In Vivo #6 EN

think health

no. 6 – July 2015

LESS IS MORE /

the BAttle AgAinst oVeR-medicAlisAtion

dIgItAl HEAltH Apple and google join the race dEBAtE Marijuana as a prescription drug pHOtO-REpORtAgE 3d-printed prosthetics published by the chuv www.invivomagazine.com IN EXtENsO gENEtIcs, tHE NEVER-ENdINg stORy

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IN VIVO / NUMBER 6 / july 2015

contents

FOCUS

19 / medicine Less is more

by Julie Zaugg and melinda marchese

MENS SANA

30 / INTERVIEW Rishi Manchanda: “Health is too rarely perceived as a group phenomenon”

by Julie Zaugg

34 / INNOVATION The battle between the giants has begun

by Clément Bürge

38 / Trends Children under close watch by emilie veillon

42 / Decoding Cannabis, just what the doctor ordered

by Clément Bürge

My (rough) life as a researcher by bertrand tappy

49 / INNOVATION The hospital improves the health of its signage

by Darcy Christen

In its “Smarter Medicine” campaign, the Swiss Society of General Internal Medicine now discourages patients with lower back pain from having X-rays done. The procedure does nothing for the patient’s diagnosis but increases radiation exposure as well as costs.

science photo library

46 / insight

cONtENts

56

49

42

65

coRPoRe sAno

in sitU

53 / tRends

11 / heAlth VAlley

Dr Iodine and Mr Salt by antoine menusier

Virtual reality applied to medicine

56 / PRosPecting

14 / ARoUnd the WoRld

Animals could be the future of human health

Eye implants to restore sight

by martine brocard

Autism in a new light by geneviÈve ruiZ

65 /

in the lens

Printed prosthetics by eriK Freudenreich

cURsUs

71 / commentARy “Quality of care should not be reduced to one or two indicators”

72 / PoRtRAit Eleonora De Stefano is a perfusionist, a relatively unknown profession.

74 / tAndem Swiss BioMotion Lab working with its Californian “mentor”

Follow us on: twitter: invivo_chuv Facebook: magazine.invivo

2

blair gable / reuters, paul nguyen, philippe gétaz

60 / decoding

editorial

DOES “DEGROWTh” MEAN “DE-SCIENCE”?

patrick dutoit

BÉAtRice schAAd chief editor

*kale ms, bishop tF, Federman ad, keyhani s. trends in the overuse oF ambulatory health care services in the united states.

Jama intern med 2013;173: 142-8 (medline) **mourir, gian domenico borasio, le savoir suisse collection, 2014. ***selling sickness, how the world’s biggest pharmaceutical companies are turning us all into patients, ray moynihan, alan cassel, paperback, 2006.

3

care is the art of giving. does that mean that, by nature, care has to be given without counting the cost? and discussing the opposite of care – its limits or stopping treatment – is difficult, even taboo. a Jama* study recently revealed that doctors are much less inclined to apply new evidence-based recommendations when they involve abstinence. yet the medical world needs to be aware that it is caught in an inflationary spiral. there are many reasons for this awareness. some are of course economic, as the swiss spend the most out of pocket of all countries in the oecd, the organisation for economic co-operation and development. but there are also medical reasons, as too much medicine can have adverse side effects.** it is even harder to “do less” when the pressure to “do more” is coming from all sides. pharmas use weapons of mass seduction to constantly push the boundaries of disease. the difference between normal and abnormal is increasingly blurred in areas such as hypertension, osteoporosis, cholesterol and cognitive disorders.*** pressure also comes from the shift from curative medicine to predictive medicine, which can turn any healthy individual into a potential patient. risk management is becoming a specialisation in itself. in economics, “degrowth is not the mathematical opposite of growth,” as the French green party member of parliament yves cochet said when the movement began. similarly, in medicine, “degrowth” is not about “de-science”. it does not mean moving towards regressive medicine, but towards a paradigm shift in the way that clinical practice views itself and communicates more transparently about its limitations. one of the most promising paths to success (see our report on p. 19) is getting patients and health care professionals together to develop care plans in the earliest treatment stages possible. why? to let patients choose an effective, realistic treatment geared towards their lifestyle ideal and their own definition of health. to prevent doctors from mistakenly feeling obligated to continue aggressive treatment, when patients actually want something else, or to discuss patient requests that may seem futile to health care professionals. For some patients, doing less may actually be doing more. ⁄

post-scriptum updates on previous “in vivo” articles You can subscribe to “in vivo” or request back issues on our website www.invivomagazine.com

ORGAN DONATION IV n° 1

p. 30

Terminally ill baby donates his kidneys

SELF-MEDICATION IV n°3

p. 58

Meditate to stave off depression British researchers have shown that mindfulness techniques can prevent depressive relapse as effectively as medication.

The Lancet, a medical journal, published the double blind study which took place over the course of two years and monitored 424 patients. The relapse rate was slightly lower for the group practising mindfulness meditation (44%), than for the group that remained on antidepressants (47%). /

4

The United Kingdom approved the sale of HIV home test kits in April. Available online for about 35 Swiss francs, these medical kits use a drop of blood to detect the presence of human immunodeficiency virus (HIV) antibodies in about fifteen minutes. Although these tests are highly reliable (99.7%), any positive results must be confirmed by a healthcare professional. These home test kits have also been available in French pharmacies since July. /

p. 19

Putting words in your mouth

Mike Segar / Reuters

MEDITATION p. 53

IV n° 3

AIDS self-testing now available in Europe

A team at the University Hospital of Wales transplanted the kidneys of a newborn just minutes old. Teddy was born with anencephaly. This birth defect causes the absence of part or all of the brain, meaning the baby would die within hours. Little Teddy’s parents learnt about the malformation in the early weeks of pregnancy, but refused an abortion so that their child could donate his organs. /

IV n° 2

PERCEPTION

Sufferers of severe hearing loss may soon have an alternative to surgically implanted cochlear devices. Researchers at Colorado State University are developing a retainer that can be pressed against the tongue. This is connected to a Bluetooth-enabled earpiece which converts sounds into electrical impulses.

The retainer then stimulates the nerves on the tongue. The scientists estimate the retainer will cost about $2,000, versus approximately $100,000 for cochlear implants. /

AGEING IV n° 3

p. 54

Is senescence a disease of the past?

The British scientist Aubrey de Grey believes that old age will soon no longer be a cause of death. The founder of the SENS project, which aims to extend life expectancy, is developing cell regenerating therapies that the body can use to heal itself.

In an interview with the site Motherboard, de Grey estimated that the likelihood is about 80% that the first human to achieve medical immortality has already been born. /

post-scriptum

smart medicine IV n° 4

p. 44

Fighting obesity with an electronic pill The Israeli start-up MelCap Systems has developed a connected appetite suppressant.

Once swallowed, the capsule is positioned in the stomach using magnetic sensors.

Patients can trigger a feeling of fullness via a smartphone app. Melcap has patented its technology and is preparing to launch clinical trials. /

CANCER IV n° 4

p. 57

The first proton beam therapy centre in the United Kingdom will open in Cardiff in 2016, with two more facilities planned in London and Northumberland by 2017. The British National Health Service has also announced that it will open two public proton beam therapy centres in 2018. This technique targets cancer cells more accurately than traditional radiotherapy, limiting damage to vital organs. /

5

Keystone / AP Photo

The United Kingdom launches proton beam therapy

GUT IV n° 5

p. 19

Gaining health and weight with faecal transplants Faecal transplants are a recent procedure which involves transplanting bacterial flora from a healthy individual into the gut of a sick person to treat intestinal diseases. The journal Open Forum Infectious Diseases reported the first case of an unwanted side effect from the treatment. A 32-year old American woman suffering from a recurrent clostridium difficile infection was successfully treated after receiving a stool transplant from a healthy but obese donor. The patient experienced a significant weight gain following the procedure. In three years, her Body Mass Index (BMI) increased from 26 to 34.5, indicating severe obesity. /

Thanks to its university hospitals, research centres and numerous start-ups specialising in healthcare, the Lake Geneva region is a leader in the field of medical innovation. Because of this unique know-how, it has been given the nickname “Health Valley”. In each “In Vivo” issue, this section starts with a depiction of the region. The accompanying map was created by the Genevois illustrator Nelson Reitz.

in situ

Health Valley Panorama of the latest innovations.

ECUBLENS

p. 11

The young company MindMaze uses virtual reality to rehabilitate stroke patients.

GENEVA

p. 09

nelson reitz

The Campus Biotech neuroscience research centre opens its doors.

6

in situ

HEALTH VALLEY

LAUSANNE

p. 10

Innovation Forum aims to develop active ties between universities, industry and investors.

SIERRE

p. 08

The start-up Medirio is developing an insulin patch for diabetics.

7

IN sItU

HEAltH VAllEy

stARt-UP

750,000

CARDIAC

gBc-Atrial was formed in 2013 at the former headquarters of merck serono in geneva. now operating out of plan-les-ouates, the start-up has signed an exclusive worldwide licence agreement with the basel-based group actelion pharmaceuticals. the agreement is for the compound gbc-a1, which has shown potential in treating cardiac rhythm disorders.

MICROSCOPE

nanolive, a start-up based at the swiss Federal institute of technology in lausanne (epFl), won the pionierpreis prize awarded by the zürcher kantonalbank and technopark zürich for its next-generation microscope. the revolutionary microscope combines holography and rotational scanning to see inside living cells with a resolution of 70 nanometres without damaging them.

the sum in millions swiss francs raised by the geneva-based firm prexton therapeutics. this funding will be poured into its research of a molecule that could address motor complications in parkinson’s patients. prexton therapeutics, set up in 2012 after the closure of merck serono’s geneva branch, boasts extensive expertise in treating neurological diseases.

the amount in dollars granted by the bill and melinda gates Foundation to im4tb, a company based in ecublens that focuses on developing a breakthrough drug to fight tuberculosis. this disease affects one-third of the world’s population and is the eighth leading cause of death in developing countries. the epFl spin-off will use this donation to move into the first clinical trials of a new antibiotic.

DIABETES

medirio, based at the technoark innovation park in sierre, focuses on improving diabetes treatments. the company has designed an insulin patch used with a digital device to make it easier for patients to manage their injections and for physicians to monitor their therapy. the start-up hopes to raise 1.2 million swiss francs to manufacture its insulin delivery system.

8

eric déroze

BIOMARKERS

the vaud-based medtech company lunaphore has invented a quick and accurate method for profiling biomarkers in cancer cells using colouration. evaluations take five minutes instead of two to eight hours using standard procedures. lunaphore was awarded 130,000 swiss francs for its technology in the venture kick final.

Lausanne and Geneva team up to treat heart disease in children

PediAtRy the vaud and geneva university hospitals have joined forces to found the centre for paediatric cardiology and cardiac surgery in French-speaking switzerland. the centre – created under the auspices of the association vaud-genève (an organisation that promotes cooperation between the cantons) will further expand this specialisation in which the chuv and hug “have jointly developed top-of-the-line expertise”. this facility, headed by professor maurice beghetti (hug), expects to reduce the length of hospital stays, complications and therefore costs. professor rené prêtre (chuv) will coordinate the centre’s paediatric heart surgery services.

IN sItU

HEAltH VAllEy

Breath test for cancer

epFl

technology a new system developed in collaboration with researchers at the swiss Federal institute of technology in lausanne (epFl) can be used to detect mouth or throat cancer more easily, with a simple breath. this patienttested “breathalyser” features extremely sensitive sensors and works equally well with a computer or mobile phone, as long as the test is done in strict conditions.

Zoom in, in the blink of an eye

APP

SOS MÉDECINS the app for geneva’s emergency medical house call service, sos médecins, was developed by atipik to make patients’ lives easier. it handles appointments and tracks the vehicle of the doctor on call in real time. a push notification is sent when the vehicle leaves or comes within 100 metres of the destination. within 48 hours, medical results are sent to the patient’s attending physician and are available on the app.

innoVAtion close your right eye to zoom in, then your left to return the image to its initial size. no, this is not sciencefiction! telescopic contact lenses may actually become an everyday device within the next few years. the swiss Federal institute of technology in lausanne (epFl) and university of california san diego are developing the technology. and this is no gadget. these lenses could bring independence back to sufferers of age-related macular degeneration, a condition caused by damage to the retina which results in the loss of central vision and affects 30 to 50 million people worldwide.

Campus Biotech now open

neURosciences “campus biotech has the potential to rise among the leading international institutions.” that is how Federal councillor Johann schneider-ammann expressed his enthusiasm as he inaugurated the new neuroscience and bioengineering research centre in may. campus biotech, located in the former merck serono building on the edge of geneva, houses more than 600 researchers mainly from the university of geneva, the swiss Federal institute of technology in lausanne, the geneva university hospitals, the Wyss center for bio- and neuroengineering, the human brain project, the swiss institute of bioinformatics and the swiss school of landscaping, engineering and architecture.

“We hope to become a European leader in our sector.”

Jurgi camblong at the inauguration oF the new oFFices oF sophia genetics in February, Jurgi camblong, ceo and co-Founder oF the lausanne-based start-up specialised in genomics data analytics, expressed his optimism about his company’s development potential.

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IN sItU

HEAltH VAllEy

imPlAntAtions

Biopharmaceutics

3 questions For

MANUEL FANKhAUSER

innovation Forum, the not-For-proFit organisation he chairs, builds bridges between academia, industry and government.

1

WhAt is the oBjectiVe oF innoVAtion FoRUm?

the swiss branch opened in lausanne on 10 march, but innovation Forum was founded in 2012 by researchers from cambridge. today, the organisation is active on a dozen campuses in north america, europe and asia. experience shows that bringing people together from different generations, spheres and disciplines fuels innovation. that’s the atmosphere we want to create by developing active ties between the circles which often remain too isolated: universities, industry, investors, policy makers, start-ups, etc.

2

the us group incyte corporation opened its headquarters for europe, the middle east and africa (emea) in geneva in april. incyte states that it wants to use this new subsidiary as a base to conduct clinical development operations. the company is looking to occupy an 800 m2 space by this summer, where it expects to bring in about 80 employees over the next five years.

Genetics

linkage biosciences, a molecular diagnostics specialist that develops products to improve complex genetic testing, is set to open a european subsidiary in geneva. the us company has chosen geneva’s high-tech incubator Fongit as its new location, which supports innovative medtech, it and cleantech start-ups.

hoW cAn We cReAte thAt Alchemy?

academia tends to cloister itself off. that’s why we want to develop the contact between these partners so that they can think differently. innovation Forum features a community of 100,000 people worldwide. this brings both a global and local perspective to our network of individuals determined to design and develop the next disruptive innovations in all disciplines, from life sciences to architecture and clean techs.

3

Why lAUsAnne?

lausanne has the advantage of being home to a number of top-notch universities and schools with various specialisations. the city also offers the ideal location as it is home to a new generation of business leaders and entrepreneurs who are ready to experiment with new forms of dialogue. by choosing lausanne, innovation Forum is also positioned to benefit from the networks and financial support from numerous partners such as novartis and venturlab. / president of the swiss branch of innovation Forum, manuel Fankhauser is a phd student at the laboratory of lymphatic and cancer bioengineering at the epFl.

10

the deVice

GLOBALDIAGNOSTIX this coalition between swiss and cameroonian research laboratories has developed a radiography device designed to resist high temperatures and interruptions in electrical power in emerging countries. priced ten times lower than a traditional device, the prototype is awaiting funding to be produced and distributed on site.

in situ

HEALTH VALLEY

Virtual reality applied to medicine A number of projects in French-speaking Switzerland use visual simulation to treat patients. anxiety disorders

The Brain and Behaviour Laboratory, a pioneering centre devoted to the study of the brain and human behaviour at the University of Geneva, has been using augmented reality since 2013. This system plays with vision, hearing and the sense of smell to immerse the subject in a fully controlled virtual environment. With this, researchers hope to better understand disorders such as anxiety and autism.

rehabilitation made fun

MindMaze, a company based in Ecublens, is developing a computer platform for the rehabilitation of stroke patients using virtual reality headsets with built-in electrodes.

Ironically, this technology, initially developed for the healthcare sector, has sparked the interest of video game giants. These developers immediately spotted the potential of this system for gaming.

phantom limb pain

cerebral brainstorming

Lausanne University Hospital (CHUV) uses augmented reality to relieve phantom pain in volunteer amputees. The therapy – still undergoing tests – uses Kinect glasses and motion sensors similar to those featured in game consoles. These devices help in total immersion and therefore visualisation of the missing limb, used as a basis for treating attacks of pain.

The RealiSM project focusing on “reality substitution”, led by the Swiss Federal Institute of Technology in Lausanne (EPFL) and the W Science Initiative, was presented at the Brain Forum 2015 in Lausanne. This technology is still being developed but could eventually replace traditional virtual reality, as it uses real-world situations to create virtual worlds. A number of clinical applications are already planned.

100 11

In millions Swiss francs, the sum donated by the US endowment fund Ludwig Cancer Research to the Ludwig Center for Cancer Research of the University of Lausanne. The branch has been operating out of the Vaud capital since the 1970s and has been designated as a priority hub among the twelve centres located throughout the world. Researchers can use this sizeable investment to continue their work on developing immunotherapy. “The scientific, computer and engineering expertise found in Lausanne is of rare value, and the biotech community there is growing,” says David Lane, scientific director of the Ludwig Institute for Cancer Research.

