In Vivo #8 ENG by IN VIVO

Think health

No. 8 – MARCH 2016

UNDERSTANDING YOUR

BACK NO MORE PAIN /

PHYSICAL ACTIVITY / SMART SURGERY / HI-TECH T-SHIRTS

BACTERIA The hunt for multidrug-resistant germs has begun INNOVATION Using video games to get well REPORT Corneal transplant in the operating room Published by the CHUV www.invivomagazine.com IN EXTENSO ALL ABOUT VITAMINS

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IN VIVO / NUMBER 8 / MARCH 2016

CONTENTS

FOCUS

11 / CARE Stopping back pain Reducing the pain and the costs. BY MELINDA MARCHESE

MENS SANA

20 / INTERVIEW Patrick Woo: “I hunt viruses around the world”

BY JULIE ZAUGG

24 / DECODING Super-bacteria are gaining ground

IN SITU

BY JULIE ZAUGG

07/ HEALTH VALLEY

27 / INNOVATION

Hospitals turn to 3D printing

Playing for health BY SÉVERINE GÉROUDET

CURSUS CORPORE SANO

31 / PROSPECTING Fixing a damaged heart BY RACHEL PERRET

34 / INNOVATION

42 / COMMENTARY Money and questions

44 / TANDEM A pair of eating disorder experts

Say cheese, you’re about to be intubated!

36 / IN THE LENS Transplant in micrometres BY MELINDA MARCHESE

NEW ARTICLES ON WWW.INVIVOMAGAZINE.COM COMING DURING THE SPRING

DR, SÉBASTIEN MARTINERIE, CLÉMENT BÜRGE

BY PAULE GOUMAZ

CONTRIBUTORS

YANN BERNARDINELLI

SÉVERINE GÉROUDET As a staff writer for LargeNetwork, Séverine Géroudet contributes regular articles on major cultural, social and technological issues affecting our society. She reported on the success of serious games in medicine for “In Vivo” (p. 27).

This former neuroscience researcher now puts his scientific expertise to use as a freelance writer. For this issue of “In Vivo”, Yann Bernardinelli contributed to the Health Valley section (p. 06).

AW ARD

The journalist Melinda Marchese, head of production for In Vivo at LargeNetwork, won the Suva Media Award in the press category for her article “The gut, your other brain”, published in March 2015. The panel of judges described

her work as “amazing, rigorously researched and clearly written, featuring beautiful iconography.” The SUVA awards promote French journalism specialised in occupational and personal accident prevention and other health issues. /

THIERRY PAREL, DR

“IN VIVO” WINS THE 2015 SUVA MEDIA AWARD

Editorial

THE SPINE: A COMPLEX AND FRAGILE ORGAN

PHILIPPE GÉTAZ

PIERRE-FRANÇOIS LEYVRAZ General Director at the CHUV

A few million years ago, man decided to stand upright. We may never know why he did that, but our back is the direct result of the thousands of years of “bipedalism” since he made that choice. The human back is an incredibly complex organ featuring intricate biomechanics that have enabled us to defy gravity. The spine is like a mast, supported by dozens of muscular stays, offering both resistance and mobility. However, behind this wonderful evolutionary triumph is a fragility that never ceases to fascinate me as an orthopaedic doctor. This fragility exposes our spine to a wide range of injuries, disorders and diseases. Research fights day after day to find ways to remedy back problems, producing reams of publications every year. And that research has paid off. Fifty years ago, herniated disc surgery was a medical adventure, with patients spending weeks in hospital for irregular results. These days, the same procedure can even be performed on an outpatient basis! And that’s just the tip of the iceberg. The number of patients suffering from back issues is clearly rising, even when no evidence of any anatomical disorder is found. That’s because our back can bear the brunt of psychosocial factors that are harder to detect. To understand what’s going on, we need to look beyond X-rays and MRI scans into lifestyle factors, such as posture at work, the exercise we get (or don’t get) and psychological problems. Hospitals now understand that doctors are no longer enough. A whole armada of professionals – physiotherapists, ergotherapists, psychotherapists, ergonomists, radiologists, etc. – is needed to treat back issues properly. Nowadays, these experts are brought together in multidisciplinary facilities like the new Centre for Spinal Surgery at the Lausanne University Hospital. This vast range of expertise is reflected in the number of different specialities that have contributed to this magazine’s special report. In deciding to stand upright, our prehistoric ancestor probably had no idea of the adventure he was taking us on. But considering the amazing progress in medicine to better understand our spine, can we really hold it against him? ⁄

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

IN SITU

HEALTH VALLEY Panorama of the latest innovations.

