In Vivo #6 EN

/the BAttle AgAinst oVeR-medicAlisAtion

LESSIS MORE

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published by the chuvwww.invivomagazine.com

think healthno. 6 – July 2015

dIgItAl HEAltH Apple and google join the race

dEBAtE Marijuana as a prescription drug

pHOtO-REpORtAgE 3d-printed prosthetics

IN EXtENsO gENEtIcs, tHE NEVER-ENdINg stORy

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IN VIVO / NUMBER 6 / jUly 2015

contentsFocUs

19 / medicine

Less is moreby 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 begunby clément bürge

38 / tRends

Children under close watchby emilie veillon

42 / decoding

Cannabis, just what the doctor orderedby clément bürge

46 / insight

My (rough) life as a researcherby bertrand tappy

49 / innoVAtion

The hospital improves the health of its signageby 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. sc

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53 / tRends

Dr Iodine and Mr Saltby antoine menusier

56 / PRosPecting

Animals could be the future of human healthby martine brocard

60 / decoding

Autism in a new lightby geneviÈve ruiZ

65 / in the lens

Printed prostheticsby eriK Freudenreich

in sitU

11 / heAlth VAlley

Virtual reality applied to medicine

14 / ARoUnd the WoRld

Eye implants to restore sight

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”

cONtENts

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BÉAtRice schAAdchief editor

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 ab-stinence. yet the medical world needs to be aware that it is caught in aninflationary 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 de-velopment. 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 hyper-tension, osteoporosis, cholesterol and cognitive disorders.*** pres-sure also comes from the shift from curative medicine to predictive medicine, which can turn any healthy individual into a potential pa-tient. 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 co-chet said when the movement began. similarly, in medicine, “de-growth” is not about “de-science”. it does not mean moving towards regressive medicine, but towards a paradigm shift in the way that clini-cal 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 doc-tors from mistakenly feeling obligated to continue aggressive treat-ment, when patients actually want something else, or to discuss pa-tient requests that may seem futile to health care professionals. For some patients, doing less may actually be doing more. ⁄

editorial

DOES “DEGROWTh” MEAN “DE-SCIENCE”?

*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 pharma-ceutical companies are turning us all into patients,

ray moynihan, alan cassel, paperback, 2006.

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iV n° 2 p. 53

ORGAN DONATION

terminally ill baby donates his kidneys

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. /

MEDITATION

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 moni-tored 424 patients. the relapse rate was slightly lower for the group practising mindfulness

meditation (44%), than for the group that remained on antide-

pressants (47%). /

SELF-MEDICATION

Aids self-testing now available in europe

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. /

PERCEPTION

Putting words in your mouthsufferers 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-ena-bled 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

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 estimat-ed that the likelihood is about 80% that the first human to achieve medical immortality

has already been born. /

iV n° 1 p. 30 iV n°3 p. 58 iV n° 3 p. 19

iV n° 3 p. 54

post-scriptum

you can subscribe to “in vivo” or request back

issues on our website www.invivomagazine.com

updates on previous “in vivo” articles

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pOst-scRIptUM

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gaining health and weight with faecal transplantsFaecal 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. /

SMART MEDICINE

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

the United Kingdom launches proton beam therapy the first proton beam therapy

centre in the united King-dom will open in cardiff in

2016, with two more facilities planned in london and north-umberland by 2017. the british

national health service has also announced that it will open two public proton beam therapy

centres in 2018. this tech-nique targets cancer cells more

accurately than traditional radiotherapy, limiting damage

to vital organs. /

iV n° 4 p. 44

iV n° 4 p. 57

iV n° 5 p. 19

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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.

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in situ

health valleyPanorama of the latest innovations.

ecublens p. 11

the young company mindmaze uses virtual reality to rehabilitate stroke patients.

geneva p. 09

the campus biotech neuroscience research centre opens its doors.

IN sItU HEAltH VAllEy

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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.

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stARt-UP

CARDIACgBc-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.

MICROSCOPEnanolive, 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.

BIOMARKERSthe 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.

DIABETESmedirio, 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.

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 compli-cations 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.

750,000the amount in dollarsgranted by the billand melinda gatesFoundation to im4tb,a company based inecublens that focuseson developing abreakthrough drugto fight tuberculosis.this disease affectsone-third of theworld’s populationand is the eighthleading cause ofdeath in developingcountries. the epFlspin-off will use thisdonation to move into the first clinical trialsof a new antibiotic.

Lausanne and Geneva team up to treat heart disease in childrenPediAtRy 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.

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Breath test for cancertechnology a new system developed in collaboration with researchers at the swiss Federal institute of technol-ogy in lausanne (epFl) can be used to detect mouth or throat cancer more easily, with a simple breath. this patient-tested “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 eyeinnoVAtion close your right eye to zoom in, then your left to return the image to its initial size. no, this is not science-fi ction! 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 suff erers of age-related macular degeneration, a condition caused by damage to the retina which results in the loss of central vision and aff ects 30 to 50 million people worldwide.

“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.

Campus Biotech now openneURosciences “campus bio-tech has the potential to rise among the leading interna-tional institutions.” that is how Federal councillor Johann schneider-ammann expressed his enthusiasm as he inaugu-rated 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 technol-ogy in lausanne, the geneva university hospitals, the Wyss center for bio- and neuro-engineering, the human brain project, the swiss institute of bioinformatics and the swiss school of landscaping, engi-neering and architecture.

epFl

APP

SOS MÉDECINSthe 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.

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imPlAntAtions

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

Biopharmaceuticsthe 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 sum-mer, where it expects to bring in about 80 employees over the next fi ve years.

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.

WhAt is the oBjectiVe oF innoVAtion FoRUm?

the swiss branch opened in lausanne on 10 march, but innovation Forum was founded in 2012 by re-searchers from cambridge. today, the organisation is active on a dozen campuses in north america, eu-rope and asia. experience shows that bringing people together from diff erent generations, spheres and dis-ciplines 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.

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 diff erently. innova-tion Forum features a community of 100,000 people worldwide. this brings both a global and local per-spective 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.

Why lAUsAnne?lausanne has the advantage of being home

to a number of top-notch universities and schools with various specialisations. the city also off ers the ideal location as it is home to a new generation of business leaders and entrepreneurs who are ready to experi-ment with new forms of dialogue. by choosing laus-anne, innovation Forum is also positioned to benefi t from the networks and fi nancial support from numer-ous partners such as novartis and venturlab. /

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GLOBALDIAGNOSTIXthis 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.

the deVice the deVice the deVice the deVice

GLOBALDIAGNOSTIX

MANUEL FANKhAUSERinnovation Forum, the not-For-proFit organisa-tion he chairs, builds bridges between academia,

industry and government.

3 questions For

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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 rehabilita-tion 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

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.

cerebral brainstorming

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.

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.100


sixth stepGENEVA

genkyotexON ThE ROADin every issue, “in vivo” meets with the leaders of health valley.

geneva is the focus of this edition.

“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 complica-tion 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. togeth-er, 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

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 manage-ment 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.” /

text: céline bilardo

12

Fighting diabetes

Genkyotex is a pioneer in developing a drug to treat

diabetic diseases.


i’m often struck by the opportuni-ties 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.

swiss institutions, pioneers in developing close ties between industry and academia, have successfully established a relationship based on

trust and mutual respect for the respective role of each partner. experience and professionalism on

the part of top academic institutions and their industrial partners have helped bring together

these two worlds. Just ten years ago, these organisations had little contact with each other

and in some countries, they still struggle to understand how they are complementary.

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 effectively built a special relationship (because it respects the interests of each party involved) between our industries, small businesses, start-ups and research and development institutes. this new innovation model, in which each partner gains, is essential for tackling the challenges that we face and for bringing patients and society innovative technological solutions. ⁄

dr

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BENOÎT DUBUISdirector of the campus biotech site and chairman of bioalps

We need an ecosystem that brings together industry and academia.

FoR moRe inFoRmAtionwww.bioalps.orgthe platform for life sciences in western switzerland

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IN sItU wORld

in situ

around the globeResearch doesn’t stop at borders.

In Vivo covers the latest medical innovations worldwide.

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.

the percentage of survival rate increase for cancer patients after using a new immuno-therapy 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.

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.

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IN sItU wORld

Le cœur éternel: Promesse ou utopie?

alain deloche and gilles dreyFus, michel laFon, 2015

Featuring a preface by professor alain carpentier, the creator of the carmat artifi cial heart, this book retraces the incredible history of research and development of artifi cial 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.

As We Age, Keys to Remembering Where

the Keys Arenew york times, Jane e. brody

the New York Times health and science columnist tackles the issue of “retriev-al 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.

Brain Maker: The Power of Gut Microbes to Heal

and Protect Your Brain–for Life

david perlmutter, kristin loberglittle, brown and company, 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, ex-amines the latest research on how the microbiome is related to the health of your brain. dr. perlmut-ter also off ers a dietary programme to better care for your microbiome and at the same time prevent neurodegeneration.

La vérité sur vos médicaments

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 ef-fi cacy of drugs. medication plays an essential role in healthcare; it is used to fi ght contagious diseases, and even cancer, more ef-fectively. progress made in cardiology and rheumatol-ogy would not have been possible without drugs. these experts also reveal the dark side of the indus-try: counterfeiting, misuse and scandals.

in ViVo

Best PicKs

to links to columns and videos see

www.invivomagazine.com

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 dia-betic 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 diabe-tes or kidney disease.

A tattoo to measure your blood sugar levels?

Best PicKs

stuart elborn,in an interview with bbc news, proFessor stuart elborn From queen’s university belFast expressed his enthusi-asm 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.

