interne générale en pratique hospitalière: l'année 2011 mise en perspective par les chefs de clinique.

The year 2011 was full of significant advances in all areas of medicine. Whether small or large issues, they all have an impact on daily practice in general internal medicine. For example, intravenous administration of diuretics in heart failure shows no benefit. But double dose may improve symptoms faster. Direct Xa inhibitors are emerging as alternative to anti-vitamin K. beta-blockers reduce overall mortality in COPD and do not worsen lung function significantly. Each year, the chief residents from the Department of internal medicine at the University hospital of Lausanne meet to share their readings. Twelve new therapeutic considerations of 2011 are reviewed here.

Use it and lose it: lipofuscin accumulation in the midbrain of a coral reef fish.

Lipofuscin, an autofluorescent biomarker of physiological wear-and-tear, was concentrated in those areas of a fish's midbrain responsible for visual performance, suggesting a potentially strong link between physiological specialization, ecological adaptation and senescence.

Crucial knowledge gaps in current understanding of climate change impacts on coral reef fishes.

Expert opinion was canvassed to identify crucial knowledge gaps in current understanding of climate change impacts on coral reef fishes. Scientists that had published three or more papers on the effects of climate and environmental factors on reef fishes were invited to submit five questions that, if addressed, would improve our understanding of climate change effects on coral reef fishes. Thirty-three scientists provided 155 questions, and 32 scientists scored these questions in terms of: (i) identifying a knowledge gap, (ii) achievability, (iii) applicability to a broad spectrum of species and reef habitats, and (iv) priority. Forty-two per cent of the questions related to habitat associations and community dynamics of fish, reflecting the established effects and immediate concern relating to climate-induced coral loss and habitat degradation. However, there were also questions on fish demographics, physiology, behaviour and management, all of which could be potentially affected by climate change. Irrespective of their individual expertise and background, scientists scored questions from different topics similarly, suggesting limited bias and recognition of a need for greater interdisciplinary and collaborative research. Presented here are the 53 highest-scoring unique questions. These questions should act as a guide for future research, providing a basis for better assessment and management of climate change impacts on coral reefs and associated fish communities.

Sirolimus-based immunosuppression in kidney transplantation for type 2 diabetic nephropathy.

INTRODUCTION: Kidney transplantation is the best replacement therapy of type 2 diabetic patients and recently similar graft and patient survival between diabetic and nondiabetic recipients has been reported. However, standard immunosuppressive protocols are lacking. We present our experience with sirolimus-based immunosuppression in a population of 24 type 2 diabetic patients who underwent a kidney transplantation. PATIENTS AND METHODS: From January 2001 to December 2006, 396 kidney transplantations were performed. Twenty-four patients had type 2 diabetes mellitus as a cause of end-stage renal disease. They were randomized in two groups: thirteen patients (group A) received an immunosuppressive treatment with sirolimus, low-dose tacrolimus and steroids, while 11 patients (group B) received sirolimus, mycophenolate mofetil and steroids. RESULTS: Clinical characteristics were similar between the two groups. A slightly better kidney functionality was observed in group B patients. There were neither acute rejection episodes nor severe infectious complications in both groups. One patient in each group underwent a foot amputation. Graft and patient survival was 100% for both groups at a median follow-up of 29 months. CONCLUSIONS: Sirolimus-based immunosuppression is safe and efficacious in type 2 diabetic patients who underwent a kidney transplantation, allowing a better glucose metabolism control.

Cation exchange membrane behaviour of extracellular polymeric substances (EPS) in salt adapted granular sludge.

This paper aims to elucidate the role of extracellular polymeric substances (EPS) in regulating anion and cation concentrations and toxicity towards microorganisms in anaerobic granular sludges adapted to low (0.22 M of Na+) and high salinity (0.87 M of Na+). The ion exchange properties of EPS were studied with a novel approach, where EPS were entangled with an inert binder (PVDF-HFP) to form a membrane and characterized in an electrodialysis cell. With a mixture of NaCl and KCl salts the EPS membrane was shown to act as a cation exchange membrane (CEM) with a current efficiency of ∼80%, meaning that EPS do not behave as ideal CEM. Surprisingly, the membrane had selectivity for transport of K+ compared to Na+ with a separation factor ( [Formula: see text] ) of 1.3. These properties were compared to a layer prepared from a model compound of EPS (alginate) and a commercial CEM. The alginate layer had a similar current efficiency (∼80%.), but even higher [Formula: see text] of 1.9, while the commercial CEM did not show selectivity towards K+ or Na+, but exhibited the highest current efficiency of 92%. The selectivity of EPS and alginate towards K+ transport has interesting potential applications for ion separation from water streams and should be further investigated. The anion repelling and cation binding properties of EPS in hydrated and dehydrated granules were further confirmed with microscopy (SEM-EDX, epifluorescence) and ion chromatography (ICP-OES, IC) techniques. Results of specific methanogenic activity (SMA) tests conducted with 0.22 and 0.87 M Na+ adapted granular sludges and with various monovalent salts suggested that ions which are preferentially transported by EPS are also more toxic towards methanogenic cells.

