Think health
No. 5 – MARCH 2015
THE gut
YOUR OTHER BRAIN
FAECAL TRANSPLANTS / THE POWER OF BACTERIA / MEDICAL REVOLUTION BERNARD PéCOUL “Pharmas ignore the poor” MEDICAL TOURISM Mind the turbulence INVESTIGATION The dangers of taboo illnesses Published by the CHUV www.invivomagazine.com IN EXTENSO what looks reveal
TELL US WHAT YOU THINK
Go to www.invivomagazine.com and answer a few questions about “In Vivo” magazine. You could win a canvas bag or notepad featuring the “In Vivo” logo.
El Bibliomata / El mundo fisico, 1882
on www.invivomagazine.com
IN VIVO / Number 5 / march 2015
contents
FOCUS
19 / REsearch The gut, your other brain Intestinal bacteria reveal their powers by MELINDA MARCHESE
MENS SANA
28 / INTERVIEW Bernard Pécoul: “Pharmas are not interested in the poor” by SOPHIE GAITZSCH
32 / Decoding Billion-dollar pills by ERIK FREUDENREICH
35 / Trends Medical tourism: mind the turbulence by JULIE ZAUGG
40 / PROSPECTIng Running rampant in the city: psychosis by JEAN-CHRISTOPHE PIOT
42 / Decoding by CÉLINE BILARDO
45 / INsight The poison of false hope by bertrand tappy
“Clostridium difficile” (here in a micrograph) is a bacterium present in the colon of many individuals. (see p. 19).
JENNIFER HULSEY/CDC/SCIENCE PHOTO LIBRARY
Toxic substances: the indoor threat
CONTENTS
64
26 21
52
CORPORE SANO
IN SITU
49 / PROSPECTing
08 / Health Valley
Hyperactive and clumsy: the same battle BY MARTINE BROCARD
Bringing together academics and the pharmaceutical industry
52 / TABOo
15 / Around the world
Doctor, I’m sick and I’m ashamed
Lamas against Aids
BY CLÉMENT BÜRGE
56 / INNOVATION The heart that goes tick tock by CLÉMENT BÜRGE
60 / Trends The gluten paradox by MARTINE BROCARD
64 /in the lens Back to the future by Melinda marchese
follow us on: twitter: invivo_chuv facebook: MAGAZINE.invivo
2
CURSUS
71 / Commentary Fighting for humanist medicine
72 / PORTRAIT Christèle Rutishauser, ergotherapist specialised in geriatrics
74 / TANDEM Researcher Anne-Sylvie Ramelet and clinical nurse Françoise Ninane
Wonge Bergmann, Heidi Diaz, Embarassing Bodies, JAVIER SORIANO/AFP
32
Editorial
Promises can be toxic
Patrick dutoit
Béatrice Schaad Chief editor
3
He’s on his bed, already partially paralysed. Simply putting on a jumper requires a formidable effort, and he needs help. His wife is usually graciously willing to assist, but that day their baby is screaming in another room and she’s left her husband to deal with it. The jumper is halfway on, his head not even through the neck. Stephen Hawking sat there for several minutes, a prisoner of his clothing. He searched for a glimmer of light through the holes in the knitting. Then the question that would take up his entire life dawned on him, in a split second. Is a black hole the origin of the universe? The history of research is full of wonderful anecdotes recounting how researchers have turned sometimes totally ordinary situations into intuition. These flashes of insight have always been the driving force of scientific advancement. However, what has changed is that scientists used to test their hypotheses secretly in their laboratory before reporting them publicly. Today, intuition and communication take place almost simultaneously. We announce what will come of research before even seeing the results. The chickens were counted long ago, but the eggs haven’t yet been laid. When the internet was still in its early stages back in 1994, didn’t Al Gore promise an unprecedented extension of human freedom? Admittedly, promises contain part utopia, part momentum. They express the end goal of creators, the people who want to change reality as it is. They inspire concrete economic and political choices. And all this is essential when it comes to persevering in the face of the harsh and sluggish world of research. But in medicine, promises can also be toxic. They are sometimes motivated by growing economic pressure to protect one’s ideas from the competition and can instil empty expectations and bitter disappointment in patients. This is what the authors of an upcoming book call “the poison of false hope” (see p. 45). Equally detrimental is early communication, all that noise upstream about what researchers hope to achieve. It fuels the idea that medicine is all-powerful and no disease can resist it. It wipes out any powerlessness or limitation. This communication pits patients – with their high expectations sustained by these promises – against healthcare professionals, who are utterly incapable of satisfying everyone. In short, promises institutionalise frustration and therefore conflict. ⁄
post-scriptum updates on previous “in vivo” articles You can subscribe to “in vivo” or request back issues on our website www.invivomagazine.com
CANCER
OOCYTES
IV n° 1
p. 17
Mice with a smart sense of smell
IV n° 1
GIVING BLOOD p. 56
Egg-freezing for female employees
STEM CELLS p. 64
Primitive eggs and sperm A discovery in the United Kingdom has once again demonstrated the vast potential of stem cells. Two researchers from the University of Cambridge have created primitive forms of sperm and eggs by culturing embryonic stem cells and are now set to test the same procedure using skin stem cells. If successful, egg or sperm cells that are genetically identical to the parents could be developed, offering hope for infertile individuals. /
4
The buzz everyone is talking about: US giants Facebook and Apple are offering to cover the costs of cryopreservation, i.e. freezing the eggs of their female employees, without them necessarily having to provide a medical reason. The social media company would pay up to $20,000 for the operation and storage. The procedure alone, without storage, is generally estimated at $12,000. /
p. 38
Could homosexuals become donors?
Heidi Diaz
Researchers from the University of Geneva (UNIGE) have discovered the technique used by mice to avoid other mice with an illness. The rodents can perceive the smell of the illness with their vomeronasal organ, present in many mammals but virtually inactive in humans. This breakthrough could lead to the development of artificial noses used to detect certain diseases such as cancer much earlier. /
IV n° 2
IV n° 2
Homosexual men may soon be allowed to donate their blood in the United States if they have not had sexual relations for one year. The US Food and Drug Administration (FDA) has been discussing the issue since December and will release a recommendation this year. The current lifetime ban on blood donations from homosexuals and bisexuals has been in force since 1983 in the United States and since 1977 in Switzerland, where the ban remains enforceable. /
Correction In our previous issue, a layout error occurred in the articles on epigenetics and psychiatric architecture, which removed an inset. You can view the full version on www.invivomagazine.com. We apologise. /
post-scriptum
PERCEPTION IV n° 3
p. 21
A book on synaesthesia
Johns Hopkins/YouTube
French-born synaesthete Vincent Mignerot, who featured in the third issue of In Vivo, has recently published Synaesthesia and conditional probability (Synesthésie et probabilité conditionnelle in French). The book explores the ties between synaesthesia – the ability to assimilate odours with words or colours with pain – and the calculations made by the human brain to anticipate how we should adapt over time. Synaesthesia could even explain the mechanism of intuition. /
AGEING IV n° 3
p. 54
Dog testing
NEUROPROSTHETICS
Two researchers from the University of Washington in Seattle plan to test rapamycin, an anti-ageing molecule, on dogs. The drug is used as an immunosuppressant in anti-rejection medicine. It has already been administered to mice, reportedly extending the lifespan of males nearly 9%. Findings from an experiment on dogs would be more comparable to humans. /
5
IV n° 2
p. 50
Major advances Research on neuroprosthetics – artificial limbs that quadriplegics and amputees can control by thought – is advancing swiftly. Johns Hopkins University in Baltimore made a landmark operation in December 2014. A man who had lost both arms was fitted with two bionic prosthetic limbs. The American amputee was able to control both robotic arms separately through nerve impulses. Meanwhile, researchers at the Swiss Federal Institute of Technology in Lausanne (EPFL) presented the e-Dura spinal implant, which is placed directly onto an injured spinal cord. Combining chemical and electrical stimulation, the device has already enabled paralysed rats to walk again. /
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. This background map was created by the graphic designer Romain Guerini and the illustrations by the Indonesian artist Lalita Prima.
in situ
Health Valley Panorama of the latest innovations.
LAUSANNE
p. 10
LAUSANNE
p. 11
The Jules Gonin Eye Hospital performed the first artificial retinal implant operation in Switzerland.
AUBONNE
p. 11
Merck Serono has opened a new centre for expertise that employs some 280 people.
lalita prima, Romain guerini
GENEVA
p. 09
The World Federation of Right to Die Societies is moving its headquarters to French-speaking Switzerland.
6
An interdisciplinary research centre specialised in food and nutrition was inaugurated at EPFL.
in situ
DELÉMONT
HEALTH VALLEY
p. 12
Mini-laboratories launched into outer space: Spacepharma is gearing for its staggering feat.
MARLY
p. 09
The start-up InnoMedica recently obtained certification authorising it to produce cytotoxic drugs.
7
in SITU
HEALTH VALLEY
Building an essential bridge Small and medium-sized companies bringing together academics and the pharmaceutical industry are emerging throughout French-speaking Switzerland. Their goal? To develop the early phases of research to the point where it captures the attention of healthcare giants.
REsearch New companies have cropped up in the life sciences sector in Frenchspeaking Switzerland. They go by Lascco, Geneva Biotech Center or Alpine Institute for Drug Discovery and they share the same ambition of bridging the gap between the universities in the region and pharmaceutical companies. Has that been the missing link so far? It has, according to Laurent Galibert, who founded the Lausanne-based Alpine Institute for Drug Discovery in 2013. “The sector giants tend to cut their investment in fundamental research,” says this immunologist who has already worked with several pharmaceutical companies. Working with the technological transfer offices at universities, these small companies manage and finance development from the molecule to the first clinical trials. In the event of a promising breakthrough, the major groups take over to cover industrialscale production. Inspired by Anglo-Saxon initiatives such as Medical Research Council Technology, a UK group that has brought 12 new drugs to market, “this new kind of ecosystem benefits everyone,” says Laurent Galibert. Even universities, which hold the rights to their molecules, can hope to see some financial returns. If a product based on their initial discoveries is developed for commercial use, they receive a percentage of the sales,” says the co-founder of Geneva-based Lascco, Samareh Azeredo da Silveira Lajaunia. By allowing companies like hers to cover these development phases, industrial groups reduce their spending while increasing their chances of identifying promising leads in diverse fields such as cancer research, immunotherapy and so on. In doing so, they meet the needs of both patients and healthcare providers. 8
Text Jean-Christophe Piot
Laurent Galibert founded Alpine Institute for Drug Discovery in 2013. The start-up operates out of the Innovation Park at EPFL.
An innovative economic model These new companies are engaged in an economic wager, given the time frame between the initial discoveries and a potential market launch, which can range from 4 to 15 years. Operating in the heart of the Innovation Park at the Swiss Federal Institute of Technology in Lausanne (EPFL), Alpine Institute for Drug Discovery was set up through its own funding with financial assistance from the Commission for Technology and Innovation (CTI) and the Foundation for Technological Innovation (FIT). The SME mainly focuses on cancer and auto-immune and inflammatory diseases. Inventive right down to their financing, these companies seek to maximise their chances of success. “We establish contact with our potential clients quite early in the process,” explains Samareh Azeredo da Silveira Lajaunia. “It’s a way of making sure that they are interested in our initial prospects.” With this strategy, Lascco has clinched several deals with various groups in the healthcare sector, including one with the US company Abbott in 2012. Is there room for everyone? “There are various areas of research and universities are making worthwhile discoveries in Switzerland and neighbouring countries,” says the young woman, who points out that she and her competitors cannot lead more than just a few projects at a time. Lascco is currently working on developing new antibiotics to counter the resistance of some bacteria. This leaves space for newcomers without sparking fierce competition. “The success of this model in the United States suggests that these intermediate echelons have a future.” ⁄
6.1 in situ
HEALTH VALLEY
Start-up IMMUNOTHERAPY
In billions of dollars, how much a US company spent to buy Covance, the largest pharmaceutical company in Geneva. The group employs 620 people in the canton.
DIABETEs
Moving from New York to Geneva
APP
Emoteo Emoteo was designed by the Department of Psychiatry and Mental Health at Geneva University Hospitals (HUG) to manage attacks remotely in patients with borderline personality disorder (BPD), especially during the evenings and weekends. The app helps assess the level of inner tension and regulate it with exercises, also offering valuable feedback on attacks for caregivers.
assisted suicide The World Federation of Right to Die Societies has decided to move its headquarters from New York to Geneva. In a press release, the Federation explained that Geneva is a good choice due to the tax-friendly conditions for NGOs and other public interest organisations. The group plans to move at some point in 2015.
“The food and pharmaceutical industries will now develop in a complementary manner” Stefan Catsicas head of research and development for the food multi-national Nestlé, said in “L’Hebdo” in December 2014 that nutrition, pharma and technology will come together more than ever before.
9
The Geneva-based company MaxiVax has developed an anti-cancer vaccine based on immunotherapy. The treatment first aims to stimulate the patient’s immune response by injecting his or her own diseased cells, which have been deactivated, to help the immune system identify and fight the body’s own cancer cells. An initial run of clinical trials is taking place at Geneva University Hospitals (HUG) until June.
The start-up Genkyotex is out to fight diabetic nephropathy. Founded in Geneva in 2006, the company has recently been awarded 20 million Swiss francs in a further round of financing. It will use the funds to continue its clinical research on this serious complication of diabetes, which most often causes renal failure.
ALLERGIEs
The young Vaud-based company Anergis raised 14.5 million Swiss francs in December to finance further research on its vaccine on birch pollen allergies. Anergis also led a successful clinical testing programme in the autumn of 2014, demonstrating the long-term efficacy of its treatment.
CANCER
The drug Talidox is used in chemotherapy to target only the patient’s cancerous cells. InnoMedica, a start-up from Bern with a production site in Marly (Fribourg), developed this innovative treatment, which can now be produced for commercial use. The company was recently awarded GMP certification by Swissmedic, authorising it to manufacture cytotoxic drugs for the next five years.
in SITU
HEALTH VALLEY
All eyes focussed
Smart contact lense
S
Operating out of Lausanne, Sensimed has recently won an award from Radio TĂŠlĂŠvision Suisse (RTS) for its smart contact lens, Triggerfish. The single-use system features a sensor that detects circumferential changes in the eye. This innovation will be used to better diagnose glaucoma, the second leading cause of blindness in the world, according to the World Health Organization (WHO).
N
ew drugs
Correcting mutations that cause incurable eye diseases, that is the goal of Innovation Therapeutics. The Lausanne-based start-up develops models of eye cells for ophthalmological drugs and cell therapy.
A rtificial retina
The first artificial retinal implant operation in Switzerland was performed at Jules Gonin Connected glasse S Eye Hospital in Lausanne last October. Developed The Lausanne-based start-up Composyt Light Labs by the US firm Second Sight, the Argus prosthesis was bought by the electronic chip giant Intel. The restores partial vision for blind or visually impaired spin-off of the Swiss Federal Institute of Technology in Lausanne (EPFL) developed a technology that can work individuals. The system comprises an implant placed with any eyewear and uses a holographic film coating for around the eye, glasses equipped with a miniature viewing projected images. The system can be integrated video camera and a tiny computer that processes into existing glasses, sending information directly to the the images and transforms them into signals that are retina without obstructing the rest of the field of vision. transmitted back to the implant.
Agenda Transplant technologies 28 May 2015, Lausanne In May, Lausanne University Hospital (CHUV) will host the 11th annual kidney transplant symposium. The one-day programme covers about 10 talks, which will focus this year on kidney transplants for children and the elderly. New technologies used in the area will also be presented. 12:00 to 5:30 pm, CĂŠsar-Roux Auditorium.
Natural medicines 26 to 29 March, Lausanne The 27th annual natural medicine, health and wellness exhibition, Mednat Expo, will take place at the Palais de Beaulieu in Lausanne. The four-day event includes a number of stands devoted to complementary therapies, organic farming and beauty products.
Big Data, Big Issues 11 June, Sierre BioArk is organising the third annual e-health day. This event focused on digital health will highlight international business models developed based on harvesting and processing big data, e.g. data generated by social media and smartphones.
www.mednatexpo.ch
www.theark.ch/e-health
All about the brain 16 to 20 March A multitude of workshops, conferences and laboratory visits will feature during international brain week. Geneva, Fribourg and Lausanne are among the Swiss cities hosting activities in this annual event to present the latest advances in neuroscience research and the new therapies developed from it. www.semaineducerveau.ch
www.chirurgieviscerale.ch
10
in situ
HEALTH VALLEY
3 questions for In millions of dollars, the amount setaside by Servier to finance the initial trials on a novel treatment used against multiple sclerosis, developed by GeNeuro, based in Plan-les-Ouates. This autoimmune disease affects nearly2.3 million people worldwide.
Francesco Stellacci
He heads the new Integrative Food and Nutrition Centre set up at the Swiss Federal Institute of Technology in Lausanne (EPFL) in October 2014.
1
What role does a food and nutrition centre have at EPFL?
Food and nutrition play a major role in society. By 2050, there will be 9 billion mouths to feed on the planet. Food will need to be produced more efficiently, with less waste. And we need to better understand the effects of nutrients on our metabolism. It’s the duty of a school like ours to take up these challenges.