“This is likely to become a fundamental treatment for

cystic fi brosis.”u

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IN sItU wORld

the Food oF the FUtURe in 3d PRintingAfter 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 rutzerveldwww.chloerutzerveld.com

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IN sItU 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

REPUBLIC OFINNOVATION

“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.”ThIERRy MAUvERNAy Delegate of the Board Debiopharm Group

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INVIVO4_6_18_EN.indd 18 23.10.2014 16:08:56

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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.

lEss Is MOREfOcUs

by Julie zaugg and

melinda marchese

/

20

fOcUs lEss Is MORE

Are our modern doctors all dr Knock? this fi c-tional character dreamt up by the French writer Jules romains in the 1920s convinced the in-

habitants 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 over-medicalised society that transforms citizens into health care consumers who just keep wanting more, hoping to feel better and better.

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-fashioned remedies. a growing number of increasingly sophisticated high-tech instruments and drugs give doctors an ever greater arsenal of therapies to choose from. “When a new product is released on the market and its manufacturers extol its vir-tues, as physicians, we want to be-lieve it,” says thomas bischoff, director of the institute of primary care at the university of lausanne. “While maintaining an analytical perspective, we hope that it will truly help us provide better care for our patients. but it’s not easy for the medical community to separate the good from the bad with all these new products.”

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

patients and health care professionals fi rmly believe in the promises of modern medicine. even though dr Knock ends up winning in the play by Jules romains, a growing number of health care providers today in-stead support more humble, modest form of medicine

that recognises its limitations and is bold enough, in some cases, to do less. “We’re seeing movements emerging that advocate the idea of ‘ less is more’ in medicine,” says arnaud chiolero, public health specialist at the university institute of social and preventive medicine in lausanne. “the objective is es-pecially to perform fewer unneces-sary treatments.”

An oVeR-medicAlised WoRld

campaigns like smarter medi-cine 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 pa-tients. the “less is more” concept invites people to acknowledge that too much medical treatment can sometimes be more risky than benefi cial.

proponents believe that Western societies are cur-rently over-medicalised. “We’re in a health care sys-tem that constantly pushes us towards ‘excessive’

treatment,” says thomas bischoff . “that can be ex-plained by the same principle that encourages other sectors in our Western cultures to keep going further. We view accumulation and growth as signs of pro-gress and performance.”

FUll-time PAtientthis 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 offi ces and hospitals, some people constantly focus on monitoring their health. “With

1

FigURes

200 In billions of dollars,

the annual cost of excess health care worldwide, estimated by

the Dartmouth Institute.

50The 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.

21

fOcUs 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

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.

iv 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 infu-sions administered so that they’re never “too dry” or “too full of liquid”. we make sure that patients

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 sur-gery. ideally they walk, as mobility speeds up recovery tremendously.

iv 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

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

iv What are the advan-tages of this method?nd this multimodal path-way helps reduce the risk of complications by 40% to 50% and shorten hospi-tal 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 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!

*nicolas demartines, chieF oF the service oF visceral surgery at the chuv.

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22

fOcUs lEss Is MORE

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 on-line. according to a study published by swisscom in 2012, 84% of swiss people have already done re-search on medical websites before or after seeing a doctor. the most common searches are about symp-toms, 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 off er the person in front of us.”

senioR citiZens on the FRont linethis issue is especially prevalent among the constant-ly growing elderly population, who are huge consum-ers 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 Libéra-tion, “any more than three or four molecules taken together and we don’t know how they will react. and, more importantly, beyond fi ve, the risk of a medica-tion accident increases considerably.”

the French may be some of the world’s biggest con-sumers 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 fi ve.

“each additional drug increases the chances of expe-riencing a side eff ect 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 con-sciousness, especially if the person is elderly.

cAUses oF the ePidemic

technological advances can now detect abnormalities in their ear-ly 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 pulmo-nary 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 identifi ed, “it’s virtually impossible, even unethical, not to investigate further and treat the patient, even if that means a high likelihood of

relational therapy over pillsin psychiatry, drug-based treat-ments can be used alongside rela-tional 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 Jean-michel kaision. often they no longer need the sleeping pill that is typically administered.

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sometimes, less is morepeople who take the most medication do not necessarily live longer.

pharmaceutical spending in usd per inhabitant and per year

life expectancy

fOcUs lEss Is MORE

24

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

RAising AWAReness Among yoUng doctoRsmedical 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-

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

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

“it’s easier to continue intensive care than to stop it” bertrand tappy

Oliver Peters, Vice President of the Swiss Federal Offi ceof Public Health (FOPH), encourages doctors to make realistic decisions, in linewith 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 such as scans or mris. not only are they sometimes performed without being truly necessary, these services are extremely expensive. innova-tion generally contributes to lowering costs (aviation, construc-tion, 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 aff ected 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

therapeutic steps. that’s why i think that analytical, integration and planning skills should be strength-ened – 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.

iv 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 (chemo-therapy, 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 What measures are recom-mended 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 fi nancial incentives encourage a treatment programme that patients wouldn’t spontaneously choose. it also reported how unsafe situations are especially vulnerable to over-medi-calisation. 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 fi nd diffi cult. 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 off er the funda-mental 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

25

fOcUs lEss Is MORE

ing with illness,” says david goodman. “modern med-icine 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 inteRestsome procedures are overused for economic reasons, such as implanting certain stents – those small pros-thetic 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 off ered 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-be-ing 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 hospi-tals 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 [edi-tor’s note: quitting smoking, losing weight] would often be enough.”

Finding Remedies

it is high time to fi nd solutions to remedy the problem of over-medicalisation. general practi-

tioners 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 specifi c 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 fi nd a bal-ance that the patient can tolerate.”

sePARAting the good FRom the BAdin 2000, sweden defi ned a “Wise list”. this list, es-tablished by an independent scientific committee, includes the 200 essential drugs for treating common diseases. in 2012, 90% of the prescriptions written in

mAKing Wisechoices

Created by about fi fty 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 ineff ective 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 eff ects.

Non-invasive treatments (physical exercise, anti-infl am-matory drugs, mild painkillers or cortisone shots) are more eff ective than arthroscopic

knee surgery.

3

fOcUs lEss Is MORE

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

“in switzerland, each hospital prepares its own list of essential drugs,” says pierre voirol, head pharmacist at the pharmaceutical assistance and clinical phar-macology 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 eff ectiveness, tolerance by patients and variety of forms available [editor’s note: tablet, liquid, powder, etc.]. cost is only factored in as a secondary criterion.”

pierre voirol also coordinates a drug commission to issue recommendations to prevent duplicating treat-ments and prescribing unnecessary ones. he points to benzodiazepines – often prescribed twice to treat both insomnia and anxiety – while one would be ad-equate. 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

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

pharmacists from pierre voirol’s unit are also in charge of assisting doctors during their patient rounds to examine their medication and make rec-ommendations. “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 simplifi ed even further with the more standardised use of electronic patient health records. “all those data grouped into one place,” he says, beaming.

moRe honest medicinein many countries, doctors’ organisations have taken steps to set out guidelines that would reduce the pre-scription of unnecessary exams or drugs with little or no value. on request from the swiss society of gen-eral 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

centuries of over-medicalisationremember back in september of 2004 when the pharmaceuti-cal group merck recalled its blockbuster vioxx, the anti-inflam-matory painkiller drug that used to generate two billion dollars a year in revenue? why? the drug, commonly prescribed to arthritis patients, increased the risk of heart attacks and strokes, causing more than 30,000 deaths in the united states alone.

another health scandal exploded a few years later. this time it involved mediator, a drug devel-oped by servier laboratories and sold as an anti-diabetic. From its market launch in 1976 until its recall in 2009, 145 million boxes were sold, and more than 5 mil-lion people had taken the drug in France. according to the in-spection report published in 2013,

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

these two highly publicised cases, along with the explosion of health care costs starting in the 1990s, thrust the issue of over-treatment into the spotlight. opinions started to sway in favour of fighting this trend. “the movement began in the united states. europe didn’t join in until later, probably because health care costs are not as excessive, and the need to stabilise them less urgent,” says david goodman from the university of bern.

the issue is not unique to modern societies. “back in the 18th century, doctors com-plained that their patients were only satisfied if they left with a remedy in hand,” says micheline louis-courvoisier, a medical

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.”

the american researcher John wennberg’s work in the 1970s considerably raised people’s awareness about over-medical-isation. he demonstrated that 7% of children from middle-bury, vermont, had their tonsils removed, compared with 70% in stowe, 80 km away. this “unwarranted variation” could not be explained by any other reason than the fact that some doctors are a bit overzealous with the knife.

26

27

fOcUs lEss Is MORE

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

at the end of 2014, the sgim singled out five com-mon procedures as “unnecessary” in switzerland (www.smartermedicine.ch). its “top 5” include X-rays to investigate certain types of lower back pain, antibiotics for bronchitis and other infections of the upper respiratory tract, X-rays before certain opera-tions 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 eventu-ally incorporate other procedures.

one of these is testing prostate specific antigen (psa) levels in the blood to de-tect prostate cancer. patients should be provided with neutral information about the advantages and disadvantag-es of the test before having the proce-dure performed, which the sgim does not recommend for men over age 75. “many cancerous lesions found in pa-tients without any symptoms will never develop into the disease, at least not during their life time,” says arnaud chiolero.

peter vollenweider adds that high psa levels do not necessarily mean that the patient has cancer, “but they lead us to run other tests, which can increase the burden and stress put on patients. if cancer is actually reported, they could undergo an operation that will affect their sex lives and some-times social lives but without necessarily increasing their life expectancy,” he explains. “is the treatment really worth it? the decision must not be made by the doctor alone. the patient needs to understand all sides of the issue and give an opinion.” PAtient cARe PlAnsinvolving patients more in decisions about their treatment is one of the highly recommended meas-ures 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-in-formed choices,” says Jessica otte, a canadian fam-ily physician who created the health care blog less is more. a study by the group health research in-stitute in seattle demonstrated that when patients

were provided with decision aids in the form of in-formational 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 do-menico borasio. “do they prefer to be treated at home? in a facility? What are their fears? What are they definitely against? addressing these issues ear-ly 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 situ-ations, it can be very beneficial for the patient. the treatments given do not try to extend the patient’s life but improve its quality,” he says. “one unexpected finding of various studies is that pallia-tive care can also extend the person’s life, while making their day-to-day ex-istence more comfortable. that’s why i think that each clinician should have some basic knowledge about palliative medicine to talk about it with their patients suffering from one or more chronic and progressive diseases.”

gian domenico borasio believes that the danish philosopher søren Kierkeg-aard perfectly expressed the attitude that doctors should have in their day-

to-day practice: “if one is truly to succeed in leading a person to a specific place, one must first and fore-most take care to find him where he is and begin there. this is the secret in the entire art of helping. anyone who cannot do this is himself under a delu-sion if he thinks he is able to help someone else.” and he concludes, “to guide patients well, we must first understand and respect their priorities. at no point should we ever abandon a person, but sometimes we need to know when to abstain for their benefit.” /

FoR moRe inFoRmAtionwww. smartermedicine.ch this swiss platform designed for patients and specialists provides an updated list of procedures deemed unnecessary, available in german and French.

www.lessismoremedicine.comthis website includes press articles, events and blog posts about over-medicalisation. in english and French.

www.choosingwisely.orgthe us campaign choosing wisely promotes dialogue between patients and health-care professionals about the treatments they are offered. in english.