GENEVA

P. 08

OncoTheis has rebuilt a piece of lung tissue in vitro to study the behaviour of tumours.

PLAN-LESOUATES P. 08

A new treatment for endometriosis was developed by the company ObsEva.

LAUSANNE

P. 10

IVÁN BRAVO

The smart bandage by Theran Optics is designed to diagnose and monitor chronic wounds.

IN SITU

HEALTH VALLEY

FRIBOURG

P. 10

A new technique triggers the immune system to fight cancer cells.

MARTIGNY

P. 08

The start-up Eyeware has developed software that can be used to control a computer by only using eye movement. 5

IN SITU

HEALTH VALLEY

START-UP CONTRACEPTION

Gene Predictis, based at the EPFL, has approved a new test that assesses the risk of blood clotting in women on birth control pills. Today, 400 out of the 350,000 Swiss women taking this form of contraception develop deep vein thrombosis. The test could identify eight times more women at risk than standard care based on the analysis of a series of genes involved in forming blood clots.

STERILISATION

Sterilising surgical equipment anywhere in the world and at a lower cost? That’s what Sterilux hopes to achieve with its autonomous UV irradiation system, the SteriBox. The SteriBox was invented by a team of students from EPFL and from the University of Art and Design (ECAL), the former responsible for technical aspects and latter for art and design.

OCULOMETRY

“We need to instil the entrepreneurial spirit at schools” PHILIPPE LEUBA HEAD OF THE DEPARTMENT OF ECONOMY AND SPORTS IN THE CANTON OF VAUD, AT THE 20TH ANNIVERSARY CELEBRATION OF THE FOUNDATION FOR TECHNOLOGICAL INNOVATION (FIT). SINCE ITS SET-UP, FIT HAS AWARDED 21 MILLION SWISS FRANCS IN LOANS AND GRANTS TO START-UPS IN FRENCH-SPEAKING SWITZERLAND.

60,000,000 In Swiss francs, the amount invested to finance a new treatment for endometriosis developed by ObsEva, a company based in Plan-les-Ouates. This gynaecological disorder affects 176 million women worldwide.

Eyeware, a Swiss start-up based in Martigny, is on its way to developing software that can track the eye and facial movements of people who have lost the use of their arms and analyse these movements to control computers. The company plans to release its invention to market in 2016.

IN VITRO

How can new lung cancer treatments be tested while limiting trials on live animals? The young Geneva-based company OncoTheis has addressed that dilemma by developing three-dimensional cell culture models that imitate both healthy and diseased lung tissue. Their system was awarded the 2015 Lush Prize for Science.

THE DEVICE

SMART BANDAGE Theran Optics, a company started by two EPFL engineers, won the AXA Innovation Award for its futuristic smart bandage developed to diagnose and monitor chronic wounds.

Brain cancer remedy

NEUROLOGY Drugs currently available on the market have turned out to be effective against glioma, the most common form of brain cancer. This observation was made by Professor Douglas Hanahan, from the Swiss Institute for Experimental Cancer Research, part of the Swiss Federal Institute of Technology in Lausanne (EPFL). Autophagy is the process of cell selfdestruction and a potential new way to fight brain tumours. Scientists have been studying existing drugs that could induce this mechanism as a therapy. They have combined an anti-depressant and an anticoagulant to slow metastasis and the growth of gliomas. The discovery offers genuine hope for developing a treatment rapidly as the drugs are already registered.

IN SITU

HEALTH VALLEY

Hospitals turn to 3D printing The use of 3D printing is increasing at Swiss hospitals, especially to prepare for surgery.

GILLES WEBER, ADRIAN SCHINDLER, SÉBASTIEN MARTINERIE

INNOVATION In December 2015, the Geneva University Hospitals (HUG) performed ankle replacement surgery using 3D printing for the first time in Switzerland. This technique is used to design guides to cut and position the implants, which are then placed directly on the patient’s tibia and talus during the operation. What are the advantages of 3D printing? Greater precision and customisation while reducing surgery time. “A traditional ankle replacement procedure lasts an hour and a half,” says Nicolas de Saussure, the spokesperson for the hospital. With 3D printing, the operation takes only 45 minutes, considerably alleviating the patient’s stress.” Victor Dubois-Ferrière, head of the foot and ankle surgery team, brought the technique back from Canada after taking a special training course. This application of 3D printing is still scarcely used in Europe. At HUG, 3D printed cutting guides are now used in most ankle replacement cases, and the new procedure could eventually be applied to shoulder, hip and knee replacements.