2 new operations
New centre opened by Merck Serono
The German group Merck Serono opened the international headquarters for its industrial operations in Aubonne, Switzerland, in October 2014. The site will welcome 280 employees. Merck Serono also announced its plans to hire about 100 specialists in 2015 at its centre for biotechnology expertise to develop biosimilar drugs.
Siemens and CHUV at EPFL
The Innovation Park at the Swiss Federal Institute of Technology in Lausanne (EPFL) has welcomed two new residents since the beginning of the year: Siemens Healthcare and Lausanne University Hospital (CHUV) have inaugurated a research and development unit specialised in medical imaging. The team of about ten researchers will focus on improving the quality of images to diagnose more diseases by MRI. 11
How does the structure work?
It’s a virtual centre, as it doesn’t have its own building or laboratory. The idea is to set up a platform to drive research and provide a better interface between scientists and industrial groups or lenders. A call for projects will take place every year at all schools at EPFL.
3
What are the winning projects for 2015?
There are ten of them, including a vitamin lyophilisation project to extend their shelf life, another on the development of carbon nanotubes to create smart food packaging and a study on reducing the amount of arsenic absorbed by rice plants. These projects were selected based on their potential impact on society. We believe it’s time for scientists who have not yet thought about applying their expertise to food to start doing so. For example, cancer research centres have brought in mechanical engineers who have opened up unexpected fields of study. We hope to see the same kind of development here at EPFL. / Francesco Stellacci is a professor of Materials Science at EPFL. After finishing his doctorate at Politecnico di Milano (Polytechnic University of Milan), he taught at the Massachusetts Institute of Technology.
in SITU
HEALTH VALLEY
fifth stop
Delémont
on the road
SpacePharma
In every issue, “In Vivo” meets with the leaders of Health Valley. Delémont is the focus of this edition.
Laboratories in orbit: bringing outer space to researchers text: Rachel antille
An ultra-sophisticated laboratory that would fit into a shoe box, hurled hundreds of kilometres above the earth at a speed of more than 7,000 metres per second. That is the technological feat in the works at SpacePharma, a company founded in 2012 and based in Delémont, Switzerland. “The first launch into orbit of one of our satellites is scheduled for mid-2015,” says Martin Aebi, Managing Director. “All the laboratory components and the remote control and data transmission systems were developed by our engineers. The launch into orbit itself will be carried out in partnership with the company Swiss Space Systems, headquartered in Payerne.” About thirty launches are planned between now and 2020. An organism freed from the forces of gravitation quickly reacts in different ways. Microgravity provides researchers with insight that is particularly useful for studying fundamental growth and degeneration mechanisms in the body. “In addition to their application in regenerative medicine, 12
our satellite laboratories are also likely to interest microbiologists and pharmacologists. In a microgravity environment, bacterial virulence increases, so we can rapidly test antibiotics resistance. Experiments on fluids are also promising, as the blends obtained in conditions of weightlessness are extremely consistent.” Martin Aebi explains that SpacePharma’s main challenge today is to attract industry and research institutes. “What was once a luxury tool for researchers is becoming affordable and available worldwide. It’s both a promise and a gamble: using space as a resource to improve life on earth.” SpacePharma employs 14 people, most of whom are based at the research and development centre in Israel. Choosing Delémont as the company headquarters offered considerable advantages,” Martin Aebi says. “The region is a biotechnology hub, offers attractive infrastructure, is tax-friendly and features a cantonal economic development programme that supports innovative companies.” /
in SITU
HEALTH VALLEY
benoît dubuis Director of the Campus Biotech site and Chairman of BioAlps
We need to cultivate “positive impatience”: anticipating the future to always remain a step ahead in a fiercely competitive entrepreneurial world.
A rush of good news, both political and economic, was whispered sweetly into our ears at the end of 2014. Citizens expressed their refusal to compromise our country’s growth, the fantastic development of major research initiatives, record amounts of funding raised, significant or even “historical” strategic partnerships, as some headlines put it. “Historic!” The word is typically used to refer to a remarkable event, but I prefer to understand it as a push to do even better. It can too quickly turn into a cushion of comfortable laziness, holding less pleasant awakenings in store. Nothing should ever be taken for granted. Success is not only built by relying on one’s strengths but especially in response to intelligent, hard work. There is a triple present that is not punctual, an instant between the past and the future, an expanded present. These three types of time coexist: the Present of the Past is memory, the Present of the Present is action and the Present of the Future is anticipation. Aware of the Past, we are building the Present and anticipate the Future. We have become a civilisation of knowledge, and we have an exceptional asset in our region with the density of top schools that generate this knowledge. Pioneers and entrepreneurs must take over and play their role as modern-day revolutionaries.
A revolutionary is someone who sees the way things are done and says, “There’s a better way! I can change the situation and lead people to do it differently.” Entrepreneurs do the same. They see dissatisfied customers or products that don’t reach the public and sense an opportunity. These men and women who, sometimes during their own lifetime, were considered enlightened individuals, renegades or even traitors, built the prosperity of our country with the mindset of striving to do something that hadn’t been done before: discover, create, and explore uncharted territory. We must remember that each large company and each product that revolutionised its field had an entrepreneur behind it. The base of our economic system depends on these entrepreneurs who found in our region a land of opportunity. New technologies develop every day, providing as many opportunities to those who have the courage and tenacity to pursue their dream. The entrepreneur and the revolutionary are one and the same, but were born at different times, under different circumstances. So the Past is not a foreign country, and thanks to history, the Past exists in the Present. Being present in the Present of the Present means opening up to what is to come, to the revolution that could occur. It means being receptive to integrating what comes from elsewhere. Acceptance and creation go hand in hand. Being present in the Present even means giving in to the impatience of the times, which will always guarantee that we remain a step ahead in a fiercely competitive world, which forces us to anticipate rather than react and which places us in the Present of the Future. ⁄ for more information
DR
www.bioalps.org the platform for life sciences in Western Switzerland 13
in SITU
world
in situ
AROUND THE WORLD Because research knows no borders, In Vivo provides information on the latest medical innovations worldwide.
215'000’000 The number of people vaccinated against meningitis A in 15 countries located along the “African meningitis belt” since the Meningitis Vaccine Project was launched in 2010. The campaign is led by the World Health Organization (WHO) in partnership with the US-based NGO PATH and the Serum Institute of India. MenAfriVac, the vaccine developed in the programme, was authorised in January for children under one year of age.
CANCER
The molecule of hope EBC-46, a molecule contained in the seeds of an Australian plant, is believed to slow the growth of solid tumours in just a few hours. Discovered by the Australian pharmaceutical laboratory QBiotics, it is being developed to treat prostate, lung and breast cancer, various melanomas and neck tumours. Pre-clinical trials conducted by the Australian QIMR Berghofer Medical Research Institute showed that in more than 70% of cases, the cure was “long-term and enduring”. Clinical trials are expected to follow.
A smart pillbox innovation Seven out of ten patients have trouble remembering to take their medication, according the California-based company Tricella. The company has developed a smart pillbox that reminds people when to take their medication. The sleekly designed sorter connects with smartphones and tablets through an app using Bluetooth and NFC wireless technologies. It can even send alerts to loved ones. The small version is available for pre-order for $44.99. Deliveries are planned for the spring of 2015.
“2015 will be remembered as the year humanity used our best scientific minds to fight back” Marie-Paule Kieny assistant director general of the World Health Organization (WHO), at a press conference in Geneva last January to announce that clinical trials would be launched for two potential vaccines in affected regions in Africa.
14
world
DAVID
in situ
Llamas against AIDS researcH Llama antibodies could help fight HIV. An international team of researchers detected molecules in the South American camelid that can neutralise nearly 60 strains of the human immunodeficiency virus. The study was published in the journal “PLoS Pathogens” in December 2014. This research began in the 1990s in Belgium, according to the French newspaper “Le Monde”.
o viv picks in best The Future of Healthcare (Quelle santé pour demain?) Jacques Marceau (ed.), Alternatives-Gallimard, 2014
In the book published by the Digital Health collective, the 16 contributors note that unlike the medical institutions struggling to adapt to digital technology, patients are actually benefiting from advances – the development of information systems, connected medical devices and widespread use of mobile internet – and taking a proactive role in their own healthcare. The authors go beyond presenting their assessment to offer solutions to improve the use of digital technology in the sector.
The coming crisis in antibiotics
The Patient Will See You Now
The Future of the Brain
TED Talk by Ramanan Laxminarayan
Eric Topol, Basic Books, 2015
Gary Marcus and Jeremy Freeman (Ed.), Princeton University Press, 2014
Antibiotics – the moleAmerican cardiologist and cules that destroy bacteria geneticist Eric Topol was or hinder their growth a called the “rock star of nd have saved millions science” by GQ Magazine of lives since the 1940s and is considered one of – will become ineffective today’s most influential due to their continued physicians. He has recently improper use to treat come out with another future harmless conditions and best seller. In his latest book, even in livestock farming. he studies what he calls Bacteria are becoming inmedicine’s “Gutenberg mocreasingly resistant, warns ment”. As the printing press the Indian economist and liberated knowledge from epidemiologist Ramanan the control of the elite, new Laxminarayan. He urges technology is on the verge people to think of antibiotof democratising medicine, ics as a limited resource leading to the emancipation and seek alternatives to of patients. E avoid running head on E OS S E AND VID LUMNS into a crisis. O C OM KS TO N NE.C FOR LI MAGAZI INVIVO WWW.
15
This book aimed at informed readers is a collection of essays by some of the world’s leading brain specialists, including the Norwegian couple May-Britt and Edvard Moser, who won the 2014 Nobel Prize in Medicine with BritishAmerican scientist John O’Keefe. The Future of the Brain explores the latest research to try to understand how the most complex organ in the human body works and analyses the implications of neuroscience for medicine, psychiatry and the human conscience itself.
in SITU
Children of the Night enjoying the sun Thomas and Vincent are twins from Bordeaux, France. Today they are allowed to go out in broad daylight without having to cover themselves completely. They suffer from a rare genetic disorder called Xeroderma Pigmentosum and must avoid any exposure to ultraviolet rays. For the past few months, they have been testing a new mask offered by several hospitals that effectively protects them. The face part of the mask is transparent and breathable, meaning they can take courses at the university and have a life almost like any other 22-year old. Dubbed “Children of the Night�, young patients with Xeroderma Pigmentosum risk developing skin cancers and lesions on the eyes if they are exposed to the sun for even a few fleeting moments. reuteurs / Regis Duvignau
16
world
in situ
17
world
UP-TO-DATE INFORMATION All you need to know about life sciences and innovation in the region. Sections that are designed for you: What’s on, Innovation, People, Science. It’s a one-stop site for news about companies, higher education, and sponsors of innovation.
D republic-of-innovation.ch
“The joys of discovery are made all the richer when shared. Learn about innovation and experience that goes beyond everyday lives.” BENOIT DUBUIs Founder BioAlps, Eclosion, Inartis
“The Republic of Innovation website is informative, smart, open, and easy to read. It’s a true delight and a real help.”
wzart consulting
ThIERRy MAUvERNAy Delegate of the Board Debiopharm Group
REPUBLIC OF INNOVATION
focus
Intestine
research
THE gut, your other brain /
Major discoveries have catapulted the gut to the centre stage of science. Unlocking the secrets of its bacteria could revolutionise the treatment of certain diseases.
/ By
ascending colon
transverse colon
Melinda Marchese
{Colon ascendens}
{Colon transversum}
First part of the colon. Extends from the caecum to the right lobe of the liver.
Continues from the ascending colon and becomes the descending colon.
jejunum
cĂŚcum
{Jejunum}
Central part of the small intestine.
{Caecum}
A pouch which joins the orifice of the ileocaecal valve. descending colon
{Colon descendens} Continues from the transverse colon and becomes the sigmoid colon.
appendix
{Appendix vermiformis} A small outgrowth of the caecum.
small intestine
{Intestinum tenue} Part of the human gastrointestinal tract between the stomach and the large intestine.
rectum
{Rectus}
Portion of the digestive tract connecting the sigmoid colon to the anal canal. anus
{Anus}
Orifice at the end of the digestive tract.
19
sigmoid colon
{Colon sigmoideum} Loop located between the left iliac fossa in the abdomen and the pelvic cavity.
W
focus
intestine
hat are the intestines? “A vast population of bacteria, which is the sum of the decisions we make, the food we ingest, the environment we live in... It’s like our own personal collection of Pokemons!” That’s how Giulia Enders describes this organ, with confidence and humour, in a “science slam” show that she has presented on several stages in her native tongue, German. The young medical student then published the book Darm mit Charme (Gut: The Inside Story of Our Body’s Most Underrated Organ) that has become one of the biggest surprise hits of the year in German bookshops (read the interview p. 26).
Hospitals (HUG). “Now we need to understand exactly ‘who does what’ in this bacterial community called the ‘gut microbiota.’” A number of studies have confirmed a hypothesis that the scientific community now acknowledges as fact: “Having a diverse and balanced microbiota prevents and protects against a number of disorders,” says Michel Maillard, a gastroenterologist at Lausanne University Hospital (CHUV). “Finding ways to restore diversity in the bacteria, fungi and other microorganisms in the intestines is now the crusade led by hundreds of researchers across the world.”
Because these little beings do not sit around idle. They actively contribute to the balance of physiological functions, and therefore the overall health, of their host. “New information and treatments will emerge as research advances on the microbiota,” says Jacques Schrenzel. “These discoveries will have such a huge impact on the care provided Reference for many conditions that all the Intestine or intestines? current medical books will have to The plural is more appropriate be updated.” And this is not rebecause there are actually two stricted to intestinal disorders. organs: the small intestine, a tube Obesity, alcohol addiction, depresabout six metres long that absorbs nutrients, and the large intestine sion and bulimia are just some of or colon. The colon measures the diseases that could benefit from between 80 cm and 150 cm in these advances in the future. length, and its main functions are
This success reflects the growing interest in the gut from both the general public and the medical community. Long considered a simple digestive organ, this five-metre long tube between the stomach and the anus actually plays a key role in the organism. A major advance has captured everyone’s attention. Molecular genetics. “The progress made in this field now enables us to describe the genome of the 100 trillion bacteria that colonise our digestive tract,” says Jacques Schrenzel, head of the bacteriology laboratory at Geneva University
to store waste, absorb certain vitamins and water to form stool. Bacteria colonise the entire digestive tract, but the vast majority of the microbiota are found in the colon.
Talkative critters What do these 2 kg of microbes do in the gut? They are obviously involved in the digestive process. “Microbes play a role in converting food into nutrients and energy and in synthesizing essential vitamins,” says Francisca Joly Gomez, gastroenterologist at Beaujon Hospital in Clichy, France. But their action goes well beyond that. They seem to be in constant dialogue with other components of the organism, especially the brain. “We’ve known for a long time that the brain sends information to the in20
testines, but now we also know that it’s a bidirectional relationship. Information is exchanged in both directions,” says the specialist who published a book last year called The Gut, Our Second Brain (original title: L’intestin, notre deuxième cerveau). The enteric nervous system is responsible for sending and receiving information. “More than 100 million neurons are concentrated and connected to one another in the gastrointestinal wall.” So what can the intestines actually “say” to the brain? “For example, it can send the brain ‘pain’ messages. Gas is generated in the intestines by the fermentation of food. Intestinal bloating can cause visible pain signals in the brain,” the specialist explains.
focus
intestine
An organ in its own right The microbiota is the ecosystem made up of billions of microorganisms that colonise the intestines. Today it is considered an organ in its own right.
400 m2 The surface area of the intestines, the equivalent of two tennis courts.
95% The percentage of the microbiota present in the colon. The rest is spread throughout the digestive tract.
1,000 The number of bacterial species identified in the human gut microbiota. There are only 150 to 170 predominant species per individual.
3 million The number of genes in the gut microbiota, 150 times more than the number of genes in the human genome.
100 trillion
benjamin schulte
The number of bacteria that colonise the gut, ten times more than the number of human cells.
21
2 kilograms The total weight of all gut bacteria.
focus
intestine
The danger of antibiotics Antoine Andremont* is one of the leading international experts on a major health problem: bacteria’s growing resistance to antibiotics. interview by
Olivier Gschwend
T
which are otherwise inoffensive, can cause blood infections or sepsis, because they become hard to get rid of. How can we prevent this disruption? aa For now, we can’t do anything to avoid resistance. The only option is prevention, by limiting courses of antibiotics and staying within the prescribed length of treatment. This situation has become a major health issue. Resistant bacteria from the digestive tract are spread in the environment through faecal matter. They can even be found in our food, invade our digestive system and replace nonresistant bacteria. It’s a vicious circle. iv
aking antibiotics upsets the balance of the gut microbiota. Antoine Andremont warns against excessive use of these drugs.