28

inteRVieW “We shoUld tAKe oUR time, insteAdoF 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.

in vivO What is excessive diagnosis?GiLBERT WELCH 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.

iv how can we fight this phenomenon?GW 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.

based on an interview with

Julie zaugg

fOcUs lEss Is MORE

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?GW 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.

iv do you have an example?GW when i was a medical student, a stroke was described as an event after which the patient showed neurological side effects, such as

expert on over-diagnosisgilbert 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.

29

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.

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-diag-nosed 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?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.

iv do you have any of those cases in mind?GW 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.

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. ⁄

fOcUs lEss Is MORE

mar

k w

ashb

urn

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

30

dr

“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.”rishi manchanda

mens sana

31

MENs sANA INtERVIEw

Rishi Manchanda champions an “upstream” approach to medicine, suggesting that healthcare take into account where and how patients live.

rishi manchanda has devoted his entire career to under-standing social and environmental factors that affect health. the water we drink, the air we breathe, the job we do. rishi manchanda has worked for a decade as a doctor in the disadvantaged neighbourhood of south central los angeles. he has developed a community approach to healthcare that aims to act upstream to prevent disease before it appears.

in vivo You invented the concept of the healthcare professional who focuses on where health begins, the “upstreamist”. What is it about? rishi ManChanda

the term comes from a parable. three friends come to a river that leads to a waterfall. it’s a beautiful set-ting, but they soon notice that the water is full of children who are drowning. the three friends jump into the river. the first tries to save the children 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 swimming away, upstream. “What are you do-ing? come back and help us!” the other friends shout. “no, i’m going to find out what’s throw-ing these children in the water,” the third friend answers. that’s exactly what up-streamist healthcare professionals do. they

look for the root cause, the social or envi-ronmental factors that have brought about the disease. all too often, the medical system only treats the patient’s symptoms. but we

should also look at the conditions that impact our health, those which are often less obvious

at first glance.

iv What are the hidden causes? rM there are two kinds. First, the patient’s living and working conditions. these include housing conditions,

where they live, and the environment where they work, eat, sleep and play. is there access to parks or

green spaces? are there leaks in their home? is there mould? do they live close to a motorway? second,

there are social or political causes. they are the invisi-ble government structures, factors that determine how

resources are allocated in society, to rich and poor.

iv Can you give us an example of how environmental factors affect people’s health? rM a study of 30 million people conducted in the united Kingdom focused on the

correlation between exposure to green space and the risk of heart disease. it found that the closer people are to green

space, the lower their chance of developing heart disease, regardless of income and education.

“Health is too rarely perceived as a group

phenomenon”

intervieW: Julie Zaugg

32

MENs sANA INtERVIEw

iv How does social equality shape our health? rM

Food insecurity is generally perceived as a third-world problem related to hunger. but it also exists in developed societies when people don’t have access to stores that sell fresh, healthy products, or if they can’t af-ford to buy food and have to skip meals or eat cheap fast food. Food insecurity af-fects an estimated one in seven ameri-cans, including 17 million children. For diabetics, food insecurity can have drastic effects and send them straight to the hos-pital. skipping a meal makes their blood sugar level drop, and if they eat high-cal-orie, energy-dense fast food or foods con-taining high-fructose corn syrup, their blood sugar level is too high. living in a constant state of hunger prevents proper glucose synthesis. the body is completely thrown off. in california, low-income in-dividuals with diabetes are 27% more likely to be admitted to the hospital at the end of the month, when their budget starts to run out.

iv When did medicine realise the effect that these social and environmental fac-

tors can have on people’s health? rM We suspected that these correlations have been around for a long time, but had no scien-tific research to back them up. the corpus of research in the area has grown massively over the past 20 years. one of the major ad-vances 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.

iv How can we detect the upstream causes of disease? rM We can use epidemiological re-search or geomapping tools to detect suspicious disease clusters. but we first have to communi-cate with the patient and ask the right questions. For example, when a lot of people are coming in with asthma, healthcare practitioners should ask about their exposure to allergens, such as mould or dust, second-hand smoke, or if they live near a motorway with high air pollution. all these factors

can trigger asthma. a doctor should also ask the patient’s opinion about what might have caused the illness. this self-analysis can often deliver surprisingly relevant re-sults. but too often, doctors are trapped in a one-way approach to practising medi-cine. they talk but don’t listen.

iv Why is there such a lack of interest?

rM doctors face several obstacles. First, how healthcare is financed. doctors are not encouraged to look for the root cause of disease because we don’t pay them to do that. We pay them for the number of ser-vices they provide, not the quality of those services. second, regulations often prevent information from being shared between environmental or housing authorities and the medical world. sharing this informa-tion could help detect and explain concen-trations of sick people. lastly, current medical practice is to focus on the indi-

BiogRAPhyrishi manchanda is a leading figure in upstream healthcare in the united states. he is the president and founder of health begins, a social network where clinicians can exchange ide-as on prevention and upstream causes of ill-nesses. he is the medical director of a veterans’ clinic within the greater los an-geles healthcare system. in 2013, rishi manchanda published The Upstream Doc-tors, in which he lays out his firm belief that we need to under-stand and ad-dress the causes and not just the symptoms of a disease.

“a doctoR should also ask the patient’s opinion about what Might have caused the illness. this self-analysis can often deliveR suRpRisingly Relevant Results.”

33

MENs sANA INtERVIEw

vidual rather than the group, putting the treatment of symptoms first, before look-ing at the causes of the illness. health is not perceived as a group phenomenon. doctors rarely belong to the same social or ethnic categories as their patients. this lack of di-versity blinds them to the socio-economic forces at work that could be making their pa-tients sick.

iv What can they do to act upstream? rM

doctors must be careful not to become social workers. that’s not their role. however, they can form healthcare teams of nurses, social workers, community representatives, etc. i worked at a homeless clinic in los angeles, and we involved public interest lawyers in their care, because we realised that patients’ inability to find a home was one of the main obsta-cles preventing them from becoming healthier. that type of work in a multidisciplinary team can be liberating and gratifying for physicians, even if it means relinquishing some of their power.

iv Are there countries or regions in the world where these practices are already a reality? rM in Kerala, india, the healthcare services take a very community-based ap-proach to medicine. some aspects of the healthcare sys-tem in costa rica and cuba factor in upstream determi-nants. the ngo partners in health in haiti also take this approach. there are many interesting local exam-ples in the united states, such as montefiore medical centre in the bronx or the blueprint for health initia-tive in vermont.

iv How can new technologies be used in upstream medicine? rM they’re not a solution in themselves but are an important tool. electronic health records can

be used to store information provided by the patient about his or her living and working conditions. big data techniques can be applied to analyse these records and spot trends or clusters of sick people. self-monitoring devices [editor’s note –

e.g. bracelets and smart watches that track the wearer’s vital signs] can help doctors identify what’s wrong with a patient. online platforms 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 ser-vices, pest control professionals, shelters for abused women, ongoing training centres] as easily as a restaurant.

iv 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 prestig-ious 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 recogni-tion of the field. that’s why i invented the term “upstreamist”. ⁄

WAtch“̓’the upstream doctors’: medical innovators track sickness to its source, ted talk, 2013.” www.invivomagazine.com

“the closeR people aRe to gReen space, the loweR theiR chance of developing heaRt disease, RegaRdless of incoMe and education.”

34

MENs sANA INNOVAtION

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 re-searcher and his team sent 300 letters to potential candi-dates, and fifty subjects ended up enrolling. “it took one year to recruit them,” the specialist

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

in march 2015, apple came out with a new tool, researchKit, which could radically change medical studies. this pro-gramme can be used by researchers to develop smart-phone apps that help them find participants for their studies. and one of the sci-entists 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.

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.

how does it work? researchKit is an open source software frame-work that allows researchers to create apps used to gather data especially useful for healthcare. eric schadt devel-oped the asthma health app to facilitate self-monitoring and encourage patients to stick to their treatment plans. pa-tients 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 hu-midity or a region’s pollution,” says eric schadt.

Four other health data apps have been developed. massa-

I

text: clément bÜrgeillustration: karen ichters

35


with the development oF sensor-equipped “wearables” like smartwatches, patients will produce

growing amounts oF data about their health.