An eye socket for 550 Swiss francs This event reflects the growing importance of 3D printing at Swiss hospitals. HUG also use it to prepare for certain orthopaedic, plastic and oral and maxillofacial surgical procedures. “3D printing is no longer considered a thing of the future. It has become a reality,” says Marc Thurner, director of RegenHU operating out of Fribourg. His company develops 3D bioprinting solutions, working with the Swiss university hospitals in Geneva, Bern and Zurich. The Lausanne University Hospital (CHUV) bought a ProJet 3500 SD 3D printer in November 2013 for 70,000 Swiss francs. The machine is mainly used to produce organs to prepare for surgery. These 7

TEXT SOPHIE GAITZSCH

ABOVE: JOSÉ PAHUD, OF CHUV’S PRINTING AND REPROGRAPHY CENTRE, A PRINTED EYE SOCKET AND A TRACHEA SEGMENT.

high-precision, life-size polymer plastic reproductions are designed based on the patient’s medical imaging. The prints help the surgeon visualise and plan the procedure, prepare the replacement part or practise. “The object can be handled, cut or perforated,” says José Pahud, head of CHUV’s Printing and Reprography Centre. “This avoids subjecting the patient to a battery of X-rays. However, the prints are not biocompatible and cannot be used as implants or cutting guides.” Nearly 70 parts have been printed at CHUV over the past two years, and a number of projects are under way. To print a model of an eye socket (the most frequently requested part), it takes an hour and a half to create the file and 19 hours of printing and finishing. The whole process costs 550 Swiss francs. “Parts used to be ordered from external suppliers, which took longer and was more expensive,” says José Pahud. The machine is primarily used by orthopaedic and maxillofacial surgeons, but the technology is attracting other specialities, including radiation oncology. The Printing and Reprography Centre has also reproduced aortic roots for the service of cardiovascular surgery and is working on producing a model of the heart. Slow change Things are definitely moving towards 3D printing, but experts agree that Switzerland has been somewhat reticent. “The process of accepting this emerging technology has been relatively slow,” says Marc Thurner of RegenHU. “Spearheading this shift are mainly the university hospitals that can more easily find funding to test innovative tools. These new techniques require staff training and incur costs, which are only partly covered by insurance.” ⁄

IN SITU

HEALTH VALLEY

3 QUESTIONS FOR

CAROLE BOURQUIN

HER TEAM HAS DISCOVERED A NEW TECHNIQUE TO INDUCE THE IMMUNE SYSTEM TO FIGHT CANCER CELLS.

WHAT PRECISELY WAS YOUR DISCOVERY?

Over the past few years, a number of drugs have been released that trigger the immune system to fight cancer cells. But cancer knows how to defend itself. It surrounds itself with regulatory T cells that protect it like a shield. This mechanism can reduce the efficacy of treatments formulated to activate our natural immune defences. We studied how certain drugs currently react during testing and discovered that they can bring down this shield of cells. This way, the immune system can reach and destroy cancer cells more effectively.

HOW EXACTLY DID YOU GO ABOUT THAT?

WHAT POTENTIAL THERAPIES CAN PATIENTS EXPECT?

My research team at the University of Fribourg worked closely with researchers from Ludwig- Maximilian University in Munich. The doctoral students from my group first observed the breakdown of the shield cells in tumours being treated. We then teamed up to find out why they were disappearing. We discovered that certain drugs prevent cancer cells from recruiting shield cells by shutting down the production of chemokine. This protein acts as a signal that the tumour uses to attract cells that can protect it.

I hope that our discovery can be used to select patients that will benefit most from this type of treatment. Patients with tumours containing large amounts of the protein chemokine and with lots of shield cells are likely to respond better to these drugs. This could be a further step towards personalised medicine. / Professor of Pharmacology at the Department of Medicine at the University of Fribourg and head of the Clinical Pharmacology Unit at the Fribourg Hospital

In millions of Swiss francs, the amount of money raised by the Lausanne-based company AB2 Bio, which develops therapeutical approaches to treat severe systemic inflammatory diseases. With this new funding round, the EPFL spin-off will complete the clinical trials of its various treatments, namely adult onset of Still’s disease, a rare form of arthritis.