IN sItU

HEAltH VAllEy

sixth step

GENEVA

ON ThE ROAD

genkyotex

in every issue, “in vivo” meets with the leaders of health valley. geneva is the focus of this edition.

Fighting diabetes Genkyotex is a pioneer in developing a drug to treat diabetic diseases. text: céline bilardo

“this is a very exciting period for us,” says ursula ney, director of genkyotex, enthusiastically describing the expansion of the geneva-based start-up and its future projects, which include an innovative treatment for diabetic nephropathy. this common complication of diabetes currently affects 20% to 40% of patients. the genkyotex adventure began in 2006 at eclosion, a business incubator in plan-les-ouates in the canton of geneva, with a team of four scientists from geneva, Kyoto and texas. together, they discovered a new family of enzymes called noX. these molecules produce oxygen derivatives involved in a number of cardiovascular diseases, forms of diabetes, and fibrosis. “until 2011, we worked on selecting an enzyme to target a specific disease and develop a drug to fight it. We then launched two rounds of financing to lead our first clinical trials.” by 2014, the company 12

had raised 72 million swiss francs, enough to conduct its trials. results are expected this summer. genkyotex now employs 21 people. the drug manufactured by genkyotex is an orally administered capsule that stops the progress of the disease, something current treatments cannot do. “if the results are positive, we will be the first to show that these molecules have therapeutic benefits! then we can develop more treatments for other rare diseases using this family of enzymes.” ursula ney took over the management of genkyotex in 2011. she is excited about the future of this research, which is attracting a growing number of scientists. “We are confident about the future. our first drug has already received approval from the us Food and drug administration (Fda), canada, australia and several countries in europe.” /

IN sItU

HEAltH VAllEy

BENOÎT DUBUIS director of the campus biotech site and chairman of bioalps

We need an ecosystem that brings together industry and academia.

i’m often struck by the opportunities that result from relations between industry and top specialised schools. but i find amazing the lack of understanding about how essential this interaction is. even more puzzling is that people think these relations carry on without any checks or regulations. industry is conveyed as a predator and the schools as the victims. there is no doubt that new therapeutic options need to be developed. nor is there any doubt that these options require research. but who is exploring them? in a well-documented article on the origin of 252 drugs, featured in the journal Nature Reviews Drug Discovery, we learn that in europe, 75% of drugs come from research led by pharmaceutical companies, and the rest are the work of academic research institutes and biotech companies. What is even more important is to understand the dynamics of r&d, which draws on these two worlds and therefore on complementary fields, expertise and especially experience.

in switzerland, we have achieved this by respecting the role of academia and industrial constraints. it is natural for experts to review the validity of these partnerships and the terms of their agreements.

What leaves me more circumspect is that when industry and academia come together, their relationship is insidiously and repeatedly suspected of conflicts of interest, of instrumentalising research or negating academic freedom or is accused of lacking transparency. let’s take that last argument. are we ready to risk taking information on innovation – that very element that drives the development and success of our companies – out of its context and make it public, presented in part (and perhaps in partial truths) to an audience unaccustomed to dealing with these considerations? isn’t forcing the publication of this sensitive industrial information in the name of “transparency” either denying the trust placed in institutions and organisations in charge of these projects or showing poor knowledge of the competition between regions, nations and companies?

in the debate surrounding this type of collaboration, let’s remember that switzerland has patiently but swiss institutions, pioneers in developing effectively built a special relationship (because it close ties between industry and academia, have successfully established a relationship based on respects the interests of each party involved) trust and mutual respect for the respective role of between our industries, small businesses, start-ups each partner. experience and professionalism on and research and development institutes. this new the part of top academic institutions and their innovation model, in which each partner gains, is industrial partners have helped bring together essential for tackling the challenges that we face these two worlds. Just ten years ago, these and for bringing patients and society innovative organisations had little contact with each other technological solutions. ⁄ and in some countries, they still struggle to understand how they are complementary.

FoR moRe inFoRmAtion

dr

www.bioalps.org the platform for life sciences in western switzerland 13

in SITU

world

in situ

AROUND THE GLOBE

Ars Electronica

Research doesn’t stop at borders.

In Vivo covers the latest medical innovations worldwide.

Eye implants to restore sight. technology Helping patients regain their vision with retinal implants. That is the technological innovation recently presented by the Vision Institute in Paris. Patients wear glasses fitted with a miniature camera and a device that sends information from the camera to the eye implant on the retina. Visual information is then converted into electrical stimulation that is transmitted to the brain. With physical therapy, previously-sighted patients can see between 50 and 60 pixels in black and white to orient themselves, recognise faces and eventually read complex texts. About ten French patients currently benefit from this implant.

the device

Technological leech Take your own blood sample at home, alone, and without a needle. The US start-up Tasso Inc. aims to let you do just that with a device called HemoLink. About the size of a ping pong ball, the device draws blood painlessly, and the collected sample can then be mailed to a laboratory. Pending clearance from the US Food and Drug Administration (FDA), the company hopes to launch the product by 2016.

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10

The percentage of survival rate increase for cancer patients after using a new immunotherapy called nivolumab. At a cancer research conference held in Chicago in June 2015, specialists from around the world were particularly enthusiastic about the drug, still in the test phase. Not only do patients live longer, but nivolumab’s side effects are considerably less toxic than effects from other treatments.

IN sItU

HEAltH wORld VAllEy

s Vo icK i V P in est B Le cœur éternel: La vérité sur vos

Promesse ou utopie?

médicaments

Featuring a preface by professor alain carpentier, the creator of the carmat artificial heart, this book retraces the incredible history of research and development of artificial pumps. the authors, heart surgeons in paris and in monaco, also look into the economic and ethical consequences if the use of these implants eventually becomes widespread.

“This is likely to become a fundamental treatment for cystic fibrosis.”

A tattoo to measure your blood sugar levels?

innoVAtion could it be the end of injections for diabetics? researchers from the university of san diego have recently tested a temporary tattoo that measures blood sugar levels in diabetic patients. applied directly to the skin, this electrochemical biosensor analyses the level of glucose in the fluid beneath the epidermis. clinical trials show that the system is accurate enough to soon be used by patients with diabetes or kidney disease.

15

Brain Maker: The Power of Gut Microbes to Heal and Protect Your Brain–for Life

As We Age, Keys to Remembering Where the Keys Are new york times, Jane e. brody

david perlmutter, kristin loberg little, brown and company, 2015

the New York Times health and science columnist tackles the issue of “retrieval disorder”, or memory loss, experienced by older people. her article, which draws on recent research, underscores that these problems are often related more to the brain’s natural ageing than to a disorder. to slow the wear and tear on our grey matter, Jane brody recommends getting regular exercise, drinking alcohol in moderation and pursuing intellectually stimulating activities.

s video n s an d colum m to o s .c k e n n to li agazi nvivom www.i

Jean-FranÇois bergmann, FranÇois chast, andré grimaldi, claire le Jeunne, odile Jacob, 2015

in this book, professors and doctors have come together to assess the efficacy of drugs. medication plays an essential role in healthcare; it is used to fight contagious diseases, and even cancer, more effectively. progress made in cardiology and rheumatology would not have been possible without drugs. these experts also reveal the dark side of the industry: counterfeiting, misuse and scandals.

stuart elborn, in an interview with bbc news, proFessor stuart elborn From queen’s university belFast expressed his enthusiasm about the Findings From trials conducted on 1,108 patients with the genetic disorder. the combination oF the two drugs ivaFactor and lumacaFtor improved patients’ lung Function.

ucsd

queen’s university belFast

alain deloche and gilles dreyFus, michel laFon, 2015

take care of your stomach to keep your head. that’s what dr david perlmutter suggests in his latest book. this renowned author, specialised in the relation between nutrition and neurological disorders, examines the latest research on how the microbiome is related to the health of your brain. dr. perlmutter also offers a dietary programme to better care for your microbiome and at the same time prevent neurodegeneration.

see

in SITU

The food of the future in 3D printing After the production of objects, clothing and human tissue, 3D printing has now moved into food. A muffin prototype was developed by the Dutch designer Chloé Rutzerveld as part of the Edible Growth project. Why is it innovative? Because the food produced by the 3D printer grows on its own. The machine first makes the dough, which creates the structure. The inner layers of the gelatinous base contain yeast, spores and seeds. After five days, the ingredients (here vegetables and herbs) sprout and are ready to eat.

The young designer Chloé Rutzerveld wants to show that food produced in a laboratory or by 3D printing can also be tasty and healthy. This food alternative could make its way to our tables within the next ten years.

Chloé Rutzerveld www.chloerutzerveld.com

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world

in SITU

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world

UP-TO-DATE INFORMATION All you need to know about life sciences and innovation in the region. Sections that are designed for you: What’s on, Innovation, People, Science.

It’s a one-stop site for news about companies, higher education, and sponsors of innovation.

D republic-of-innovation.ch

“The joys of discovery are made all the richer when shared. Learn about innovation and experience that goes beyond everyday lives.”

BENOIT DUBUIs Founder BioAlps, Eclosion, Inartis

“The Republic of Innovation website is informative, smart, open, and easy to read. It’s a true delight and a real help.”

wzart consulting

ThIERRy MAUvERNAy Delegate of the Board Debiopharm Group

INVIVO4_6_18_EN.indd 18

REPUBLIC OF INNOVATION

23.10.2014 16:08:56

focus

less is more

medicine

Less is more /

People are beginning to speak out against over-medicalisation. Measures are being taken to encourage less care, even if that means giving up old certainties.

/ by

Julie Zaugg and Melinda Marchese

19

fOcUs

A

lEss Is MORE

re our modern doctors all dr Knock? this fictional character dreamt up by the French writer Jules romains in the 1920s convinced the inhabitants of an entire village that they were ill and had to be treated. similar to molière with his Imaginary Invalid, romains criticised the excesses of an overmedicalised society that transforms citizens into health care consumers who just keep wanting more, hoping to feel better and better.

patients also hope that new cutting-edge technology or treatments will cure them. and the healthy are advised to remain prudent. “patients are constantly bombarded by warnings coming from public health campaigns, media and advertising to get screened or treated,” says rosemary gibson, author of The Treatment Trap. “their belief that ‘prevention is better than cure’ runs deep.” david goodman, professor of community medicine at the university of bern, notes that “early detection and aggressive treatment are often considered evidence of quality care.”

over-medicalisation has been around for decades (see inset p. 26). but in the 21st century, health care is no longer reduced to bleeding, purging and other old- patients and health care professionals firmly believe in fashioned remedies. a growing number of increasingly the promises of modern medicine. even though dr sophisticated high-tech instruments and drugs give Knock ends up winning in the play by Jules romains, doctors an ever greater arsenal of therapies to choose a growing number of health care providers today infrom. “When a new product is released on the market stead support more humble, modest form of medicine that recognises its limitations and and its manufacturers extol its viris bold enough, in some cases, to do tues, as physicians, we want to beless. “We’re seeing movements lieve it,” says thomas bischoff, FigURes emerging that advocate the idea of director of the institute of primary ‘less is more’ in medicine,” says care at the university of lausanne. arnaud chiolero, public health “While maintaining an analytical In billions of dollars, specialist at the university institute perspective, we hope that it will the annual cost of excess health of social and preventive medicine truly help us provide better care for care worldwide, estimated by the Dartmouth Institute. in lausanne. “the objective is esour patients. but it’s not easy for pecially to perform fewer unnecesthe medical community to separate sary treatments.” the good from the bad with all these new products.”

200

50

The percentage of unnecessary drugs, of which 5% are potentially harmful, according to The Guide of 4,000 Useful, Unnecessary or Dangerous Drugs (Le Guide des 4000 médicaments utiles, inutiles ou dangereux), published by a surgeon and a French pulmonologist.

1

An oVeR-medicAlised WoRld

campaigns like smarter medicine in switzerland, or choosing Wisely and slow medicine in the united states, are embracing medical care that is moderate and gradual. doing less in no way means questioning necessary and useful treatments for patients. the “less is more” concept invites people to acknowledge that too much medical treatment can sometimes be more risky than beneficial. proponents believe that Western societies are currently over-medicalised. “We’re in a health care system that constantly pushes us towards ‘excessive’ 20

treatment,” says thomas bischoff. “that can be explained by the same principle that encourages other sectors in our Western cultures to keep going further.

We view accumulation and growth as signs of progress and performance.”

FUll-time PAtient

this general practitioner believes that medicine takes up too much of people’s lives today. “We don’t just go to the doctor when we’re sick, we also have routine checks and other tests done,” he notes. “and that can transform healthy people into potential patients.” outside medical offices and hospitals, some people constantly focus on monitoring their health. “With

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less is more

“The simpler it is, the better it works” Surgeon Nicolas Demartines* supports a new multimodal approach to reduce complications and hospital stays after surgery, known as the Enhanced Recovery After Surgery (ERAS) pathway. based on an interview with

Melinda Marchese

A

now almost never placed during surgery, and feeding tubes are removed in the operating room, so the patient feels nothing.

What are the advantages of this method? nd This multimodal pathway helps reduce the risk of complications by 40% to 50% and shorten hospital stays from 10 to 6 days on average, e.g. for colon and rectal surgery. The cost of care is also cut by 2,000 to 7,000 Swiss francs per patient depending on the type of surgery (colon, liver, etc.). By adapting the guidelines to each organ, the ERAS protocol can be applied to any surgical procedure. iv

t Lausanne University Hospital (CHUV), more than 1,500 patients have undergone surgery based on the ERAS pathway since it was implemented in 2011.

The CHUV’s Service of Visceral Surgery was one of the first facilities in the world to introduce this method, which is now used on every continent.

21

eat a full meal the evening before the operation and are given food as soon as possible, ideally the evening of the operation. Food stimulates the regeneration of intestinal mucosa, which can also contribute to boosting immune defences. Patients are also put in a wheelchair a few hours after surgery. Ideally they walk, as mobility speeds up recovery tremendously.

Is postoperative care any different? nd Thanks to the progress in pain management, we can better calibrate each patient’s need for medication so that they only receive the doses necessary to maintain their comfort. Drains are iv

This new approach simplifies care (fewer devices and drugs, etc.). Have we been overdoing it all these years? nd It’s true that we considerably complicated things for years, due to historical reasons. A lot of precautions were taken because antibiotics, surgical instruments and sutures were not as effective and safe as they are today. We can now say in 2015 that for surgery, the simpler it is, the better it works! iv

*Nicolas Demartines, chief of the Service of Visceral Surgery at the CHUV.

ErIC Déroze

In concrete terms, what does the ERAS approach involve? nd The protocol includes a list of 22 steps to take before, during and after the operation that will help improve postoperative recovery. These care elements concern surgeons, anaesthetists and nursing staff, and the patients themselves are highly involved.

For example, one of the guidelines is not to leave the patient on an empty stomach for endless hours before an operation. We give them two glasses of water with sugar two hours before the operation, then we adapt the number of infusions administered so that they’re never “too dry” or “too full of liquid”. We make sure that patients iv

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new technology, applications and connected objects, anyone can measure their insulin levels, pulse or blood pressure whenever they want.” if they find anything suspicious, the temptation is nearly irresistible to seek out more information online. according to a study published by swisscom in 2012, 84% of swiss people have already done research on medical websites before or after seeing a doctor. the most common searches are about symptoms, diseases and possible treatments. “patients feel reassured when they leave with a prescription,” says peter vollenweider, chief physician at the service of internal medicine at lausanne university hospital (chuv). “prescribing medication takes up less of a doctor’s time than explaining why not to. but we need to take that time if we believe that the treatment has nothing positive to offer the person in front of us.”

relational therapy over pills in psychiatry, drug-based treatments can be used alongside relational forms of therapy. “art therapy, music therapy and ergotherapy are some of the alternatives available that can be used depending on the patient’s needs,” says Jean-michel kaision, director of the department of psychiatry at lausanne university hospital. “certain daily activities, such as walking or reading, can also be part of the programme.” the idea is to organise the patient’s day by marking out a schedule, providing a form of stability. “recent research has shown that these therapies are also effective for patients with dementia or alzheimer’s disease,” the specialist says. these alternatives often help reduce the patient’s consumption of medication. For example, people with sleep disorders can be treated using massages or snoezelen, a dutch technique that involves placing patients in a room specially equipped to stimulate all their senses through music, coloured lighting, relaxing scents and mats in different materials. “it helps soothe patients so they go to bed more relaxed,” says Jeanmichel kaision. often they no longer need the sleeping pill that is typically administered.

22

senioR citiZens on the FRont line

this issue is especially prevalent among the constantly growing elderly population, who are huge consumers of medication. a 2013 study by the French society of geriatrics and gerontology reported that more than 90% of people over age 80 took an average of ten pills a day. the coordinator of the study, olivier saint-Jean, chief of the department of geriatrics at georges pompidou european hospital in paris, said in an interview with the French newspaper Libération, “any more than three or four molecules taken together and we don’t know how they will react. and, more importantly, beyond five, the risk of a medication accident increases considerably.” the French may be some of the world’s biggest consumers of medication (see infographic on the right), but the numbers are also high throughout the rest of europe. a survey published by the swiss paper L’Hebdo in april 2015 reported that nearly 20% of patients age 80 and over took ten types of medication or more per day, and 50% to 60% took at least five. “each additional drug increases the chances of experiencing a side effect or triggering an interaction with another compound,” says robert vander stichele, professor of clinical pharmacology at the university of ghent (belgium) and author of several studies on the consumption of medication by senior citizens.