Acute renal failure due to ureteral obstruction in a kidney transplant recipient with Candida albicans contamination of preservation fluid.

Reported rates of positive preservation fluid cultures range from 5% to 23%, with fungi accounting for 2-10% of all positive cultures. We report the case of a kidney transplant recipient who received a graft with preservation fluid contaminated by Candida albicans, who developed acute renal failure due to ureteral obstruction by fungus balls. The patient was treated with voriconazole with complete restoration of graft function. This rare clinical entity demonstrates the usefulness of pre-transplant cultures of preservation fluid, in order to identify a group of patients who could benefit from antifungal prophylaxis therapy and thereby prevent the need for graft nephrectomy.

The Y606C RET mutation causes a receptor gain of function.

CONTEXT: Medullary thyroid carcinoma (MTC) is the most common feature of multiple endocrine neoplasia type 2A (MEN2A) and occurs in almost all patients affected by germline RET mutations. OBJECTIVE: We identified and characterized an activating germline RET point mutation (G>A substitution leading to the heterozygous missense mutation Y606C in exon 10), in a 58-year-old female affected by MTC. DESIGN: The RET/Y606C and RET/C620Y, obtained by site-directed mutagenesis, as well as the RET/wild-type (wt) were cloned in an expression vector and transiently transfected in NIH3T3 fibroblasts. In vitro cell model was used to evaluate the effect of Y606C mutation on the RET downstream signalling pathways through Western blot analysis. RESULTS: We found that the cysteine insertion, due to the Y606C mutation, results in increased receptor dimerization, which is accompanied by an increased tyrosine phosphorylation of the Y905 residue in the RET/Y606C, demonstrating that the Y606C mutation is associated with constitutive receptor activation. As RET activation results in an intracellular signalling cascade involving extracellular signal-regulated kinases (ERKs), we investigated ERK activity in our transfected cells. Results demonstrated a significant increase in ERK2 phosphorylation in the RET/Y606C vs. the RET/wt and RET/C620Y transfected cells, suggesting an up-regulation of RET signalling. CONCLUSIONS: All these findings demonstrate that the Y606C mutation is associated with RET constitutive activation and thus has to be considered of pathogenetic relevance in the development of MTC.

Perinatal exposure to 5-methoxytryptamine, behavioural-stress reactivity and functional response of 5-HT1A receptors in the adolescent rat.

Serotonin is involved in a wide range of physiological and patho-physiological mechanisms. In particular, 5-HT1A receptors are proposed to mediate stress-adaptation. The aim of this research was to investigate in adolescent rats: first, the consequences of perinatal exposure to 5-metoxytryptamine (5MT), a 5-HT1/5-HT2 serotonergic agonist, on behavioural-stress reactivity in elevated plus maze, open field and forced swim tests; secondly, whether the behavioural effects induced by perinatal exposure to 5MT on open field and forced swim tests were affected by the selective 5-HT1A receptor agonist LY 228729, a compound able to elicit a characteristic set of motor behaviours on these experimental models, and by the co-administration of the selective and silent 5-HT1A antagonist WAY 100635. Results indicate that a single daily injection of 5MT to, pregnant dams from gestational days 12 to 21 (1mg/kg s.c.), and to the pups from postnatal days 2 to 18 (0.5mg kg s.c.), induce in the adolescent rat offspring: an increase in the percentage of entries and time spent on the open arms in the elevated plus maze; a reduction in locomotor activity and rearing frequency, and an increase in the time spent on the central areas in the open field test; a decrease in immobility and an increase in swimming in the forced swim test. Acute administration of LY 228729 (1.5mg/kg s.c.) strongly decreases rearing frequency and increases peripheral activity in the open field test, and decreases immobility and increases swimming in the forced swim test both in perinatally vehicle and 5MT-exposed offspring. Co-administration of WAY 100635 (0.25mg/kg s.c.) abolishes the effects exerted by LY 228729. These results suggest that, in the adolescent rat, perinatal exposure to 5MT enhances the stress-related adaptive behavioural responses, presumably through a predominant action on presynaptic 5-HT1A receptors and does not deteriorate the functional response of 5-HT1A receptors to selective agonist and antagonist compounds.

Infective complications in renal allograft recipients: epidemiology and outcome.