The game of entrepreneurship INNOVATION The third edition of StartInnov, a one-day workshop in Lausanne for potential entrepreneurs, honoured a team from the community laboratory Hackuarium in Renens. Their project is an automatic protein purification system (APPS), which cuts costs and speeds up traditional processes by automating time-consuming steps. The winners presented a convincing prototype made of Lego bricks. www.startinnov.ch

Using robots in chemotherapy

ONCOLOGY Geneva University Hospitals (HUG) have launched an automated service for mixing chemotherapy drugs. The number of chemotherapy preparations has nearly doubled in the past fifteen years. To deal with that while maintaining staff availability, HUG has turned to robotics. This technology – the PharmaHelp robot designed by Fresenius-Kabi – can produce 10 sterile bags per hour while protecting staff against the toxicity of the compounds. As the first hospital in Switzerland to introduce the machine, HUG plans to develop the long-term use of these robots at other hospitals.

IN SITU

HEALTH VALLEY

specialised centre

At the end of 2015, the University of Geneva (UNIGE) opened a centre to bring together the expertise of all Geneva-based experts specialising in metabolic disorders. Many fields are involved in caring for these issues, including genetics, endocrinology, immunology and surgery.

Diabetes affects half a million people in Switzerland. Potential new treatments are being developed to address this metabolic disorder as are new ways to make day-to-day life easier for patients.

DIABETES kids’ app

The Geneva University Hospitals (HUG) have come out with “Webdia HUG”, an application for smartphones and tablets that children can use to manage their diabetes. With Webdia HUG, kids can estimate amounts of food using photos of what they’re eating and calculate insulin doses. A function stores their blood sugar levels on a server, making them available anytime and anywhere for the child, his or her family and health care providers. The app can be downloaded from the AppStore and Google Play.

artificial pancreas

The Lausanne-based firm Debiotech and the University of Bern have developed an artificial pancreas. Diabetics have a defective pancreas, which cannot produce the insulin needed to regulate blood sugar levels properly (glycaemia). A synthetic pancreas is designed to automatically and continuously measure blood sugar and deliver the right dose of insulin. The two organisations have teamed up to develop a software programme that can estimate hormone requirements based on the patient’s personal variables (food, exercise). A smart algorithm will connect via Wi-Fi to an electromechanical micropump placed directly on the skin, like a patch.

How sugar feeds the brain

EPFL / JAMANI CAILLET

NEUROSCIENCE Using a geologist’s imaging tool, researchers from the Swiss Federal Institute of Technology in Lausanne, the Nestlé Health Institute and the University of Lausanne have developed high-resolution images of how glucose is integrated into the brain. This technology provides new insight into the pathway of glucose as it circulates among neurons and could eventually be applied to develop new methods for diagnosing and treating neurological diseases.

IN SITU

HEALTH VALLEY

BENOÎT DUBUIS Director of the Campus Biotech site and Chairman of BioAlps

Inartis Challenges and MassChallenge: Two new initiatives aiming to support innovators.

Humans have an amazing propensity for dreaming, for generating ideas. But how many of these ideas are transformed into innovations to improve our day-to-day lives? Not enough! What can we do to change that? A region’s entrepreneurship can be measured by the number of opportunities it offers. But that alone is not enough. Those opportunities have to be identified. Even if they’re identified, they have to be transformed. And that requires passion and expertise. Two new initiatives in Switzerland go beyond the awards that recognise existing solutions. The Inartis Challenges aim to identify and stimulate new ideas, while MassChallenge transforms them by providing that passion and expertise. Inartis Challenges The Challenges offer a way to pick up on new solutions and unleash society’s creative potential by giving meaning to ideas. They provide guidance for collective intelligence. Taking an interdisciplinary approach has become both a necessity and a reality in today’s world. People need to engage in intellectual cooperation fuelled by an extraordinary technical environment. This will help spark disruptive and truly revolutionary ideas. These crucial factors will allow us to build our future together. It is in this mindset that Debiopharm Inartis Challenge has decided to make a tangible difference in the lives of hospital patients. A 50,000 Swiss franc award was created to promote “Quality of life for patients undergoing treatment”.