When diabetes medication is given to someone whose blood sugar level is barely above average, they risk going into hypoglycaemia and falling or losing consciousness, especially if the person is elderly.

2

cAUses oF the ePidemic

technological advances can now detect abnormalities in their early stages that used to be invisible. that all looks good on the surface... “diagnostic tests have become more sensitive,” says arnaud chiolero.

“For example, ct scans are used to identify pulmonary emboli that are merely harmless mini-emboli.” similarly, a routine X-ray procedure can often reveal a spot on the kidney, a lump in the breast or a nodule in the lung that could be cancerous lesions, but for the most part are innocuous. once the abnormality has been identified, “it’s virtually impossible, even unethical, not to investigate further and treat the patient, even if that means a high likelihood of

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1000

900

Sometimes, less is more

0

80

600

70 0

People who take the most medication do not necessarily live longer.

500

Pharmaceutical spending in USD per inhabitant and per year

0 1 2 3 Switzerland

4

5

6

400

Japan

7

8

Italy

9

10

France

11

12

15

0 30

Canada

14 16

OECD average

83

17

Denmark

82

0

Chili

20

20

81

19

80

18

United States

Mexico

22

100

0

78

21

79

Hungary

77

23

76

24 26

75 74

25

Life expectancy

73

27

72

28

71

29

31

69

70

30

68

32

67

33

66

34

65

35

64

36

63

37

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

23

38

62

Sources: Organisation for Economic Co-operation and Development (OECD), 2011 figures, infographiC: Romain

13

New Zealand

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over-diagnosis,” says the lausanne-based physician in a research paper.

less? screening always looks more attractive than it actually is, for both doctors and patients.”

“doctors also fear regretting not having anticipated more, once the cancer is reported,” says Jacques cornuz, director of the lausanne university medical polyclinic. “how can we be sure that a lesion is harm-

medical students have not been adequately exposed to the issue throughout their training. “as physicians, we are taught to act, not to remain passive when deal-

RAising AWAReness Among yoUng doctoRs

“it’s easier to continue intensive care than to stop it”  bertrand tappy

Oliver Peters, Vice President of the Swiss Federal Office of Public Health (FOPH), encourages doctors to make realistic decisions, in line with the patient’s wishes, to provide quality health care. iv The “less is more” movement advocating less medical care is taking off in western countries.

What does that mean to you?

OP We have made the same observations as the “too much medicine” campaign. it’s a complicated issue, but we have isolated several factors and are already taking action. the main focuses are the fragmentation of health care and excess supply of highly specialised and therefore more costly services. iv For example?

OP high-tech services

brigitte batt

such as scans or mris. not only are they sometimes performed without being truly necessary, these services are extremely expensive. innovation generally contributes to lowering costs (aviation, construction, etc.), but in health care, prices haven’t changed since the 1990s! iv Are certain categories of patients more directly concerned?

OP older patients typically need more medical services and are therefore affected more, but it’s not just an issue of age group. generally speaking, a huge contradiction has developed between increasingly sick patients – who need more advanced and integrated patient care planning – and the growing fragmentation of health care that focuses on episodes or individual

24

therapeutic steps. that’s why i think that analytical, integration and planning skills should be strengthened – as was done in the 1980s and 1990s in other service-based sectors such as banking, insurance and engineering – and applied to medicine. patient care plans, because that’s actually what we’re talking about, should be used more.

Is this approach also useful for patients at the end of their life?

OP most certainly. the swiss newspaper NZZ published a study comparing end-of-life care in the united states and switzerland. this situation is over-medicalised in both countries. in switzerland, a high number of hospitalisations and aggressive therapies (chemotherapy, radiotherapy, etc.) were reported in the last month of life. and procedures were performed more frequently on patients with supplemental insurance coverage. in the united states, despite the patient self-determination act passed in 1990, patients are treated more aggressively than they would like, and they are not cared for in the way that their general practitioner would choose for themselves in a comparable situation. iv

iv What measures are recommended to change that?

OP the us study explained that modern medicine is based on a principle of maximum therapy for everyone, and the system’s financial incentives encourage a treatment programme that patients wouldn’t spontaneously choose. it also reported how unsafe situations are especially vulnerable to over-medicalisation. it’s easier to initiate or continue intensive care than to stop it. doctors have to face discussion with the patient or their loved ones that they find difficult. they must also accept full responsibility if they decide that an aggressive treatment is not or no longer appropriate. and doctors often have no one to turn to when dealing with an unsafe situation.

so many factors are swinging in the direction of the “too much medicine” campaign. to counter that pressure, realistic patient care plans that are continuously adjusted and in line with the patient’s wishes offer the fundamental cornerstone for providing quality health care. i also think that another key response is access to specialised expertise to aid in decision-making in challenging environments (emergencies, intensive care). lastly, i believe it’s essential to allow patients (and their loved ones) to take control of some decisions about their treatment, especially at the end of their life. exit cannot be the only solution.

read the entire interview on www.invivomagazine.com

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lEss Is MORE

ing with illness,” says david goodman. “modern medicine is based on action,” adds gian domenico borasio, professor and chair in palliative medicine at the university of lausanne and chief of the palliative care service at the chuv. “We now need to set off a change in culture by encouraging young physicians to get out of that trap of taking action at any cost.” economic inteRest

some procedures are overused for economic reasons, such as implanting certain stents – those small prosthetic devices used to widen blocked blood vessels. in switzerland, they doubled in number between 2002 and 2013, going from 11,000 to 22,000. this rise is partly due to population ageing and the fact that this treatment is now frequently offered to patients over 80, explained urs Kaufmann, president of the swiss society of cardiology, in an april interview published in Le Matin Dimanche and SonntagsZeitung. “but this increase also suggests that the patient’s well-being is not always the main reason for initiating the procedure,” he says. “these procedures are lucrative and easy to plan. We might suspect that some hospitals place purely financial considerations before medicine.” arnaud chiolero adds, “a growing number of stents are implanted, while a more conservative treatment based on medication and a change in lifestyle [editor’s note: quitting smoking, losing weight] would often be enough.”

3

Finding Remedies

it is high time to find solutions to remedy the problem of overmedicalisation. general practitioners have a crucial role to play. “the family doctor must consider the patient as a whole,” says thomas bischoff. “specialists prescribe treatments to deal with a specific condition, but a patient with several conditions will be taking multiple treatments at the same time,” he goes on. “the general practitioner should be able to prioritise treatments and find a balance that the patient can tolerate.” sePARAting the good FRom the BAd

in 2000, sweden defined a “Wise list”. this list, established by an independent scientific committee, includes the 200 essential drugs for treating common diseases. in 2012, 90% of the prescriptions written in 25

mAKing Wise choices Created by about fifty US medical organisations, the Choosing Wisely list covers tests and procedures that can be avoided. Some of the examples include: Only 0.5% to 2% of cases of sinusitis develop into a bacterial infection. antibiotics should therefore be avoided for moderate symptoms that clear up on their own within two weeks. the same applies for ear infections.

Each transfusion bears risks, especially of allergic reactions. a limited amount of blood (7 to 8 g/dl) is enough for stable patients. anaemics should be treated with oral supplements rather than transfusions.

Pap smears are ineffective in detecting cervical cancer in women under 21. most abnormalities that occur at this age clear up on their own. in women age 30 to 65, a test every three years is adequate.

Prescribing antipsychotic drugs and sleeping pills to older patients with dementia should be a last resort to be used only after other non-medical treatments have failed. these medications increase the risk of stroke, falls and premature death.

Metastatic breast cancer should be treated with only one chemotherapy drug instead of combining several. the second option does not increase the chances of survival, but has more severe side effects.

Non-invasive treatments (physical exercise, anti-inflammatory drugs, mild painkillers or cortisone shots) are more effective than arthroscopic knee surgery.

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stockholm were compliant. France plans to define a similar list by 2016. a preliminary document lists 151 drugs out of more than 5,000 on the market.

market, we will also specify in which cases it’s worth using it and when an existing treatment should be used,” he adds.

“in switzerland, each hospital prepares its own list of essential drugs,” says pierre voirol, head pharmacist at the pharmaceutical assistance and clinical pharmacology unit at the chuv. “ours includes 1,000 drugs out of the 2,200 in stock at the hospital.” What gets a drug on the list? “its effectiveness, tolerance by patients and variety of forms available [editor’s note: tablet, liquid, powder, etc.]. cost is only factored in as a secondary criterion.”

pharmacists from pierre voirol’s unit are also in charge of assisting doctors during their patient rounds to examine their medication and make recommendations. “For example, we’ll remind them that administering a drug against stomach ulcers is not necessarily required after the patient is released from intensive care.” this process would be simplified even further with the more standardised use of electronic patient health records. “all those data grouped into one place,” he says, beaming.

pierre voirol also coordinates a drug commission to issue recommendations to prevent duplicating treatments and prescribing unnecessary ones. he points to benzodiazepines – often prescribed twice to treat both insomnia and anxiety – while one would be adequate. he also notes that, instead of administering antibiotics intravenously, it would be safer for the patient and less costly to take them orally once the patient is stabilised. “if a new medication hits the

centuries of over-medicalisation

moRe honest medicine

in many countries, doctors’ organisations have taken steps to set out guidelines that would reduce the prescription of unnecessary exams or drugs with little or no value. on request from the swiss society of general internal medicine (sgim), Jacques cornuz laid out a list of avoidable procedures. “certain exams and treatments are used, but no one really knows if they

the drug caused damage to heart valves and a form of pulmonary hypertension, killing nearly 2,000 people.

historian from the university of geneva. in some ways, the situation was even worse than it is today, as the medical field was more open in those days, with healers and bonesetters providing treatments in the same way doctors did. “it wasn’t until the 19th century that doctors and surgeons teamed up to form guilds, relegating other types of healers to society’s margins.”

remember back in september of 2004 when the pharmaceutical group merck recalled its these two highly publicised blockbuster vioxx, the anti-inflam- cases, along with the explosion matory painkiller drug that used of health care costs starting in to generate two billion dollars a the 1990s, thrust the issue of year in revenue? why? the drug, over-treatment into the spotlight. commonly prescribed to arthritis opinions started to sway in patients, increased the risk of favour of fighting this trend. “the heart attacks and strokes, causing movement began in the united more than 30,000 deaths in the the american researcher John states. europe didn’t join in until united states alone. wennberg’s work in the 1970s later, probably because health considerably raised people’s care costs are not as excessive, another health scandal exploded and the need to stabilise them awareness about over-medicala few years later. this time it isation. he demonstrated that less urgent,” says david goodman involved mediator, a drug devel7% of children from middlefrom the university of bern. oped by servier laboratories and bury, vermont, had their tonsils sold as an anti-diabetic. From removed, compared with 70% the issue is not unique to its market launch in 1976 until its in stowe, 80 km away. this modern societies. “back in recall in 2009, 145 million boxes “unwarranted variation” could the 18th century, doctors comwere sold, and more than 5 milnot be explained by any other plained that their patients were lion people had taken the drug reason than the fact that some only satisfied if they left with a in France. according to the indoctors are a bit overzealous remedy in hand,” says micheline spection report published in 2013, louis-courvoisier, a medical with the knife.

26

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less is more

offer any significant improvement to the patient’s health,” the physician says. “When clinical and epidemiological research confirms the lack of any beneficial impact, medicine should be honest enough to acknowledge it.”

At the end of 2014, the SGIM singled out five common procedures as “unnecessary” in Switzerland (www.smartermedicine.ch). Its “Top 5” include Xrays to investigate certain types of lower back pain, antibiotics for bronchitis and other infections of the upper respiratory tract, X-rays before certain operations and proton pump inhibitors to treat stomach acid. In the United States, a similar list covers about fifty guidelines (see p. 25). The Swiss list may eventually incorporate other procedures.

One of these is testing prostate specific antigen (PSA) levels in the blood to detect prostate cancer. Patients should be provided with neutral information about the advantages and disadvantages of the test before having the procedure performed, which the SGIM does not recommend for men over age 75.

“Many cancerous lesions found in patients without any symptoms will never develop into the disease, at least not during their life time,” says Arnaud Chiolero.

were provided with decision aids in the form of informational videos, 38% of them opted against knee surgery, while 26% refused a hip replacement.

Working with patients and their family is even more important in the case of a chronic and progressive disease. “It is vital that we discuss their values and priorities early on in their treatment,” says Gian Domenico Borasio. “Do they prefer to be treated at home? In a facility? What are their fears? What are they definitely against? Addressing these issues early helps set out a patient care plan in line with their personality and preferences.”

The specialist points out that since October 2014 all medical students at the University of Lausanne now take both a clinical and classroom course on palliative care. “In some situations, it can be very beneficial for the For more information www. smartermedicine.ch patient. The treatments given do not try This Swiss platform designed for to extend the patient’s life but improve patients and specialists provides an updated list of procedures its quality,” he says. “One unexpected deemed unnecessary, available finding of various studies is that palliain German and French. tive care can also extend the person’s www.lessismoremedicine.com life, while making their day-to-day exThis website includes press istence more comfortable. That’s why I articles, events and blog posts think that each clinician should have about over-medicalisation. In English and French. some basic knowledge about palliative medicine to talk about it with their www.choosingwisely.org The US campaign Choosing patients suffering from one or more Wisely promotes dialogue chronic and progressive diseases.” between patients and health-

Peter Vollenweider adds that high PSA care professionals about the Gian Domenico Borasio believes that levels do not necessarily mean that the treatments they are offered. the Danish philosopher Søren Kierkegpatient has cancer, “but they lead us to In English. aard perfectly expressed the attitude run other tests, which can increase the that doctors should have in their dayburden and stress put on patients. If cancer is actually reported, they could undergo an to-day practice: “If one is truly to succeed in leading operation that will affect their sex lives and some- a person to a specific place, one must first and foretimes social lives but without necessarily increasing most take care to find him where he is and begin their life expectancy,” he explains. “Is the treatment there. This is the secret in the entire art of helping. really worth it? The decision must not be made by Anyone who cannot do this is himself under a deluthe doctor alone. The patient needs to understand sion if he thinks he is able to help someone else.” And he concludes, “To guide patients well, we must first all sides of the issue and give an opinion.” understand and respect their priorities. At no point

should we ever abandon a person, but sometimes we Patient care plans Involving patients more in decisions about their need to know when to abstain for their benefit.” / treatment is one of the highly recommended measures taken to reduce the overuse of medical services.

“Patients should be presented with the pros and cons of each option, so that they can make well-informed choices,” says Jessica Otte, a Canadian family physician who created the health care blog Less Is More. A study by the Group Health Research Institute in Seattle demonstrated that when patients 27

fOcUs

based on an interview with

Julie zaugg

in vivO

lEss Is MORE

inteRVieW “We shoUld tAKe oUR time, insteAd oF RUshing into A tReAtment”

gilbert welch is a community medicine professor at dartmouth college. we met with this family doctor who has brought his stethoscope along on his travels from alaska through the native american reservations of oregon to zambia.

What is excessive diagnosis?

it happens when a patient is told that he or she has a disease but will never develop the symptoms. over-diagnosis is a side effect of our obsession to spot any abnormality as early as possible to treat it even before it sets in.

GiLBERT WELCH

iv

how can we fight this phenomenon?

we need to review and adapt our diagnostic methods. the best cancer screening tool is not the one that discovers the most cases, but the one that detects the most worrying conditions, the tumours that count.

GW

expert on over-diagnosis gilbert welch is a professor at the dartmouth institute for health policy and clinical practice (usa) and the author of “less medicine, more health, overdiagnosed: making people sick in the pursuit of health and should i be tested for cancer? – maybe not and here’s why”. he is a regular columnist for “the new york times“ and “the washington post“, writing on the excesses of the health care system.

28

iv And once the diagnosis is reported, how can we know if the patient should be treated or not?

GW when that happens, we enter a grey area. the key is to take our time. instead of rushing into a treatment, we should examine all the options available and their consequences, wait a while to see if the condition changes and not hesitate to take a second or even third look before making any decisions. even with a serious disease like cancer, we often have more time than we think.

iv Are there countries that over-diagnose more than others?

GW it happens more in cultures that want to anticipate and predict the future. they are also the ones that are overly enthusiastic about screening, routine exams and early disease detection. this pattern is found in all societies with advanced medical technologies. iv

how can that excess be explained?

disease has become easier to find. the new diagnostic tools available to doctors now enable us to spot tiny abnormalities, such as infinitesimal biochemical or anatomical variations. that also represents a multimillion-dollar industry. the market for detecting diseases is huge. and medicine has changed the rules of the game. the definition of some diseases has been revised and expanded.