INTRODUCTION: Successful renal transplantation strictly depends on good control of rejection and better prevention and treatment of infections, which remain serious threats. METHODS: This retrospective, observational study of 245 renal allograft recipients who underwent transplantation between January 2002 and December 2005 included a 21+/-10 months follow-up. RESULTS: A total of 110 (44.9%) patients developed an infective process during the posttransplantation period, namely, 232 infective processes. Eighty patients developed at least 1 episode of urinary tract infection (UTI) 11 patients (4%) had a wound infection, and 30 patients (12%) had pneumonia. We diagnosed 35 cases of bacteremia (35%), whereas cytomegalovirus (CMV) infection was demonstrated in 40 patients (16%). CONCLUSIONS: Immunosuppressive therapy, necessary to avoid acute and chronic rejection, exposes patients to a higher rate of infectious complications. The immunosuppressive protocols led to a relatively low incidence of infectious complications, mainly of little clinical significance. The highest incidence was evident by the sixth month after transplantation, when the immunosuppressive regimen exercised its most depressive effects on patient immune systems.

New-onset diabetes mellitus after kidney transplantation: the role of immunosuppression.

BACKGROUND: Complications related to posttransplantation immunosuppressive therapy remain common. New-onset diabetes mellitus after transplantation (PTDM) is a well-recognized complication associated with reduced graft and patient survival. The type of immunosuppression may be responsible for more than two thirds of PTDM. We retrospectively reviewed our experience in a population of 284 kidney transplant recipients, evaluating the incidence of PTDM with regard to the type of immunosuppression. PATIENTS AND METHODS: From January 2001 to December 2005, 284 kidney transplantations were performed using tacrolimus-based (TAC) immunosuppression in 192 patients and a cyclosporine-based (CyA) regimen in 62 patients, whereas 30 patients received sirolimus-based immunosuppression. RESULTS: The overall incidence of PTDM was 4.9%. Among the immunosuppression protocols, 8 patients (4.1%) received TAC and 6 patients (9.6%) received CyA, whereas no patients treated with sirolimus developed PTDM. Graft and patient survival rates were 93% and 100%, respectively. CONCLUSIONS: The overall risk of PTDM with recent immunosuppressive protocols is low, but it is increased among calcineurin inhibitor (CNI)-treated kidney transplant recipients. Sirolimus did not increase the risk of PTDM, allowing potential clinical application in diabetic recipients and in patients affected by PTDM.

Efficacy of methanogenic biomass acclimation in mesophilic anaerobic digestion of ultrasound pretreated sludge.

Methanogenic biomass plays a key role with regard to methane production during anaerobic bioconversion of organic substrates. In this study, the effect of two different acclimated inocula on digestion performances was investigated by means of anaerobic batch tests on untreated and sonicated waste-activated sludge. Organics solubilization and removal kinetics, the abundance and physiological conditions of archaeal cells on ultimate methane yield were evaluated. The simultaneous presence of Methanosarcina and Methanosaeta in the archaeal biomass, the higher initial archaeal cells relative abundance and their occurrence in the aggregated forms were the main factors positively affecting the conversion into methane. The presence of the acclimated inoculum at the start-up influenced positively the methane improvement due to sonication, and the methane-specific production increased from 0.335 ± 0.03 to 0.420 ± 0.05 Nm3/kg VSfed. Moreover, the better physiological state of methanogens permitted to appreciate the effect of hydrolysis improvement by ultrasound pretreatment.

The potential of osmolytes and their precursors to alleviate osmotic stress of anaerobic granular sludge.

Increasing amounts of saline (waste)water with high concentrations of organic pollutants are generated globally. In the anaerobic (waste)water treatment domain, high salt concentrations are repeatedly reported to inhibit methanogenic activity and strategies to overcome this toxicity are needed. Current research focuses on the use of potential osmolyte precursor compounds for osmotic stress alleviation in granular anaerobic sludges upon exposure to hypersalinity shocks. Glutamic acid, aspartic acid, lysine, potassium, gelatine, and tryptone were tested for their potential to alleviate osmotic stress in laboratory grown and full - scale granular sludge. The laboratory grown granular sludge was adapted to 5 (R5) and 20 (R20) g Na+/L. Full-scale granular sludge was obtained from internal circulation reactors treating tannery (waste)water with influent conductivity of 29.2 (Do) and 14.1 (Li) mS/cm. In batch experiments which focused on specific methanogenic activity (SMA), R5 granular sludge was exposed to a hypersalinity shock of 20 g Na+/L. The granular sludge of Do and Li was exposed to a hypersalinity shock of 10 g Na+/L with sodium acetate as the sole carbon source. The effects on R20 granular sludge were studied at the salinity level to which the sludge was already adapted, namely 20 g Na+/L. Dosing of glutamic acid, aspartic acid, gelatine, and tryptone resulted in increased SMA compared to only acetate fed batches. In batches with added glutamic acid, the SMA increased by 115% (Li), 35% (Do) and 9% (R20). With added aspartic acid, SMA increased by 72% (Li), 26% (Do), 12% (R5) and 7% (R20). The addition of tryptone resulted in SMA increases of 36% (R5), 17% (R20), 179% (Li), and 48% (Do), whereas added gelatine increased the SMA by 30% (R5), 14% (R20), 23% (Li), and 13% (Do). The addition of lysine, meanwhile, gave negative effects on SMA of all tested granular sludges. Potassium at sea water Na/K ratio (27.8 w/w) had a slight positive effect on SMA of Do (7.3%) and Li (10.1%), whereas at double the sea water ratio (13.9% w/w) had no pronounced positive effect. R20 granular sludge was also exposed to hyposalinity shock from 20 down to 5 g Na+/L. Glutamate and N-acetyl-ß-lysine were excreted by microbial consortium in anaerobic granular sludge adapted to 20 g Na+/L upon this exposure to hyposalinity. A potential consequence when applying these results is that saline streams containing specific and hydrolysable proteins can be anaerobically treated without additional dosing of osmolytes.