How do antibiotics affect the gut microbiota? aa Ingested antibiotics are assimilated by the small intestine and flow into the bloodstream to eliminate unwanted bacteria. But some molecules go from the blood back into the digestive system through bile. The bacteria eventually develop defence mechanisms against these molecules and become resistant. Excessive use of these drugs speeds up that process. The flora is completely thrown off balance and dominated by multi-resistant strains. iv
Why is that a problem for a person’s health? aa A disruption in the gut flora often goes unnoticed by the patient and doesn’t have any direct consequences. It shows up in other ways. For example, some patients undergoing chemotherapy or a transplant are immunodeficient. Resistant bacteria in the digestive system,
* Antoine Andremont is a professor at Université Paris Diderot and author of the book “Antibiotics: The Shipwreck” (Antibiotiques: le naufrage, title translation provided for information purposes) from Bayard.
DR
iv
22
focus
intestine
The connection between the brain and the gut has led to major discoveries about Parkinson’s disease. Researchers from the French Institute of Health and Medical Research (Inserm) have shown that the abnormalities in the brain neurons of patients with this degenerative condition have “equivalent” abnormalities in the neurons of the digestive tract. In the future, the disease could potentially be identified and diagnosed early through an intestinal biopsy. “The defective neurons in the intestines can apparently be detected before their counterparts in the brain.”
through certain immune cells and prevent the proteins responsible for allergic reactions from entering the bloodstream.”
The Spanish National Research Council published its research findings in October 2014 in the journal of the American Society for Microbiology, highlighting further links between the microbiota and certain autoimmune diseases. The gut microbiota of patients with lupus, a chronic disease that attacks healthy tissue, shows an imbalance in the ratio between two Each individual’s gut dominant types of microorganisms microbiota is unique. in the human gut, revealing more true One-third of our Bacteroides than Firmicutes. gut microbiota is shared
TRUE OR FALSE?
Over the past ten years, mounting evidence has confirmed the link between Parkinson’s disease and the patient’s gut. The latest research includes a study from the University of Helsinki, which found that patients with Parkinson’s disease have much less bacteria from the Prevotellaceae family in their gut. “In addition, we will have to see if these changes in the bacterial ecosystem are apparent before the onset of motor symptoms,” says neurologist Filip Scheperjans. “We may finally perhaps treat Parkinson’s by focusing on gut microbiota.”
“Protective barrier” The intestines communicate not only with the brain, but also the immune system. “The bacteria of the microbiota send signals to the receptors located on the cells of the gastrointestinal wall, which in turn sends a signal to our immune cells to help them exclude pathogens that might try to colonise the intestines,” says Francisca Joly Gomez.
by most individuals, but the other two-thirds are specific to each of us. The gut microbiota is innate. false The gut microbiota starts developing at birth. A newborn’s digestive tract goes from being sterile inside the uterus to being rapidly colonised through contact with the microorganisms of the mother (vaginal, faecal, skin, etc.) and the environment where the birth takes place. After that, the composition of the gut microbiota depends on how the infant is fed. Scientists believe that the microbiota stabilises around the age of three and continues to develop steadily over the person’s lifetime. Probiotics promote a healthy microbiota. TRUE/FALSE Many studies have shown the benefits of probiotics on the gut flora. However, research led by French microbiologist Didier Raoult showed the unwanted effects of these bacteria. They can lead to obesity.
Exploring the microbiota’s role of “protective barrier” opens up new possibilities for treatments of certain conditions, such as food allergies. “Tests on mice that had been administered peanut allergens showed that the presence of the bacteria Clostridium in their gut microbiota blocked the allergic reaction,” says Cathryn Nagler, from the University of Chicago, who led the study. “This leads us to believe that these specific bacteria may act 23
The source of many diseases Efforts are growing worldwide to make the most of these discoveries (MetaHIT, MetaGenoPolis and MyNewGut projects in Europe, Human Microbiome Project in the United States), and findings are regularly published in the most prestigious scientific journals. “Small intestinal bacterial overgrowth has finally been demonstrated and recognised,” says Alain Schoepfer, gastroenterologist at the CHUV. “This refers to abnormally high numbers of bacteria in the organ that can cause severe abdominal pain, bloating or diarrhoea. We now know that administering an antibiotic used to treat urinary infections can effectively improve the patient’s health.”
Several studies have also linked gut microbiota to metabolic diseases such as obesity and diabetes. An international team headed by Jeffrey Gordon from the Washington University School of Medicine in the United States showed that introducing the gut microbiota from an obese individual into mice, the animals grew fatter as well. Conversely, the microbiota of a thin person keeps them lean. The researcher explained in the journal Nature that gut
focus
intestine
The faecal social network
bacteria have an impact on regulating fat storage in adipose tissue. The permanent dialogue between the gut and the brain has made scientists wonder if the microbiota also influences the behaviour of its host. To answer that question, researchers from University College Cork in Ireland tested “axenic” mice, i.e. bacteria-free, raised in a sterile environment since birth. The mice showed behavioural changes. They preferred to stay in an empty cage instead of with other mice. Their attitude changed once bacteria were injected into their digestive system, and they gladly shared their living space. “All of this work on mice is valuable and provides us with interesting ideas for further research,” says Michel Maillard. “We shouldn’t get too excited just yet. Humans will not necessarily react the same way.” Alcohol dependence and bulimia are other diseases suspected to be linked to the microbiota. Research led by a team from the Université catholique de Louvain reported that alcoholic patients with an altered gut microbiota showed more depression, anxiety and alcohol craving than alcoholics with a “normal” microbiota. The protein ClpB could cause eating disorders. “This protein is produced by certain bacteria, such as Escherichia Coli, which are naturally present in the intestinal flora,” says Serguei Fetissov, from the French Institute of Health and Medical Research (Inserm) of
The gut now has its very own social network: my.microbes.eu. Peer Bork, a biochemist from the European Molecular Biology Laboratory (EMBL) in Heidelberg, Germany, created the site to set up a community where people with a similar microbial profile are connected. Anyone can provide the organisation with a stool sample for more information about their digestive disorder. For €840, your stool is analysed and your bacterial genome sequenced. Participants can find out what enterotype (a category of individuals based on their gut microbiota) they belong to and be put in contact with others who have the same characteristics. They can discuss any health problems they may have, eating habits, environment, etc. The my.microbes.eu project is part of the participatory medicine movement (see “In Vivo” No. 2), with a huge database that its team uses to continue its research on gut flora. Microbes now have their own museum. Micropia has recently opened in the heart of Amsterdam. An entire section of the museum entitled “A world hidden in your intestines” focuses on the microbiota’s role in the human body.
Obesity
Alcoholism
Autism
Inflammations
Several studies, such as the one by the National Institute for Agricultural Research (Institut national de la recherche agronomique), have shown that having “poor” gut bacteria is associated with being overweight. This lack of diversity increases the risk of developing complications due to obesity, such as diabetes or cardiovascular diseases.
Research led by the Université catholique de Louvain reported that some alcoholics present alterations in the composition of their gut microbiota. This discovery opens up new possibilities for therapies focusing on the intestines and not just the brain in treating alcohol dependence.
Researchers from the California Institute of Technology improved symptoms of autism in mice by administering a human gut bacterium, “Bacteroides fragilis”, known for contributing to tightness in the colon wall.
Patients with chronic inflammatory bowel diseases have excessive concentrations of potentially pathogenic bacteria and a lower proportion and number of species of a beneficial category of bacteria called “Firmicutes”.
24
focus
intestine
the University of Rouen. “The protein is secreted when the bacteria are subjected to stress. ClpB has anorexigenic properties, meaning that it reduces the appetite and triggers an immune reaction in which antibodies are produced against it. These will also bind to the satiety hormone because of its structural homology and result in anorexia or bulimia.”
The target of new treatments “The long-term objective is personalised prevention or treatment of certain diseases based on patients’ specific combination of bacterial strains,” says the Geneva-based microbiologist Jacques Schrenzel. Several treatments developed from microbiota research have been applied to certain patients. The most widespread is the faecal transplant, i.e. placing fresh stool from a healthy donor by colonoscopy. “We began performing this procedure in 2014 on patients suffering from recurring Clostridium difficile colitis,” says Michel Maillard. “These bacteria are sometimes resistant to antibiotics and need to be eliminated because they cause severe diarrhoea, which can be serious for the patients.” “The response rate to this treatment is close to 90%,” says Alain Schoepfer from the CHUV. “In less than two weeks, patients are doing better.” The stool donor is generally someone close to the patient. “Before the transplant, donors undergo microbiology screening. They must be healthy and not carry Clostridium difficile.” In Geneva, the HUG will also perform this procedure starting in the spring of 2015. “We will first use this method to treat patients with an infection resistant to Clostridium difficile, but we hope that we can also apply it to patients suffering from inflammatory bowel diseases such as Crohn’s disease or ulcerative colitis,” says Jacques Schrenzel. Although there is no recommendation against having faecal transplants, nothing is known about the long-term side effects. “We inject a ‘black box’ of several billion microbes into the patient,” Alain Schoepfer says. “We know that it will treat a targeted condition, but will this ‘new’ microbiota cause another illness? We explain these risks to patients, who must give us their consent.” Most importantly, this treatment is, in its entirety, much less invasive than an organ transplant. “Small 25
bowel transplantation is very rare,” says Nicolas Desmartines, chief of the Service of Visceral Surgery at the CHUV. The gut is a very sensitive organ, easily rejected and infected. If we operate on the small intestine, it starts forming ‘adhesions’, a type of obstruction that prevents digestion and causes severe abdominal pain. The organ can stop working for two or three days. Colon transplants are rare because the organ contains such an extraordinary number of bacteria that is not suited to transplants. Plus, the small intestine can take over some of its functions.” Food is always another option for taking in “good” bacteria. “Probiotics are live microorganisms that are already added to some products such as yoghurt,” says Michel Maillard. “Today, food industry giants are trying to introduce more bacteria and yeasts into food. In the future, we may find them in our supermarkets.” “If one day we determine the ‘ideal’ microbiota, we could develop a treatment in the form of a pill to restore microbiota diversity and above all microbial balance,” says the gastroenterologist Francisca Joly Gomez. “That’s still a long way away. We have already to know more www.mynewgut.eu made a huge leap forward 30 partnerships in by accepting a change in 15 different counparadigm: we don’t always tries came together have to destroy the ‘bad’ for the My New Gut project. Its objective bacteria with a blast of anis to understand tibiotics. Instead, we need the role played by to learn to live in harmony the microbiota in human metabolism with them.” / and developing food that is good for gut microorganisms.
www.hmpdacc.org The Human Microbiome Project (HMP), launched by the US National Institutes of Health, aims to collect microorganisms in the human body and analyse their genome to understand how they affect human health. www.mgps.eu MetaGenoPolis (MGP) is a French project set up to understand how the human gut microbiota impacts health and disease.
focus
intestine
INTERVIEW “The small intestine is not an impermeable organ”
interview by
Bettina Wurche
Adaptation
Erik Freudenreich
The little book that Giulia Enders dedicated to the wonders of the gut has been flying off bookshop shelves.
The relationship between the gut, the immune system and the mind has been known for a long time. How is this knowledge applied to medicine?
in vivo
Our knowledge changes, but for now there are not many specific instructions on the subject. And doctors obviously need accurate evidence before they can safely recommend anything to their patients. That said, some advice can help patients improve their intestinal health through small dietary changes.
ge
iv
For example?
Avoiding certain foods for a given period. For example, eliminating dairy products from the diet can bring significant relief for intestinal disorders. And it won’t harm you. For conditions like gastroenteritis, probiotics [bacteria] can also be useful. Ideally, those that come in microcapsules, which protect the bacteria against the stomach and bile before they reach the gut.
ge
Do some doctors recommend using probiotics?
iv
Many doctors remain sceptical. And rightly so, as certain probiotics are relatively ineffective. But others can have a very positive effect. Several studies have shown how effective Lactobacillus plantarum and Bifidobacterium can be for irritable bowel syndrome. E. coli Nissl 1917 bacteria (available in stores by the name of Mutaflor) also have excellent properties. Research reports that it is just as effective as commonly used drugs in delaying an attack in the event of chronic intestinal inflammation.
ge
iv
What do you think of natural probiotics?
Some studies point out that yoghurt can have positive effects for digestion and the immune system. But there’s a downside. The bacteria
ge
26
contained in yoghurt can be too strong for people with a serious immune deficiency.
What other unusual knowledge have you gained about the gut?
iv
During an internship in gastroenterology, I saw patients suffering from small intestinal bacterial overgrowth. It causes bloating that can be very painful.
ge
Is a stool sample still the only option for diagnosis?
iv
Bacterial overgrowth can be detected by a patient’s breath! The bacterial metabolites float throughout the body, as the small intestine is not an impermeable organ. They are absorbed by the lungs then breathed out. We often think everything is static, but in a living organism, everything flows. Our purely rational explanations provide only a simplified view of the body. But
ge
Biography Born in 1990 in Mannheim, Germany, Giulia Enders is currently finishing medical school at the University of Frankfurt. The young German student won a science slam on the gut and published “Darm mit Charme” (“Gut: The Inside Story of Our Body’s Most Underrated Organ”), which became a surprise best-seller in Germany. The English version of her book will be released in 2015 by Greystone Books.
intestine
Medical student Giulia Enders authored the best-selling book “Darm mit Charme” (“Gut: The Inside Story of Our Body’s Most Underrated Organ”).
that is not enough to understand the complexity of a living being. Furthermore, the exclusively rational view of the body, which many doctors consider to be the most professional, is not ideal for patients. It’s better to retain an emotional side, to offer the patient a more positive form of attention. Giving a better image of the body is essential for personal well-being and would help many people to better deal with their disease and the deficiency of their body.
Are some of these intestinal disorders due to changes in our eating habits?
iv
We have done away with some foods that were very good for our health, such as sauerkraut! This food contains a lot of vitamins and good bacteria. Sauerkraut used to be eaten regularly throughout the winter, and was a form of treatment for gut flora. We eat a lot more processed foods, which leads to fibre deficiency. These foods bring quick
ge
27
enjoyment and satiety, because they are rapidly absorbed by the body. But the large intestine often comes out the loser, waging a battle with the rest of the body for something to digest. People didn’t used to eat much processed food. Their diet gave them a longer-lasting feeling of satiety, and the entire gut was put to use.
More than one million copies were sold in Germany. How did you handle that literary success?
iv
Of course I was thrilled about the attention my book received, but there were less pleasant aspects of it. Like when journalists called my grandmother to get personal information about me... I’d like to continue to write to explain to people how beautiful the human body is, that we need to take care of it and give it positive attention, but I don’t want to do it for a living. I definitely do not want to become a public figure. ⁄
ge
wonge bergmann
focus
mens sana
In emerging countries pharmas could end up focusing on “rich people’s” diseases, such as diabetes and high blood pressure, while a large proportion of the population continues to be overlooked by medical progress. bernard pécoul
28
MENS SANA
INTERVIEW
bernard pécoul Serious tropical diseases are neglected due
to their lack of commercial potential. This French-born physician says it’s time for an alternative model.
interview: Sophie Gaitzsch photo: Thierry parel
“Pharmas are not interested in the poor” Malaria, African sleeping sickness or leishmaniasis. These IV What are some of the other neglected extremely common diseases in developing countries have diseases? BP Companies also overlook Afrilargely been ignored by the pharmaceutical industry. The can sleeping sickness and leishmaniasis even physician Bernard Pécoul, director of the Geneva-based though they are far from rare. Three hundred non-governmental organisation Drugs for Neglected and fifty million people risk contracting leishDiseases initiative (DNDi), met with In Vivo for an inmaniasis, a parasitic disease that can be either depth interview. He describes the devastation caused by cutaneous or visceral in form. Spread by the a business model incapable of meeting the needs of the tsetse fly, sleeping sickness is endemic in 36 Afleast fortunate. rican countries, threatening 60 million people. However, some “neglected diseases” attract more attention than others. Malaria has always raised IN VIVO Today, there is still no adequate treatment some interest as travellers to affected countries risk for Chagas disease, which kills nearly 13,000 exposure. Another of these better known neglected people every year. Why? BP This tropical disdiseases is tuberculosis. Specialised TB treatment cenease caused by a parasite is one of the so-called tres still exist in developed countries. “neglected” diseases. Pharmaceutical companies are not interested because it only affects poor populations in Central and South America and IV How did the Drugs for Neglected Diseases initiative therefore lacks commercial appeal. That is also get started? BP The project began under the impetus of why many widespread diseases in Africa and Médecins Sans Frontières (MSF). In the early 2000s, the Asia are not part of any research and developorganisation realised that research and development was ment programmes, simply because they are lacking for a large number of diseases and decided to act. outside the market. A study shows that only 1% of new drugs developed between
29
MENS SANA
INTERVIEW
French company Sanofi. The drug is based 1975 and 2000 can be used to treat neglected illnesses, which on a combination of two existing molecules, represent 11% of the global burden of disease. This imbalance artesunate and amodiaquine, and was regis not offset by the public sector. And the situation is unlikely to istered in 2007. Since then, 320 million improve as the pipeline of new products is completely empty. treatments, sold for $1 each, have been disThe Drugs for Neglected Diseases initiative (DNDi) was set up tributed on the African market. We hope to in 2003 to take action by developing new medicines. France’s develop seven additional drugs by 2018. Pasteur Institute, the World Health Organization and several research organisations in affected countries have teamed up under the initiative. IV Your development costs are far below the billion dollars per drug commonly seen in the industry. How do you achieve that? BP We often either combine existing products that are no longer patent protected or improve drugs on which research has been discontinued. Many companies give us access to their library of molecules. Improving or combining existing formulas costs us between $10 million and $40 million for the entire process, while developing a new drug costs up to $100 million or $150 million. We’re opportunists! We take advantage of discontinued research. Vast scientific knowledge about tropical diseases is out there but has simply not been used to benefit the sick. Our partners contribute by bringing their expertise and investment. We also outsource on a contract basis, but the financial terms are not even comparable to those practised in the industry.