GW

iv

do you have an example?

when i was a medical student, a stroke was described as an event after which the patient showed neurological side effects, such as GW

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difficulty speaking, walking or moving one side of the body. today, the definition of this condition has been enlarged to include “silent” strokes without any symptoms. a study by boston university found that if 2,000 healthy, average age people undergo a cerebral mri, 10% will show evidence of a “silent” stroke. if we look hard enough, we’ll always end up finding an abnormality. human bodies are full of them.

informing a patient that he or she has a disease but will never develop the symptoms is over-diagnosis, says gilbert Welch.

iv how widespread is over-diagnosis?

GW it’s very hard to tell. the only way to be 100% sure that someone has been over-diagnosed would be to not treat the disease detected and wait to see if it develops in that person’s lifetime. if not, the diagnosis was excessive. but in practice, it wouldn’t be ethical to work that way.

iv is there really no way to know how many people have been over-diagnosed?

iv do you have any of those cases in mind?

in the early 2000s, south korea experienced a thyroid cancer epidemic. in 2011, the number of tumours diagnosed in that population was 15 times higher than in 1993. but the mortality rate from thyroid cancer, which had traditionally been very low, remained completely stable during that period. what happened? in 1999, the government initiated a nationwide screening programme involving various forms of cancer. thyroid cancer was not included, but many practitioners still offered it to their patients.

GW

29

mark washburn

GW over-diagnosis is like a black hole in astronomy. to measure them, you have to observe what’s happening around them. when a group of new patients suddenly emerges where there hadn’t been any before, that’s a sign of over-diagnosis.

and the number of koreans who underwent a neck ultrasound rose massively. as a result, many suspicious nodules were detected and then biopsied. now diagnosed with cancer, two-thirds of the patients chose to undergo surgery to remove part or all of their thyroid. most of these tumours would never have caused symptoms in these patients. they had been unnecessarily exposed to the risks of a surgical procedure and must now take thyroid replacement drugs for the rest of their life. ⁄

mens sana

“All too often, the medical system only treats the patient’s symptoms. But we should also look at the conditions that impact our health, which are often less obvious at first glance.”

DR

Rishi manchanda

30

MENS SANA

INTERVIEW

Rishi Manchanda Champions an “upstream” approach to medicine,

suggesting that healthcare take into account where and how patients live. interview: Julie Zaugg

“Health is too rarely perceived as a group phenomenon” look for the root cause, the social or enviRishi Manchanda has devoted his entire career to underronmental factors that have brought about standing social and environmental factors that affect health. the disease. All too often, the medical system The water we drink, the air we breathe, the job we do. only treats the patient’s symptoms. But we Rishi Manchanda has worked for a decade as a doctor in should also look at the conditions that impact the disadvantaged neighbourhood of South Central Los our health, those which are often less obvious Angeles. He has developed a community approach to at first glance. healthcare that aims to act upstream to prevent disease before it appears.

IV What are the hidden causes? RM There are two kinds. First, the patient’s living and working IN VIVO You invented the concept of the healthcare conditions. These include housing conditions, professional who focuses on where health begins, the where they live, and the environment where they “upstreamist”. What is it about? RISHI MANCHANDA work, eat, sleep and play. Is there access to parks or The term comes from a parable. Three friends come green spaces? Are there leaks in their home? Is there to a river that leads to a waterfall. It’s a beautiful setmould? Do they live close to a motorway? Second, ting, but they soon notice that the water is full of there are social or political causes. They are the invisichildren who are drowning. The three friends jump ble government structures, factors that determine how into the river. The first tries to save the children resources are allocated in society, to rich and poor. who are in the greatest danger, those closest to the waterfall. The second friend starts building a raft from piece of wood. And the third friend starts IV Can you give us an example of how environmental swimming away, upstream. “What are you dofactors affect people’s health? RM A study of 30 million ing? Come back and help us!” the other friends people conducted in the United Kingdom focused on the shout. “No, I’m going to find out what’s throwcorrelation between exposure to green space and the risk ing these children in the water,” the third of heart disease. It found that the closer people are to green friend answers. That’s exactly what upspace, the lower their chance of developing heart disease, streamist healthcare professionals do. They regardless of income and education.

31

MENS SANA

INTERVIEW

IV When did medicine realise the effect that these social and environmental factors can have on people’s health? RM We suspected that these correlations have been around for a long time, but had no scientific research to back them up. The corpus of research in the area has grown massively over the past 20 years. One of the major advances comes from epigenetics, a science that looks at the link between environment and gene expression. We now know that these transformations can even be passed on to the next generation.

“A doctor should also ask the patient’s opinion about what might have caused the illness. This self-analysis can How can we detect the upstream causes of often deliver disease?

We can use epidemiological research or geomapping tools to detect suspicious surprisingly disease clusters. But we first have to communirelevant cate with the patient and ask the right questions.

For example, when a lot of people are coming in results.” with asthma, healthcare practitioners should ask IV

RM

about their exposure to allergens, such as mould or dust, second-hand smoke, or if they live near a How does social equality shape our health? RM motorway with high air pollution. All these factors Food insecurity is generally perceived as a thirdcan trigger asthma. A doctor should also world problem related to hunger. But it ask the patient’s opinion about what might also exists in developed societies when BIOGRAPHy people don’t have access to stores that sell Rishi Manchanda have caused the illness. This self-analysis fresh, healthy products, or if they can’t af- is a leading figure can often deliver surprisingly relevant results. But too often, doctors are trapped in ford to buy food and have to skip meals or in upstream healthcare in the a one-way approach to practising medieat cheap fast food. Food insecurity afUnited States. He cine. They talk but don’t listen. fects an estimated one in seven Ameri- is the president cans, including 17 million children. For and founder of diabetics, food insecurity can have drastic Health Begins, IV Why is there such a lack of interest? a social network effects and send them straight to the hosRM Doctors face several obstacles. First, where clinicians pital. Skipping a meal makes their blood can exchange ide- how healthcare is financed. Doctors are sugar level drop, and if they eat high-cal- as on prevention not encouraged to look for the root cause orie, energy-dense fast food or foods con- and upstream of disease because we don’t pay them to do causes of illtaining high-fructose corn syrup, their that. We pay them for the number of sernesses. He is the blood sugar level is too high. Living in a medical director vices they provide, not the quality of those constant state of hunger prevents proper of a veterans’ services. Second, regulations often prevent glucose synthesis. The body is completely clinic within the information from being shared between Greater Los Anthrown off. In California, low-income inenvironmental or housing authorities and geles Healthcare dividuals with diabetes are 27% more System. In 2013, the medical world. Sharing this informalikely to be admitted to the hospital at the Rishi Manchanda tion could help detect and explain concenend of the month, when their budget published The trations of sick people. Lastly, current Upstream Docstarts to run out. medical practice is to focus on the inditors, in which he IV

lays out his firm belief that we need to understand and address the causes and not just the symptoms of a disease.

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INTERVIEW

vidual rather than the group, putting the IV Are there countries or regions in the world where treatment of symptoms first, before lookthese practices are already a reality? RM In Kerala, India, ing at the causes of the illness. Health is not the healthcare services take a very community-based apperceived as a group phenomenon. Doctors proach to medicine. Some aspects of the healthcare sysrarely belong to the same social or ethnic tem in Costa Rica and Cuba factor in upstream determicategories as their patients. This lack of dinants. The NGO Partners in Health in Haiti also take versity blinds them to the socio-economic this approach. There are many interesting local examforces at work that could be making their paples in the United States, such as Montefiore Medical tients sick.

Centre in the Bronx or the Blueprint for Health initiative in Vermont.

IV What can they do to act upstream? RM Doctors must be careful not to become social IV How can new technologies be used in upstream workers. That’s not their role. However, they medicine? RM They’re not a solution in themselves but can form healthcare teams of nurses, social are an important tool. Electronic health records can workers, community representatives, be used to store information provided by etc. I worked at a homeless clinic in watch the patient about his or her living and “̓’The Upstream Doctors’: Los Angeles, and we involved public Medical Innovators Track working conditions. Big data techniques interest lawyers in their care, because Sickness to Its Source, can be applied to analyse these records we realised that patients’ inability to TED talk, 2013.” and spot trends or clusters of sick people. www.invivomagazine.com find a home was one of the main obstaSelf-monitoring devices [Editor’s note – cles preventing them from becoming healthier. e.g. bracelets and smart watches that track the That type of work in a multidisciplinary team can wearer’s vital signs] can help doctors identify be liberating and gratifying for physicians, even if what’s wrong with a patient. Online platforms it means relinquishing some of their power. could be created – like a Yelp for health – that community members use to find the resources they need to stay healthy [Editor’s note – social services, pest control professionals, shelters for abused women, ongoing training centres] as easily as a restaurant.

“The closer people are to green space, the lower their chance of developing heart disease, regardless of income and education.”

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Should this type of medicine be integrated more into medical training? RM The education authorities still think of community health as the poor relative of medicine, as a less prestigious career than surgery, for example. But a new generation of practitioners is emerging, who are aware of the importance of social and environmental determinants to health. I’m both frustrated by the current way doctors are trained and hopeful about its future. In the United States we ideally need 24,000 upstreamist doctors by 2020, i.e., one out of 20 or 30 traditional clinicians. Choosing a name was the first step towards recognition of the field. That’s why I invented the term “upstreamist”. ⁄

IV

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INNOVAtION

the BAttle BetWeen the giAnts hAs BegUn the forays of google, apple and Facebook into medicine are stirring both enthusiasm and apprehension. here’s why.

text: clément bÜrge illustration: karen ichters

says. this tedious process soon sparked a small revolution in the research world.

I n July 2013, dr eric schadt, a professor of genomics at the icahn school of medicine at mount sinai, was looking for participants to conduct a new study on asthma. the researcher and his team sent 300 letters to potential candidates, and fifty subjects ended up enrolling. “it took one year to recruit them,” the specialist

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in march 2015, apple came out with a new tool, researchKit, which could radically change medical studies. this programme can be used by researchers to develop smartphone apps that help them find participants for their studies. and one of the scientists who collaborated with apple is none other than… eric schadt. a few weeks later when he launched a new call for participants using this framework, his team found 3,500 participants in less than three days. “Without apple’s toolkit, that would have taken us years,” he says.

how does it work? researchKit is an open source software framework that allows researchers to create apps used to gather data especially useful for healthcare. eric schadt developed the asthma health app to facilitate self-monitoring and encourage patients to stick to their treatment plans. patients report any acute asthma attacks, while the programme tracks and sends researchers a broad range of other data.

“We can ask the app to send us information about factors that could trigger attacks at a given time, including indoor air humidity or a region’s pollution,” says eric schadt.

Four other health data apps have been developed. massa-

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INNOVAtION

with the development oF sensor-equipped “wearables” like smartwatches, patients will produce growing amounts oF data about their health.

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chusetts General Hospital has created GlucoSuccess to track blood sugar levels, Stanford University’s medical department has designed MyHeartCounts to monitor cardiovascular health, Sage Bionetworks and the University of Rochester have developed mPower to allow patients with Parkinson’s disease to measure their symptoms, while the Dana-Farber Cancer Institute, University of Pennsylvania, Sage Bionetworks and University of California Los Angeles have teamed up to produce Share The Journey, which studies why breast cancer patients experience symptoms differently.

Enter Google and Facebook

The launch of these apps means that Silicon Valley’s tech giants have now penetrated the research world. Eric Schadt believes that these firms will “fundamentally transform medicine and improve patients’ lives while reducing healthcare costs.” Their biggest impact will be in data collection. “With the new sensor-equipped wearables and social media, patients will pool larger amounts of information about their state of health,” says Schadt. “Doctors and researchers will be able to better understand what’s happening with their patients.”

Dr Schadt sees it as if there was a doctor constantly at the patient’s bedside, whether or not the person is sick. “On

INNOVATION

average, people spend ten minutes a year with a doctor, which is nothing compared to the amount of data smartphones and other connected objects can collect about our health.”

Over the past few years, Microsoft has developed hospital management software, IBM has created Watson, a supercomputer that helps physicians diagnose diseases, and Facebook is home to a number of patient support groups.

But one tech behemoth is shooting higher than mere data gathering, and that is Google. “The firm hopes to revolutionise healthcare,” says Thomas Gauthier, a specialist in healthcare and new technologies at the HEG Geneva management school. “Google has the drive and financial means to change a lot of things.”

In March 2015, Google announced its collaboration with Johnson & Johnson to develop robots that could perform surgical procedures with infinite precision. The California-based

group will also build a system used to visualise blood vessels and other hard-to-see anatomical structures in real time on a screen.

But its real gamechanger is Calico, a special research unit focused on developing treatments for age-related illnesses.

Its clearly stated objective?

Immortality. The man behind Calico is none other than Arthur D. Levinson, a star player in the convergence between medicine and technology.

The biochemist has served as Apple’s Chairman of the board and as Genentech’s Chief Executive Officer. In 2015, Google announced that it would invest $1.5 billion in the project.

Future challenges

Success in these projects is not guaranteed. Google’s first medical project launched in 2008 was a flop. Google Health was developed to centralise health records online. Due to lack of use, the service was discontinued in 2013. “The company didn’t get involved enough in the project,” says

o 150

In millions of dollars, the sum invested by Google in 2014 to buy health and biology start-ups.

100,000

The number of health apps available for download worldwide.

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Thomas Gauthier. “Today, things are different. Google has since introduced a vast official programme focused on health and proved its commitment by setting up concrete, independent ventures such as Calico,” he says. “They are unlikely to make the same mistake.”

One of the main threats that could compromise its ambitions is government regulation. During a panel in 2014, Google co-founder Larry Page stated that he was “excited” about health and longevity. But health is “so heavily regulated.”

He fears that the United States enforces too many rules and kills any potential that new technologies may have to offer before they get started. When developing a new product, he believes that the administrative process to obtain approval from the authorities is too complicated.

And the medical community does not necessarily welcome these newcomers with open arms. Some are concerned that investing private money into medical research can distort research priorities. Preston Estep, director of gerontology for Harvard Medical School’s Personal Genome Project, accused the tech giants of funding “pseudoscience,” pointing specifically to Calico.

To avoid these obstacles, several companies have begun collaborating directly with

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INNOVATION

the medical community, such as Apple with Eric Schadt.

Calico has forged a partnership with the pharmaceutical group AbbVie to benefit from “its profound medical expertise”.

And Google has teamed up with Novartis to develop smart contact lenses that measure patients’ glucose levels. “Novartis is one of

the largest contact lens producers,” says Novartis Chief Executive Officer Joe Jimenez.

“But we don’t know anything about microprocessors or sensors.” This collaboration will enable companies to harness the strengths on each side of the project and earn the trust of health professionals. ⁄

Swisscom and Swiss Post move into health services In Switzerland, it is Swiss Post and Swisscom that are moving into the world of medicine.

The postal services group has formed a team of 30 people to create a management system for electronic patient records. Its extensive experience in handling confidential data and data transmission has prompted the Swiss giant to get involved in providing medical information. Lausanne University Hospital (CHUV) will experiment with the system developed by Swiss Post as part of a project set up by the eHealth unit in the Canton of Vaud. Pierre-François Regamey, director of information systems at the CHUV, feels that this new system will be extremely useful.

“Hospitals still use a lot of paper,” he says.

“Electronic records will help health professionals easily find a patient’s medical history, and we will avoid running the same tests over and over again.”

Meanwhile, Swisscom has launched a new Health division with 300 people. It offers various services such as electronic health records, management software for doctor’s offices and the Evita programme, which patients can use to create a personal health record using data gathered from their smartphone. “It’s a very promising area,” says Stefano Santinelli, CEO of Swisscom Health. “Hospitals could save up to 90% in administrative costs if they digitised procedures.”

text: emilie veillon

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tRENds

childRen UndeR close WAtch

more and more parents watch their kids so closely that they prevent them from developing self-confidence and independence.

high tech devices to watch closely over our children are available on the market.

t he american journalist hanna rosin sparked a heated debate in the united states last year with her article “the overprotected Kid”. she makes a troubling observation. in a single generation, the parent-child relationship has totally changed. From her own childhood, she remembers playing with friends in her neighbourhood for hours on end. as a mother, she has realised that her three children do not have nearly as much freedom. she spends virtually every minute of her spare time with them, either playing or driving them to activities supervised by other adults. basically, they are never alone. hanna rosin is hardly the only parent doting on her children. parents, espe-

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in the cRAdle owlet baby care has come out with a smart sock that monitors an infant’s heart rate in real time. if any abnormality is detected, the device sends an alert to the parents’ smartphone. side By side the guardian bracelet sends a notification to parents’ smartphones if a child moves outside the defined safety perimeter.

KeePing tRAcK gadgets are available to locate your teenager in real time, such as “Jelocalise”, a gps beacon that can be fitted onto their scooter.

cially mothers, tend to spend more time with their children, even though more of them now have jobs. the journalist indicates that in the 1970s, 80% of children in the united Kingdom walked to school alone, as opposed to less than 10% today. the trend is just as striking in switzerland, as shown by the figures from the swiss Federal statistical office (oFs). in 2013, parents spent an average of 34.3 hours per week taking care of their children, feeding and bathing them, playing with them, helping with homework and getting them around. that’s three hours more per week than in 2000.