Fast anaerobic sludge granulation at elevated salinity.

It is commonly accepted that high salt concentrations negatively affect microbial activity in biological wastewater treatment reactors such as upflow anaerobic sludge blanket (UASB) reactors. Microbial aggregation in such reactors is equally important. It is well documented that anaerobic granules, when exposed to high salinity become weak and disintegrate, causing wash-out, operational problems and decreasing process performance. In this research, the possibility of microbial granule formation from dispersed biomass was investigated at salinity levels of 5 and 20 g Na+/L. High removal efficiencies of soluble influent organics were achieved at both salinity levels and this was accompanied by fast and robust formation of microbial granules. The process was found to be stable for the entire operational period of 217 days. As far as we know this is the first time it has been demonstrated that stable granule formation is possible at a salinity level as high as 20 g Na+/L. Methanosaeta was identified as the dominant methanogen at both salinity levels. Streptococcus spp. and bacteria belonging to the family Lachnospiraceae were identified as the dominant microbial population at 5 and 20 and g Na+/L, respectively.

Genetics and biology of pheochromocytoma.

The familial forms of pheochromocytoma have recently been demonstrated to be more frequent than believed in the past. The genes currently known to be responsible for tumor formation are RET, VHL, NF1, SDHB, SDHC and SDHD. Germline mutations of these genes increase the risk of developing pheochromocytomas and/or paragangliomas which variably associate with other neoplasms and characterize diverse clinical syndromes such as MEN 2, von Hippel-Lindau (VHL), and neurofibromatosis type 1 (NF 1), or the PGL syndromes, respectively. Although the pathogenesis of pheochromocytoma/paraganglioma formation is still largely unknown, studies of the familial forms have started to uncover some pathways that favor tumor formation, such as activation of tyrosine-kinase, induction of hypoxia-inducible factors, activation of the oncogene Ras or reduced apoptosis. These studies have also demonstrated that various gene mutations can differently affect the biological characteristics of pheochromocytoma: for example, while the tumors are mostly adrenergic (epinephrine secreting) and episodically secreting in MEN 2, they are mostly noradrenergic (norepinephrine secreting) and continuously secreting in VHL. Biological variability can also be observed in the PGL syndromes where tumors develop in the head and neck and are parasympathetic in origin and non-secreting, or in the thorax and the abdomen, where they are sympathetic in origin and catecholamine secreting. Genetic testing in patients with pheochromocytomas or paragangliomas is, at present, strongly recommended and is mandatory in young patients or in cases of multiple or recurrent tumors. The clinical picture and the biological characteristics of the tumor may suggest the priority of the genes to be tested first.

Fenoldopam vs dopamine as a nephroprotective strategy during living donor kidney transplantation: preliminary data.

UNLABELLED: Fenoldopam is a selective DA1 agonist with potential nephroprotective capabilities. The aim of this study was to compare the nephroprotective effect of fenoldopam and dopamine during general anesthesia for living donor kidney transplantation. METHODS: Forty donors enrolled in the study received a similar anesthetic and fluid protocol. The patients were randomly divided into group F (receiving 0.1 mg*kg-1*min-1 fenoldopam) versus group D (receiving "renal dose" 3 mg*kg-1*min-1 dopamine). The mean volume of infused fluids, diuresis, and urinary electrolytes (Na, K, Cl) at infusion start and 120 minutes later were studied. RESULTS: Anthropometric parameters, administered anesthetics, mean infused volume, and urine outputs, did not show significant differences between the groups. Statistically significant differences were observed for urinary excretion of sodium, potassium, and chloride after 120 minutes of continuous fenoldopam infusion, with significant variations within groups for sodium only. CONCLUSIONS: Fenoldopam compared with dopamine resulted in better nephroprotective effects. No adverse events were recorded, and side effects were minimal. Further studies are necessary to evaluate these data.