“If adequate efforts had been made in the past, a product would already exist to fight the Ebola virus.”
IV Where does DNDi’s financing come from? BP It’s a balanced combination of public and private funding. We receive money from governments, mainly in Europe, as well as Médecins Sans Frontières. Other IV As an NGO, how does DNDi go about decontributors include large philanthropic organisations veloping a drug? BP We bring together various such as the Bill and Melinda Gates Foundation, which public and private partners – companies, public donated $60 million to DNDi in November 2014, and health organisations, research institutions and the UK-based Wellcome Trust. No single donor provides universities – to focus on one objective. We don’t more than 25% of our budget so that we can maintain have a laboratory. The role of DNDi involves diversity in our funding and our independence. pooling resources and coordinating the different actions of our partners throughout the process: research, development, clinical trials and IV Why do pharmas agree to work with DNDi? BP I’ve registration. For each project, we work with noted several factors. In supporting the initiative, pharmaa pharmaceutical company that commits to ceutical companies improve their image and show they’re producing the treatment on a large scale and concerned about social responsibility. The projects are also selling it at cost price. DNDi has developed extremely well perceived by employees. They meet internal six drugs this way. ASAQ, used to treat macommunication objectives. Pharmas also cooperate for comlaria, is the result of a partnership with the mercial reasons, as they gain a foothold in new markets such
30
MENS SANA
INTERVIEW
as Latin America, Asia and Africa. By consolidating their position in these regions, they are laying the groundwork to sell other products in the future.
“Many widespread diseases are not part Do you also work with Swiss pharmaceuof any research tical companies? We have worked with Novartis on several occasions and have miniand development mal relations with Roche. programmes, simply What is your view of the current Ebola outbreak? Huge progress has been made in because they are treating virus diseases, but Ebola has not benoutside the market.” efited from it. For the first time, the virus could IV
BP
IV
BP
not be contained to a single geographical region. A short-term response to the crisis was implemented, work on existing drugs resumed, and vaccine potential came out of it. In a few months, researchers identified three candidate vaccines. This clearly shows that if adequate efforts had been made in the past, a product would already exist. It’s not an unattainable goal! However, if the epidemic is brought under control, I still fear that we will fall into the previous trap as the disease mainly continues to affect poor countries. Does this type of event help improve the fate of patients suffering from other neglected diseases? BP Unfortunately, no. Because there is no risk of sleeping sickness or leishmaniasis spreading in Geneva or New York. But I hope the epidemic will make people realise that research efforts cannot depend exclusively on a system governed by the market. Ebola is a sad illustration of that reality. The market’s inability to meet needs will probably be demonstrated again in the next few years with the growing resistance to antibiotics and the resurgence of certain diseases. It shows the complete short-sightedness regarding the issue. IV
IV In 2012, the World Health Organization made research and development a priority. What happened to that shift in policy? BP The initial momentum was
31
followed by half-measures. For example, the WHO’s project to create a global health R&D observatory for developing countries is being put in place, but very slowly. Organisation members will be asked to come up with new proposals in 2016. The WHO reflects what governments want. A long-term solution must therefore come from them, which would involve a change in the regulatory framework, an incentivebased system for developing new products and increased public funding. More public-private partnerships are needed. If BIOGRAPHY After graduating no change is made, in emerging countries from medical pharmas could end up focusing on “rich school at the people’s” diseases, such as diabetes and University of high blood pressure, while a large proClermontFerrand, Bernard portion of the population continues to be Pécoul began his overlooked by medical progress. career managing public health projects for refugees. He joined Médecins Sans Frontières (MSF) in 1983 and carried out several field assignments in Africa, Asia and Latin America. In the early 1990s, he became director of MSF France and later led MSF’s project Campaign for Access to Essential Medicines. Pécoul has been at the helm of the Drugs for Neglected Diseases initiative (DNDi) since it was founded in 2003.
IV What should be done to wipe out these neglected diseases? BP Political involvement is absolutely necessary to eliminate the failure of research. But the problem goes beyond that. These diseases are the result of the extreme poverty in which these people live. Reducing poverty would drastically improve the situation. /
MENS SANA
decoding
Billion-dollar pills
As the cost of new drugs skyrockets, health systems are asking themselves if they should accept pharmaceutical companies’ full conditions.
Text Erik Freudenreich
ovaldi is a new drug used to treat hepatitis C. It is said to cure almost 90% of patients in just 12 weeks. This is a leap forward in the fight against this disease, as current treatments have a far lower healing rate and are often accompanied by unwanted side-effects.
The catch? The price. A three-month course of treatment in the US costs more than 80,000 Swiss francs. The 80 pills are sold for around 49,000 Swiss francs in Germany, while a Swiss citizen would have to shell out almost 60,000 Swiss francs to benefit from the miracle cure. But in Egypt, where almost 15% of the population is infected, the US laboratory behind the medicine, Gilead, is offering the treatment for around 800 Swiss francs. The company argues that the price charged in Western countries enables it to sell the drug at cost price in places where it is needed most. These differences sparked a heated polemic a few months ago when the drug was released in France, where the cost of treatment has been set at around 41,000
Swiss francs following persistent negotiations by the French Health Minister. In reaction to this controversy, the Swiss Federal Office of Public Health (FOPH) published a report in early February. It observed that “certain representatives of the pharmaceutical industry are using a new type of pricing strategy to try to generate as much profit as possible thanks to social security systems in developed countries, which are financed by taxes and insurance premiums.” According to Thomas Cueni, general secretary of the central association of Swiss pharmaceutical companies, Interpharma, the long-term benefits should be considered. “Hepatitis C is an illness that generates considerable costs due to procedures such as transplants and treating cirrhosis of the liver. The fact that the disease could now be treated in the majority of cases, and in a very short time, should push us to put
1
The world’s three most expensive drugs
Soliris
With an annual cost of more than 400,000 Swiss francs, Soliris is currently considered to be the world’s most expensive drug. Sold by the American company Alexion Pharmaceuticals, it is used to treat paroxysmal nocturnal haemoglobinuria (PNH), a rare form of anaemia.
32 65449872872674
654498728
MENS SANA
decoding
Tom Craig / Demotix
The advocacy group Act Up organised a demonstration in front of the Gilead laboratory in Paris in August 2013, protesting against the exorbitant price of its miracle drug used to treat hepatitis C.
the price of a drug like Sovaldi into perspective.” The cost of research
This example is far from E l a p r a se marginal. Today a great Shire, a UK pharmaceutical number of new medicines laboratory, charges almost are released at staggering 375,000 Swiss francs per year for Elaprase. The drug is used prices, particularly in the to treat Hunter syndrome, a rare field of immunotherapy, disease caused by an enzyme where cancer treatments deficiency which affects just 2,000 people around the world. are developed to boost patients’ immune defences. In the US, a drug called Avastin has been developed to fight colon cancer, and costs between 4,000 and 9,000 Swiss francs per month, depending on the patient’s weight. Blincyto, a treatment for leukaemia, costs around 13,000 Swiss francs per month. And
9879461798712137530218906808751
33
a new drug developed by Novartis to treat lung cancer, sold under the name Zykadia, costs around 14,000 Swiss francs per month. Pharmaceutical groups justify these prices by citing regulatory constraints, shareholders’ expectations and increasingly expensive research and development costs. “It’s true that, when you consider the amounts invested in research that ultimately proves to be fruitless, R&D costs for a drug can vary from single- to double-digit billion amounts, say from $4 billion to $11 billion,” says Quebec biologist Jacques Beaulieu, author of a recent work entitled Ces médicaments qui ont changé nos vies (Multimondes, 2014). A study carried out by the economic magazine Forbes shows that a pharmaceutical company must pay out at least $350 million
MENS SANA
Decoding
before being able to sell a given drug. Since most large groups develop several projects at the same time, the American magazine calculated that the total bill adds up to an average of $5 billion for each new drug that hits the market. These are enormous figures, but figures alone cannot justify the prices demanded by the pharmaceutical industry. According to Forbes’ analysis, R&D costs represent around 20% of the sale price, while pharmaceutical groups spend higher sums to promote their products and rake in profits of between 20% and 30% per drug sold. The Swiss case
In Switzerland, the FOPH judges whether a drug should be reimbursed by the Swiss basic health insurance system. “We make this decision based on opportunity, efficiency and cost criteria,” says Oliver Peters, Vice President of the FOPH. “We have decided to reserve the use of the drug in the treatment of hepatitis C for patients suffering from advanced liver disorders. This limitation has been medically justified by a recent study that showed that healing rates for this illness were quite positive, even in cases of late treatment.” But after taking everything into account, what is an acceptable price for saving someone’s life? The Federal Supreme Court of Switzerland was called to review the question a few years ago. An elderly patient had been diagnosed with an adult form of Pompe disease, a genetic disorder that causes muscle damage due to an anomaly in the metabolism of glycogen. The patient’s insurance first accepted a sixweek Myozyme treatment, a medicine used to treat some of the symptoms and which costs around 500,000 Swiss francs per year. However, after judging the treatment to be too expensive, the patient’s health insurance refused to continue its reimburse-
34
ments. The patient brought the case before the Supreme Court, which acquitted the insurance company, stating that the cost of the treatment was disproportionate and that the therapeutic benefits were insufficient. In its decision, the Supreme Court judged that around 100,000 Swiss francs was a reasonable cost for each year of extra life in good health.
Naglazyme
Developed by the California company BioMarin Pharmaceuticals, this drug costs around 365,000 Swiss francs per year. Naglazyme is used to treat a rare hereditary metabolic disease called Maroteaux-Lamy syndrome, whose characteristics include dwarfism and skeletal deformations.
Is the solution to this problem to develop generic medicine? “Unfortunately Switzerland’s generic medicine market is too small, 3 9984164612 and there is a sort of tacit agreement between manufacturers,” says Thierry Buclin, physician-in-chief of the Clinical Pharmacy Division at the CHUV. Buclin did, however, put forward several ideas to improve the situation. “There would be a place in our country for the manufacturing of generic medicine, which would be available to the people – a sort of public cooperative. It could produce combined generic medicine, as most elderly patients, who are big consumers of medicine, suffer from similar pathologies including heart problems, diabetes and hypertension.” One thing is sure: Swiss patients will have to keep paying high prices for their pills in 2015, as the price of imported medicine is not immediately adjusted to the current exchange rate. This situation concerns Stefan Meierhands, the Swiss federal price watchdog. A document published by the Swiss newspaper Berner Zeitung calculated that, based on the current exchange rate of €1.05, the potential annual savings would amount to almost 800 million Swiss francs. ⁄
84215483
1237936472
MENS SANA
trends
Medical tourism: mind the turbulence
Floresco Productions/Getty Images
Countries where medical care is cheap continue to attract new patients. But getting treatment abroad is not without risk.
BY Julie Zaugg
35
“P
MENS SANA
trends
atients who come here trust us with their heart, and we treat them with all of ours,” says Rujira Songprakon, a nurse. The camera crosses an ultramodern operating room, panning in front of computers decked out with a 3D imaging system, and then stops at a bilingual sign in Thai and English. The commercial posted on YouTube promotes the brand new cardiac arrhythmia centre at Bumrungrad hospital in Bangkok. The video reflects the rapidly growing phenomenon of medical tourism. Aristocrats used to travel for treatment to the thermal resort cities of France or southern England in the 18th century, but it was not until the 1990s that we began to see a large-scale migration of people seeking medical treatment. “Those patients were generally wealthy and from developing countries,” says Josef Woodman, the CEO of the US organisation Patients Beyond Borders, which publishes medical tourism guides. “They could not find quality medical treatment services in their home country, so they would come to North America or western Europe.” Germany and Switzerland stood out in this segment among Russian-speakers and Arabs. Then in the early 2000s, a whole other type of travelling patient emerged. “They are middle class citizens from rich countries who seek inexpensive medical treatment, often in poor countries where the cost of living is cheaper,” Josef Woodman notes. They most often go for low-risk surgery. Out of the 65,000 British patients who travelled abroad for treatment in 2013, 41% had cosmetic surgery, 32% sought dental work, 9% underwent weight loss
36
Travelling patients Every year, millions of tourists cross the globe to benefit from low cost healthcare, especially in Asia and South America. infographic: diana bogsch, Romain guerini / largenetwork
Mexico This neighbour of the United States attracts many cross-border patients. Americans take advantage of its close location to go to the dentist or have bariatric surgery. Mexico receives a total of 200,000 to 1.1 million medical tourists per year.
Brazil This country is visited by 180,000 medical tourists per year. Most come for cosmetic surgery, especially to the Ivo Pitanguy Clinic in Rio de Janeiro, one of the most reputed centres in the country.
trends
= 100,000 medical tourists
Hungary Germans, Austrians and Swiss have turned this country into a leading destination for dental care. One northwestern city, Gyor, has more than 150 dental clinics aimed at foreigners. For dental care alone, Hungary attracts 60,000 to 70,000 patients per year.
India The subcontinent is the least expensive medical tourism destination. Procedures cost 60% to 90% less than in developed countries. Orthopaedic and heart surgery are the most popular, particularly at the prestigious Wockhardt hospitals. The country attracts between 350,000 and 850,000 patients a year.
Thailand This medical tourism pioneer welcomes between 1.3 million and 1.8 million patients every year. One hospital alone, Bumrungrad International, receives 400,000 foreign patients a year from 120 countries. Cosmetic and gender reassignment (sex change operations) surgery are popular.
Turkey This country located at the gateway to Europe specialises in laser eye surgery. The Dunya Goz centres in Istanbul are considered among the best. In 2013 Turkey welcomed 110,000 medical tourists. Malaysia This Asian country is a very inexpensive destination that welcomes 670,000 foreign patients per year. Most are drawn by the Well Man packages that offer eye tests, dental and hearing check-ups, along with an MRI or PET scan for $1,500.
37
Singapore This microstate has some of the top clinics and hospitals in the world, focusing on oncology. The Johns Hopkins Singapore International Medical Centre is located here. Singapore attracts 400,000 to 610,000 patients a year.
Source: Patients without borders
MENS SANA
MENS SANA
trends
médecine sociale et préventive) at Lausanne University Hospital. “Some Swiss people retire on the Spanish Costa Brava, in buildings with nursing staff and other medical services.”
procedures (bariatric surgery) and 4.5% fertility treatment. “Ten years ago, only five or six destinations offered healthcare to foreigners,” says Jonathan Edelheit, who heads the Medical Tourism Association. This US-based organisation focuses on the quality and transparency of healthcare provided through medical tourism. “Today there are more than 100.” Most specialise in a handful of procedures. For example, Hungary attracts western Europeans who want dental care. South Africa, Colombia, Mexico, Brazil, Costa Rica, Tunisia and Morocco have become cosmetic surgery hubs. India and Thailand mainly offer orthopaedic and heart surgery.
But medical tourism is not just about money. “The ageing population and increase in the number of serious and chronic disease cases in an overwhelmed healthcare system have boosted the phenomenon,” Josef Woodman points out. In the United Kingdom and Canada, waiting lists can be as long as several months, even years for certain procedures. Receiving treatment abroad is also a way of circumventing laws in the patient’s home country. Medically assisted procreation is not open to single women and lesbians in many countries, but it is in Spain, Sweden and the United States. Similarly, assisted suicide is legal in Switzerland, making the country a destination for “suicide tourism”.
The Swiss are also part of the trend. “We send our customers to Barcelona, Hungary and Istanbul for dental care, to Grenoble and Istanbul for laser eye surgery or Belgium and Istanbul for cosmetic procedures,” says Stéphane de Buren, founder of the Geneva-based medical tourism agency Novacorpus. But what motivates them to get treatment abroad? The price is the main argument. Savings are as high as 70% to 90%. A coronary artery bypass costs $88,000 in the United States but only $14,400 in India, according to figures from Patients Beyond Borders. In vitro fertilisation (IVF) is charged at $15,000 in the United States but only $1,150 in Ukraine. Some patients – mainly older people or those suffering from a chronic illness – go as far as moving to a country where healthcare is less expensive. “Germans with Alzheimer’s go to live in North Africa,” says Fred Paccaud, director of the University Institute of Social and Preventive Medicine (Institut universitaire de
38
The numbers
38
In millions, the number of medical tourists per year, according to the World Health Organization.
60
In billions, the size of the global medical tourism market.
11,500
In dollars, the price of a hip replacement in Mexico. In the United States, the same operation costs $33,000, according to Patients Beyond Borders.