This initiative, with the support of the Inartis Foundation, is the first of three challenges jointly organised with industry leaders in French-speaking Switzerland. More than awards for a past contribution, the challenges focus on bringing about deep changes in current thinking to come up with tomorrow’s solutions. MassChallenge Coming up with new ideas is the process that experienced minds go through using their honed sense of observation. But the “translation” phase from idea to innovation is hardly ever spontaneous and natural. MassChallenge is on its way to Switzerland this year. Its purpose is to set off the revolution to be launched by tomorrow’s start-ups by driving new projects and drawing on all existing energies. Aren’t innovators expected to be visionary and business-orientated, utopic and pragmatic, passionate and patient? MassChallenge, the leading international start-up accelerator – with the advantages of being completely independent and requiring no fees – offers four-month accelerator programmes for the most ambitious innovators. Start-ups are shaping our future with the strengths available to them. You and your network have these skills and these energies. MassChallenge is the godsend we need to perform and turn these initiatives into a springboard for innovative projects in Europe. Onlookers, come take part in the revolution. Join us and join them at www.inartis.ch. ⁄

FOR MORE INFORMATION

www.bioalps.org the platform for life sciences in Western Switzerland

FOCUS

THE BACK

CARE

STOPPING BACK PAIN /

It’s easier than we think to put an end to this condition which affects 80% of the population and drives health care costs through the roof. Report.

/ BY

HERMANN BRAUS, «ANATOMIE DES MENSCHEN», 1921

MELINDA MARCHESE

FOCUS

THE BACK

f all the punishments the heroes of Greek ‘non-specific’ pain and how to relieve it, such as gemythology were given, the giant Atlas was netic predisposition or the exposure to vibrations at certainly handed down one of the most bur- the workplace.” densome sentences. To get back at Atlas for going into battle against him, Zeus forced the god to carry Eighty per cent of the population in industrialised the Earth on his back for eternity. Perhaps a dubious countries consults a doctor at least once in their life consolation for the poor Titan, but his story inspired for pain in their lower back (lumbago), the middle the fathers of anatomy, who named the first cervical of their back (dorsalgia) or their neck (cervicalgia). vertebra after him. The atlas verAnd the Swiss League Against tebra carries the weight of the Rheumatism says that 85% of FIGURES head and provides its mobility. that pain is not caused by a specific injury or disease. This small bone sits at the top of a pile of 24 joint-linked verteThe costs generated by back pain brae which together form the reflect how bad the situation is. In The percentage of the Swiss vertebral column. This extremely Switzerland, the Swiss Federal population that suffers from back pain between once a year sophisticated structure makes up Statistical Office estimates that and several times a week. the core of the skeleton, like a low back pain alone incurs costs central mast for the human body. representing between 1.6% and / All the back muscles are attached 2 . 3 % o f S w i s s G D P, w h i c h to it, allowing the torso to move equalled about 10 billion Swiss In millions, the number of Swiss about and the entire body to refrancs in 2005. That amount inpeople unable to work for several main upright. cludes both direct costs for treatdays or weeks a year due to low ment and indirect costs due to back pain. “Today, we understand how the work disruption. “Those are the / vertebral column and the strucmost recent official figures,” says tures surrounding it work,” says Iohn Norberg, from the Service of Viktor Bartanusz, head of the Rheumatology at CHUV. “But the new Unit of Spinal Surgery at the percentage remains the same toLausanne University Hospital day, at about 14 billion.” Many (CHUV). “But we still don’t fully measures have been taken to regrasp the pain it causes. Certain duce these numbers. “We need to In millions, the number of days spinal problems cause sharp pain come up with solutions for ecoper year Swiss people take leave, unfit to work due to back pain. in some people but no symptoms nomic reasons of course, but also in others,” he says. “And even to help people to regain an active more puzzling is that some pasocial and professional life,” the exSource: Report, Le dos en Suisse 2011 (The Back in Switzerland), by the Swiss tients complain of back pain for pert says. “But to do that, patients League Against Rheumatism. years but have no organic cause. must take care of their back (see Does it come from the bones? point 1 below), and health profesMuscles? Discs? Ligaments? A wide range of theo- sionals need to adapt by only providing care that is ries is now being studied on the reasons for this truly useful and beneficial in the long term.”