36


o150

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.

chusetts general hospital has created glucosuccess to track blood sugar levels, stanford university’s medi-cal 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 penn-sylvania, sage bionetworks and university of california los angeles have teamed up to produce share the Jour-ney, which studies why breast cancer patients experience symptoms differently.

enteR google And FAceBooKthe 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 wear-ables 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 hap-pening 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

average, people spend ten min-utes 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 hospi-tal management software, ibm has created Watson, a super-computer that helps physicians diagnose diseases, and Face-book 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 technol-ogies at the heg geneva man-agement school. “google has the drive and financial means to change a lot of things.”

in march 2015, google an-nounced its collaboration with Johnson & Johnson to develop robots that could perform sur-gical procedures with infinite precision. the california-based

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

but its real gamechanger is calico, a special research unit focused on developing treat-ments for age-related illnesses. its clearly stated objective? immortality. the man behind calico is none other than ar-thur 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 ex-ecutive officer. in 2015, google announced that it would invest $1.5 billion in the project.

FUtURe chAllengessuccess 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

37


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 profes-

sionals 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 vari-ous 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.”o

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, independ-ent ventures such as calico,” he says. “they are unlikely to make the same mistake.”

one of the main threats that could compromise its ambi-tions is government regula-tion. 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 administra-tive 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, ac-cused the tech giants of fund-ing “pseudoscience,” pointing specifically to calico. to avoid these obstacles, several companies have begun collaborating directly with

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 pro-ducers,” 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. ⁄

38

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-

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.”

MENs sANA tRENds

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

text

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

in the cRAdleowlet baby care has come out with a smart sock that moni-tors an infant’s heart rate in real time. if any abnormality is detected, the device sends an alert to the parents’ smart-phone.

side By sidethe guardian bracelet sends a notification to parents’ smart-phones if a child moves outside the defined safety perimeter.

KeePing tRAcKgadgets are available to locate your teen-ager in real time, such as “Jelo-calise”, a gps beacon that can be fitted onto their scooter.

t

39

hug

h kr

etsc

hmer

MENs sANA tRENds

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

40

MENs sANA 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 relation-ship 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 indePendenceby 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

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 overpro-tected children.

danielle laporte, a canadian psycholo-gist and author of several books on child psychology who died in 1998, defined self-esteem as the inner certain-ty 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. ⁄

Glossary

a whole list of terms has cropped up in english to describe trends in overprotec-tive parenting. here are a few examples.

helicoPteR PARentalways hovering over their child, ready to fly in and rescue the youngster as soon as a prob-lem arises.

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

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

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

41

gil

les

web

er

MENs sANA tRENds

iv is parents’ anxiety related to any specific factors?mmh in psychotherapy sessions, we often see mothers traumatised by a complicated preg-nancy, parents of pre-mature 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 how does that surface in their behaviour? mmh parents of a pre-mature 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 develop-ment. what if some-thing 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

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.

iv 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

them and that they need to leave the child some space for free-dom. 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.

inteRVieW“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.

42

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.

cannabisjust what the doctor ordered

and reimbursed like any other medication.

MENs sANA dEcOdINg

hen philippe süsstrunk opened his eyes that night back in march 2013, the first thing he noticed was the cold. his clock said 3:00 a.m. he then realised that his body had been shaken by a series of endless spasms and cramps. he felt as though

he’d turned into a block of wood. “i couldn’t move,” says the 62-year old resident of the Jura canton. “i didn’t know what to do.” philippe had to wait thirty minutes for the attack to finally subside. by that time, he was exhausted and in tears. he had never experienced anything like it.

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

suffer regularly from spasms and cramps. his doctor tried to reduce the intensity of these incidents using various medications,

without success. “he kept increasing the dosage,” philippe says. “We had reached the maximum limit. i wasn’t allowed to take any more.”

but one day shortly after his night-time flare-up, his doctor had him try a new miracle product, cannabis tea. “it changed everything,” the patient says. “my spasms and

cramps disappeared almost instantly. i could once again lead a normal life.”

the chinese, egyptians and indians began using cannabis

NETHERLANDSEUROPEAN LEADER

medical hemp was legalised in the nether-

lands in 2003. bedrocan, the only company that

grows medical cannabis seedlings, is based in the

country. the company 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 can-

nabis in the country.

text:clément bÜrge

w«with cannabis drops, i can live again.»– philippe süsstrunk

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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 switzer-land. in the early 20th century, bern became one of the main cannabis research centres.

but as the pharmaceutical industry grew, cannabis began

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

43

MENs sANA dEcOdINg

CANADAVERY LIBERAL

canada has the most developed system for legal medical mari-

juana. this therapeutic substance has been

legal since 1999, and the government author-ises 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.

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.

44

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 depend-encies 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 treat-ment, 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

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 prepa-ration 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

MENs sANA dEcOdINg

UNITED STATESA WORK

IN PROGRESS

at the federal level, cannabis is considered

illegal and danger-ous. but several states,

including colorado, washington, oregon, alaska and the district of columbia, have le-

galised marijuana in re-cent years. twenty-one have legalised medical cannabis. some states plan to legalise certain

compounds in cannabis, such as cannabidiol (cbd), but refuse to

authorise tetrahydrocan-nabinol (thc).

atlanta, georgiaFebruary 2015

obtain medical marijuana for a limited number of conditions. “the Foph has

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

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.”

at the pharmacy and took to looking for cannabis on the black market. he’s tried 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


times and at others too light.”

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.”

obtain medical marijuana for a limited number of conditions. “the Foph has been more flexible in the past year or


pilot study... when cannabis can be used in its natural state for medical purposes as

says. the national council member would like the Federal

an alternative to synthetic cannabis or tincture of cannabis.” “medical cannabis is too expensive, and the prepa-ration process is currently too complicated,” margrit Kessler says. the national council

state for medical purposes as

complicated,” margrit Kessler says. the national council member would like the Federal council to explore the potential of this product that we have “known

says. the national council member would like the Federal council to explore the

says. the national council

can be used in its natural state for medical purposes as an alternative to synthetic

cannabis.” “medical cannabis is too expensive, and the prepa-ration process is currently too

can be used in its natural state for medical purposes as an alternative to synthetic

is too expensive, and the prepa-ration process is currently too complicated,” margrit Kessler says. the national council

potential of this product

says. the national council member would like the Federal

potential of this product

complicated,” margrit Kessler says. the national council member would like the Federal member would like the Federal

complicated,” margrit Kessler

member would like the Federal member would like the Federal member would like the Federal

state for medical purposes as

galised marijuana in re-cent years. twenty-one have legalised medical

atlanta, georgiaFebruary 2015atlanta, georgiaatlanta, georgia

plan to legalise certain

cent years. twenty-one have legalised medical cannabis. some states have legalised medical

authorise tetrahydrocan-authorise tetrahydrocan-nabinol (thc).

authorise tetrahydrocan-nabinol (thc).

authorise tetrahydrocan-authorise tetrahydrocan-

compounds in cannabis, such as cannabidiol (cbd), but refuse to

authorise tetrahydrocan-

compounds in cannabis, compounds in cannabis, plan to legalise certain plan to legalise certain cannabis. some states plan to legalise certain

at the pharmacy and took to looking for cannabis on the black market. he’s tried making biscuits or steeping it in alcohol to making biscuits or steeping it in alcohol to make his own tincture, but the effects are making biscuits or steeping it in alcohol to make his own tincture, but the effects are make his own tincture, but the effects are

still a complicated process.”

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.”

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

today, the Foph authorises patients to

widely. the effect would be too strong at times and at others too light.”

cannabis found on the street varies too widely. the effect would be too strong at

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.”

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

today, the Foph authorises patients to obtain medical marijuana for a limited number of conditions. “the Foph has

two, including other conditions such as


cannabis found on the street varies too widely. the effect would be too strong at

number of conditions. “the Foph has been more flexible in the past year or

obtain medical marijuana for a limited number of conditions. “the Foph has number of conditions. “the Foph has been more flexible in the past year or number of conditions. “the Foph has



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 the dosage,” he says. “the thc content in cannabis found on the street varies too

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

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 widely. the effect would be too strong at

today, the Foph authorises patients to obtain medical marijuana for a limited today, the Foph authorises patients to

two, including other conditions such as epilepsy,” says barbara boers. “but it’s still a complicated process.”

two, including other conditions such as epilepsy,” says barbara boers. “but it’s epilepsy,” says barbara boers. “but it’s two, including other conditions such as epilepsy,” says barbara boers. “but it’s two, including other conditions such as

number of conditions. “the Foph has been more flexible in the past year or two, including other conditions such as

number of conditions. “the Foph has been more flexible in the past year or two, including other conditions such as

obtain medical marijuana for a limited number of conditions. “the Foph has been more flexible in the past year or


today, the Foph authorises patients to

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

the saint gallen national council member margrit Kessler moved a motion in december 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

the saint gallen national council

moved a motion in december 2014 for the Federal council 2014 for the Federal council to “examine, in a scientific pilot study... when cannabis can be used in its natural

moved a motion in december 2014 for the Federal council moved a motion in december 2014 for the Federal council

pilot study... when cannabis can be used in its natural can be used in its natural state for medical purposes as state for medical purposes as


the saint gallen national council


the saint gallen national council the saint gallen national council

epilepsy,” says barbara boers. “but it’s still a complicated process.”epilepsy,” says barbara boers. “but it’s still a complicated process.”

two, including other conditions such as epilepsy,” says barbara boers. “but it’s two, including other conditions such as two, including other conditions such as been more flexible in the past year or two, including other conditions such as two, including other conditions such as been more flexible in the past year or two, including other conditions such as two, including other conditions such as two, including other conditions such as

cannabis.” “medical cannabis

ration process is currently too

cannabis.” “medical cannabis is too expensive, and the prepa-ration process is currently too ration process is currently too is too expensive, and the prepa-ration process is currently too

cannabis.” “medical cannabis is too expensive, and the prepa-ration process is currently too is too expensive, and the prepa-ration process is currently too ration process is currently too complicated,” margrit Kessler ration process is currently too

state for medical purposes as state for medical purposes as

is too expensive, and the prepa-


including colorado, washington, oregon,


including colorado, including colorado, washington, oregon, alaska and the district of columbia, have le-

ous. but several states, including colorado,

galised marijuana in re-of columbia, have le-

galised marijuana in re-

including colorado, washington, oregon, alaska and the district of columbia, have le-

galised marijuana in re-cent years. twenty-one galised marijuana in re-cent years. twenty-one have legalised medical

galised marijuana in re-cent years. twenty-one have legalised medical

IN PROGRESS

state for medical purposes as state for medical purposes as state for medical purposes as at the federal level,

cannabis is considered at the federal level,




at the federal level,

including colorado, washington, oregon,

ous. but several states,

cannabis is considered illegal and danger-

ous. but several states, illegal and danger-

ous. but several states, ous. but several states, including colorado,

washington, oregon, alaska and the district of columbia, have le-

cannabis is considered illegal and danger-


the saint gallen national council the saint gallen national council the saint gallen national council the saint gallen national council