Certain procedures are only available abroad. “The ‘Birmingham hip’, a hip resurfacing technique to avoid a hip replacement was long practised only in India,” notes Josef Woodman. However, medical tourism is not without danger. A University of California study of 33 patients who had received a kidney transplant abroad reported a higher-thanaverage rejection rate. In the United Kingdom, a survey of members from the British Association of Plastic, Reconstructive and Aesthetic Surgeons showed that 37% of them had treated patients with complications following an operation performed overseas. “I have seen work done by real butchers in some dental offices located on the Mexican border or in Hungary,” says Josef Woodman. The travel
trends
itself involves risks. Some tropical or developing countries have viruses and bacteria that are absent – or less common – in developed countries, such as tuberculosis, malaria, dengue, typhoid fever and AIDS. Air travel shortly after an operation can also lead to deep vein thrombosis or pulmonary embolism. Postoperative care often needs improvement as well. “Patients are often not allowed follow-up consultations,” Jonathan Edelheit points out. The average hospital stay rarely exceeds a few days. In the event of a complication or medical error, the chances of having it repaired are slim. “Patients are often alone. The clinic that treated them has discarded their case, and their regular doctor doesn’t want to hear about complications that occur abroad,” says Keith Pollard, managing editor of the Treatment Abroad website and the International Medical Travel Journal. The arrival of these western visitors has also had an impact on locals. “We’ve seen human tissue trafficking in China, the Philippines and Colombia,” says Jonathan Edelheit. “Although it’s never legal to buy an organ, some countries authorise donations from mere ‘friends’.” This gives rise to abusive practices. “In India, some illiterate women find themselves enlisted in an egg donation programme without knowing it,” says Elizabeth Beck-Gernscheim, a German sociologist who has studied the phenomenon. “Others are forced, due to poverty, into becoming surrogates.” More generally, medical tourism has resulted in a reallocation of healthcare funding and staff to foreign visitors, sacrificing the needs of the local population. For example in Thailand, hospitals outside cities and the treatment of
39
infectious diseases have been neglected over the past few years in favour of large urban hospitals and premium orthopaedic and cardiac services. ⁄
Switzerland gets its piece of the pie
Ralf Schulze
MENS SANA
The Agra sanatorium in Ticino, photographed in 1930.
Switzerland has a long tradition of medical tourism, beginning in the time of thermal spa resorts and sanatoriums. The Gottlieb Duttweiler Institute estimates that around 30,000 people come for treatment every year. These tourists spend 1 billion Swiss francs, representing 6% of annual hospital revenue. “Most come from Russia, Kazakhstan, Ukraine, Saudi Arabia, United Arab Emirates, China or neighbouring countries,” says Andrej Reljic, who heads Swiss Health, an organisation created in 2008 that promotes the Swiss medical market. “Switzerland boasts expertise with development potential in rehabilitation, orthopaedics, sports medicine (ski accidents), prevention and wellness,” says Franz Kronthaler, professor at the School of Technology and Economics in Chur. In addition to the university hospitals in large cities, several regions have designed customised offerings aimed at foreign patients. Lucerne and Ticino have launched initiatives through the Lucerne Health and Ticino Health services, along with Montreux and its Clinique La Prairie.
MENS SANA
prospection prospectiNG
Running rampant in the city: psychosis Several studies have confirmed that schizophrenia is more common IN URBAN THAN IN RURAL AREAS. So what are the mechanisms involved? Text: Jean-Christophe Piot, illustration: Adam quest
s the city bad for mental health? The idea is not new. “The observation of a higher number of schizophrenics in urban areas dates back to 1939,” says Philippe Conus, chief of the Department of Psychiatry at Lausanne University Hospital (CHUV). This hypothesis has been confirmed in recent research from the Institute of Psychiatry at King’s College London. The findings are conclusive. Schizophrenia, like other psychotic disorders, is twice as common in urban environments. With half of the world’s population living in cities these days, the implications are huge. Understanding the causes of this correlation is not easy. “Epidemiological studies have their limits,” the psychiatrist admits. Hence the idea of launching a study with an original approach, at the crossroads between human sciences and life sciences. Led by the Depart-
40
ment of Psychiatry at the CHUV and the Institute of Geography at the University of Neuchâtel, with the support of the Swiss National Research Foundation, this project initiated by Philippe Conus and geographer Ola Söderström will, in its first stage, cover about forty patients who have recently developed early signs of the illness. Its aim? To pinpoint the specific factors that contribute to the development of the disease, and the solution that could isolate their impact in the emergence of this complex, multi-faceted pathology. How can we distinguish between specifically urban factors, genetic, biological or psychological predisposition and external stress factors? How can we account for the fact that city dwellers are more often diagnosed with the disease than their fellow citizens from rural areas? “We don’t know if the size of the city plays a part in the prevalence
of schizophrenia,” says Philippe Conus, “but it is understood that the risk increases with the number of years spent in the city, especially in childhood. And this effect persists, even after correcting the potential impact of other more common risk factors in the city, such as the use of cannabis.” By filming their reactions over a series of journeys through the city, researchers expect to identify which areas are experienced by these patients as safe and which are stressful. All of these factors will then be analysed against epidemiological data compiled by psychiatrists. Supported by the Swiss branch of the International Society for Psychological and Social Approaches to Psychosis (ISPS), this first phase will help define various hypotheses which will then be verified in broader patient groups over the next three years. This should result in valuable insight into better understanding the disease. ⁄
MENS SANA
41
prospection prospectiNG
MENS SANA
Decoding
Toxic substances: the indoor threat Paints, detergents and sprays heavily pollute the air in our homes. And no regulations limit their use in Switzerland. Text: Céline Bilardo, photo: Heidi Diaz
N
What is causing this phenomenon? “We don’t know,” says the specialist. “Once we’ve ruled out all the typical triggers of an irritation, an allergy or inflammation of the airways, most often we are faced with a black box, a dead end. We used to think that these new cases were mainly due to cigarette smoke. And scientific evidence
42
confirmed it,” he says. “Today we know that smoking and second-hand smoke cause 60% of these illnesses, but what about the remaining 40%? The idea of air pollution has been under study for a few years now.” Specialists agree hands down: indoor air is ten times more polluted than outdoor air. Wall covering such as paint, flooring, deodorising or sealant sprays and even cleaning products, with their high solvent content, are responsible for poor indoor air Benzene is a cancercausing irritant conquality. They all sidered to be one of emit toxic the most toxic indoor chemicals that we air pollutants. This inhale and that substance is used to accumulate in our manufacture products such as petrol, glue, body. “There are hundreds, even thousands, of
plastic, paint and detergent. Benzene is a “VOC”. Volatile Organic Compounds include a number of chemicals that evaporate, such as propane, butane, acetone and ethanol. The pictogram of flames shown on the label of some cleaning products indicates that they contain these compounds.
Benzene
early 10% of the Swiss population suffers from asthma. Children more commonly develop this respiratory disease, but today a growing number of adults consult their Text doctor for similar Céline symptoms. “We receive Bilardo many women age 30 to 45, who suffer from a recent onset of asthma, a chronic cough or bronchitis,” says Laurent Nicod, head of the Service of Pulmonology at Lausanne University Hospital (CHUV).
MENS SANA
Decoding
Radon
pollutants floating in our indoor air,” says Laurent Nicod. “Exposure to this pollution, even in small doses, has chronic effects. It mainly affects the airways and, over time, can cause allergies or asthma, damage the bronchial tubes and make some people susceptible to developing lung cancer.”
This radioactive, naturally occurring gas is formed in the soil and can accumulate in buildings if underground spaces are not sealed properly or are poorly ventilated. It is the second most common cause of lung cancer after smoking. In Switzerland, the highest concentrations of radon are especially prevalent in the Alps and Jura mountains. The OFSP regularly updates a “radon map” on its website.
Past heritage
Construction specialists are trying to identify these toxic agents. Asbestos is a fibre used for insulation that was included in construction materials and suspended ceilings in Switzerland until 1990. Today it is banned. “There’s a risk of exposure to asbestos in buildings built before 1991,” says Marcel Kohler, director of the Toxicology and Construction Environment Service of Geneva (Service de toxicologie de l’environnement bâti de l’Etat de Genève). “That represents nearly 80% of the property in Geneva. But the risk only arises when works are to be done, for example renovation. Asbestos testing and removal are required, and professionals are aware of that.” Used in paint until 2006, lead has also been clearly identified as toxic. “Children
Laurent Nicod, head of the Service of Pulmonology at the CHUV, warns against chronic exposure to indoor air pollution.
43
MENS SANA
Air out frequently The windows of a room – bedroom, office or classroom – should be opened several times a day. Automatic ventilation systems are available. New eco-friendly buildings with the Minergie ecolabel are supposed to have them. Use water-based solutions When painting your walls, use water-based paint that contains no solvents, or low amounts of them, and emits fewer particles. Find the right labels In Switzerland, “L’étiquette environnementale” for paint, “GuT” for rugs and “Ange bleu” for several consumer goods are some of the eco-friendly labels to spot for interior items. Use creams rather than sprays Aerosols used for sealing often have an equivalent in cream form, which pollutes less and is also better for maintaining the quality of objects and accessories treated.
Decoding
are the most exposed to this danger. All it takes is lead paint to start deteriorating and chipping. If a child inhales or ingests the dust or debris, he or she could get lead poisoning.” Irritants
Many interior objects are also sources of pollution. “Pressed wood furniture, paints and glues can also give off high amounts of formaldehyde, a gas irritant,” says Marcel Kohler. “Formaldehyde is also generated from smoking cigarettes or burning incense sticks, as is carbon monoxide (CO). This odourless gas is given off due to incomplete combustion in a space with little oxygen.” Over time, everyone risks some degree of exposure to deodorising and sealant sprays, cleaning products and disinfectants. These agents are considered toxic, forming a cloud of particles often so fine that they can reach the pulmonary alveoli. “Their domestic use should not cause any problem,” says Horacio Herrera, an occupational hygienist at the Institute
This colourless, odourless gas can be given off by space heaters (gas, fuel oil, wood) or poorly ventilated stoves. CO can also be released if these appliances are defective or not adjusted properly. In 2010, the World Health Organization (WHO) recorded over 400 deaths due to indoor carbon monoxide poisoning in Europe. There are fewer of these cases in Switzerland, where residences have to comply with ventilation standards (e.g. for chimney flues).
44
Carbon monoxide
How to reduce indoor air pollution
for Work and Health of French-speaking Switzerland (Institut universitaire romand de Santé au Travail, or IST). “The danger lies in their excessive use. For sealants, this means using them in a closed environment. Manufacturers are required to mention the ingredients on the label, but they do not have to indicate their concentration…” No regulation
In Switzerland, no maximum limit is defined for manufacturers. “Construction materials and interior products and objects are sold assuming that manufacturers run their own checks,” says Marcel Kohler. “There is no inspection system similar to that required to sell medicine, for example.” Switzerland’s Federal Office of Public Health (OFSP) does not have the authority to enforce regulations but to “inform the public about the health risks, offer recommendations and set guidelines on amounts of certain pollutants,” says Roger Waeber, head of the indoor pollutants service at the OFSP. Experts all bemoan the lack of epidemiological study of these toxins in indoor environments. “People are gradually becoming aware of the problem,” says Laurent Nicod. “France set up an Indoor Air Quality Observatory (Observatoire de la qualité de l’air intérieur) in 2001, and the Stockholm Convention regularly updates a list of hazardous substances. But considerable data are still needed to implement safe prevention initiatives before this public health issue becomes any more serious.” ⁄
MENS SANA
insight
The promise, or “the poison of false hope”
is carried out by professional speakers and not the researchers themselves – is at a rather By regularly guaranteeing spectacular innovations, remarkable the scientific community runs the risk of losing crossroads in touch with the public. Researchers at the Lausanne history. On the University sounds the alarm in a new book. one hand, there are amazing promises, even Text: bertrand tappy dreams, and on the other hand there are more realistic imperanome Project. Their goal n 17th century England, tives: finding funding, making was to explain a huge number the king’s renowned work stand out in an ultra-comof phenomena in biology and in councillor Francis Bacon petitive context in order to access life by decoding human DNA, wrote Novum Organum. more opportunities in an increasand hoped to develop new mediDespite never being finished, ingly specialised environment. In cal treatments. this monumental work is one of this situation, we can be forgiven the pillars of modern empirical for questioning the criteria for Despite the 400 years between science. In it, the philosopher defining research objectives.” the two events, both ideas have outlined an idea which was set something in common: these to enjoy great success. He adambitious projects to improve vocated that, thanks to science, hile the statethe world through science did humankind could create the ment may not announce actual discoveries, tools it needed to establish its seem a little only promised them. understanding and domination provocative, of Nature. the book goes much further than “The history of the sciences is suggesting researchers are merely punctuated with promises and At the end of the 20th century, a salespeople. “With the competiutopias”, says Marc Audétat*. tion between countries and the group of scientists from differ“But the sciincredible advances in commuent nations Francis Bacon entific debate nication, the politico-scientific launched the The Novum Organum (literally, – which today ecosystem has become a very Human Ge-
I
W
the “New Instrument”) is British philosopher Francis Bacon’s major work, published in 1620. In Novum Organum, Bacon develops a new system of thought for understanding nature, giving experimentation a central role for the benefit of scientific progress. Thanks to this work, Bacon is considered to be the father of modern experimental philosophy. 45
MENS SANA
complex machine that sometimes works in the same way as speculative bubbles in finance”, says Alain Kaufmann**. Its objective is to attract credits and thereby provoke the supposed competition into contributing to economic growth. Behind this mechanism lies a sort of cynical complicity. The discourse on promises tries to give credibility to a hypothetical correlation between the guarantee of improvements in the near future on the one hand, and legitimate concerns, expectations and social and economic interests transformed into political promises by decision-makers on the other. The “promises market” sits between scientific and political opportunism. In science, broken promises rarely end up in the moral courts, and even less so in those of reason.”
insight
mechanisms, and by controlling their functions we could develop treatments targeting the original cause. This reasoning is not ridiculous, but we cannot ignore the gap between what was promised in the 1990s and the actual results produced 25 years later.
T
Moore’s Law Moore’s Law, which owes its name to its creator, was put forward in 1965 in Electronics Magazine by the engineer Gordon Moore, one of the men who co-founded the computer giant Intel. Moore observed that the processing power of computer circuits available to the public had doubled every year at a constant cost since 1959 when they were invented. He put forward the hypothesis, soon christened Moore’s Law, that this growth would continue, and even increase exponentially in the future.
his observation can be applied to many other “promising” projects, including nanotechnology, GMO, and more recently neuroscience. And saying this is not anti-science. On the contrary, it is scientific through and through to observe that the production of promises is often inversely proportional to the scientific strength of prophetic arguments expressed in these ambitious projects. I also believe this yo-yoing between wonder and disappointment that we put the public through, despite the fact they are increasingly affected, is dangerous. We run the risk of provoking not just criticism, which is theoretically a sound reaction, but, above all, rejection.
“With a little hindsight, let’s look at the Human Genome Project launched in 1990, for example”, says Francesco Panese***. Right from the beginning, its objective was not just to sequence all three billion basic pairs of the human genome, but also, and perhaps above all, to identify specific genes linked to the wide range of human pathologies. The project’s stance was built on fairly simple reasoning: by identifying pathogen “Wired”: The End of Science sequences we In an article published in June 2008, Wired magazine would be able editor-in-chief Chris Anderson wrote: “Now Google to understand and like-minded companies are shifting through the most the pathological measured age in history, treating this massive corpus as
a laboratory of the human condition. They are the children of the Petabyte Age.”
46
As philosopher Michel Foucault said, what is historically built can be politically destroyed.”
Another recent mascot of this phenomenon is Big Data and its scientific derivative. Thanks to the phenomenal calculating ability of modern computers (without forgetting those in the future), it should soon be possible to discover new, unthought-of correlations between increasing numbers of factors which, at first, seem incomparable. These factors include your DNA, your living environment, your diet and your metabolism when healthy and when ill. We therefore start believing and promising that the algorithms of statistical correlations could replace fundamental research at little cost, putting forward arguments such as the famous Moore’s Law. “Wired magazine got carried away with this promise, and published an article in 2008 under the headline “The End of Science”, says Audétat. “They explained that we would soon be able to do without scientific models, and that many scientists would become irrelevant.
O
f course, the journalists at the famous magazine have since come back down
MENS SANA
insight
intel free press
“Wired”
Gordon Moore
Francis Bacon
to earth. However, the powerful head of Google, Larry Page, went as far as saying he wanted to change the face of medicine using the algorithmic processing of petabytes of individualised health data stored in the search engine’s immense servers.” According to Panese, this was a new prophecy “in which an author like Eric Topol saw the possibility of a creative destruction of medicine”, which was the title of his best-seller published in 2012.