What is happening? “children have become a narcissistic extension of the parent,” says olivier halfon, chief physician of the university unit for child and adolescent psychiatry at lausanne university hospital (chuv). in previous generations, the high risk of child mortality and the larger number of siblings meant that parents invested less mental energy in their children. today, scarcity creates value. the prime example is china, where the only child is treated like royalty.”

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hugh kretschmer

“helicopter mom” (2010) is american photographer hugh kretschmer’s take on the overprotective parent.

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trends

Olivier Halfon asserts that the more children are considered valuable, the more they become the narcissistic extension of the parents and are therefore overprotected. This relationship emerges in the first days of a newborn’s life. Video surveillance is used to monitor their breathing, room temperature and humidity.

For older children, this behaviour transforms into over-involvement in their schooling. “Performance worship and pressure to succeed push parents to overstimulate their kids, trusting them less and not allowing them to have their own learning experiences,” Halfon says.

Close protection is also prevalent in playgrounds and leisure activities.

Some American elementary schools ban games deemed too dangerous during break time. In the city, children are often made to wear helmets and knee pads when out on their scooter.

Playgrounds have soft ground surfacing, nearly flat slides, and parents assist their kids in climbing. “It’s a shame,” the psychiatrist says, “because children have exceptional motor and balance skills. But also because they need to be allowed to get into danger and take risks. That’s what builds their self-confidence.”

Lack of independence

By constantly fussing over their children, parents do not leave them the space they need to develop on their own and gradually become independent.

“It’s a vicious circle, because the more attentive parents are to their children, the more they worry, and the more their baby senses the parents’ lack of trust and is affected psychosomatically,” says Mathilde Morisod Harari, associate

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Glossary A whole list of terms has cropped up in English to describe trends in overprotective parenting.

Here are a few examples.

Helicopter parent

Always hovering over their child, ready to fly in and rescue the youngster as soon as a problem arises.

Lawnmower parent

Mows down any obstacle in their child’s path, smoothing out problems the child may face.

Cotton wool kid

Metaphorically wrapped by their parents in a suit of cotton wool to protect them in all circumstances.

Teacup kid

Psychologically fragile, does not take criticism or rejection well and is easily shattered when it comes time to go out into the world.

physician in liaison child psychiatry at the CHUV. As they get older, children become anxious and aggressive because they don’t understand the world as well.

Curiously, this gushing love prevents children from being alone and having psychological space where they can form their own opinion, disagree, and which helps them to build who they are as a person. A lack of independence, difficulty in understanding where real dangers lie – because they have never learnt to gauge them properly – and low self-esteem are common in overprotected children.

Danielle Laporte, a Canadian psychologist and author of several books on child psychology who died in 1998, defined self-esteem as the inner certainty of one’s own value and the awareness of being a unique individual and someone with strengths and limits.

She went on to say that self-esteem is linked to the perception we have of ourselves in different areas of life.

Laporte also believed that children forge their self-image by observing and listening to their parents.

Saying things such as “Be careful, you’re going to fall!” or “You can’t do it” can be toxic. “In the worst cases, parents’ overprotection can lead to behaviour disorders, even in girls, including attention deficit hyperactivity disorder, oppositional defiant disorder and other behaviour disorders,” says Olivier Halfon. Each parent needs to try to strike the right balance between protecting his or her children against the dangers of the world that they are still too young to perceive, and leaving them the freedom to experiment and grow at each stage of their development. ⁄

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tRENds

inteRVieW

gilles weber

“the cAUses oF oVeRPRotection cAn oFten Be FoUnd in the PARents’ PAst”

mathilde morisod harari, associate physician in liaison child psychiatry at the chuv, believes that therapy can help overprotective parents reduce their anxiety. is parents’ anxiety related to any specific factors? mmh in psychotherapy sessions, we often see mothers traumatised by a complicated pregnancy, parents of premature infants, babies with sleep disorders, or babies who cry incessantly. in most cases, we see significant parental anxiety linked to the child’s history, and these parents tend to overprotect their babies. iv

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how does that surface in their behaviour? mmh parents of a premature newborn can, for example, remain attached to that first image of a fragile baby. that can cause fear that will continue throughout the child’s development. what if something happens while the baby’s sleeping? at the playground, can my child go down the slide without breaking a leg? in other cases, a baby’s sleep disorders iv

are often influenced by a parent who has issues with separation. they have to be confident enough to leave their baby alone in his or her bed, all night long.

What can these parents do about it? mmh when they come for therapy, we work together on changing parental perceptions. if we catch it early enough, we help them understand that the anxiety comes from iv

them and that they need to leave the child some space for freedom. transgenerational factors often come up.

For example, a previous experience, such as a case of sudden infant death syndrome in one of the parent’s siblings, can play out again and disrupt the brand new relationship with the baby. therapy sessions help detoxify all that and remove the old experience from the present one.

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dEcOdINg

cannabis just what the doctor ordered medicinal marijuana, although legal in switzerland, is still hard to come by. patients and politicians are fighting for the plant to be recognised and reimbursed like any other medication. suffer regularly from spasms and cramps. hen philippe süsstrunk opened his doctor tried to reduce the intensity of his eyes that night back in these incidents using various medications, march 2013, the first thing he without success. “he kept noticed was the increasing the dosage,” philippe cold. his clock says. “We had reached the said 3:00 a.m. he maximum limit. i wasn’t then realised that allowed to take any more.” his body had been shaken by a series text: but one day shortly after of endless spasms clément his night-time and cramps. he bÜrge flare-up, his doctor felt as though had him try a new he’d turned into a block of miracle product, wood. “i couldn’t move,” says EUROPEAN LEADER cannabis tea. “it the 62-year old resident of «with cannabis drops, medical hemp was changed everything,” the Jura canton. “i didn’t i can live again.» legalised in the nether– philippe süsstrunk the patient says. know what to do.” philippe lands in 2003. bedrocan, “my spasms and had to wait thirty minutes for the only company that cramps disappeared almost the attack to finally subside. by that time, grows medical cannabis instantly. i could once again he was exhausted and in tears. he had seedlings, is based in the country. the company lead a normal life.” never experienced anything like it.

w

philippe süsstrunk was diagnosed with multiple sclerosis in 1990, and he used to

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the chinese, egyptians and indians began using cannabis

produces four varieties of natural cannabis, which contain different levels of thc. distribution is managed by the office for medicinal cannabis, which comes under the dutch department of health. bedrocan’s products are costly, between €7 and €12 per gram. about 1,200 patients use medical cannabis in the country.

sedrik nemeth, blair gable / reuters

NETHERLANDS

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dEcOdINg

ryan douglas, the “master grower” of the ontario-based company tweed, watering hundreds of marijuana plants. he is one of the twenty or so authorised marijuana producers who has been issued a licence from canada health.

CANADA VERY LIBERAL canada has the most developed system for legal medical marijuana. this therapeutic substance has been legal since 1999, and the government authorises patients to grow marijuana plants in their home. “doctors and nurses can prescribe it for any condition,” says dr mark ware, director of clinical research in the alan edwards pain management unit at mcgill university. but, in 2014, the law restricted this access. nearly 4,000 people take medical marijuana in the country.

for medicinal purposes back in the 8th century, followed by the greeks and romans. in the middle ages, the rest of europe began using the plant to treat cholera, tetanus, rheumatism, migraines, whooping cough and even asthma. but it was not until the 19th century that the use of medicinal cannabis really took off, including in switzerland. in the early 20th century, bern became one of the main cannabis research centres. but as the pharmaceutical industry grew, cannabis began

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to be ignored and developed a bad reputation. in 1951, cannabis was officially listed as a narcotic under swiss law. a few years later, it had disappeared from the list of medication available to swiss patients. an amendment to the swiss narcotics act, supported by the committee for social security and health of the council of states, authorised the use of cannabis for medical purposes as of 1 July 2011. “We can now prescribe medical cannabis for certain people,” says Jacques besson, chief of the service of community psychiatry at lausanne university hospital (chuv). “if a patient thinks the product is necessary, the attending physician can file a request

dEcOdINg

with the swiss Federal office of public health (Foph).” but only a handful of medications, such as marinol pills, are legal in switzerland. in 2008, a pharmacist in bern obtained authorisation to make cannabis tincture using hemp synthesised in a laboratory. that variety contained cannabidiol (cbd) but no tetrahydrocannabinol (thc). “cbd is a compound specific to cannabis. it boasts medicinal properties and can relieve patients without the mind-altering effect,” says barbara broers, chief of the dependencies unit at geneva university hospitals. then in 2011, authorisation was granted to develop a natural cannabis preparation containing thc. pharmacies require special authorisation to deliver these products. “it’s still an exceptional treatment, and the procedure is complex,” the expert says. medical cannabis is currently available in various forms on the swiss market, as sprays, tinctures, and pills. philippe süsstrunk’s doctor managed to get him a medication made with synthetic cannabis in the form of a tincture. “i would take seven drops in the morning, at midday and in the evening,” he says. and the results were spectacular. “i could finally walk without pain. it was magic,” he says, with emotion. all that, with no side effects. but the relief was short-lived. the drops of dronabinol cost 560 swiss francs per month, and his health insurance refused to cover his treatment. “my insurance company explained that the treatment was not one of the medications that swissmedic believed to be reimbursable,” philippe explains. “and i couldn’t pay out of pocket. i’ve been on disability for several years.”

Without the money to pay for it, philippe süsstrunk stopped buying his medication

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at the pharmacy and took to looking for cannabis on the black market. he’s tried making biscuits or steeping it in alcohol to make his own tincture, but the effects are not the same. “it was too hard to control the dosage,” he says. “the thc content in cannabis found on the street varies too widely. the effect would be too strong at times and at others too light.” today, the Foph authorises patients to obtain medical marijuana for a limited number of conditions. “the Foph has been more flexible in the past year or two, including other conditions such as epilepsy,” says barbara boers. “but it’s still a complicated process.” the saint gallen national council member margrit Kessler moved a motion in december 2014 for the Federal council to “examine, in a scientific pilot study... when cannabis can be used in its natural state for medical purposes as an alternative to synthetic cannabis or tincture of cannabis.” “medical cannabis is too expensive, and the preparation process is currently too complicated,” margrit Kessler says. the national council member would like the Federal council to explore the potential of this product that we have “known

atlanta, georgia February 2015

UNITEDD STATES A WORK IN PROGRESS at the federal level, cannabis is considered illegal and dangerous. but several states, including colorado, washington, oregon, alaska and the district of columbia, have legalised marijuana in recent years. twenty-one have legalised medical cannabis. some states plan to legalise certain compounds in cannabis, such as cannabidiol (cbd), but refuse to authorise tetrahydrocannabinol (thc).

keystone / epa, keystone / imagebroker / bJoern kietzmann, kenzo tribouillard / aFp

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dEcOdINg

within my field of community psychiatry, my colleagues don’t agree on the issue of legalising marijuana,” says Jacques besson. “some favour regulation as a policy to reduce risks. but others are concerned that legalisation would increase access to the drug and complicate treatment of psychiatric diseases.”

about for a long time but on which little research has been done”. the Federal council replied in February 2015 that the issue does not fall within its powers, stating that it is the responsibility of the industry to conduct scientific research, to create the conditions required for natural cannabis to be authorised as a medication and covered by the swiss healthcare system. and that’s the whole problem. “marijuana research needs to catch up,” says Jacques besson. “Few companies or medical institutions have studied marijuana because of the stigma attached to it.” but things are changing. a growing MORE RELAXED number of organisations and germany legalised countries are financing and medicinal cannabis in authorising medical cannabis.

2008. three medica“several studies have shown tions are authorised in the potential of cannabis in the country: nabiximols relieving symptoms of serious (sativex®), dronabinol illnesses, such as crohn’s (marinol®) and nabilone (cesamet®). only disease and cancer,” says sativex is reimbursed for barbara broers.

GERMANY

patients with multiple sclerosis. buying cannabis seedlings in a pharmacy and growing the plants at home, which is less expensive, has been legal since 2012. this requires special authorisation from the Federal office of narcotics (bundesopiumstelle), which has been granted to about 200 patients.

the amendment to the swiss law in 2011 offered fresh hope. new products are gradually hitting the market, such as sativex, a spray made with natural cannabis. but broadening access to these products remains a heated debate. “even

philippe süsstrunk did not give up. “i fought with my health insurance for months to get them to reimburse the medication,” he says. a few months ago, they finally agreed to reimburse his tincture of cannabis. “i argued based on article 71b of the order of health insurance, which stipulates that a product can be reimbursed if no other medication on the market has the same effect.” and ever since, life has been wonderful for philippe STRICT LAWS süsstrunk. “i can France issued its first live again,” he decree authorising the says, relieved. “i medical use of cannabis and cannabinoids in just have a small 2013. patients can be knot remaining granted temporary in my right leg.” use authorisation to to treat that, his obtain the substance, doctor has but only a limited recommended number of medications are authorised. sativex taking a few spray was not released extra drops of on the market until 2015. tincture of the French national cannabis. he’ll agency for medicines feel better. ⁄ and health products

FRANCE

safety has only granted about 100 authorisations since 2001.

berlin august 2014

paris may 2015

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insight

My (rough) life as a researcher unteers for clinical studies and what measures will be taken, by whom, over what time frame and with what tools. Once all that has been wrapped up,” he goes on, “the whole package must be submitted and approved by an ethics committee before the data collection phase can be launched.”

Behind every advance in knowledge is at least one research study. Between launching funding rounds and publishing their papers in scientific journals, what do the people who advance research do on a day-to-day basis?

Text: bertrand tappy

I

f you thought that modern scientists made their brilliant discoveries while taking a bath or fixing the family clock, you’re in for a shock. In the 21st century, several years can go by before research is completed that will support or refute a scientist’s hypothesis.

has examined the subject in the same way,” says Vincent Mooser, chief of the Department of Laboratories at Lausanne University Hospital (CHUV) and vice-dean of research at the Faculty of Biology and Medicine at the University of Lausanne.

“This step means attending conferences and reading lots of books and articles. The general public doesn’t know about this step, but it is crucial.”

Before being enlightened, researchers must first possess an in-depth understanding of Once that is done, researchers their field to come up with an still haven’t received financing original question based on a for the study. And if their intuihypothesis. “Researchers’ work tion is as novel as it is promisstarts with a critical analysis of ing, the process is as many existfar from over! “The ing sources of BASIC VS. CLINICAL next step is what information as Biomedical research covwe call ‘research possible. And this ers all work conducted to develop our knowledge of design’,” says Vinaffects the very living organisms, but clinical cent Mooser. “This outcome of their research specifically refers study. They must to studies involving humans. means determining research methods, be certain that no Swiss legislation (Human Research Act) governing this the number of volone before them area of study went into effect on 1 January 2014. Clinical research can be observational (limited to examining volunteers, as with the CoLaus study in Switzerland) or experimental (to test a product, behaviour or device, as with the study on the vaccine for the Ebola virus).

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A

nd therein is precisely where the sinews of war lie: fundraising. There is more to it than just buying a laptop and a hard drive. They need to finance equipment (either purchased or rented), work space, services (from testing to data processing), staff salaries, fees charged for submitting the project to various commissions and expenses covered for volunteers. “Funding can come from three sources,” Vincent Mooser says, “government grants, such as from the SNSF, a philanthropic foundation or industry. They each have their advantages and drawbacks.”

snsF created more than 60 years ago, the swiss national science Foundation has poured more than 11 billion swiss francs into scientific research in switzerland, of which more than 800 million francs was in 2013.

INsIgHt

gyRo geARloose

FRAncine BehARcohen

B

ut the lack of financial resources is not the only imminent threat weighing on researchers’ shoulders. over the 10 years a study can last, a number of potential pitfalls await them. they may end up with inadequate volunteers or data, inconclusive findings, etc. researchers at the chuv benefit from the support of the clinical research centre to lead their project successfully through all phases, from concept development and

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research findings in a scientific methodology, until the study journal, is no small feat. the is complete. “it’s a life that paper can go back and forth requires endurance and many – between the writing, requalities other than pure reading and other scientific expertise,” FUnding corrections – over says vincent mooser. government grants are several months “but the findings more selective and therefore more prestigious, before it is finally make it all worth it, but amounts are often made public. For when researchers limited. Funds from this step, proper push the frontiers philanthropic foundations of knowledge and pour in more quickly than referencing is vital, from public sources, but as it puts the work open new fields amounts are unpredictinto perspective of investigation.” able. industry contributes and measures its higher amounts, but sponvalue. then there’s and the final step, sors are concerned with scientific issues relating the “impact factor”, i.e., publishing to their business. there is a risk of researchers being influenced in their objectives. an agreement between the research institute and the sponsor is required to protect the interests of the institute and is reviewed by its legal department.

James king-holmes / science photo library, newsom, eric déroze

MENs sANA

MENs sANA

INsIgHt

the savvy mix that measures the importance of the journal which published the paper and the number of citations by other researchers.