STATESUNITEDUNITED STATESSTATESUNITED STATESD STATESSTATESSTATESSTATESUNITED STATESA WORK

IN PROGRESS

STATESSTATESA WORK

IN PROGRESS

STATESA WORK

IN PROGRESS


illegal and danger-cannabis is considered cannabis is considered

illegal and danger-cannabis is considered

illegal and danger-

two, including other conditions such as epilepsy,” says barbara boers. “but it’s two, including other conditions such as two, including other conditions such as two, including other conditions such as epilepsy,” says barbara boers. “but it’s two, including other conditions such as epilepsy,” says barbara boers. “but it’s two, including other conditions such as two, including other conditions such as two, including other conditions such as

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45

MENs sANA dEcOdINg

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 number of organisations and countries are financing and authorising medical cannabis. “several studies have shown the potential of cannabis in relieving symptoms of serious illnesses, such as crohn’s disease and cancer,” says barbara broers.

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 broaden-ing access to these products remains a heated debate. “even

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.”

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 süsstrunk. “i can live again,” he says, relieved. “i just have a small knot remaining in my right leg.” to treat that, his doctor has recommended taking a few extra drops of tincture of cannabis. he’ll feel better. ⁄

sativex, a spray made with natural cannabis. but broaden-ing access to these products remains a heated debate. “even remains a heated debate. “even

sativex, a spray made with natural cannabis. but broaden-ing access to these products remains a heated debate. “even

sativex, a spray made with natural cannabis. but broaden-ing access to these products remains a heated debate. “even

life has been

to treat that, his doctor has recommended

cannabis. he’ll feel better. ⁄

taking a few extra drops of

recommended taking a few extra drops of tincture of cannabis. he’ll

knot remaining in my right leg.” to treat that, his

hitting the market, such as sativex, a spray made with natural cannabis. but broaden-ing access to these products remains a heated debate. “even

hitting the market, such as sativex, a spray made with natural cannabis. but broaden-ing access to these products remains a heated debate. “even

knot remaining in my right leg.” to treat that, his doctor has recommended

in my right leg.” to treat that, his doctor has

new products are gradually

natural cannabis. but broaden-natural cannabis. but broaden-ing access to these products remains a heated debate. “even

recommended taking a few extra drops of tincture of cannabis. he’ll

doctor has recommended taking a few extra drops of tincture of cannabis. he’ll

natural cannabis. but broaden-

remains a heated debate. “even remains a heated debate. “even

tincture of cannabis. he’ll cannabis. he’ll feel better. ⁄cannabis. he’ll feel better. ⁄cannabis. he’ll feel better. ⁄cannabis. he’ll feel better. ⁄feel better. ⁄remains a heated debate. “even cannabis. he’ll feel better. ⁄remains a heated debate. “even cannabis. he’ll feel better. ⁄

hitting the market, such as new products are gradually hitting the market, such as new products are gradually hitting the market, such as sativex, a spray made with hitting the market, such as sativex, a spray made with sativex, a spray made with hitting the market, such as sativex, a spray made with hitting the market, such as sativex, a spray made with hitting the market, such as sativex, a spray made with natural cannabis. but broaden-

new products are gradually hitting the market, such as sativex, a spray made with

new products are gradually hitting the market, such as new products are gradually hitting the market, such as

besson. “Few companies or medical institutions have studied marijuana because of the

of cannabis. “i argued based on article 71b of the order of health insurance, which

marijuana because of the stigma attached to it.” but

law in 2011 offered fresh hope. new products are gradually law in 2011 offered fresh hope. new products are gradually

stigma attached to it.” but things are changing. a growing number of organisations and countries are financing and

the amendment to the swiss law in 2011 offered fresh hope.

institutions have studied marijuana because of the stigma attached to it.” but marijuana because of the stigma attached to it.” but things are changing. a growing

law in 2011 offered fresh hope. new products are gradually law in 2011 offered fresh hope. new products are gradually law in 2011 offered fresh hope. new products are gradually law in 2011 offered fresh hope. new products are gradually law in 2011 offered fresh hope.

things are changing. a growing number of organisations and countries are financing and authorising medical cannabis.

the amendment to the swiss law in 2011 offered fresh hope. the amendment to the swiss law in 2011 offered fresh hope.

countries are financing and authorising medical cannabis. “several studies have shown the potential of cannabis in relieving symptoms of serious illnesses, such as crohn’s relieving symptoms of serious illnesses, such as crohn’s disease and cancer,” says

the amendment to the swiss law in 2011 offered fresh hope. the amendment to the swiss law in 2011 offered fresh hope.

disease and cancer,” says disease and cancer,” says


research needs to catch up,” says Jacques besson. “Few companies or medical

marijuana because of the stigma attached to it.” but things are changing. a growing stigma attached to it.” but things are changing. a growing things are changing. a growing number of organisations and countries are financing and authorising medical cannabis. “several studies have shown the potential of cannabis in relieving symptoms of serious illnesses, such as crohn’s disease and cancer,” says barbara broers.

the amendment to the swiss the amendment to the swiss law in 2011 offered fresh hope.

authorising medical cannabis. “several studies have shown the potential of cannabis in relieving symptoms of serious illnesses, such as crohn’s illnesses, such as crohn’s disease and cancer,” says disease and cancer,” says

sativex, a spray made with natural cannabis. but broaden-

hitting the market, such as hitting the market, such as hitting the market, such as hitting the market, such as new products are gradually hitting the market, such as new products are gradually hitting the market, such as new products are gradually law in 2011 offered fresh hope. new products are gradually law in 2011 offered fresh hope. new products are gradually new products are gradually hitting the market, such as new products are gradually hitting the market, such as new products are gradually hitting the market, such as new products are gradually hitting the market, such as new products are gradually new products are gradually new products are gradually

things are changing. a growing number of organisations and

barbara broers.

the amendment to the swiss law in 2011 offered fresh hope. new products are gradually

things are changing. a growing number of organisations and countries are financing and authorising medical cannabis. “several studies have shown the potential of cannabis in relieving symptoms of serious illnesses, such as crohn’s disease and cancer,” says barbara broers.

illnesses, such as crohn’s disease and cancer,” says barbara broers.

the amendment to the swiss law in 2011 offered fresh hope. new products are gradually

things are changing. a growing number of organisations and countries are financing and authorising medical cannabis. “several studies have shown the potential of cannabis in relieving symptoms of serious illnesses, such as crohn’s disease and cancer,” says barbara broers. barbara broers.


GERMANYMORE RELAXED

germany legalised medicinal cannabis in 2008. three medica-

tions are authorised in the country: nabiximols (sativex®), dronabinol

(marinol®) and nabilone (cesamet®). only

sativex is reimbursed for patients with multiple sclerosis. buying can-nabis 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 (bundeso-piumstelle), which has been granted to about

200 patients.

FRANCESTRICT LAWS

France issued its first decree authorising the

medical use of cannabis and cannabinoids in 2013. patients can be granted temporary use authorisation to

obtain the substance, but only a limited

number of medications are authorised. sativex spray was not released

on the market until 2015. the French national

agency for medicines and health products

safety has only granted about 100 authorisations

since 2001.

sativex is reimbursed for patients with multiple patients with multiple patients with multiple patients with multiple sclerosis. buying can-sclerosis. buying can-sclerosis. buying can-sclerosis. buying can-nabis seedlings in a nabis seedlings in a nabis seedlings in a

pharmacy and growing pharmacy and growing the plants at home, the plants at home, the plants at home, the plants at home,

which is less expensive, which is less expensive, which is less expensive, has been legal since has been legal since has been legal since has been legal since has been legal since 2012. this requires

special authorisation from the Federal office of narcotics (bundeso-of narcotics (bundeso-piumstelle), which has piumstelle), which has been granted to about

200 patients.

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 süsstrunk. “i can live again,” he says, relieved. “i just have a small knot remaining

life has been wonderful for philippe süsstrunk. “i can live again,” he says, relieved. “i

philippe süsstrunk. “i can live again,” he says, relieved. “i says, relieved. “i just have a small knot remaining

says, relieved. “i just have a small knot remaining

says, relieved. “i just have a small knot remaining in my right leg.”

stipulates that a product can be reimbursed if no other medication on the market has

of the order of health insurance, which stipulates that a product can be reimbursed stipulates that a product can be reimbursed if no other medication on the market has

of the order of health insurance, which marijuana because of the

of the order of health insurance, which stipulates that a product can be reimbursed

stigma attached to it.” but things are changing. a growing number of organisations and

stipulates that a product can be reimbursed if no other medication on the market has

countries are financing and authorising medical cannabis. FRANCEFRANCEFRANCE

STRICT LAWSSTRICT LAWSSTRICT LAWSSTRICT LAWSSTRICT LAWS

France issued its first France issued its first France issued its first France issued its first France issued its first decree authorising the decree authorising the decree authorising the

medical use of cannabis medical use of cannabis medical use of cannabis and cannabinoids in and cannabinoids in and cannabinoids in and cannabinoids in 2013. patients can be 2013. patients can be 2013. patients can be 2013. patients can be 2013. patients can be granted temporary granted temporary granted temporary granted temporary use authorisation to use authorisation to use authorisation to use authorisation to use authorisation to

obtain the substance, obtain the substance, obtain the substance, but only a limited but only a limited

45

200 patients.

berlinaugust 2014

parismay 2015

46

MENs sANA INsIgHt

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.

before being enlightened, researchers must first possess an in-depth understanding of their field to come up with an original question based on a hypothesis. “researchers’ work starts with a critical analysis of as many exist-ing sources of information as possible. and this affects the very outcome of their study. they must be certain that no one before them

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.”

once that is done, researchers still haven’t received financing for the study. and if their intui-tion is as novel as it is promis-

ing, the process is far from over! “the next step is what we call ‘research design’,” says vin-cent mooser. “this means determining research methods, the number of vol-

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 ap-proved by an ethics committee before the data collection phase can be launched.”