80% 1.4

MOVING HEALS

THE IMPORTANCE OF STAYING ACTIVE

❶

n the past few years, a major change has revolutionised care for people suffering from chronic back pain not due to injury. No more forced bed rest. Physical activity is now highly recommended. “Anyone who doesn’t show signs of obvious trauma, such as a fracture or tumour, needs to stay active and use their 12

back,” says Iohn Norberg. “For acute pain, inactivity is not recommended for more than three weeks.” Doctors long recommended not doing exercise or carrying any weight, but the result of inactivity is that the muscles weaken and get to be out of shape. “Many studies have shown how effective physical

FOCUS

THE BACK

“THERE ARE A LOT OF MISCONCEPTIONS” Liliana Belgrand insists on the importance of taking a biopsychosocial approach.

INTERVIEW BY

MELINDA MARCHESE

And also that persistent pain is a sign something is seriously wrong.

his expert has been monitoring patients with chronic low back pain for 20 years.

What causes back pain? lb Apart from the wear and tear of the anatomical structures due to age or injury following an accident, for example, several factors can cause pain. A poor position held for too long or an improper movement can create a muscle inflammation that becomes painful. We talk of “acute pain”, which goes away after a few days with a bit of rest and anti-inflammatory drugs. It must not be left to turn into chronic pain. iv

How can it occur? All pain affects people both physically and mentally. It can leave traces, and some types iv

lb HEIDI DIAZ

So it’s “all in their heads”? lb No, the pain is very real. The treatment should not simply be restricted to the organic cause that we’re addressing with drugs or surgery. Today, we recommend taking a “biopsychosocial” approach, meaning that we also consider psychological aspects and the social environment in which the patient lives. A person who’s been in pain for years is very often depressed, doesn’t sleep well, etc. Their health worsens, and that can lead to both social and professional isolation. Before even prescribing an X-ray, the patient should be asked about their family and social life. That’s why we need multidisciplinary care to get the best results when treating such complex pain. ⁄ iv

are deeper than others. When a patient is in a complicated family situation, they can let themselves be overrun by the pain and gradually give it an important place in their thoughts. If they lose control, they risk changing their perception and making it chronic. There are a lot of misconceptions about back pain, especially that all back pain is due to an injury and that the pain is proportionate to the damage.

LILIANA BELGRAND JOINED THE SERVICE OF RHEUMATOLOGY AT CHUV AS A PHYSICIAN IN 1998 AND RETIRED IN LATE 2015.

THE BACK

HEIDI DIAZ

FOCUS

“I came to terms with my back!” INTERVIEW BY MELINDA MARCHESE

Chloé Buchmann Sanroma decided to start exercising again. She was diagnosed with scoliosis as a teenager. For 25 years, she only allowed herself to do a bit of dance, thinking she was protecting her back. Chloé Buchmann Sanroma has recently made drastic changes in her day-to-day life. “I started jogging, doing fitness and even took up skiing again,” says the nearly 40-year old mother. “I never would have thought I’d be able to do so much,” she says. As a teenager, the doctors made it clear. The young woman had scoliosis (a malformation of the vertebral column) and had to avoid any intense physical activity. “I wore a brace for two years, which prevented my scoliosis from getting worse,” she says. “Only swimming was recommended. From that point on in school, a medical certificate prohibited me from going to gym class with my classmates.”

That’s how the young woman lived for more than twenty years, giving her back pain an important place in her everyday life. “I took it as a fate that I had to live with. Not one day went by that I didn’t repeat to myself that my back hurt. Like a routine that I had ingrained in my mind.” Chloé Buchmann Sanroma tried several methods to relieve her chronic low back pain. “I took the advice of several schools on back pain, did a lot of physiotherapy, practised the right postures in ergotherapy and saw my osteopath a lot. I never stopped going to my orthopaedic doctor, who prescribed anti-inflammatory drugs every year. Nothing really changed.” Until 2013. “I was sick of it! I couldn’t see myself living with that pain all my life! I told my new doctor that I wanted surgery. That’s when I heard an all-new viewpoint for the first time, which questioned

what I’d thought was true and lived with for years. I needed to reactivate my muscles, stop protecting my back and put an end to my fear of pain.” In 2015, she had three weeks of rehabilitation at the Unit of Spinal Rehabilitation at CHUV. “The programme is very dense,” says Chloé Buchmann Sanroma. “I did 35 hours a week of strengthening and cardiovascular exercises, aqua fitness and weight lifting at an intensive pace! It was a revelation, a real wake-up call. I could actually do all of it!” Did her pain totally disappear? “I approach it in a completely different way,” she says. Now, as soon as I’m in pain, I put on my sport clothes and go running! It warms my muscles, and I feel less discomfort. I’m extremely motivated to continue these efforts and am delighted to have finally come to terms with my back.” ⁄