T

oday, more than a million scientific articles are published worldwide every year. that enormous output now causes major problems, to the point of challenging the system of “peer review”. this process requires each paper to be evaluated by an independent committee to uphold standards of quality. over the past few years, a number of issues have come up regarding lags and negligence. the magazine Technologist suggests that it is high time this technique is replaced with automatic publication followed by review by the entire online scientific community. and how long would gyRo geARloose this disney duck it take a researcher character symboto get there? “it delises the stereopends on the study,” typical eccentric says vincent mooser. inventor. “if your work uses an existing database, it might take a maximum of one year, but if you start from scratch, it could take up to 10 years!” then what? to know whether a discovery will have a long and prosperous life, it must go through the patenting process, a pre-requisite to commercialisation. and there begins a whole new marathon. ⁄

“the RUles oF the gAme ARe UncleAR” Francine behar-cohen* encourages researchers to speak out more to defend and protect their ideas. iv over your career, you’ve had to wear many hats (researcher, entrepreneur, fundraiser). how do you feel about that experience today?

Fbc it has certainly been a rewarding one, because you have to learn as you go and are confronted with new people and situations.

however, the problem lies in the lack of transparency in the system, conflicts of interest and the lack of protection for researchers in the system. the game rules are unclear, and people can take advantage of that. many researchers refuse to get involved in promoting their discoveries because they know they risk giving up a bit of their soul. support units have been developed over the past few years, offering immense help with aspects such as intellectual property, but we need to rethink the system. i don’t believe that venture capital is a viable system for long-term projects. iv last year you presented a tedx talk called “no market, go away!**”. do you think that there is still a place for research that promises no return on investment?

Fbc research, yes. development, no. many substances and drugs that are no longer patent protected could still be developed, but who will do that? a number of initiatives aim to develop research for rare diseases, but then who will develop treatments if the research is successful? who will invest those large amounts? iv What challenges do the next generation of researchers face?

Fbc i think researchers should get more involved in society. they must communicate more and “take their place” in society. the field must open up beyond the scientific world. the gyro gearloose in his laboratory, a reclusive scientist, detached and disconnected from the world can’t survive. we are in a world of communication and must speak out to defend our ideas. that will be our challenge for the future.

*Francine behar-cohen is the medical director oF the Jules gonin eye hospital. she headed a research unit at the French institute oF health and medical research (inserm) Focused on understanding eye diseases and therapeutic innovations. Francine behar-cohen also created the start-up optis. ** watch on www.invivomagazine.com

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MENS SANA

INNOVATION

The hospital improves the health of its signage

P

rioritising information, directing visitors clearly and simply and preventing additional stress. These are the challenges of creating successful signage systems. And when they are transposed into a hospital context, the challenge is even more difficult. “Hospital signs are some of the most difficult to design,” says Laurence Guichard, director of the Paris-based design agency Locomotion, which recently participated in the construction of a new hospital in Marne-La-Vallée, just east of the capital.

Stifled by their esoteric terminology and endless corridors, hospitals are now beginning to entrust their signage systems to design professionals, borrowing from the formulas used in airports and supermarkets.

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Hospitals are now enlisting more and more professional designers to develop their signage.

Graphic designer Ruedi Baur stresses the importance of an efficient wayfinding system to improve patients’ well-being. text: Darcy Christen

To learn more about it, In Vivo met with Ruedi Baur, the master of modern signage, on his way back from Tehran and passing through Geneva where he teaches at the Geneva University of Art and Design (HEAD). For him, wayfinding begins with the invitation to come to a medical appointment, and the path within the hospital is just an extension of the path in a city. Like in a city, the combination of meticulous signing and the specific charm of each neighbourhood is what helps everyone to find their way.

conglomeration keeps growing.

Human beings are confronted with huge architectural blocks that are often unintelligible. A successful signage system is one that is aware of that complexity.

I’m first and foremost an activist, aiming to make our society more understandable. That is essential for a democracy to function properly and for people to feel comfortable. The intelligibility that needs to be developed is not just about visuals or graphic design. It’s mainly about understanding systems and space.

IV What do you think is

In a complicated world, our first reflex is often to suggest bigger, brighter signs with more imposing typefaces. Then there is the widespread culture of “branding”.

Every structure has its own logo.

successful signage?

RUEDI BAUR We live in a world of increasing complexity. Infrastructure is more and more vast, and the movement towards

MENs sANA

INNOVAtION

1 the signage system

designed by ruedi baur already features on several floors at the chuv.

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sity hospital, “it’s not that there aren’t enough signs, the problem is that there are too many.” to mAKe something UndeRstAndABle, mUst We Be ABle to simPliFy it?

iv

rb the

solution of standardising everything is not the right way either. people get lost when everything looks the same. the telephone book is definitely practical, but it’s not where you’d want to move about. We have to find a third way. We need to work on the atmosphere in different areas and contribute to the well-being of the body in movement. the point is not just to direct patients. We also want to make sure they feel comfortable. i think that we don’t just

find our way around by using data but also through atmosphere, lighting, materials and colours. We find our way by using things that make sense to us, like in a city. in a city, we spot the cathedral and figure out where we are in relation to that. it’s obviously harder to do that on an obstructed hospital floor, where nothing can be named. but that’s where the challenge lies. i’d even dare say that the sign is actually just like a spare tyre. ideally, i should be able to get around in a place with references of understanding. the need for signs should only be secondary. this is even more important in a time of life when the stress factor is high for me or a loved one.

philippe gétaz, intégral ruedi baur

they each develop their own way of expressing themselves without any thought for the environment in which these signs will live, without working on that relationship. and it obviously doesn’t work well. With a research team, we are currently analysing information related to the university of strasbourg. as in many other situations, we have noted that each activity is viewed in relation to others. at best, we can understand the institutions but not the subject developed. then there’s the culture of acronyms, which makes everything unapproachable for non-specialists.

We found thousands of acronyms used at the university! i remember the first thing i noticed when i first visited lausanne univer-

MENs sANA

INNOVAtION

2 the designer

developed the wayfinding system for the new airport in vienna.

people get lost when everything looks the same –

rUeDi BaUr

3 ruedi baur

has developed a visual identity for the entire building complex at the university hospital of bern.

biography

ruedi baur is one of the big names in graphic design and signage. the internationally renowned French-swiss designer has worked on major projects such as the vienna airport and the future greater paris metro. For nearly two years, he and his team worked on rethinking how lausanne university hospital could improve its signage by making information signs more readable and by better prioritising information. ruedi baur believes it is essential to give meaning to signs, by thinking about the atmosphere and identifying factors that make it easier to find one’s way.

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so signAge cAn contRiBUte to RedUcing stRess?

iv

rb that’s

the whole issue of spatial intelligibility. if you have to read everything and everything looks the same, it’s a huge effort for the user to read every piece of information. getting disoriented comes from the fear of getting lost. i’ve studied a lot about chinese culture, which lived 3,000 years without arrows for people to find their way around. in the West, we can’t get by without arrows. in traditional china, where the compass was invented, orientation integrated architecture. a ritual of codes was used to distinguish between types of buildings, their use and the hierarchy of occupants. these identifying factors were reflected in the colour of stones, the shape of the roof, entrances determined by the cardinal points, etc.

WhAt ARe yoUR otheR PRojects?

iv

rb one

of my passions is reintroducing a “useful/useless” component into public space, with installations that are more poetic than they are there to guide us. signs that don’t want to sell us anything or dictate our behaviour. i’m currently exploring a project in mons – the european capital of culture – with 10 km of poetic writings that stretch over both public spaces and through private properties. today, i think it’s essential to bring out the wealth of things and not just remain focused on their functionality. ⁄

MENs sANA

cOMMENtARy

amanda sacker director of “the international centre for lifecourse studies in society and health”, university college london

Can life course research help shape public health policy?

the popularity of life course epidemiology continues apace given its endorsement by the World health organization as an approach to understanding the origins of health, well-being and (mainly non-communicable) diseases. it has an intuitive appeal with its focus on development over time and generations unfolding under different socio-economic conditions. led by the uK, there are now many surveys that have followed up large numbers of individuals from birth, re-interviewing their families and themselves at intervals throughout their lives. these longitudinal “cohort studies” have given us much of the data needed to research the life course and have been used extensively by social scientists. they underpin the conclusions by economists that investments at the beginning of life will have greatest dividends in the long-term. yet if lifecourse epidemiology has taught us anything, it has shown that individual lives are diverse and complex and that there is no “quick fix”.

school – a two year difference in verbal ability measured at three, five and seven years for a child with none versus 7+ disadvantages, for example. this suggests that intervening in the pre-school years will permanently reduce the gap, but test the same children again at age eleven and the difference has grown to five years. this is not because the advantaged have surged ahead but because the disadvantaged have fallen further behind. it is a stark reminder that we must not forget our vulnerable children who need targeting for continued support throughout childhood and not just in the early years. maximising children’s cognitive capabilities is so important because it sets them off on more optimal life course trajectories in work and family spheres. in adult life, as in childhood, each adverse experience such as unemployment, family break-up and poverty increases the risk of poor health.

one of the more consistent findings from lifecourse epidemiology is that social support and networks protect us from poor health, especially as we get older. lifecourse research emphasises that it is not only public health policy that can time and again, it has been shown that the improve public health. the older person’s free bus more social, physical, economic and psycho- pass in england was introduced in response to a logical disadvantage a child is exposed to, the need to reduce social exclusion and in so doing has more they are behind at kindergarten and improved the health of our aging population, partly through increased incidental physical activity.

PRoFile

dr

amanda sacker has directed the international centre for lifecourse studies in society and health (icls), part of the university college london, since January 2013. her research specialises in social inequality in health and the impact policy can have on population wellness.

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now a new generation of life course epidemiological research is evolving with the addition of bio-medical surveys into our cohort studies. investigating how the social “gets under the skin” to affect our bodies and hence our health status many years later will add to the evidence base for policy. ⁄ to KnoW moRe

www.ucl.ac.uk/icls

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DR IODINE AND MR SALT

François c., age 28, from the pyrenees region, was listed as having a goitre in benedict augustin morel’s treatise on degeneration (Traité des dégénérescences published in 1857).

text: antoine menusier

corpore sano

health authorities insist on the urgent need to reduce salt intake, but deficiencies of iodine – a vital element contained in salt – are emerging.

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An Age-old PRoBlem iodine is found in high concentrations in seawater. switzerland’s soil, far from any coastline, contains little iodine, and the swiss people have historically shown symptoms of iodine deficiency. the swiss federal authorities introduced iodised salt in 1922 to fight the human developmental problems caused by the scarcity of the trace element. “iodine deficiency has long been the cause of congenital cretinism, a form of dwarfism associated with mental retardation triggered by a deficiency of thyroid hormones,” says murielle bochud from the iumsp. the expression ealth is a major issue in the apocalyp- “cretin of the alps” tic film “world war z”. in the film, brad originally referred pitt’s character sets out to save human- to inhabitants of the swiss, French ity, which is in danger of extinction and italian alps. due to a fearsome virus. he pieces the disease together an insane but spectacular plot was particularly to kill the deadly virus with another prevalent there, as inhabitants pathogen that is slightly less lethal for humans. and his plan works. here, lived far from the coast. individuals the situation is in absolutely no way with goiter could comparable, except that the concept, also be found in in its boldness, is the same. a vector the region. this potentially harmful to human health if condition causes an enlargement ingested in large amounts, i.e. salt, is of the thyroid used to supply the body with iodine, gland, which is an element essential to its developoften caused by ment and thyroid hormone synthesis. iodine deficiency.

h

the swiss no longer consume enough iodine. “daily dietary intake of iodine is 150 micrograms (µg) for adults and cORpORE sANO

tRENds

200 to 250 µg for pregnant women,” says murielle bochud, chief physician at the university institute of social and preventive medicine (iumsp) at lausanne university hospital (chuv) and full professor at the Faculty of biology and medicine at the university of lausanne. “in a nationwide survey on salt intake conducted from January 2010 to april 2012 and coordinated by the iumsp and the nephrology department at the chuv led by professor michel burnier on behalf of the swiss Federal office of public health (Foph), we found cases of iodine deficiency in swiss women over age 15: 14% – i.e. one out of seven – had urinary iodine excretions of less than 95 µg over a 24-hour period.”

the population should be encouraged to consume iodine without increasing their salt intake. these are worrying figures because iodine deficiency can cause developmental delays and intellectual disabilities (see inset). so what’s happening? do swiss women use less iodised salt in their cooking? or are they eating more pre-cooked meals made without iodine-enriched salt?

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iodine is an essential trace element found in its natural state in seafood and dairy products. however, excessive salt intake increases the risk of developing cardiovascular diseases. the population, especially women of childbearing age, should be encouraged to consume iodine without increasing their salt intake. “the main problem is processed food. pre-cooked meals account for 95% of salt intake, while only 5% is from table salt,” says vincent dudler, head of the risk assessment division at the Fsvo. “due to the freedom of trade and industry, swiss producers are not required to add iodine to the salt used in preparing processed foods, such as bread or dried meat, but they can do it without being forced to.” the swiss Federal Food commission (coFa) issued a recommendation for all swiss sodium chloride producers to increase iodine content per kilogram of table salt produced in switzerland from 20 to 25 milligrams. the vaudbased saltworks company la saline de bex, which extracts and sells salt, and other manufacturers voluntarily complied. “we increased the iodine content per kilogram of sodium chloride,” says loïc Jaunin, head of quality, safety and environment at cORpORE sANO

Seafood the sea contains vast amounts of iodine, and the food provided by the sea is generally the best source of this trace element. the most iodinerich foods include haddock, salmon, cod and prawns.

Dairy products milk and dairy products provide about one-third of the daily intake requirement and are the main dietary source of iodine in western countries. this is due to the use of iodine-rich fertilisers used on grazing land for dairy cattle and antiseptic products containing iodine to prevent the development of bacteria in the treatment chain.

Eggs eggs, along with seaweed, are a valuable source of iodine for vegetarians. containing 9.3 micrograms of iodine per 100 grams, eggs provide about 33% of the daily iodine requirement.

tRENds

murielle Bochud, from the university institute of social and preventive medicine, says that the daily iodine requirement for an adult is 150 micrograms.

la saline de bex, “which involves spraying the salt crystals with a potassium iodide solution.” the process is not financed by the government and has a significant impact on the price of salt. we need to consume more “dr iodine”, that precious trace element found in saltwater fish and eggs, while watching our intake of “mr salt”. ⁄

gilles weber

in any case, they do not seem to be eating less salt. averaging 9.1 grams per inhabitant per day, with men eating more salt than women, salt intake is too high. the world health organization (who) recommends average salt intake of less than 5 grams per day. in switzerland, the swiss Federal Food safety and veterinary office (Fsvo) sets the target at 6 grams per day.

STOCKING UP ON IODINE iodine plays a key role in a number of the organism’s metabolic reactions. it occurs naturally in various types of foods:

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Text: Martine Brocard

Animals could be the future of human health Scientists are fascinated with finding compounds in animals to make humans healthier.

W

hat if we could find remedies directly in animals and apply them to humans? The concept sounds innovative, but has actually been around for centuries. Back in 1667 in Paris, a young 15-year old man received a transfusion of lamb’s blood to cure him of his fever.

Luckily, and probably because only a small amount was injected, the patient survived, and his health even improved. Satisfied with this initial success, the physician Jean-Baptiste Denis attempted the experiment two more times, but with CORPORE SANO

calf’s blood. His patients died during the transfusion.

A few centuries later, transplants were becoming popular. In the early 20th century in Lyon, a surgeon transplanted a goat kidney into a woman. The operation rapidly ended in rejection of the organ. Between 1920 and 1940, a Russian-born French surgeon, Serge Voronoff, became famous for grafting monkey testicle tissue on to men to delay ageing. But he wound up completely discredited.

Scientists have always pushed on through setbacks like these, convinced that biological compounds in animals can be useful in developing treatments or drugs to cure humans.

Some applications have been widely accepted for so long that no one even realises that prospecting

they came from an animal. For example, horseshoe crab blood has been used to guarantee the safety of injectable drugs and vaccines for more than 40 years (see image opposite).

The field of research is expanding as previously unknown or unexplored organisms come under the microscope. “Places with high biodiversity and where access has until recently been limited, such as the ocean floor or tropical forests, hold huge potential,” says Jean-Christophe Vié, Deputy Director, IUCN Species Programme and Director, Save Our Species Initiative at the International Union for Conservation of Nature (IUCN). He sees it as one more argument to encourage the protection of biodiversity, as long as animals are not over-exploited once their medicinal virtues have been established.

The holy grail of pharmas The horseshoe crab, a sea arthropod mainly found on the east coast of North America, contains a coagulating agent called amoebocyte lysate. Pharmaceutical companies use it to detect the presence of endotoxins in certain injectable drugs and implantable medical devices. Horseshoe crabs are collected, and up to 30% of their blood is harvested before they are released back into the environment. Studies estimate mortality rates varying between 15% and as high as 30%.

CORPORE SANO

prospecting

Andrew Tingle

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But you don’t have to travel to the other side of the world to find new remedies. Animals considered much less exotic, such as worms from the Brittany coast, or even domestic animals, like pigs, are undergoing extensive research and have already yielded some encouraging results.

1 A sea worm with superhuman haemoglobin

The “Arenicola marina”, or lugworm, lives on beaches stretching from the North Sea to Biarritz, France. This invertebrate may hold the secret to the universal blood type. In the early 2000s, the French biologist Dr Franck Zal discovered that its haemoglobin could transport 50 times more oxygen than human haemoglobin. The specialist has since patented the molecule and is working on potential applications.