A nd therein is pre-cisely 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 (ei-ther purchased or rented), work space, services (from testing to data processing), staff salaries, fees charged for submitting the project to various commis-sions 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.”

BAsic Vs. clinicAlbiomedical research cov-ers all work conducted to develop our knowledge of living organisms, but clinical research specifically refers to studies involving humans. swiss legislation (human research act) governing this area of study went into effect on 1 January 2014. clinical research can be observa-tional (limited to examin-ing volunteers, as with the colaus study in switzerland) or experimental (to test a product, behaviour or device, as with the study on the vac-cine for the ebola virus).

my (rough) liFe as a researcherbehind 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

47

But the lack of finan-cial 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 success-fully through all phases, from concept development and

methodology, until the study is complete. “it’s a life that requires endurance and many qualities other than pure scientific expertise,” says vincent mooser. “but the findings make it all worth it, when researchers push the frontiers of knowledge and open new fields of investigation.”

and the final step, i.e., publishing

research findings in a scientific journal, is no small feat. the paper can go back and forth – between the writing, re-

reading and other corrections – over several months before it is finally made public. For this step, proper referencing is vital, as it puts the work into perspective and measures its value. then there’s the “impact factor”,

MENs sANA INsIgHt

FUndinggovernment grants are more selective and there-fore more prestigious, but amounts are often limited. Funds from philanthropic foundations pour in more quickly than from public sources, but amounts are unpredict-able. industry contributes higher amounts, but spon-sors are concerned with scientifi c issues relating to their business. there is a risk of researchers being infl uenced 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.

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

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FRAncine BehAR-cohen

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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 evalu-ated by an independent com-mittee to uphold standards of quality. over the past few years, a number of issues have come up regarding lags and negli-gence. the magazine Technolo-gist 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 it take a researcher to get there? “it de-pends on the study,” says vincent mooser. “if your work uses an existing database, it might take a maxi-mum 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 commer-cialisation. and there begins a whole new marathon. ⁄

48

MENs sANA INsIgHt

gyRo geARloosethis disney duck character symbo-lises the stereo-typical eccentric inventor.

“the RUles oF the gAme ARe UncleAR”

Francine behar-cohen* encourages research-ers 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 transparen-cy 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, offer-ing 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 substanc-es 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

49


The hospiTal improves The healTh of iTs signage

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 activ-ist, aiming to make our society more understandable. that is es-sential for a democracy to func-tion properly and for people to feel comfortable. the intelligibil-ity that needs to be developed is not just about visuals or graphic design. it’s mainly about under-standing systems and space.

in a complicated world, our first reflex is often to suggest bigger, brighter signs with more impos-ing typefaces. then there is the widespread culture of “branding”. every structure has its own logo.

rioritising information, directing visitors clearly and simply and preventing additional stress. these are the challenges of creating suc-cessful 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 par-ticipated in the construction of a new hospital in marne-la-vallée, just east of the capital.

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

to learn more about it, In Vivo met with ruedi baur, the master of modern signage, on his way back from tehran and pass-ing 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.

iv WhAt do yoU thinK is sUccessFUl signAge?rUedi baUr We live in a world of increasing complexity. infra-structure is more and more vast, and the movement towards

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 christenp

50


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 rela-tionship. and it obviously doesn’t work well. With a research team, we are currently analysing infor-mation related to the university of strasbourg. as in many other situations, we have noted that each activity is viewed in rela-tion to others. at best, we can understand the institutions but not the subject developed. then there’s the culture of acronyms, which makes everything unap-proachable for non-specialists. We found thousands of acronyms used at the university! i remem-ber the fi rst thing i noticed when i fi rst visited lausanne univer-

sity hospital, “it’s not that there aren’t enough signs, the problem is that there are too many.”

iv to mAKe somethingUndeRstAndABle, mUst We Be ABle to simPliFy it?rb the solution of standardis-ing everything is not the right way either. people get lost when everything looks the same. the telephone book is defi nitely practical, but it’s not where you’d want to move about. We have to fi nd a third way. We need to work on the atmosphere in diff erent 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 comfort-able. i think that we don’t just

fi nd our way around by using data but also through atmos-phere, lighting, materials and colours. We fi nd our way by us-ing things that make sense to us, like in a city. in a city, we spot the cathedral and fi gure out where we are in relation to that. it’s obviously harder to do that on an obstructed hospital fl oor, 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.

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

1

phil

ippe

gét

az, i

ntég

ral

rued

i bau

r

51


the designer developed the wayfind-ing system for the new airport in vienna.

2 iv so signAge cAn contRiBUte to RedUcing stRess?rb that’s the whole issue of spatial intelligibility. if you have to read everything and every-thing looks the same, it’s a huge eff ort 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 ar-rows for people to fi nd 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 refl ected in the colour of stones, the shape of the roof, entrances determined by the cardinal points, etc.

iv WhAt ARe yoUR otheRPRojects?rb one of my passions is rein-troducing 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 explor-ing a project in mons – the eu-ropean 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. ⁄

ruedi baur has devel-oped a visual identity for the entire building complex at the university hospital of bern.

3

people get lost when everything looks the same

– rUeDi BaUr

biographyruedi 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.

MENs sANA cOMMENtARy

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-com-

municable) diseases. it has an intuitive appeal with its focus on development over time and generations unfolding under dif-

ferent 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 fi x”.

time and again, it has been shown that the

more social, physical, economic and psycho-logical disadvantage a child is exposed to, the

more they are behind at kindergarten and

school – a two year diff erence in verbal ability measured at three, fi ve 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 diff erence has grown to fi ve 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 fi ndings from life-course 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 improve public health. the older person’s free bus pass in england was introduced in response to a need to reduce social exclusion and in so doing has improved the health of our aging population, partly through increased incidental physical activity.

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 aff ect our bodies and hence our health status many years later will add to the evidence base for policy. ⁄

PRoFileamanda 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.

to KnoW moRewww.ucl.ac.uk/icls

52

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?

dr

53

text:antoine menusier

DR IODINE AND MR SALT

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

corpore sano

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).

54

cORpORE sANO tRENds

h200 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 depart-ment 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.”

these are worrying figures because iodine deficiency can cause develop-mental delays and intellectual disabili-ties (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?

ealth is a major issue in the apocalyp-tic film “world war z”. in the film, brad pitt’s character sets out to save human-ity, which is in danger of extinction due to a fearsome virus. he pieces together an insane but spectacular plot to kill the deadly virus with another pathogen that is slightly less lethal for humans. and his plan works. here, the situation is in absolutely no way comparable, except that the concept, in its boldness, is the same. a vector potentially harmful to human health if ingested in large amounts, i.e. salt, is used to supply the body with iodine, an element essential to its develop-ment and thyroid hormone synthesis.

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

An Age-old PRoBlem iodine is found in high concentra-tions in seawater. switzerland’s soil, far from any coastline, contains little iodine, and the swiss people have historically shown symp-toms of iodine deficiency. the swiss federal authorities intro-duced 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 congeni-tal cretinism, a form of dwarfism associated with mental retarda-tion triggered by a deficiency of thyroid hor-mones,” says murielle bochud from the iumsp. the expression “cretin of the alps” originally referred to inhabitants of the swiss, French and italian alps. the disease was particularly prevalent there, as inhabitants lived far from the coast. individuals with goiter could also be found in the region. this condition causes an enlargement of the thyroid gland, which is often caused by iodine deficiency.

the populationshould be encouraged to consume iodine without increasing their salt intake.

cORpORE sANO tRENds

55

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 organiza-tion (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.

iodine is an essential trace element found in its natural state in seafood and dairy products. however, excessive salt intake increases the risk of devel-oping cardiovascular diseases. the population, especially women of child-bearing 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 vaud-based 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

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

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

Dairy productsmilk 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 prod-ucts containing iodine to prevent the development of bacteria in the treatment chain.

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

the populationshould be encouraged to consume iodine without increasing their salt intake.

murielle Bochud, from the university

institute of social and preventive medicine,

says that the daily iodine requirement

for an adult is 150 micrograms.

gil

les

web

er

la saline de bex, “which involves spraying the salt crystals with a potas-sium 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”. ⁄

56

hat if we could find remedies directly in animals and apply them to humans? the con-cept 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 inject-ed, the patient survived, and his health even improved. sat-isfied with this initial success, the physician Jean-baptiste denis attempted the experi-ment two more times, but with

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 sur-geon 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 com-pounds 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

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 unex-plored 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 pro-gramme and director, save our species initiative at the interna-tional 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.

AnimAls coUld Be the FUtURe oF hUmAn heAlth

W

text: martine brocard

cORpORE sANO pROspEctINg

scientists are Fascinated with Finding compounds in animals to make humans healthier.

57


the holy gRAil oF PhARmAsthe horseshoe crab, a sea arthropod

mainly found on the east coast of north america, contains a coagulating agent

called amoebocyte lysate. pharmaceuti-cal 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%.

and

rew

tin

gle


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 ani-mals, like pigs, are undergoing extensive research and have already yielded some encouraging results.