47
The authors of Sciences et technologies émergentes: pourquoi tant de promesses? show, however, that another approach is possible. “The terms of citizen science and collaborative research are increasingly considered and implemented,” says Kaufmann. They oppose those who settle for promising a vision of science as more participative and integrated into society. By listening to researches on a daily basis, there is a certain apparent weariness. We might be
heading for a division within the research community itself, between those who proclaim and benefit from promises, and those who stand against the poison of false hope.” ⁄
* Marc Audétat, Head of Research at the UNIL Sciences-Society Interface **Alain Kaufmann, Director of the UNIL Sciences-Society Interface ***Francesco Panese, Associate Professor at the UNIL Institute of Social Sciences and Director of the UNIL-CHUV Musée de la main
MENS SANA
commentary
claude halmos Psychoanalyst and writer
Your social life can make you sick.
Today, anyone can talk, without (too much) fear, about their psychological suffering from their private life, discussing the challenges one faces as a son, daughter, parent, lover, etc. This pain has gained a legitimate place in our society. But this has not always been the case. Before those now lumped into the category of “psychologists” invaded the media in the 1990s, these problems were taboo. (For example, no one would have dared talk about their sexual problems in public.) “Private pain” is now out in the open and sometimes even making magazine headlines. How times have changed!
How can we explain this silence about individual psychological issues caused by this situation (and their complexity)? By understanding that it is essentially based on poor knowledge of theory. We live with the implicit but dominant idea that human beings build their private lives and one day will have a social life as well. On that basis, attacks on one’s social life are believed to damage their “possessions” but in no way their being. Which is false. Human beings have two sides. They have what could be called (even though the term is unsuitable) a “two-sided psychological backbone”, half-private, half-social. For the child, the social half starts developing in school. That is where children develop a new image of themselves, a new understanding of their worth, etc. that will co-exist with those already built in their family life.
But another taboo has emerged. The taboo of suffering from one’s social life, the sometimes immense suffering that millions of men and women endure. And they do so not because of their private life, their personal When humans are affected in their social life, situation or their childhood but because society half of their being is wounded, sometimes forces them. A society ravaged by an economic even destroyed. This can be devastating, which crisis so severe that some are forced to deal explains the significant rise in depression and with unemployment and poverty, while others suicide rates in times of crisis. And which justifies are led to live in fear – even terror – of this job- the urgency of care. ⁄ lessness, impoverishment, downward mobility, when there is no real lack of security.
Serge Picard
PROFILe
The French psychoanalyst Claude Halmos is a childhood specialist. She has authored several books on the subject, such as Why love isn’t enough and Authority explained to parents. She is also a regular guest on France Info radio and answers readers’ questions in Psychologies magazine.
48
to read
“Is this how humans live? Coping with and resisting crisis” (original title: “Est-ce ainsi que les hommes vivent? Faire face à la crise et resister”), Fayard, 2014.
49
Text: Martine Brocard Photo: Philippe Gétaz
Hyperactive and clumsy: the same battle Children with attention disorders often suffer from motor problems. This discovery can be used to develop alternatives to medication.
R
emember, at school, how there were always those who would stumble in the playground, knock over their tube of glue or were incapable of catching a ball? The awkward ones. There were also those who would never listen in class, forget their gym bag and disturb the class by getting up without asking permission. The halfwits. Medical research has shown that the latter do not suffer from a lack of intelligence but of concentration (attention deficit hyperactivity disorder, or ADHD). We now know that those who are chronically clumsy frequently share the same problem. A study has recently proved it. When Ritalin improves motor skills
The Ergotherapy Service at Lausanne University Hospital cORPORE SANO
(CHUV) sometimes receives children suspected of having motor disorders, like the awkward ones described above, but motor and coordination tests reveal nothing abnormal. However, their lack of dexterity significantly affects their daily life. “We believed that there was another cause,” says Marie-Laure Kaiser, chief ergotherapist at the CHUV. To test her hypothesis, she compiled 45 studies that covered both attention and motor disorders during a research sabbatical from March to October 2014 at the University of Groningen in the Netherlands. The specialist focused on two types of studies: those involving the motor skills of children diagnosed with an attention disorder, but who were not treated with medication, and those involving the influence of psychostimulants
(like Ritalin) on the motor skills of children with an attention disorder. She found that more than half (51% to 73%) of children with ADHD also had a motor disorder. Moreover, the psychostimulants improved the motor functions in these children in 28% to 67% of cases. “This compilation brings proof that there is a correlation between attention and motor disorders,” MarieLaure Kaiser says. Children without a motor problem may fall all the time because their head is always in the clouds or miss a ball because they are not concentrating. Strengthened synergies
“This study shows that, in addition to learning disabilities such as dysorthographia and dyscalculia often associated
50
Adults too
with ADHD, we must take into consideration motor and coordination disorders,” says Michel Bader, child psychiatrist and privatdozent at the Faculty of Biology and Medicine at the University of Lausanne. The existing synergies between neuropaediatrics, child psychiatry and paediatrics, the areas that generally deal with ADHD, and ergotherapy, will grow stronger through joint consultations and combined therapeutic strategies. This will benefit the patient. “When a child with coordination problems is taken to a psychiatrist, a year is often wasted before the child is referred to an ergotherapist,” says Marie-Laure Kaiser. But time is precious. “A child aged 6 or 7 has plenty of room for improvement and progresses quickly. However, for a 10-year old child who comes to see us, it’s often too late.” This development is part of a movement to provide a broader scope of care for hyperactivity and attention disabilities, which affect 5% to 6% of children. “It is important not to limit ourselves to medication but rather to enlarge the spectrum of appropriate therapies, such as psychotherapy and parent and children’s groups,” says Michel Bader. Speech therapists, ergotherapists and psychotherapists now focus on having the patient work on other disorders associated with ADHD. New neuro-cognitive approaches are also used, such as working memory training with computer programmes. CORPORE SANO
Pilot study focussed on a game
Michel Bader, working with Hansel Schloupt – a secondyear Master’s student in product design at the Lausanne Art School, has recently developed a construction game using wooden and rubber pieces that is specially designed for children with ADHD. “The child has to be concentrated, control his or her motor functions, follow directions, make decisions and not get angry in order to build the highest tower possible,” the child psychiatrist explains. The game is to be played by two people, with a parent in a fun and relaxed environment. “The point is for these children, who often have major difficulties in school, to have a successful experience and feel enjoyment from playing with their parents outside of the tense environment of homework,” he says. A pilot study on this gamebased approach is expected to begin in February 2015 with the collaboration of Marie-Laure Kaiser. Ten children between 6 and 9 diagnosed with ADHD and ten other children who do not have an attention disorder will participate in 20 game sessions over four weeks at home. They will be assessed before and after treatment. By this autumn, we expect to know if this type of game can be combined with, or even substitute, psychostimulant drugs. ⁄ prospecting
It was long believed that attention deficit hyperactivity disorder (ADHD) only affected children, and that they grew out of it in their teens. But this is not true. “Today, we know that ADHD persists in about 60% of cases,” says Nader Perroud, a psychiatrist at Geneva University Hospitals and head of a practice specialising in adult hyperactivity which opened in 2011. Some 2% to 3% of adults, both men and women, are affected by the disorder. The symptoms are internalised with age. The person experiences an endless series of thoughts and ideas that prevents them from concentrating, especially when they have to perform boring or repetitive tasks. “Adults with ADHD are also very impulsive. They say that they think without really giving things consideration, cut other people off mid-sentence and take decisions without weighing the consequences,” says the Geneva-based psychiatrist. But hyperactivity can also be transformed into an asset. “Hyperactive people can process information with great speed and show extraordinary energy and determination when they enjoy something.” In this case, they no longer count the hours, overflow with ideas and often demonstrate immense creativity.
51
Hansel Schloupt (pictured), Product Design student at Lausanne Art School and child psychiatrist Michel Bader have developed a construction game specially designed for children with ADHD.
CORPORE SANO
prospecting
52
Doctor, I’m sick and I’m ashamed Sexual dysfunction, mental illness and other health problems remain taboo. This silence could prevent patients from getting better.
T
Crohn’s disease is an intestinal disorder that causes severe diarrhoea and affects about 8,000 people in Switzerland.
he diagnosis was simple. Agnès Déom had Crohn’s disease. She was 13 when she found out. And no one could know anything about it. “I was a teenager. I didn’t want to talk about it with my friends,” she says. “I only talked about it with my parents. But since then, I’ve even stopped talking about it with them. It’s too complicated. I’d rather keep it to myself.”
CORPORE SANO
text: Clément Bürge
“People with the disease don’t dare talk about it. It’s very taboo,” says Bruno Raffa, chairman of the Swiss Crohn’s and Ulcerative Colitis Association. “Suffering takes place in the toilet, a very private place. People are also afraid of ridicule and therefore tend to withdraw. Some are even scared to talk about it with their doctor.” Now age 30, Agnès Deom has overcome the taboo. An osteopath from the canton of Vaud, she can now better manage her illness. “Everything started getting better the day I decided to stop taking care of my disease by myself,” she says. “I talk to my doctor and we decide together which treatment is best for me.” Crohn’s disease is not the only disorder patients have trouble accepting. Mental illness and neurodegenerative diseases can be a thorny issue to discuss. According to a French survey by TNS Sofres, 47% of the population would be willing to hide their Parkinson’s disease if they developed it and 9 out of 10 would find a reason for hiding the disease. “It’s one of the biggest taboos in medicine today,” says Vincent Barras,
TABOo
53
medical historian at Lausanne University Hospital (CHUV). “These disorders affect the person as a subject. A man or woman would not be himself or herself if they have a mental illness. That’s what frightens them.” For a long time, patients suffering from this kind of illness did not even have the right to speak. “As the patients had lost their ability to reason, it was believed that they couldn’t discuss things with the doctor as an equal,” says Julien Dubouchet, Secretary General of the organisation Pro Mente Sana. Sexual dysfunction is another health problem that patients have difficulty discussing with their doctor. “Medical
“WHEN SOMEONE IS KNOWN TO HAVE A MENTAL ILLNESS, PEOPLE think every aspect of their behaviour is a symptom of their disorder.” Julien Dubouchet, pro mente sana
staff often have trouble talking about it because it confronts them directly with their own sexuality. That’s disturb-
Embarrassing Bodies, patients showing it all The sensationalist, irreverent and voyeuristic British TV reality programme “Embarrassing Bodies” shows the most shameful illnesses. During the show, Dr Christian Jessen and his assistants reshape deformed breasts, treat people with severe digestive tract disorders or help morbidly obese patients lose weight. The most famous case is Charlotte, now 13, whose feet were covered with warts. Her condition was a symptom of a faulty immune system. She needed a bone marrow transplant, which was performed during the show. “Embarrassing Bodies” draws millions of TV viewers and generates nearly 42% of the traffic on the Channel 4 website. CORPORE SANO
TABOo
54
ing,” says Francesco Bianchi-Demicheli, sexology specialist at Geneva University Hospitals. “Very often, the dysfunction is often considered less important because sexuality is perceived as being a ‘luxury’ problem. But it can destroy couples and propel people into a deep depression.”
willing to hire a person with that kind of disorder,” he says. “And only 14% would be willing to let them babysit their child.” The cruel irony of this prejudice is that it can change the patient’s own perception of themselves. “After continuously hearing that depressed people are lazy and cannot keep a job, the patient ends up integrating this mindset and becomes unable to work,” Julien Dubouchet points out. “That kind of thinking is toxic.”
Not only do patients suffer, but the taboo can lead them to understand very little about their condition. That can have a devastating effect on the patient’s private and professional life. “When someone is known to have a mental illness, people think every aspect of their behaviour is a symptom of their disorder,” says Julien Dubouchet. “An expression of normal joy will be interpreted as a mood swing caused by the illness. This unscientific analysis of their behaviour can then be used to justify dismissing them from their job.”
In some cases, the taboo can also impact where money goes into research. “For several decades, studies on sexual dysfunction have had more trouble obtaining financing than other disorders,” says Francesco Bianchi with a sigh.
In a recent study, Wulf Rossler, former director of the Department of Psychiatry at Zurich Hospital, showed that people do not trust someone suffering from a mental illness such as depression or schizophrenia. “According to our survey, only 38% of people would be
How can we turn that process around? A growing number of diseases previously thought to be “shameful” have been accepted as normal. “Ten years ago, women were uncomfortable talking about breast cancer,” says Claire Allamand, co-chair of the Breast Cancer Network. “And doctors wouldn’t listen. That situation has totally changed today.” Patients suffering from the disease have since started publicly opening up about it. “Not everything is perfect. Breast cancer treatments cause a number of sexual problems that are not yet discussed openly,” explains Claire Allamand. “But overall, things are better.” Prevention campaigns can make a difference, such as the “How are you?” posters that Pro Mente Sana put up all over Switzerland. “They raise awareness about mental illness,” says Wulf
CORPORE SANO
TABoo
55
Rossler. “But to truly break the taboo, more needs to be done.” The expert believes that the best way of fighting discrimination is contact with patients. “By spending time with those with a mental illness at work or in a fun activity, people realise that they
are normal and trustworthy. Several studies have proved that this type of interaction helps improve the image of certain diseases,” he says. “People become more tolerant from being in contact with others.” /
“Doctors would speak in Latin so that the patients wouldn’t understand them” Vincent Barras, medical historian at the CHUV, traces the origin and evolution of taboo illnesses. When did the first taboo illnesses appear? In the 19th century, when the moral values of high society – by definition more conservative – emerged and established a clear distinction between what was acceptable and what was not.
diagnosed with the disease was equivalent to a death sentence, hence the silence. People would use metaphors to talk about it. For example, tuberculosis was called “consumption”. In the 20th century, cancer gave rise to the same kind of behaviour.
What were the first “shameful” diseases? Certain kinds of sexual behaviour considered “deviant”, such as homosexuality, were rapidly deemed taboo. The upper classes believed anything sexual was impure. When doctors spoke about it, they would discuss it in Latin so that no one would understand.
Why is that? Very little was known about the disease, and no one knew how to treat it. Even worse, until only recently it was believed that people got cancer because of some bad behaviour, like smoking or eating poorly. People also thought the disease could come from guilt caused by committing an immoral act.
What were the most taboo illnesses? The major epidemics, such as tuberculosis, were long considered taboo. Being
Is cancer still a disease that is difficult to discuss? Until 30 or 40 years ago, doctors rarely told patients the truth about the serious-
CORPORE SANO
TABoo
ness of their case. But today, the disease does not carry the same taboo. Doctors now understand that they need to inform patients, so that they can better care for themselves. Legally, it has also become more difficult to hide the truth. Although cancer in itself is no longer considered “shameful”, certain aspects of the disease remain so, such as sexual problems resulting from certain treatments. How can these taboos be broken? We need to talk about them. It’s a challenge getting rid of past stigma, but talking about those disturbing diseases is a good way of fighting the taboo.
56
The heart that goes tick tock Text: Clément Bürge
A swiss researcher is developing a battery-free pacemaker with a mechanism based on the automatic wristwatch.
he 65-kg Alpine sheep lay motionless on the operating table, under anaesthesia. The researchers moved it onto its right side. Then a surgeon delicately made an incision into its chest wall and attached a small, round gold-coloured device to the animal’s beating heart. Adrian Zurbuchen, a brainy-looking, brown-haired young man, anxiously watched. It was the first time that the prototype he had just developed was being tested on a live animal. The University of Bern researcher wanted to create a battery-free pacemaker that worked using a mechanism inspired by automatic wristwatches. The energy harvested from the heart’s motion is what charges the instrument. CORPORE SANO
INNOVATION
One hour later, Adrian Zurbuchen felt relief. His experiment was a success. The sheep’s cardiac activity generated a constant electric flow of 16 microwatts, enough energy to power a basic pacemaker. Since this initial test was performed in April 2010, the 34-year old researcher has conducted a number of other trials and developed a more sophisticated prototype. “We tried the system on pigs,” he says. “We are now looking for a company that can finance our research and develop the product for commercial use within the next two to three years.” His next step is to integrate his self-charging system into an operational pacemaker.
57
eta
1. The motion of the heart sets off the oscillating weight, which starts moving. 2. A mechanical rectifier converts this movement into a rotation that turns in one direction. 3. The rotation winds a mechanical spring. 4. Once fully wound, the spring unwinds and charges an electric micro-generator. 5. The generator powers an accumulator used to store the electricity generated and produce a continuous flow of energy. 6. The accumulator in turn powers an electric circuit that provides energy for the pacemaker.