One of these is to develop a substitute for the universal blood type. The lugworm’s haemoglobin, unlike human haemoglobin, is not contained in a red blood cell and circulates freely in its veins. This means blood type compatibility becomes a non-issue. The molecule can even be freeze-dried and therefore potentially used in combat or catastrophe zones.

This research also holds great potential for organ donations.

“Today, it’s a race against the CORPORE SANO

clock. The organ is immersed in a water and salt solution but with no oxygen carrier. If we add our solution, the oxygen supply extends the life of the organ,” says Franck Zal. The time that a heart can be preserved goes from 4 to 8 hours and a kidney from 12 to 48 hours. Clinical trials are scheduled to begin this year. Lastly, the lugworm’s haemoglobin could also help wound healing in diabetics, as the natural process can be impaired due to low tissue oxygenation. Special bandages are being studied.

“The idea could potentially revolutionise blood transfusion and tissue oxygenation,” says Raffaele Renella, associate physician and head of the research unit in paediatric haematologyoncology at Lausanne University Hospital (CHUV). But he remains cautious. “There are several major problems with cell-free artificial haemoglobin from other species,” he says.

“In humans, some forms can bring about immune reactions or major cardiovascular and renal dysfunction or collect in tissue and cause damage.

Much more research is needed before any routine clinical use,” he says, reminding people to donate blood in the meantime.

2 Pig cell transplants to treat diabetes

These transplants could soon provide a lasting solution prospecting

for 40% of sufferers of Type 1 diabetes for whom daily injections of insulin are not adequate for keeping the disease under control. “We need to restore endogenous insulin regulation in these patients,” says Philippe Morel, professor of surgery and chief physician of the Visceral and Transplantation Surgery Service at Geneva University Hospitals.

They have two options: a transplant of the pancreas or the islets of Langerhans, the cells directly responsible for producing insulin. But either way, donors are rare.

For 20 years, Dr Morel and his team have been working on a project to transplant the islets of Langerhans from pigs into humans. “As it is a xeno-transplantation [between species], the risk of rejection is extremely high,” he adds.

They have teamed up with the Swiss Federal Institute of Technology in Lausanne to develop a capsule surrounding the islets to protect them from being rejected, while secreting insulin into the blood.

The pigs used are certified as having “no pathogenic agents”. They are born by C-section and raised in a completely sterile environment. “Sacrificing young pigs for medical reasons raises a number of ethical issues, but no more than a pig that will be eaten,” the specialist

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WhAt the lAW sAys points out. clinical trials are expected to begin within the next two years.

3 A PRotein FoUnd in BeARs coUld Act AgAinst AlZheimeR’s

what if bear hibernation could help repair alzheimer’s disease? the link is not obvious. but it prompted a group of researchers from the university of cambridge led by dr giovanna mallucci, professor of neurobiology, to delve further. her team is studying the protein rbm3 produced by bears when hibernating. when the bear wakes up, its neural connections (synapses) are intact due to the action of this compound. “rbm3 is also present in humans, but we don’t yet understand exactly how it interacts with the protection of synapses,” the scientist says.

ers eventually hope to develop a drug that can act like this protein to protect against neurodegenerative diseases.

4 Anti-cAnceR dRUgs FRom shARKs

squalamine, found in the tissues of the dogfish shark (squalus acanthias), could serve as an ally for humans in fighting cancer or age-related macular degeneration. the compound was discovered in 1993 by a team led by dr michael zasloff from georgetown university in washington dc, then was synthesised in 1995.

its anti-angiogenic activity prevents blood vessels from proliferating abnormally, which can contribute to the growth of cancerous tumours or cause age-related macular degeneration. that is what interests researchers and the pharmaceutical industry so much. clinical studies on lung cancer tests on mice induced into patients are underway and the hibernation showed that us group ohr healthy mice began to ReAd moRe pharmaceuticals is secreting rbm3 on the trail of koalas conducting clinical and recovered their to cure aids research on developneural connections antibiotic ing squalamine when they emerged. ain new horse manure eye drops. however, mice with www.invivomagazine.com brain disorders did but that’s not all. not secrete the protein. researchers administered “the dogfish shark is surprisingly immune to viral infecrbm3 to them, which preventtions,” says michael zasloff, ed neurodegeneration. who attributes that to squalamine. the broad spectrum of clinical tests are expected to anti-viral properties of the take place in 2016. researchcORpORE sANO

pROspEctINg

switzerland has no general ban preventing the use of animal compounds in medicine. however, different laws govern their use.

For transplants of animal organs, tissues or cells into humans, the swiss Federal office of public health grants the authorisations. article 43 of the swiss transplantation act stipulates that clinical trials for xeno-transplantation may be authorised if the risk of infection for the population can be ruled out with high probability and if therapeutic benefit is expected. when products manufactured using animal organs, tissues or cells are standardised, they are considered medicine and are subject to the authorisation procedure of swissmedic, the swiss agency that authorises and supervises therapeutic products. if animal compounds come from protected or genetically modified species, the animal protection act and the environmental protection act apply.

compound is also being studied. in vitro tests on dengue fever and hepatitis b viruses have produced promising results. ⁄

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AUTISM IN A NEW LIGhT text: geneviÈve ruiz

based in gland, the centre run by the organisation objectif vaincre l’autisme uses the aba method to help its young patients to improve social behaviour.

intensive therapies are making it possible for many autistic children to get the same schooling as other children. Just a few years ago, most had no independence and could not even speak.

“A

utism needs to be diagnosed as early as possible.” hilary wood, head of the centre for early intervention in autism in geneva, insists on the early detection of autism spectrum disorders (asd) – a banner term used to refer to the range of conditions described as autistic – because scientific studies now widely support the effectiveness of care for very young children. “most of the time, we can now detect a potential disorder in toddlers as early as 12 to 18 months of age,” the psychologist says. “regardless of the method used, research shows that the two keys for successfully treating autistic children are early care and intensive therapy, i.e. between 15 and 40 hours per week,” says hilary wood. the advances in neuroscience and genetics now prove that autistic children are born with a number of genetic abnormalities. their brain functions differently from that of other babies, which is especially prevalent in social interactions. these children then slip into a vicious circle. during the first two years of life, most children acquire skills through cORpORE sANO

social contact, by imitating, playing and communicating. From the earliest stages of childhood, young autistic children cannot progress normally and fall further and further behind. since the 1980s, several therapeutic methods to deal with autism disorders have been developed in the united states. they aim specifically to stimulate babies’ brains early, focusing ThE CAUSES on social interaction OF AUTISM and language. if autistic children develop in these areas, they can about a hundred make headway in other genes are involved skills. the oldest and more than a hundred genes are most widely known believed to be involved in asd. therapy is applied the disease is four times more prevalent in boys than girls. children behavior analysis with an autistic sibling are ten times (aba). created by the more likely to develop autism, and norwegian psycholotwice as likely if they have a cousin gist ivar lovaas in 1987, with the disorder. some cases of this technique analyses autism come from breaks in the dna the child’s behaviour sequence, which may be related to and aims to increase or in vitro fertilisation or the parents’ decrease the frequency age. the chances of having an of a given behaviour autistic child are four times higher through repetition and for a 40-year old couple than for a 25-year old couple. reinforcement.

dEcOdINg

Recognising the eARly signs Parents are often the first to notice their child’s unusual behaviour.

Autistic traits can be observed in children as early as 12 months old, but only an expert can perform an accurate diagnosis.

social interaction disorders

Lack of smile, indifference to others, indifference or overreaction to noise, indifference when their name is called, failure to hold out their arms to be carried, refusal to be held, solitary activities.

bsip / newscom

verbal and non-verbal communication disorders

the treatment and education of autistic and related communication handicapped children (teacch) programme is based on a structured teaching model that uses the strengths and preferences of autistic children to help them develop, for example through detailed visuals to reinforce verbal Xxxxxxxlanguage and help them learn to communicate. this method was develcORpORE sANO

oped in the 1960s by eric schopler, a psychologist from the university of north carolina at chapel hill. another programme is the early start denver model (esdm), which mainly draws on aba and was developed in 2003 by american psychologists geraldine dawson and sally rogers. this method

dEcOdINg

Lack of language or language delays, difficulty in imitating certain movements (pointing, clapping, waving), lack of response to communication attempts from others, lack of appropriate intonation, difficulty in using personal pronouns correctly (“you” instead of “I”).

repetitive and stereotyped behaviour

Patterned handling of objects (spinning or arranging them), unusual body movements (rocking, hand flapping), gazing at objects or lights for long periods, resistance to (even insignificant) change.

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focuses more on stimulating the toddler’s social motivation. when children’s desire to make contact with others grows, they become more independent and communicate more easily. since 2010, the centre for early intervention in autism in geneva has been applying the denver method with a small group of children age 1 to 3. “the results are spectacular,” says stéphane eliez, psychiatrist and director of the geneva medical learning office (office médico-pédagogique). “some children have gained the equivalent of 15 iq points using this method, which radically transforms the outlook for their future. seventy-five percent of the children who leave our centre can get standard schooling.” this success rate is impressive, but requires costly resources. each child benefits from individual care from a psychologist for fifteen hours a week. the parents increased risks during pregnancy the uterine environment plays a predominant role in the development of autism. taking antiepileptic medication around the 19th week of pregnancy increases the risk, as do certain viruses affecting the mother, such as cytomegalovirus. it has been proven that if the mother lives within 300 metres of a field sprayed with industrial pesticides during the first three months of pregnancy, the likelihood of her child developing asd increases substantially. extremely premature babies weighing less than 1.5 kg at birth are 20% more likely to suffer from autism than babies born at term. cORpORE sANO

also have to learn the therapy and continue it at home. the teaching plan is personalised and reviewed every quarter by a multidisciplinary team to adapt the method as closely as possible to the child’s progress and abilities. care at the centre costs between 70,000 and 80,000 swiss francs per year.

autoimmune disease ten percent of autism cases are an autoimmune disease. ample research, including one study conducted in 2013 by a team at arkansas children’s hospital in the united states, has reported a high incidence of cerebral folate receptor autoantibodies in autistic children. and folate deficiency is associated with autistic symptoms.

Following this discovery, researchers administered high doses of folinic acid (vitamin b9) to autistic children. the findings were spectacular. the children’s verbal communication, attention and characteristic behaviour all improved, with low adverse side effects. but for the time being, no one yet understands the long-term consequences of administering such high doses of vitamin b9.

but stéphane eliez has no doubt that the investment is worth it. “a disabled person who lives in an institution also costs 80,000 swiss francs a year, but for the rest of their life. you do the maths,” he says. “the investment that the government should provide in the first years of an autistic child’s life is, in time, largely offset. and the benefits for families are incomparable.” in the united states, care is free for all autistic children under age 3, quite different from the situation in switzerland. the geneva centre is a test project of the Federal social insurance office, which has begun looking into the subject. “the government is starting to understand the need to invest in autism very early,” says hilary wood. and if the public authorities don’t act now, they could set off a time bomb. autism now affects about one in 100 children, but official statistics are not yet available in switzerland. its prevalence has increased sharply in recent years, identified in one in every 68 births in the united states. “i’ve noted in recent years that care has improved immensely, and attitudes have changed in switzerland regarding autistic children. but we’re still far behind

dEcOdINg

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means they require less guidance and support as adults.

Will you focus on one educational method in particular?

NC We will use methods (ABA, TEACCH or Denver) whose effectiveness has been scientifically proven in recent years. They need intensive care, requiring one educator per child and involving the parents. I wouldn’t emphasise one method over another because each child is unique and needs an individual development plan. Some methods are better suited to certain children than others.

IV

Heidi diaz

“You’re born autistic, you don’t become autistic” interview Nadia Chabane is the director of the Cantonal Centre for Autism, scheduled to open in Lausanne in the autumn of 2015. She wants all autistic people in French-speaking Switzerland to be able to receive care with the latest methods.

You’re inaugurating the Cantonal Centre for Autism this autumn. What will the centre do?

NC Its main role will be to implement a high-quality clinical structure for autism. Our purpose is to offer the best possible conditions for care. The centre also aims to provide quality training to people who work with autistic children.

A research team will focus on neuroscientific projects.

IV

My goal is to develop a network of a wide range of professionals who deal with autism and create specialised units throughout the Canton of Vaud. I plan to disseminate a set of best practices in autistic care. For example,

paediatricians should be aware of symptoms so that they can rapidly get adapted care for a child showing signs of abnormal behaviour.

You want autistic children to be diagnosed systematically before the age of 2. Why is that?

NC Research shows that early diagnosis is essential. You’re born autistic, you don’t become autistic.

Children must be cared for as early as possible, because the brain is the most plastic between the age of 2 and 4. They can make remarkable strides. Some of them can even get standard schooling.

Those who cannot go to school still progress, gaining independence and socialisation. That IV

Anglo-Saxon and Scandinavian countries and need to catch up,” she says. “Many parents are angry and desperate. And it’s their fight that has brought us where we are today.”

Yves Crausaz, president of the organisation Autisme Romandie (Autism in French-speaking Switzerland), is one of these parents. The father of an autistic child, he says that he is satisfied with CORPORE SANO

Decoding

Will psychoanalysis play a role at your centre?

NC The causes of autism are genetic and affect how the brain functions. The latest research statistics don’t recommend psychoanalytic treatment for autism. However, psychoanalysis and psychotherapy are definitely valid guidance tools, especially for families.

IV

Do you think that autism research will produce any major findings over the next few years?

NC I’m convinced it will. Over the past ten years, heavy investment has gone into autism research.

Neuroscience still has much to offer us. We will probably better understand the different causes of autism and we will also better know how to diagnose it. The therapeutic methods available will be developed further to become even more effective. Drugs may eventually be developed as well.

IV

the recent advances. “But we’ve had to fight for years against the psychoanalytic view that blamed parents and forced our children to live a life of disability. I praise early care for children,” he says, “but I’d also like to sound an alarm.

The lack of adequate structures for the many autistic teenagers and adults out there is doing them harm. And for them, the ABA and Denver methods come too late.” ⁄

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Acetylsalicylic acid c 9H 9O 4

c 9h 8 o4 eVeRy molecUle, tells A stoRy text: bertrand tappy

anti-inflammatory agents are derived from the bark of willow trees. the plant’s effectiveness in reducing fever and pain has been recognised since the time of ancient civilisations. in the 19th century, scientists in both France and germany purified the active ingredient responsible for this therapeutic action, salicylic acid. salicylic acid is effective in relieving pain, but upsets the stomach. in 1904, Felix hoffmann, a chemist working at the pharmaceutical group bayer, developed a method of producing acetylsalicylic acid that causes significantly less irritation to the stomach and only releases salicylic acid once it is absorbed into the bloodstream. this advance led to the commercial development of a drug a few years later, patented as aspirin (its name was derived from acetylation and spiric acid). aspirin soon became a huge

Everyone knows what aspirin is. But acetylsalicylic acid, its scientific name, has sparked much debate.

success as a pain reliever and anti-inflammatory drug. but another effect eventually surfaced: aspirin caused bleeding. surgeons reported that patients treated with aspirin lost more blood during surgery. the medical community then examined how this action could benefit patients with arterial thrombosis, especially in the coronary arteries. in 1975, one of the very first “randomized, double-blind” studies was published, demonstrating aspirin’s preventive effectiveness following a myocardial infarction. half of the heart attack patients received a daily dose of 300 mg of aspirin and the other half an inert placebo. the results

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ZOOM

confirmed the hypothesis. with its antiplatelet effect, aspirin prevented subsequent heart attacks. it was a major discovery, since in the 1970s, heart attack patients had a one in ten chance of having another heart attack and dying within the year! aspirin reduced this risk to one in 13. in other words, 40 patients would have to be treated for one year to prevent one death (while three will still die with the aspirin, instead of four without aspirin). at first, heart patients were given the same dose as that given for pain relief. over time and with a lot of perseverance, physicians managed to convince their

colleagues to use lower doses administered over a long period of time to prevent blood clots. today, more than 30 years later, doses of 100 mg or less are given to patients with a risk of heart attack and stroke. “it’s not surprising,” says thierry buclin, chief of the clinical pharmacology division at lausanne university hospital. “many other drugs have been administered at a dosage that was too high when they were first released, including the contraceptive pill, antipsychotic medicines, diuretics and anticancer drugs. using high doses early on guarantees effectiveness for and against everything. it takes longer to figure out how to optimise safety in administering them.” isn’t it contradictory then that pharmacies sell 500 mg of aspirin over the counter, while the 100 mg dose used to treat heart patients is only available with a prescription? ⁄

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Printed prosthetics Text: Erik Freudenreich Images: philippe gĂŠtaz

A Swiss orthopaedist uses 3D printing to design prosthetics that perfectly fit the patient’s body shape.

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in the lens

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INNOVATION Messmer Orthopaedics, the small shop near the train station in La Chaux-de-Fonds, looks as though it hasn’t changed for ages. Yet they now use the latest 3D printing techniques. Philippe Messmer, the owner and an orthopaedist by training, has been making thumb and foot braces, along with other arm and leg prosthetics, for a year. “3D printing is used for greater precision, but also to duplicate a part, which can’t be done with a mould,” says the technology enthusiast, who used to work with the International Committee of the Red Cross. “These prosthetics are also considerably more comfortable for patients. A plaster cast weighs more than a printed cast.”