1A seA WoRm

With sUPeRhUmAn hAemogloBin

the “arenicola marina”, or lugworm, lives on beaches stretching from the north sea to biarritz, France. this inver-tebrate may hold the secret to the universal blood type. in the early 2000s, the French biolo-gist 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 circu-lates freely in its veins. this means blood type compatibility becomes a non-issue. the mol-ecule 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

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 pre-served goes from 4 to 8 hours and a kidney from 12 to 48 hours. clinical trials are sched-uled to begin this year. lastly, the lugworm’s haemoglobin could also help wound heal-ing 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 phy-sician and head of the research unit in paediatric haematology-oncology at lausanne univer-sity 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.

2Pig cell

tRAnsPlAnts to tReAt diABetes

these transplants could soon provide a lasting solution

for 40% of sufferers of type 1 diabetes for whom daily injections of insulin are not ad-equate 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 trans-plantation 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 work-ing 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 environ-ment. “sacrificing young pigs for medical reasons raises a number of ethical issues, but no more than a pig that will be eaten,” the specialist

58

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

3A 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 pre-sent in humans, but we don’t yet understand exactly how it interacts with the protection of synapses,” the scientist says.

tests on mice induced into hibernation showed that healthy mice began secreting rbm3 and recovered their neural connections when they emerged. however, mice with brain disorders did not secrete the pro-tein. researchers administered rbm3 to them, which prevent-ed neurodegeneration.

clinical tests are expected to take place in 2016. research-

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

4Anti-cAnceR dRUgs FRom

shARKssqualamine, 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 degenera-tion. that is what interests researchers and the pharma-ceutical industry so much. clinical studies on lung cancer patients are underway and the

us group ohr pharmaceuticals is conducting clinical research on develop-ing squalamine eye drops.

but that’s not all. “the dogfish shark is surpris-ingly immune to viral infec-tions,” says michael zasloff, who attributes that to squala-mine. the broad spectrum of anti-viral properties of the

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

59


WhAt the lAW sAys

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 authorisa-tions. 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 manufac-tured using animal organs, tissues or cells are standard-ised, 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 geneti-cally modified species, the animal protection act and the environmental protec-tion act apply.

to ReAd moRe

on the trail of koalas to cure aidsa new antibiotic in horse manurewww.invivomagazine.com

60

“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 tod-dlers 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 genet-ics now prove that autistic children are born with a number of genetic abnor-malities. their brain functions differ-ently from that of other babies, which is especially prevalent in social interactions. these children then slip into a vicious cir-cle. during the first two years of life, most children acquire skills through

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 meth-ods to deal with autism disorders have been developed in the united states. they aim specifically to stimulate babies’ brains early, focusing on social interaction and language. if autistic children develop in these areas, they can make headway in other skills. the oldest and most widely known therapy is applied behavior analysis (aba). created by the norwegian psycholo-gist ivar lovaas in 1987, this technique analyses the child’s behaviour and aims to increase or decrease the frequency of a given behaviour through repetition and reinforcement.

text:geneviÈve ruiz

AUTISM IN A NEW LIGhT

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.

cORpORE sANO dEcOdINg

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.

about a hundred about a hundred genes are involvedgenes are involvedgenes are involvedgenes are involvedgenes are involvedmore than a hundred genes are more than a hundred genes are more than a hundred genes are more than a hundred genes are more than a hundred genes are more than a hundred genes are more than a hundred genes are believed to be involved in asd. believed to be involved in asd. believed to be involved in asd. believed to be involved in asd. believed to be involved in asd. the disease is four times more the disease is four times more the disease is four times more the disease is four times more the disease is four times more prevalent in boys than girls. children prevalent in boys than girls. children prevalent in boys than girls. children prevalent in boys than girls. children with an autistic sibling are ten times with an autistic sibling are ten times with an autistic sibling are ten times with an autistic sibling are ten times more likely to develop autism, and more likely to develop autism, and more likely to develop autism, and more likely to develop autism, and twice as likely if they have a cousin twice as likely if they have a cousin twice as likely if they have a cousin twice as likely if they have a cousin with the disorder. some cases of with the disorder. some cases of with the disorder. some cases of autism come from breaks in the dna autism come from breaks in the dna autism come from breaks in the dna sequence, which may be related to sequence, which may be related to sequence, which may be related to sequence, which may be related to sequence, which may be related to sequence, which may be related to in vitro fertilisation or the parents’ in vitro fertilisation or the parents’ in vitro fertilisation or the parents’ age. the chances of having an age. the chances of having an age. the chances of having an age. the chances of having an age. the chances of having an age. the chances of having an autistic child are four times higher autistic child are four times higher autistic child are four times higher for a 40-year old couple than for a for a 40-year old couple than for a for a 40-year old couple than for a for a 40-year old couple than for a 25-year old couple.25-year old couple.

ThE CAUSES OF AUTISM


Xxxxxxx

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 exam-ple through detailed visuals to reinforce verbal language and help them learn to communicate. this method was devel-

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

Recognising the eARly signs

Parents are often the fi rst 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 disordersLack of smile, indiff erence to oth-ers, indiff erence or overreaction to noise, indiff erence when their name is called, failure to hold out their arms to be carried, refusal to be held, solitary activities.

verbal and non-verbal communication disordersLack of language or language delays, diffi culty in imitat-ing certain move-ments (pointing, clapping, waving), lack of response to communication attempts from oth-ers, lack of appro-priate intonation, diffi culty in using personal pronouns correctly (“you” instead of “I”).

repetitive andstereotypedbehaviourPatterned han-dling of objects (spinning or arranging them), unusual body movements (rocking, hand fl apping), gazing at objects or lights for long periods, resistance to (even insignifi cant) change.

bsip

/ n

ewsc

om

62


focuses more on stimulating the toddler’s social motivation. when children’s desire to make contact with others grows, they become more independent and commu-nicate more easily.

since 2010, the centre for early inter-vention 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 school-ing.” this success rate is impressive, but requires costly resources. each child ben-efits from individual care from a psycholo-gist for fifteen hours a week. the parents

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 meth-od 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.

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 govern-ment 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 differ-ent 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

autoimmune diseaseautoimmune diseaseautoimmune diseaseautoimmune diseaseten percent of autism cases are ten percent of autism cases are ten percent of autism cases are ten percent of autism cases are an autoimmune disease. ample an autoimmune disease. ample an autoimmune disease. ample an autoimmune disease. ample research, including one study research, including one study research, including one study research, including one study conducted in 2013 by a team at conducted in 2013 by a team at conducted in 2013 by a team at conducted in 2013 by a team at arkansas children’s hospital in arkansas children’s hospital in arkansas children’s hospital in arkansas children’s hospital in the united states, has reported a the united states, has reported a the united states, has reported a the united states, has reported a high incidence of cerebral folate high incidence of cerebral folate high incidence of cerebral folate high incidence of cerebral folate receptor autoantibodies in autistic receptor autoantibodies in autistic receptor autoantibodies in autistic receptor autoantibodies in autistic children. and folate deficiency is children. and folate deficiency is associated with autistic symptoms. associated with autistic symptoms. Following this discovery, researchers Following this discovery, researchers administered high doses of folinic administered high doses of folinic acid (vitamin b9) to autistic children. acid (vitamin b9) to autistic children. the findings were spectacular. the the findings were spectacular. the children’s verbal communication, at-children’s verbal communication, at-tention and characteristic behaviour tention and characteristic behaviour all improved, with low adverse side all improved, with low adverse side effects. but for the time being, no effects. but for the time being, no one yet understands the long-term one yet understands the long-term consequences of administering such consequences of administering such high doses of vitamin b9.high doses of vitamin b9.

increased risks increased risks during pregnancyduring pregnancyduring pregnancyduring pregnancythe uterine environment the uterine environment plays a predominant role in plays a predominant role in plays a predominant role in the development of autism. the development of autism. the development of autism. taking antiepileptic medica-taking antiepileptic medica-taking antiepileptic medica-taking antiepileptic medica-tion around the 19tion around the 19tion around the 19tion around the 19thth week of pregnancy increases the risk, pregnancy increases the risk, pregnancy increases the risk, pregnancy increases the risk, pregnancy increases the risk, as do certain viruses affecting as do certain viruses affecting as do certain viruses affecting as do certain viruses affecting as do certain viruses affecting as do certain viruses affecting the mother, such as cytomeg-the mother, such as cytomeg-the mother, such as cytomeg-alovirus. it has been proven alovirus. it has been proven alovirus. it has been proven alovirus. it has been proven that if the mother lives within that if the mother lives within 300 metres of a field sprayed 300 metres of a field sprayed with industrial pesticides with industrial pesticides during the first three months during the first three months of pregnancy, the likelihood of pregnancy, the likelihood of her child developing of her child developing asd increases substantially. asd increases substantially. extremely premature babies extremely premature babies weighing less than 1.5 kg at birth are 20% more likely to suffer from autism than babies born at term.

63


iv you’re inaugurating the cantonal centre for Autism this autumn. What will the centre do?nc its main role will be to imple-ment a high-quality clinical struc-ture 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.

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 dis-seminate 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 show-ing signs of abnormal behaviour.

iv 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 independ-ence and socialisation. that

means they require less guidance and support as adults.

iv Will you focus on one educa-tional method in particular?nc we will use methods (aba, teacch or denver) whose ef-fectiveness 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 meth-ods are better suited to certain children than others.

iv Will psychoanalysis play a role at your centre?nc the causes of autism are genet-ic and affect how the brain func-tions. 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.

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 organisa-tion 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

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.” ⁄

“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.