Zurbuchen’s device resembles a bare watch, with no face, external components or bracelet, but is equipped with fine wiring. The system boasts the advantage of lasting longer than traditional models. “A pacemaker generally lasts six to twelve years,” he says. “A Swiss timepiece mechanism can last 20 years without repair.” By changing the system, he believes that it could even work for CORPORE SANO
30 or 40 years. “Our mechanism is simpler than that of a watch, because it does not need to be aesthetic or tell time,” he says. “The device would also be operating in a protected environment with a stable temperature,” i.e. inside the human body. Martin Fromer, a cardiologist specialised in pacemakers at Lausanne University Hospital INNOVATION
(CHUV), believes that this innovation would be especially useful for young patients with heart conditions. “When a 12-year old child develops heart disease, we try to replace his or her pacemaker as rarely as possible,” the expert says. “Those are rather complex operations.” Adrian Zurbuchen’s instrument would also reduce the size and
58
Instruments for both surgery and watchmaking weight of pacemakers in general. “The battery is often what takes up the most space in the device,” he says. Another advantage is that the contraption would be placed directly on the patient’s heart. This eliminates the need for the leads that link the pacemaker to the heart muscle, and in doing so, makes it more reliable.But the road lying ahead for the researcher is not without obstacles. “An automatic watch is strapped onto the wrist and self-winds with the movement of the arm, which is different to the motion of the heart,” he explains. “We are trying to develop a system that best harnesses heartbeats. For several years, we have been analysing these movements to create the best absorption mechanism.” Complicating things, a sick heart does not necessarily beat regularly. “The irregularity of heartbeats could prevent the device from charging.” Adrian Zurbuchen’s invention highlights the potential of applying watchmaking expertise to medical technology. “The two fields share many similarities,” notes Simon Henein, who holds the Patek Philippe Chair in Micromechanical and Horological Design at the Swiss Federal Institute of Technology in Lausanne (EPFL). “Both surgeons and watchmakers work on a tiny scale and have to be extremely precise. These specialisations are also part of the same economic fabric. We have the same sub-contractors and use the same materials.” CORPORE SANO
The Patek Philippe Chair in Micromechanical and Horological Design at the Swiss Federal Institute of Technology in Lausanne (EFPL) is working with the measuring systems manufacturer Sensoptic SA to develop new surgical instruments that are useful to both watchmakers and doctors. “Watchmakers, like doctors, work on a scale that is so small that they can no longer feel the surfaces they press on,” says Charles Baur. “We are developing surgical instruments that would measure the pressure applied by a surgeon to a patient’s eye during corneal surgery.”
Luc Tissot, former chairman of the eponymous group, is one of the watchmakers who took advantage of this potential early on. Back in 1978, he used the expertise of his employees at his factory in Le Locle to produce pacemakers in collaboration with the pharmaceutical giant Roche. “We had to work with various metals at different temperatures. There were many technical constraints, and manufacturing a pacemaker has to follow a rigorous process,” Luc Tissot says. The product resulting from this collaboration has since been bought by the Swiss company Intermedics. More recently, Luc Tissot has founded a new start-up, Tissot Medical Research. The company has developed a contact lens that measures intraocular pressure to detect the first signs of glaucoma. “As in watchmaking, it involves a miniscule object,” the entrepreneur says. “We placed a sensor on the lens to measure eye pressure every time the patient closes their eyelid.” The device is expected to be available on the INNOVATION
market within the next two years. Despite this handful of examples of synergy between watchmaking and medicine, partnerships between the two fields remain too rare. “The design of medical devices is regulated by very strict standards, which watchmakers are unfamiliar with,” Luc Tissot says. “It is very complicated, or even impossible, to develop a product without first forging a partnership with a medical company.” However, Charles Baur, in charge of medical microtechnology of the Patek Philippe Chair at the EPFL, believes that watchmaking and medicine will soon work together as never before. “Connected watches have huge potential in medicine,” he says. “For example, a surgeon could check patient data in the middle of an operation simply by looking at his or her wrist, while remaining focused on the patient. That would be fantastic.” ⁄
59
Omeprazole C 17H 19N 3O 3S
C 17H 19N 3O3S every molecule tells a story Text: bertrand tappy
Whether caused by the food we eat, our lifestyle or our genetic make-up, excess stomach acid might seem to be a condition of our times. The number of ads boasting the merits of drugs and other therapies used to treat heartburn also show that it is a highly lucrative market. However, the problem has been around for decades. The only difference is that doctors were unable to control acid production in the stomach as well. “In the 1960s, antihistamines such as cimetidine and ranitidine were used to regulate gastric acid,” says Thierry Buclin of the Clinical Pharmacology Division at Lausanne University Hospital (CHUV). “But these drugs did not always pro-
A short biography of omeprazole, the “golden boy” drug of the pharmaceutical industry in the 1990s.
duce the desired results. If it developed into an ulcer, the only alternative at the time was surgery.” The situation changed radically in the 1990s with the introduction of omeprazole. This drug took a novel approach by directly inhibiting the mechanism responsible for producing gastric acid, known as the “proton pump”. Sold by Astra (since renamed AstraZeneca) after several years of development, it rapidly became the best-selling product in the history of the pharmaceutical industry. “Its launch was tremendous,” says Thierry Buclin.
CORPORE SANO
“Given its unquestionable effectiveness and low risk of side effects, many physicians started prescribing it at the slightest mention of gastric trouble.” We now know that things are not so simple. “The drug still improves day-today life for the thousands of patients who really need it,” says Thierry Buclin. “But it has recently been established that omeprazole can not only damage the bones and respiratory tract but can also cause a form of addiction in regular users. As long as they take the medication, their stomach still tries to produce acid,
zoom
despite the inhibition,” he explains. “When patients stop taking omeprazole, the stimulation persists and acid is secreted in higher amounts than before! They become convinced that they constantly need the drug.” Captive customers obviously guarantee long-term gains for the producer. But the patent expired in the early 2000s, and a tidal wave of generics came from the competition. Fortunately, Astra still had one more star: esomeprazole, a simplified version of the molecule claimed to be even more effective. “But we still have to wonder what its real benefits are, apart from providing the firm with a new patent” says Thierry Buclin. /
Text: Martine Brocard photo: philippe gĂŠtaz
60
The Gluten Paradox Many people are going gluten-free despite not being gluten intolerant. How does that impact their health?
C elebrities such as the tennis player Novak Djokovic, actress Gwyneth Paltrow and television host Oprah Winfrey have been swearing by it for years. Glutenfree eating is praised for helping lose weight, improving skin quality, boosting energy and more. The movement counts millions of devotees around the world. CORPORE SANO
Trends
61
INTERVIEW “It’s becoming an obsession” Dietitian Nicoletta Bianchi* regrets that gluten is getting all the blame. What should we think of the current “anti-gluten” trend observed in the United States? NB It’s really extreme. No food should be demonised like that without reason. Gluten is not toxic. It’s only a problem if someone is gluten intolerant. We’ve seen the same trend with milk. It’s only not recommended for people who are lactose intolerant or have a proven allergy to milk proteins. IV
How can the gluten-free trend cause problems? NB For some people, it becomes an obsession. The worst is when gluten-free eating is forced on children who did nothing and need it in their diet. We’re actively fighting against that, especially by explaining to parents the social drawbacks involved, for example at birthday parties. IV
How widespread is the gluten-free trend in French-speaking Switzerland? NB It’s really difficult to estimate the number of people who follow the diet. They often start doing it on their own or based on advice from alternative medicine practitioners. IV
*Nicoletta Bianchetti is a qualified dietitian at the Endocrinology, Diabetology and Metabolism Service at Lausanne University Hospital (CHUV) and consultant dietitian with the Swiss Coeliac Disease Association (Association Romande de la Coeliakie).
CORPORE SANO
Trends
62
About 30% of Americans have stopped or reduced their consumption of foods containing wheat, rye and barley, according to a survey conducted by the US market research firm NPD Group in 2013. In the United States, some even go as far as “bread shaming”, i.e. looking down on someone who eats bread. Although not as extreme, the glutenfree trend also exists in Switzerland. No figures are available on Swiss followers, but gluten-free products in supermarkets and specialised bakeries have met with resounding success, notwithstanding their high prices. Gastroenterologists report that gluten-related consultations have doubled or even tripled in the past three to four years. “There are two scenarios. People who are genuinely allergic with markers in the blood, and people who are sensitive to gluten but not allergic,” says JeanLouis Frossard, chief of the Gastroenterology Service at Geneva University Hospitals (HUG). A “good placebo”
The first case refers to coeliac disease, an autoimmune disorder. It gradually destroys the small intestinal wall and affects 1% of the population. Its varying symptoms include digestive disorders, diarrhoea, constipation, skin problems, depression, fertility problems, diabetes and arthritis. The list is long. No other treatment is available apart from a strict gluten-free diet.
“The diet involves a huge sacrifice and is very expensive.” Vanessa Brancato, dietician
From Communion hosts to lipstick Coeliac disease has long been a problem for practising Catholics, because the hosts – the pieces of “bread” or wafers eaten in Christian liturgical rites – contain gluten. A French company has come up with a solution and makes a glutenfree version that coeliac patients can bring to Holy Communion. Gluten-free lipstick and other cosmetics have also cropped up on the market. Specialists believe this to be more of a marketing stunt riding the glutenfree trend than a necessity for patients.
The second case refers to irritable bowel syndrome. “Patients suffer from constipation, diarrhoea or bloating, but tests reveal nothing abnormal,” says Jean-Michel Cereda, Gastroenterologist and Hepatologist at Sierre Hospital and CORPORE SANO
TRENDS
consultant at the HUG. A growing number of these non-coeliac sufferers are copying the stars and going gluten-free, often on their own volition, and say they feel better. To date, no study has substantiated this approach. “I get the feeling instead that it has the effect of a good placebo,” Jean-Michel Cereda says. His colleague Jean-Louis Frossard, however, believes that, “If people feel better, there must be some effect, but we don’t yet know what it is.” Expensive and complicated
Nutrition specialists share this scepticism. “Someone who is not intolerant but decides to give up gluten might feel better because they begin paying attention to what they eat, stop snacking and start eating a more balanced diet,” says Vanessa Brancato, a qualified dietitian and head of the Vaud chapter of the Swiss Association of Registered Dietitians. But if there is no need to go gluten-free, people should think twice about it. “The diet involves a huge sacrifice and is very expensive,” she says. In supermarkets, 500 grams of gluten-free spaghetti cost 4.20 Swiss francs, (8.40 Swiss francs per kilo), compared with 95 cents a kilo for the least expensive brand of spaghetti. What’s more, completely cutting gluten out of their diet is more complicated
63
than people think. “Some people say that they have adopted the diet but have only stopped eating bread and pasta. They don’t realise that many other foods contain gluten. It is in pre-cooked dishes, beer, sauces and so on.” says Thérèse Farquet, a dietitian based in Geneva. The diet involves being very strict. For example, a wooden spoon used to stir regular pasta must not be used in a saucepan of gluten-free pasta. That said, giving up gluten even if it is not necessary “is not particularly dangerous, as long as people maintain a balanced diet,” says Vanessa Brancato. “By opting for other grains, people even end up eating more whole starch foods, such as corn, buckwheat, lentils, quinoa or chestnuts, thus increasing their fibre intake.” Thérèse Farquet believes that, “Followers risk a boring diet more than any nutritional deficiencies.” Necessary testing
Be careful, doctors warn, there is a paradox when it comes to gluten-free diets. Individuals who have no problem digesting rye, wheat and barley give up these foods to join the fad, while coeliac sufferers have not been diagnosed as such and run a higher risk of developing cancer. “The risk returns to normal when they follow a treatment that completely eliminates gluten,” Jean-Louis Frossard points out. It is important to detect the disease early. A 1999 study by researchers from Umea University in Sweden reported that eight out of ten adult coeliac sufferers have not been diagnosed with the disease. Another study conducted by Dr Cereda in 2004 revealed that in Sierre, Switzerland, only one person out of 500, or even 1,000, is diagnosed with the disease. CORPORE SANO
What is gluten intolerance? Gluten is a family of proteins found in wheat, barley and rye that gives dough its elasticity. Gliadin, one of the molecules contained in gluten, is what causes coeliac disease. This disorder is not an allergy to gluten, but an immune reaction. Unlike an allergy to bee stings, in which the antibodies react within minutes following the sting, the cells react gradually with coeliac disease. Gliadin causes inflammation of the digestive tract, gradually blunting the intestinal villi. These small, finger-like projections line our small intestinal wall and are responsible for absorbing the nutrients contained in the foods we eat. When the villi are damaged, the absorptive surface area shrinks, therefore increasing the risk of cancer.
tRENDS
This means a prevalence that is five to ten times lower than the European average. Yet diagnosis is relatively simple. It involves a blood test to detect immune markers of the disease. A positive test is confirmed with a biopsy of the small intestine. When a coeliac patient begins the diet, the results are often spectacular. “I had a 25-year old patient who was never feeling well, couldn’t get out of bed before noon and couldn’t have a child. Since her diagnosis, she now has three children and runs the Sierre-Zinal race and the New York marathon,” says Jean-Michel Cereda. Practitioners therefore ask all those interested in going gluten-free to get tested first. “When someone tells me that they feel much better since they began their diet but has not been tested, I can’t be sure if they suffer from coeliac disease or not,” the specialist says. “If they give up gluten, the disease will not be detected in their blood tests. So I have to ask them to start eating gluten again to get tested. Things should be done in the right order!” The test for coeliac disease is becoming as simple as a pregnancy test. The Valais-based start-up Augurix has developed one that costs 45 Swiss francs and has been available in pharmacies since 2011. Migros also came out with a test in 2013 for half the price, but specialists disagree as to its reliability. ⁄
64
Back to the future Innovation Current high-tech prosthetics and instruments date back to rudimentary but ingenious systems. Illustration in images. Text: Melinda Marchese
The earliest versions of the clyster were in wood, then in pewter. This large cylindrical instrument could weigh up to 2 kg and came into widespread use in the 17th and 18th centuries, mainly as a cleansing enema. Its modern descendant is no other than the plastic syringe that has been in use since the 1970s. And it weighs only a few grams. “Plastic revolutionised medical instruments,” says Roxane Fuschetto, head of collections at the University Institute of History of Medicine and Public Health in Lausanne. “Objects became lighter, and some, like the syringe, are now disposable for single use. This guarantees that they remain as sterile as possible.” Technological advances have also been used to create artificial systems that are increasingly similar to the ones they are designed to replace. A premature newborn is now placed in an incubator providing an environment close to that of the mother’s uterus. Amputees are soon likely to regain a movable limb that is sensitive and covered in skin.
CORPORE SANO
in the lens
65
1/
Hand in hand
lifehand2, touch bionics, Science Museum, London/Wellcome Images
The image below depicts an artificial wooden hand dating back to World War I from Birmingham, United Kingdom. During this period, 41,000 British soldiers lost limbs on the front lines, prompting innovation in prosthetics. The thumb, index and middle fingers are visibly jointed. Spectacular progress has been made since then, both in materials and transplant methods. The UK company Touch Bionics has developed a bionic hand called i-limb digit, featuring an outer appearance meant to resemble a natural limb (opposite). The i-limb can be used to push, pull, carry lightweight objects or type on a keyboard. In March 2013, a neuroprosthetic device developed by the Swiss Federal Institute of Technology in Lausanne caused a buzz when its user was able to grip objects and feel sensations (left).
CORPORE SANO
in the lens
66
2/
Snug and warm
The survival rate for premature newborns has continued to rise in the past few years due to progress made in the design of incubators. These little glass cubes can now maintain the optimum temperature in an environment very close to that of the mother’s uterus. The incubator opposite has a simple electric heating system. Photographed in Prague in 1947 at the Štvanice Birth Centre, this premature infant is wrapped in warm clothing, as hypothermia is one of the causes of neonatal mortality.
CORPORE SANO
in the lens
67
Listening in
/3
heidi diaz, Venek Svorcik/CTK, DR, SCIENCE PHOTO LIBRARY
In Switzerland, nearly 100 new cochlear implants are fitted every year. These devices, like the one opposite, manufactured by the Austrian company Med-El, are used today to improve the hearing capability of the profoundly deaf or severely hard-of-hearing, by surgically implanting electrodes directly on the auditory nerve.The ancestors of hearing-aid systems are ear trumpets. These instruments were placed in the auditory canal of the hearing impaired patient. The funnel system collected and amplified sound waves to improve hearing. The model in the picture opposite was made in England around 1860 by F.C. Rein and Son, a manufacturer specialised in acoustic instruments.
CORPORE SANO
in the lens
68
CORPORE SANO
in the lens
69
/4
On 22 December 1895, German physicist Wilhelm Conrad Röntgen produced the first X-ray using the hand of his wife, Anna Bertha Ludwig Röntgen. The bones are visible, surrounded by shading which represents the flesh. The dark spot on the ring finger is Mrs Röntgen’s wedding ring. One of the most common imaging techniques today uses magnetic resonance signals. An MRI shows details down to the micrometre, such as the brain’s nerve fibres (pictured above).
5/
Headaches
Trepanning, a word derived through the French trépan from the Greek trupao, meaning bore or pierce, was long used to penetrate the skull in order to operate on the brain. The instrument dating from the 19th century was photographed at the museum in the National veterinary school of Alfort, France. Today, devices like the Gamma Knife are used to treat brain lesions without having to open the skull. The Gamma Knife delivers 192 beams of cobalt radiation focused precisely on the targeted areas. This out-patient procedure does not require general anaesthesia.
CORPORE SANO
in the lens
Association des amis du patrimoine médical de Marseille, Heidi Diaz, Patric hagmann, Deutsche Röntgen-Museum
Seeing through it all
70
ISABELLE LEHN
Director of Healthcare at Lausanne University Hospital (CHUV)
We must stand together and be innovative, with a shared vision for patient care research.