2/

Philippe Messmer currently uses the Gigabot (opposite) and RigidBot 3D printers.

The ingenious orthopaedist bought them online and then modified and adapted them. “With its 60 x 60 x 60 centimetre build volume, Gigabot can print large parts but the settings often take a lot of work.”

Measurements

The first step in the process is to measure the stump or residual limb using a 3D scanner to model a prosthetic or orthotic limb. This simple procedure comes as an immense relief to the parents of young patients.

“Instead of casting a mould of the child’s limb, which takes hours, measurements only take a few minutes.” This simplified manufacturing process makes it easier to print new prosthetic limbs as the child grows.

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in the lens

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3D Printers

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3/

Modelling

The imprint is then imported into 3D modelling software, which refines the model and analyses movement to make any necessary corrections or adjustments to the prosthesis.

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in the lens

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in the lens

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4/

Printing

Once the 3D model is finalised, it is time for printing.

The process uses nylon, ABS or PLA polymers and requires a lot of adjustments to the settings, and a lot of patience, to achieve the desired outcome. “It can take nearly five days to print a very thin cast,” says Philippe Messmer. “The temperature and printing speed also need to be set, and they’re not the same for the surface and inner section.” Once the process is complete (above image), the prosthetic is covered in leather or fabric before being fitted on the patient.

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in the lens

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patrick genoud associate director of patient care

managing with uncertainty

When the traditional toolbox used by managers is turned upside down by major changes, when strategies lose their clarity, when proven solutions based on best practices become ineffective in handling unknown challenges, managers must display “resistance” and “momentum”. the first of these qualities is the ability to question oneself, reassess the situation and learn constantly. the second is the capacity to continually move forward with energy and conviction. today, managers combine these two opposing characteristics to develop integrative leadership, mitigating any extreme reactions to prevent employees from feeling disbelief, frustration, guilt, despair or indifference. they do that by driving teams to understand the meaning of challenge, competitiveness, adventure and collaboration. We should stop protecting ourselves from uncertainty and instead embrace it as a component of management that can boost investment, commitment and loyalty.

the vast majority of us, as human beings, would refuse an invitation to scuba dive, citing our fear of the unknown, of darkness and of danger. however, many of us would agree to try snorkelling, reassured by the feeling of control over the risks we think we can identify. yet most scuba diving accidents occur at the water’s surface, in that zone of comfort and certainty where we think we are protected from danger.

in the history of industry, there are many examples of managers who, clinging to their belief in a static world, have watched their companies sink. in healthcare, two studies led in the united states of panels of doctors show a positive correlation transforming mistakes into progress, giving between doctors who express their uncertainty and improvement in patient relations, value to novelty rather than comfort, turning more information shared with the patient threats into opportunities... that’s the very crux and better pain management. of the entrepreneurial spirit that leaders should instil in the world of healthcare. We must build the future. We still have much to learn and need to remain curious. uncertainty is not the problem. our certainties are. ⁄

to KnoW moRe

cemcav

read the entire commentary on www.invivomagazine.com

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cOMMENtARy

cURsUs

cOMMENtARy

and maintain expertise with the best results for both surgery and the treatment of certain diseases.

We must find ways anne-claude griesser to help people form an assistant medical director objective opinion using at the chuv indicators based on rigorously and statistically proven methods. that’s not so easy. atients frequently experts recommend publishing relevant ask how they should figures that reflect the quality of services. choose their hospital. data must be precisely defined in order to it is a legitimate be compared using consistent collection question, but there is no simple answer. any methods and then adjusted for risks that account for patient complexity. For ranking that suggests that you should choose example, consider the infection or mortality rate. leading hospitals that care for your hospital based on two or three quality complex and seriously ill patients will indicators (e.g. infection rates, patient naturally have a higher complication and satisfaction or mortality rates) reflects a mortality rate than a clinic that accepts simplistic approach to patient care.

Facilities should have an overall quality elective patients for less complicated procedures, and that can transfer patients assessment including structure indicators, to a top hospital in the event of a problem. such as available equipment, certified these differences must be taken into intensive care, staff expertise and continuaccount when evaluating quality indicators. ous training. organisation methods that Finally, indicators must be understandpromote teamwork and the best care at able for patients, with clear explanations the right time, such as in neurovascular about their implications, limits and units and breast centres, should also be interpretation. ⁄ integrated. another aspect to factor in is the way in which best practices are implemented to prevent infections and operating room safety. the volume of activity performed by the hospital is another important factor in the quality of care. hospitals need to reach a critical mass to gain experience

P

chloé pracchinett

cursus

career at the chuv

“Quality of care should not be reduced to one or two indicators”

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e

cAREER At tHE cHUV

eleonora de stefano is chief perfusionist, a relatively unknown profession despite its crucial role during major heart surgery. text: camille andres, photos: heidi diaz

leonora de stefano stumbled onto her field in 2002. “i planned on studying medicine and surgery in siena, where the university required an entrance exam. i was accepted, but only for the perfusionist option. i didn’t even know what it was!” but she was soon fascinated by her medical technical training, which combined both academic and practical internships. “our general classes were similar to those in medicine, including anatomy, physiology, pharmacology, chemistry, etc. and we were introduced to the reality of cardiac surgery right in the first year.” that is where perfusionists are essential. they specialise in extracorporeal circulation using the heart-lung machine, which maintains systemic perfusion, ensures the exchange of gases, and regulates body temperature. blood is collected from the systemic venous side, oxygenated,

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and then sent back to the aorta or another major artery. pulmonary circulation is circumvented during complex procedures in which surgeons need to operate on an unbeating heart, such as heart transplants, coronary artery bypass surgery and cardiac valve replacement. in intensive care, perfusionists also play a key role in managing cardiac and respiratory support systems for patients awaiting an organ and immediately following the transplant. the reality of the job involves complex and delicate operations. “implementing an extracorporeal circuit has risks. there are several possible techniques, which differ with each patient. you have to be very careful about which option you choose. our job is a bit like applied fluid mechanics”, says eleonora de stefano. she regularly participates in humanitarian missions in countries such as mozam-

bique, cambodia and senegal to share her knowledge. the discipline requires the utmost concentration and meticulousness, and a strong personal commitment. “we begin early in the morning, at 7:00, to install the machine in the operating room, assist throughout surgery and manage the post-operative procedures of stabilising the patient and re-equipping the machine.” no one can replace a perfusionist. at the chuv, these specialists work in shifts to be available 24 hours a day, seven days a week. the team comes from countries around the world. “there is a real shortage of perfusionists as the field is relatively unknown. Finding people with experience who are immediately operational is difficult. plus, there are no official federal training programmes,” says this italian native from calabria, who joined the chuv in 2006. this should change with the first federal training programme offering european certification set to launch in zurich in september 2015. the chuv, a leading training centre in the field, is expected to play an active role. ⁄

cURsUs

cAREER At tHE cHUV

the “heart-lung machine” is used by perfusionists to maintain vital body functions while the heart is temporarily stopped during cardiac surgery.

As a perfusionist, eleonora de stefano monitors the various parameters of extracorporeal circulation and makes sure the patient’s physiological needs are met.

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jUlien FAVRe

tAndem

thomAs AndRiAcchi

cURsUs cURsUs

cAREER At tHE cHUV

a

room full in other components, Julien Favre is joint director of of cameras, and, if possible, toswiss biomotion lab. professor electrodes gether.” this realisation thomas andriacchi, working and force sensors. on drove him to join the the computer screens biomotion lab headed from california, supports this are 3d images and a by dr andriacchi, a state-of-the-art laboratory. lengthy set of graphprofessor of mechanitext: camille andres, photos: philippe gétaz ics. at first glance, the cal engineering and gait analysis laboraorthopaedic surgery, tory at the nestlé hospital resembles a film set. one of the fathers of biomechanics, and a pioneer except here, the people are not actors, but patients, in the multiparametric analysis of arthritis at stansuffering from arthritis and here to have the way ford university in california. they walk analysed. the process exists elsewhere in the world, but lausanne university hospital after more than five years of successful research (chuv) has developed an innovative approach. in the united states, Julien Favre joined the chuv. in 2014, he participated in setting up sbml, the “we not only analyse all aspects of knee movesmaller branch and partner to the us laboratory. ment, but also work to change the movement and understand how it affects cartilage and bones,” sbml’s research also develops augmented reality says Julien Favre, who set up swiss biomotion lab techniques to offer patients personalised advice (sbml) with professor brigitte Jolles-haeberli at and change the way they walk. this aims to reduce the chuv. pain and slow the development of the disease. their novel approach to the joint disease views a healthy knee as a system whose components – movement, structure and biology – are in harmony. From this perspective, arthritis is viewed as a problem with this balance. this global approach brings together the three components, which are traditionally analysed separately.

Julien Favre chose this approach following his phd in biomechanics at epFl, which focused on knee movement after cruciate ligament injuries. “everything suggested that analysing movement alone was not enough to understand the knee and the conditions that affect it. we needed to factor

in the united states, most of their work consists in monitoring arthritis patients to better understand knee mechanics and to adapt the changes to standard patient profiles. the collaboration between the two laboratories goes beyond sharing scientific knowledge and analysis techniques by establishing regular dialogue between swiss and american researchers. the chuv and the stanford biomotion lab currently engage in a researcher exchange programme. this is a key step forward to finding more therapeutic options (which are currently quite limited) for arthritis, a painful and debilitating joint disease that affects nearly onethird of people over age 65.

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cURsUs

NEws

New auditoriums

Advance in schizophrenia research

state council members anne-catherine lyon and pascal broulis laid the first stone at the construction site for two new auditoriums that will be located in the basement of the university of health sciences (HESAV) in lausanne. the auditoriums will serve the Faculty of biology and medicine at the university of lausanne as part of measures to increase the infrastructure available for educating doctors. BT

The disease could be related to a disturbance during the critical periods in brain development.

edUcAtion

Hospitals join forces switzerland’s largest university hospitals and the faculties of medicine from swiss universities have set up the swiss association for university medicine to strengthen their drive to work together. “it is essential for representatives from university medicine to bring their knowledge and expertise and to take part in the discussions about society,” says the organisation’s president rita Ziegler, director of Zurich university hospital. BT collABoRAtion

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ReseARch

in a co-written paper published in Biological Psychiatry, the research teams of professor takao hensch from harvard university and professor Kim do cuénod from the center for psychiatric neurosciences (department of psychiatry at lausanne university hospital and university of lausanne) have revealed a new concept in neurobiological research on schizophrenia. the scientists report that the disease could be related to a disturbance during the critical periods in brain development, altering synaptic plasticity. rebalancing brain oxidative stress would help remedy that.

input) permanently affects the neural connections. these windows occur at different stages in brain development, depending on whether they involve a sensory system or higher cognitive functions such as language. the research team led by professor do cuénod (and dr Jan-harry cabungcal) has shown that the dysregulation of brain oxidation is involved in the onset of schizophrenia, impacting certain cells in the nervous system. professor do cuénod says that the dysregulation impairs the normal development and full maturation of parvalbumin neurons and cells responsible for forming myelin. these two cell mechanisms are precisely those responsible for starting and ending the critical period in brain development.

BT

professor hensch’s research group focuses on the critical periods in brain development, during which human or animal experience (environmental

cURsUs

cAREER At tHE cHUV

migRAtion

michael saraga left for mcgill university in montreal for one year to build new ties between clinical practice and social sciences.

What is your professional background? i studied in lausanne. after two years as an assistant in internal medicine, i received training at the department of psychiatry at lausanne university hospital (chuv). i joined the lausanne university medical polyclinic as head of liaison psychiatry. it was while i was working there, between psychiatry and general clinical practice, that i got the idea to leave on an academic stay.

What was your goal when you left? my plan was to develop a new model for integrating social sciences into medicine, in both teaching and clinical practice. and it turns out that mcgill university is one of the rare institutions with a department of social sciences within the Faculty of medicine.

alexandre claude

how is your stay going? very well. i’m extremely lucky to have a whole year to develop ideas! i’m particularly interested in a mentoring programme developed by mcgill university over the past ten years that lasts over the course of medical school. students are divided up into small groups overseen by a more experienced physician recognised for his or her clinical experience. the idea is to guide students

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last name saraga First name michael with the chuv since 2001 title Associate physician

in developing their professional identity by providing them with a group work space. i think that one of the most interesting aspects is the impact this experience has on the mentors, who say that the contact with students reminds them of when they themselves were starting out in medicine. they describe it as a transformative experience.

What are your plans for afterwards? i’ll resume my clinical practice at the psychiatry liaison service at the chuv. i’ll be working with the chuv management to develop a hospitalwide project that follows on from my work in montreal. and i hope that my experience in canada will benefit both clinical practice and research. ⁄ BT

BAcKstAge

tandem the photographer philippe gétaz transported a skeleton from a storage facility at the chuv to the nestlé hospital, where professor andriacchi’s photo shoot took place. (p. 74)

heidi diaz

cover graphic designer diana bogsch arranged several hundred pills of various shapes and colours to feature on this issue’s magazine cover.

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cONtRIBUtORs

GENEVIÈVE RUIZ geneviève is the editorial manager for “hémisphères” magazine and a journalist for largenetwork, writing regularly on health issues. after contributing articles on comas and meditation (iv nos. 1 and 2), for this issue of “in vivo” she looked into the latest therapies available for autism, offering new hope for children and their families (p. 60).

thierry parel, dr, Johann pelichet, mathieu martin

GILLES WEBER gilles took the portraits of mathilde morisod-harari (p. 41) and murielle bochud (p. 55) for this issue of “in vivo”. the photographer has been working with the medical teaching and audiovisual communication centre (cemcav) since 1992.

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ROBERT GLOY with a master’s in French and german journalism from the university of Freiburg and the school of Journalism of the university of strasbourg, robert joined largenetwork in January 2015. For this issue’s “in extenso” supplement, he studied the history and current issues surrounding genetics.

DARCY ChRISTEN currently working with the communication department at lausanne university hospital, darcy interviewed the designer ruedi baur for this issue of “in vivo” (p. 49). this hospital communications specialist held several positions with the international committee of the red cross from 1986 to 2003, mainly on field assignments in africa, afghanistan, iran and Jerusalem.

In Vivo

Magazine published by the Lausanne University Hospital (CHUV) and the news agency LargeNetwork www.invivomagazine.com

PUBLISHER

CHUV, rue du Bugnon 46 1011 Lausanne, Switzerland T. + 41 21 314 11 11, www.chuv.ch redaction@invivomagazine.com Editorial and graphic production LargeNetwork, rue Abraham-Gevray 6 1201 Geneva, Switzerland chief editors T. + 41 22 919 19 19, www.LargeNetwork.com Béatrice Schaad and Pierre-François Leyvraz Project manager and online edition

Bertrand Tappy Thanks to

publications managers

Gabriel Sigrist and Pierre Grosjean

project manager

Melinda Marchese Fiona Amitrano, Alexandre Armand, Anne-Marie Barres, Francine Billote, Valérie Blanc, Gilles Bovay, Virginie Bovet, Mirela Caci, Stéphane Coendoz, Muriel Graphic design managers Cuendet Teurbane, Stéphanie Dartevelle, Diane De Diana Bogsch and Sandro Bacco Saab, Frédérique Decaillet, Muriel Faienza, Marisa Figueiredo, Pierre Fournier, Serge Gallant, Christine editorial staff Geldhof, Nicole Gerber, Katarzyna Gornik-Verselle, Déborah Hauzaree, Aline Hiroz, Pauline Horquin, LargeNetwork (Camille Andres, Alexandre Babin, Céline Bilardo, Martine Brocard, Clément Bürge, Erik Freudenreich, Mouna Hussein, Melinda Marchese, Antoine Menusier, Joëlle Isler, Nathalie Jacquemont, Nicolas Jayet, Emilie Jendly, Anne-Renée Leyvraz, Cannelle Jean-Christophe Piot, Geneviève Ruiz, Gaëlle Sinnassamy, Emilie Veillon, Julie Zaugg), Keller, Elise Méan, Laurent Meier, Brigitte Darcy Christen, Bertrand Tappy.

Morel, Thuy Oettli, Denis Orsat, Manuela Palma De Figueiredo, Odile Pelletier, iconographic research Fabienne Pini-Schorderet, Isabel Prata, Sabrine Elias Ducret and David Stettler Sonia Ratel, Massimo Sandri, Dominique Savoia Diss, Jeanne-Pascale Simon, Christian Sinobas, Elena Teneriello, Images Laure Treccani, Céline Vicario and the CEMCAV (Eric Déroze, Heidi Diaz, Philippe Gétaz, Gilles Weber), CHUV’s Communications Service. Nelson Reitz distribution partner

BioAlps

Layout

Diana Bogsch, Romain Guerini and Jennifer Freuler

TRAnslation

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PCL Presses Centrales SA 18,000 copies in French 2,000 copies in English The views expressed in “In Vivo” and “In Extenso” are solely those of the contributors and do not in any way represent those of the publisher.

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IN EXTENSO

Genetics The never-ending story