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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 puri-fied the active ingredient re-sponsible for this therapeutic action, salicylic acid.

salicylic acid is effective in relieving pain, but upsets the stomach. in 1904, Felix hoffmann, a chemist work-ing at the pharmaceutical group bayer, developed a method of producing ace-tylsalicylic acid that causes significantly less irritation to the stomach and only releases salicylic acid once it is absorbed into the blood-stream. this advance led to the commercial develop-ment of a drug a few years later, patented as aspirin (its name was derived from acetylation and spiric acid). aspirin soon became a huge

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 effective-ness 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

confirmed the hypothesis. with its antiplatelet effect, aspirin prevented subse-quent 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 divi-sion at lausanne university hospital. “many other drugs have been administered at a dosage that was too high when they were first released, including the con-traceptive pill, antipsychotic medicines, diuretics and anti-cancer drugs. using high doses early on guarantees effectiveness for and against everything. it takes longer to figure out how to opti-mise 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? ⁄

Everyone knows Everyone knows what aspirin is. But what aspirin is. But

acetylsalicylic acid, its acetylsalicylic acid, its scientifi c name, has scientifi c name, has

sparked much debate. sparked much debate.

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cORpORE sANO IN tHE lENs

printed prostheticstext: erik Freudenreichimages: philippe gétaz

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a swiss orthopaedist uses 3d printing to design prosthetics that perfectly fit the patient’s body shape.

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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.”

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.”

3d printers/1

2/ 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.


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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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.

cORpORE sANO cOMMENtARy

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

between doctors who express their uncertainty and improvement in patient relations,

more information shared with the patient and better pain management.

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 ineff ec-tive in handling unknown challenges, managers must display “resistance” and “momentum”. the fi rst 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 char-acteristics to develop integrative leadership, mitigating any extreme reactions to prevent employees from feeling disbelief, frustration, guilt, despair or indiff erence. they do that by driving teams to understand the meaning of challenge, competitiveness, adventure and collaboration. We should stop protecting our-selves from uncertainty and instead embrace it as a component of management that can boost investment, commitment and loyalty.

transforming mistakes into progress, giving value to novelty rather than comfort, turning threats into opportunities... that’s the very crux 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. ⁄

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patrick genoudassociate director of patient care

managing with uncertainty

to KnoW moReread the entire commentary on www.invivomagazine.com

their clarity, when proven solutions

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cURsUs cOMMENtARy

atients frequently ask how they should choose their hospital. it is a legitimate question, but there is no simple answer. any ranking that suggests that you should choose

your hospital based on two or three quality indicators (e.g. infection rates, patient satisfaction or mortality rates) refl ects a simplistic approach to patient care.

Facilities should have an overall quality assessment including structure indicators, such as available equipment, certifi ed intensive care, staff expertise and continu-ous training. organisation methods that promote teamwork and the best care at the right time, such as in neurovascular units and breast centres, should also be 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

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

We must fi nd ways to help people form an objective opinion using indicators based on rigorously and statistically

proven methods. that’s not so easy. experts recommend publishing relevant fi gures that refl ect the quality of services. data must be precisely defi ned in order to be compared using consistent collection methods and then adjusted for risks that account for patient complexity. For example, consider the infection or mortality rate. leading hospitals that care for complex and seriously ill patients will naturally have a higher complication and mortality rate than a clinic that accepts elective patients for less complicated procedures, and that can transfer patients to a top hospital in the event of a problem. these diff erences must be taken into account when evaluating quality indicators.

Finally, indicators must be understand-able for patients, with clear explanations about their implications, limits and interpretation. ⁄

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

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anne-claude griesserassistant medical director at the chuv

eleonora 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, pharma-cology, 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 sys-temic venous side, oxygenated,

and then sent back to the aorta or another major artery. pulmo-nary 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 car-diac 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 follow-ing the transplant.

the reality of the job involves complex and delicate opera-tions. “implementing an extra-corporeal 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 partici-pates in humanitarian missions in countries such as mozam-

bique, cambodia and senegal to share her knowledge.

the discipline requires the utmost concentration and meticulous-ness, 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 proce-dures of stabilising the patient and re-equipping the machine.”

no one can replace a perfu-sionist. 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 short-age of perfusionists as the field is relatively unknown. Finding people with experience who are immediately operational is dif-ficult. 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. ⁄

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

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cURsUs cAREER At tHE cHUV

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

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

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aroom full of cameras, electrodes

and force sensors. on the computer screens are 3d images and a lengthy set of graph-ics. at first glance, the gait analysis labora-tory at the nestlé hospital resembles a film set. except here, the people are not actors, but patients, suffering from arthritis and here to have the way they walk analysed. the process exists elsewhere in the world, but lausanne university hospital (chuv) has developed an innovative approach.

“we not only analyse all aspects of knee move-ment, but also work to change the movement and understand how it affects cartilage and bones,” says Julien Favre, who set up swiss biomotion lab (sbml) with professor brigitte Jolles-haeberli at the chuv.

their novel approach to the joint disease views a healthy knee as a system whose components – movement, structure and biology – are in har-mony. 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 other components, and, if possible, to-gether.” this realisation drove him to join the biomotion lab headed by dr andriacchi, a professor of mechani-cal engineering and orthopaedic surgery,

one of the fathers of biomechanics, and a pioneer in the multiparametric analysis of arthritis at stan-ford university in california.

after more than five years of successful research in the united states, Julien Favre joined the chuv. in 2014, he participated in setting up sbml, the smaller branch and partner to the us laboratory.

sbml’s research also develops augmented reality techniques to offer patients personalised advice and change the way they walk. this aims to reduce pain and slow the development of the disease.

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 be-tween 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 one-third of people over age 65.

Julien Favre is joint director of swiss biomotion lab. professor thomas andriacchi, working from california, supports this state-of-the-art laboratory. text: camille andres, photos: philippe gétaz

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FoR moRe inFoRmAtionwww.chuv.ch/sbmlFoR moRe inFoRmAtionwww.chuv.ch/sbml

cURsUs NEws

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New auditoriums

state council mem-bers anne-catherine

lyon and pascal broulis laid the fi rst stone at the construction site for two new auditoriums that will be located in the base-ment 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

edUcAtion edUcAtion

Advance in schizophrenia research

switzerland’s largest univer-

sity hospitals and the faculties of medicine from swiss universities have set up the swiss associa-tion for university medicine to strengthen their drive to work together. “it is essential for representatives from university medicine to bring their knowl-edge and expertise and to take part in the discussions about society,” says the organisation’s president rita Ziegler, director of Zurich university hospital. BT

Hospitals join forcescollABoRAtion collABoRAtion

The disease could be related to a

disturbance during the critical periods in brain development.

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.

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

ReseARch ReseARch input) permanently aff ects the neural connections. these windows occur at diff erent 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

What is your professional background?i studied in lausanne. after two years as an assistant in internal medicine, i received train-ing 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 inte-grating social sciences into medicine, in both teaching and clinical practice. and it turns out that mcgill university is one of the rare institu-tions with a department of social sciences within the Faculty of medicine.

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

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

migRAtion

michael saraga left for migRAtion

last name saraga

First name michael

with the chuv since 2001

title Associate physician

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Associate physician

in developing their professional identity by pro-viding 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 hospital-wide 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

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BAcKstAge

tandemthe 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)

covergraphic designer diana bogsch arranged several

hundred pills of various shapes and colours to feature on this issue’s magazine cover. on this issue’s magazine cover.

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cONtRIBUtORs

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GENEVIÈVE RUIZgeneviève 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).

ROBERT GLOYwith 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.

GILLES WEBERgilles 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.

DARCY ChRISTENcurrently 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.

PUBlisheRchuv, rue du bugnon 46

1011 lausanne, switzerland t. + 41 21 314 11 11, www.chuv.ch

[email protected]

chieF editoRsbéatrice schaad and pierre-François leyvraz

PRoject mAnAgeR And online editionbertrand tappy

thAnKs toFiona amitrano, alexandre armand, anne-marie barres,

Francine billote, valérie blanc, gilles bovay, virginie bovet, mirela caci, stéphane coendoz, muriel

cuendet teurbane, stéphanie dartevelle, diane de saab, Frédérique decaillet, muriel Faienza, marisa

Figueiredo, pierre Fournier, serge gallant, christine geldhof, nicole gerber, katarzyna gornik-verselle, déborah hauzaree, aline hiroz, pauline horquin, Joëlle isler, nathalie Jacquemont, nicolas Jayet, emilie Jendly, anne-renée leyvraz, cannelle

keller, elise méan, laurent meier, brigitte morel, thuy oettli, denis orsat, manuela

palma de Figueiredo, odile pelletier, Fabienne pini-schorderet, isabel prata,

sonia ratel, massimo sandri, dominique savoia diss, Jeanne-pascale simon,

christian sinobas, elena teneriello, laure treccani, céline vicario and the

chuv’s communications service.

distRiBUtion PARtneRbioalps

editoRiAl And gRAPhic PRodUctionlargenetwork, rue abraham-gevray 6

1201 geneva, switzerland t. + 41 22 919 19 19, www.largenetwork.com

PUBlicAtions mAnAgeRsgabriel sigrist and pierre grosjean

PRoject mAnAgeRmelinda marchese

gRAPhic design mAnAgeRsdiana bogsch and sandro bacco

editoRiAl stAFFlargenetwork (camille andres, alexandre babin, céline bilardo, martine brocard,

clément bürge, erik Freudenreich, mouna hussein, melinda marchese, antoine menusier, Jean-christophe piot, geneviève ruiz, gaëlle sinnassamy, emilie veillon, Julie zaugg),

darcy christen, bertrand tappy.

iconogRAPhic ReseARchsabrine elias ducret and david stettler

imAgescemcav (eric déroze, heidi diaz, philippe gétaz, gilles weber),

nelson reitz

lAyoUtdiana bogsch, romain guerini and Jennifer Freuler

tRAnslAtiontechnicis

PRinting pcl presses centrales sa

18,000 copies in French2,000 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.

IN VIVOmagazine published by the lausanne university hospital (chuv)

and the news agency largenetwork

www.invivomagazine.com

Follow us on: twitter: invivo_chuv

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COMPETENCE

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IN EXTENSO Genetics

The never-ending story

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In Vivo #6 EN

Documents

Transcript of In Vivo #6 EN