For 2014 alone, the French government allocated €4.4 billion to 28 projects as part of the nursing and paramedical hospital research programme. That is three times more than the funding set aside in 2012, for a programme launched just barely four years ago. This rapid growth reflects the promising development of patient care research.
Now that this first step in the SNSF’s strategy is complete, the first PhD in nursing science earned in French-speaking Switzerland was awarded in 2013. To conduct and finance their scientific studies, researchers in these developing specialities must now look to the longterm structures of the SNSF and seek out support from foundations, organisations and specialised government research councils, as do others on the market.
This is no small feat. We must be effective and innovative, standing together with a shared vision of patient care research. Nursing science has taken this route with the Swiss Research Agenda for Nursing (SRAN). Nursing, physiotherapy and ergotherapy However, it needs to work on establishing are relatively young fields in Europe more collaboration networks between univerin terms of academic research. In sities, top specialised schools and hospitals, Switzerland, these areas have developed gradually increasing the quantity and quality over the past ten years thanks to funding of proposed projects. Being newcomers could from the Do Research (DORE) programme, actually work in our favour, as we will be able under the Swiss National Science to team up with existing research platforms Foundation (SNSF) and the backing from and forge partnerships with government bodies prestigious specialised schools. This support, geared specifically to promoting emerging and more experienced researchers, such as our fields of study, was offered to help them physician colleagues. gradually gain the necessary expertise and set up research structures. That is how knowledge and patient care practices will continue to develop, guided by clinical research that will serve both patients and their loved ones. ⁄
To know more
PHILIPPE Gétaz
Swiss National Science Foundation: www.snf.ch/en Swiss research agenda for nursing: www.svpl.ch
CORPORE SANO
commentary
cursus
commentary
More importantly, this staggering progress is extraordinarily beneficial for the majority of patients. However, it makes patient Prof. Pierre-François Leyvraz care and hospital organiGeneral Director at the CHUV sation considerably more complex. How can we offer quality medicine and medical research – which the University of fter graduating in Lausanne and the hospital are constantly 1975, I firmly bedeveloping to provide the best of what lieved that I was, is available (and not everything that is like my contemavailable) – while factoring in the patient’s poraries, lucky to cultural, social and economic environhave experienced ment? How can we practise sophisticated, an extraordinary complex medicine without disregarding period in the the human aspect that is essential to its development of medicine. Science has effectiveness? progressed more in these past forty years Even though science has made than over any previous centuries. When I mind-boggling progress, the patient’s was a student in the 1970s, I read Chance and Necessity (Le hasard et la nécessité) by needs were the same in the 16th century Jacques Monod, which said, “The ancient as they will be in the year 2300. Patients alliance has been broken; man finally need to be received, cared for and above knows that he is alone in the indifferent all, heard. The major risk now with the immensity of the universe from which he development of personalised medicine, has emerged by chance. No more than his when patients can realistically receive destiny, his duty is written nowhere. It is custom care based on their genome, is for him to choose between the Kingdom that the practice of medicine becomes and the darkness.” depersonalised. That it loses precisely Jacques Monod, working with what it should keep, its humanity. ⁄ François Jacob, won the Nobel Prize for showing that DNA was the trigger for biochemical reactions. It was the early stages of genetics. Now, some forty years later, genome sequencing can be ordered online for $5,000. That’s a quantum leap.
A
philippe gétaz
curSUS
career at the chuv
Fighting for humanist medicine
71
cursus
portrait
A
career at the chuv
Christèle Rutishauser is an ergotherapist. After starting her career in France, she joined Lausanne University Hospital to specialise in geriatrics. Text: Bertrand Tappy, pHOTOS: GILLES WEBER
n 85-year old woman busies herself in the kitchen. We’ll call her Jeanine. She had an operation at Lausanne University Hospital (CHUV) a few weeks ago after a bad fall and is now a patient at the Centre for Geriatric Treatment and Rehabilitation (CUTR Sylvana), just north of Lausanne. Jeanine hasn’t been back to her apartment for several days and is eager to go home. But she’s afraid she won’t be as independent as she used to be. Will she be able to get dressed on her own? Prepare her food? Christèle Rutishauser is one of the people who can answer Jeanine’s questions. She is responsible for drawing up an initial assessment of just what this elderly woman, who is bustling about in a kitchen located in the ergotherapy unit, is able to do. “My colleagues
72
and I assess every person who comes to Sylvana,” says the specialist. “Physiotherapists take care of general mobility, while we check if the patient can perform everyday tasks and movements at home, such as bathing, getting around, preparing tea or coffee, etc. We sometimes hear that ergotherapists just watch people bake cakes and organise fun workshops,” she says. “We may look as though we’re just observing, but we actually have more than 35 criteria to evaluate as we watch the patient working!” Although Christèle now talks passionately about her job, she basically stumbled into the field. “I wanted to work in healthcare but didn’t really know what area,” says the Lyon native. “When it came time to choose my specialisation, I was convinced by friends that the job would be fascinating. And I
don’t regret my choice.” The next decision would be to come and work in Switzerland, where “the conditions allow you to do the job much better than in France, even though the field is expanding rapidly there too.” Apart from these assessments, Christèle Rutishauser and the other members of the ergotherapy team work side by side with all the other professionals at the hospital (doctors, care providers, physiotherapists, liaison nurses, dietitians and chaplain) and from outside healthcare services so that Jeanine can regain independence that is as close as possible to what she had “before”. “Naturally, many other jobs require this interdisciplinary approach,” says Christèle Rutishauser. “But in geriatrics, as in paediatrics, patients depend more on their family and friends. It involves a lot of dialogue, which gives our work a unique human aspect,” she goes on. “Not to mention that – of course – ergotherapists never stop challenging themselves and growing. You can see that we do much more than bake cakes!” ⁄
cursus
career at the chuv
Although observation is an essential part of Christèle Rutishauser’s work, it does not mean being passive. She has more than 35 behavioural criteria to evaluate at any given time.
At Sylvana, just north of Lausanne, a kitchen was built to measure residents’ functional independence.
73
franรงoise ninane
tandem
Anne-sylvie ramelet
cursus cursus
career at the chuv
S
ometimes the Researcher Anne-Sylvie Ramelet Anne-Sylvie Ramelet little things and Françoise Ninane and clinical nurse Françoise Ninane are all it takes: now co-chair the work to continuously improve a word, attention paid CHUV’s recently to room temperature, formed Research and patient care practices at Lausanne sharing information, Development CommitUniversity Hospital. and so on. Whatever tee (“Commission de Text: Camille Andres, photos: eric déroze it may be, for a recherche et dévelhospitalised patient, oppement”, CRD) set this “care — day to day, hour by hour, down to the up to promote synergies between the hospital and most infinite detail — counts tremendously,” says the IUFRS. As Anne-Sylvie Ramelet explains, “This Françoise Ninane, assistant director of patient care will help academics keep up with the realities of at Lausanne University Hospital (CHUV). What is patient care, produce research that meets people’s very generally referred to as “patient care” is now needs and make this research expertise more the subject of extensive research, to the same systematically available to the CHUV.” degree as medicine and pharmacology. Françoise Ninane can count on Anne-Sylvie Ramelet In French-speaking Switzerland at the University to “translate a clinical concern into a scientifically Institute of Training and Research in Patient Care provable research topic”. And likewise, Ms Ramelet (“Institut universitaire de formation et de recherche considers the associate director of patient care en soins”, IUFRS) in Lausanne, nursing science has the ideal ally in wading through the maze of the been developing since 2008 and collaborating hospital. “Françoise perfectly understands the with the CHUV. “This exchange gives students the institution and how it works. She gives me precious chance to gain hands-on clinical experience,” says advice and immediately tells me who to go see,” Anne-Sylvie Ramelet, full professor and director says Anne-Sylvie Ramelet. This is key as the CHUV of the IUFRS since January 2015. has nearly 10,000 employees. Several student research studies have resulted in improvements to hospital practices. When the Nursing Health Care Centre at Lausanne University Medical Polyclinic (“Policlinique Médicale Universitaire”) decided to review its health care programme for asylum seekers, it contacted IUFRS students. They examined the existing guidelines then came up with ideas to help the nursing team make choices relevant to the context. The collaboration between the two establishments has intensified since June 2014.
75
Like Françoise Ninane, whose career has mainly been dedicated to caring for children, Anne-Sylvie Ramelet is specialised in paediatrics. “We share the same formatting,” Françoise Ninane jokingly says. The CRD has not yet defined its research priorities, but both chairwomen mention pain management and caregivers as priority topics. These issues concern each department at the CHUV, from the emergency room to psychiatry to surgery. ⁄
cursus
CHUV physician wins an award Dr Nicolas Bertholet, associate physician at the Alcohol Treatment Centre at Lausanne University Hospital, has recently received the New Investigator/Educator Award from the Association for Medical Education and Research in Substance Abuse (AMERSA) in recognition for the Centre’s cross-border collaboration projects. BT ADDiction
A new chief of service Prof. Philippe Ryvlin was appointed the new chief of the Department of Clinical Neuroscience on 1 January 2015. Prior to this position, he was chief of the Department of Functional Neurology and Epileptology at the Hospices Civils de Lyon hospital in France. Dr Ryvlin has been highly active with international organisations, acting as president of the European Association of Video-EEG monitoring units or co-director of the European epileptology research network. BT NEUROSCIENCE
76
news
Novel therapeutic approach Dr Hassib Chehade and Professor Manuel Pascual published a case report in the journal Pediatrics, suggesting a novel therapeutic strategy for cases of severe acute rejection of kidney transplants. transplants
It all began with Fabio*, a seven-year old boy braving doctors’ second attempt at a kidney transplant. The operation went well, performed by Dr Maurice Matter from the Service of Visceral Surgery. On the fourth post-operative day, the patient’s condition began to deteriorate. The new kidney was being attacked by Fabio’s own antibodies. This type of severe acute rejection is extremely rare and fortunately only affects 5% of cases. “As he had already lost a first kidney, we knew there was a significant immunological risk of rejection,” says Manuel Pascual, head of the transplantation centre. “That’s what motivated us to attempt – with approval from Fabio and his family – this new therapeutic strategy.”
The doctors decided to try eculizumab, an anti-C5 monoclonal antibody. The drug is typically used to treat certain rare diseases affecting the enzymatic system, which is also involved in certain forms of severe acute rejection. “Eculizumab had already been prescribed in adult organ transplantation, but as a last resort. So it was often too late to save the transplanted organ,” says Hassib Chehade, head of the Paediatric Nephrology Unit. What was novel in Fabio’s case is that the drug was administered early on, avoiding the need for more aggressive traditional treatments. In less than 24 hours his condition improved and the boy is now saved. Two other adult cases have recently been treated successfully at Lausanne University Hospital (CHUV). This confirms the efficacy of this new therapy in dealing with severe acute antibody-mediated rejection. “And we hope that we can study and apply this discovery to other types of transplants,” says Manuel Pascual. BT
cursus
career at the chuv
migration
Dr Sébastien Déglise spent one year in France to learn a new surgical technique. One of your specialities is aortic endoprosthesis implantation. What more can you tell us about that? I treat patients who’ve been diagnosed with an abdominal or thoracoabdominal aortic aneurysm. This dilation of the aorta can rupture and cause often fatal haemorrhaging. Treatment requires surgery, but the alternative to traditional open surgery is the implantation of an endoprosthesis. The spring-like tube is inserted through the femoral artery by way of small incisions in the groin. The doctor is guided to the aneurysm site by imaging and places the endoprosthesis in the aorta to cover the swelling and prevent it from rupturing. The hospital stay is reduced considerably and the consequences are much less serious for the patient. Plus, these implants are standard, so less costly and more readily available. Sometimes the aneurysm is located too close to the kidneys. A traditional prosthesis can’t be used without the risk of covering the renal arteries.
GILLES WEBER
Which is not the case with the new “complex” prosthesis. That’s right. The endoprosthesis developed in recent years can be used for more hard-to-treat aneurysms that involve the renal or visceral arteries.
77
last Name Déglise first name Sébastien with the chuv since 2002 TITle Associate physician with the Vascular Surgery Service
You had to go abroad to learn this technique? I spent one year at Bordeaux University Hospital in the Vascular Surgery Service headed by Dr Midy and Dr Ducasse. At the Lausanne University Hospital, I worked with my colleague Dr Saucy to present the project to our department, where we had to take into account medical and financial factors. By January 2015, we had already implanted nearly 10 complex endoprostheses and come up with different ways of teaching this technique to our colleagues. ⁄ BT
BACKSTAGE THROUGH THE LENS The portfolio presented on p. 64 of this issue was developed in collaboration with the University Institute of the History of Medicine and Public Health in Lausanne. Roxane Fuschetto (pictured) is in charge of the archiving and conservation of the few thousand objects held by the Institute.
schizophrenia
heidi diaz
For the article on psychosis in cities, Polish artist Adam Quest designed the metaphorical illustration on p. 41.
78
contributors
Clément Bürge
Rachel antille
MARTIne brocard
Clément Bürge is a Swiss journalist based in New York. With a degree in journalism from New York University, he won the Media Award 2014 from the Swiss Academy of Science. Clément Bürge contributed to this issue by delving into how watchmaking techniques are being applied to innovate in medicine (p. 56) and how patients deal with having a taboo disease (p. 52).
Rachel Antille has been a web editor at Lausanne University Hospital since 2013. Prior to this, she worked at the Swiss public broadcasting organisation Radio Télévision Suisse and the Swiss Federal Department of Foreign Affairs. For this issue of “In Vivo”, she interviewed the engineers from Spacepharma in Delémont (p. 12).
Holding a degree in Russian linguistics, Martine Brocard has been working for several years as a journalist for various magazines in French-speaking Switzerland. For this issue of “In Vivo”, she focused on the trend of gluten-free diets (p. 60) and the latest research on hyperactivity (p. 49).
In Vivo has added two more awards to its list of honours. In October 2014, the magazine won the “Special Jury Prize” at the SVIK Awards held in Basel by the Swiss Association for Internal Communication. “In Vivo succeeds in presenting health issues in a news magazine format,” says jury president
AWAR D
philippe gétaz, DR, Lucas chambers
Two more awards for “In Vivo”
79
Daniel Ambühl. “That’s precisely how information from a major institution should be presented!” In December, In Vivo won the award for best external publication at the European Excellence Awards (EEA) celebrated in Paris. The EEA recognises the best work in communication and public relations at the European level.
In Vivo
Magazine published by the Lausanne University Hospital (CHUV) and the news agency LargeNetwork www.invivomagazine.com
PUBLISHER
CHUV, rue du Bugnon 46 1011 Lausanne, Switzerland T. + 41 21 314 11 11, www.chuv.ch redaction@invivomagazine.com Editorial and graphic production LargeNetwork, rue Abraham-Gevray 6 1201 Geneva, Switzerland chief editors T. + 41 22 919 19 19, www.LargeNetwork.com Béatrice Schaad and Pierre-François Leyvraz Project manager and online edition
Bertrand Tappy Thanks to
publications managers
Gabriel Sigrist and Pierre Grosjean
project manager
Fiona Amitrano, Alexandre Armand, Anne-Marie Barres, Melinda Marchese Francine Billote, Valérie Blanc, Gilles Bovay, Virginie Bovet, Mirela Caci, Stéphane Coendoz, Muriel Cuendet Graphic design managers Teurbane, Stéphanie Dartevelle, Isabel De Dias, Diane Diana Bogsch and Sandro Bacco De Saab, Muriel Faienza, Marisa Figueiredo, Serge Gallant, Christine Geldhof, Déborah Hauzaree, Katarzyna Gornik-Verselle, Pauline Horquin, Nathalie editorial staff Jacquemont, Nicolas Jayet, Emilie Jendly, Laure LargeNetwork (Camille Andres, Céline Bilardo, Martine Brocard, Clément Bürge, Treccani, Anne-Renée Leyvraz, Cannelle Keller, Erik Freudenreich, Sophie Gaitzsch, Olivier Gschwend, Benjamin Keller, Melinda Elise Méan, Laurent Meier, Brigitte Morel, Oettli Marchese, Jean-Christophe Piot, Julie Zaugg), Rachelle Antille, Bertrand Tappy Thuy, Denis Orsat, Manuela Palma, Odile Pelletier, Fabienne Pini-Schorderet, Isabel iconographic research Prata, Sonia Ratel, Massimo Sandri, Marite Sabrine Elias Ducret Sauser, Dominique Savoia Diss, JeannePascale Simon, Christian Sinobas, Elena Teneriello, Céline Vicario, Joëlle Isler, Images Nicole Gerber, Pierre Fournier, Fabio CEMCAV (Eric Déroze, Heidi Diaz, Philippe Gétaz, Gilles Weber), Becce, Patric Hagmann and the CHUV’s Thierry Parel, Lalita Prima, Adam Quest Communications Service. distribution partner
BioAlps
Layout
Romain Guerini and Diana Bogsch
TRAnslation
Technicis printing
PCL Presses Centrales SA 17,500 copies in French 2,500 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.
follow us on: twitter: invivo_chuv facebook: MAGAZINE.invivo
EMPATHY
CARE
EDUCATION COMPETENCE
IN EXTENSO
What looks reveal