FOCUS

THE BACK

activity can be,” the rheumatologist says. “Strengthening the back muscles provides better support for the vertebral column.” Exercise is an excellent way to relieve back pain, but also to prevent it,” says a study published in January 2016 in the Journal of The American Medical Association (JAMA). But what sport is best? “Everyone should choose an activity that they enjoy and that suits them,” Norberg advises. “Stéphane Genevay, a fellow rheumatologist from the Geneva University Hospitals (HUG), and I were involved in developing the website www.mon-sport.ch. In just a few clicks, users are given several ideas based on their abilities and what they enjoy doing.”

The back’s enemies Time

Starting in the teen years, the structures of the vertebral column gradually begin to experience wear and tear. Disc degeneration is when the intervertebral discs show clear signs of wear. These thin cartilaginous structures play a vital role as shock absorbers. Over time, the discs dry out and lose their elasticity and their resistance to pressure. They naturally become less flexible and more brittle. Disk tears can result in a compressed nerve root. This is called a spinal disc herniation, which can become painful if inflamed.

THE FEAR OF MOVEMENT It’s not just about muscles. Guillaume Finti, a physiotherapist registered with the Unit of Spinal Rehabilitation at CHUV, sees patients every day who have “kinesiophobia”, the fear of movement. “Some people stop moving for too long after experiencing acute pain and they end up afraid to move,” he says. “Unfortunately, that’s how acute pain can become chronic. What we do is help these people get over their fear.” The physiotherapist works with a team of ergotherapists, psychologists and rheumatologists to help people with kinesiophobia overcome their anxiety. “We offer a three-week treatment programme,” Finti says. “Patients spend 35 hours a week doing physical exercises as a group and individually, receiving care and advice. In most cases, we manage to rebuild their confidence in their abilities, which gradually leads them to start moving again, experience their pain differently and resume professional activity.” Iohn Norberg points out that this type of programme has been available for several years. “This type of care should be offered on a wider scale, and all doctors, both with public and private institutions, should encourage patients to move more in their daily lives. That’s certainly less profitable than regular cortisone injections or other repetitive treatments, but physical activity remains without a doubt the best long-term remedy.”

PROGRESS OF SURGERY

Stress

A study by the Occupational Health and Safety Research Institute (IRSST) in Canada establishes a direct link between back pain and occupational stress. When under constant pressure, the muscles— especially those in the shoulders and neck—cannot relax, storing toxins and becoming painful. Other negative emotions such as anxiety and nervous tension are also responsible for making pain chronic. The expression to lift or have a “weight off your shoulders” appropriately refers to being relieved of a burden, concern or a trouble after some time.

❷

LESS, BUT BETTER

new mindset is also emerging about back surgery. Patients should only have surgery if the anatomical cause of the pain has been specifically identified and can be treated with a surgical procedure. In its Smarter Medicine campaign launched in 2014 to limit unnecessar y procedures, the Swiss Society of Internal Medicine also advises against X-rays for patients experiencing low back pain for less than six weeks if they show no other alarming signs (read our report on the “Less is more” movement on www.invivomagazine.com). “Any image of such a complex structure can show a small, harmless abnormality,” says Iohn Norberg. “Is that the cause of the pain? Often, we have no idea! The patient might end up focusing on it, whereas with a

FOCUS

Being overweight

Several studies have shown that excess weight accelerates degenerative disc disease and puts pressure on joints between the vertebrae, causing ligament pain and muscle degeneration. Overweight people often suffer from back pain. Another category of the population seems increasingly affected—children. A study published in the “Journal of the American Academy Of Orthopedic Surgeons” in January 2016 reported that one out of three adolescents have back pain. Child obesity and wearing heavy backpacks are suggested to be the causes of pain and deformation in the vertebral column.

Sedentary lifestyle

All research into the causes of back pain point to sedentary lifestyles. Inactivity weakens the muscles in the back, passing on the support function of these muscles to the vertebral column and making it more vulnerable to injury. This problem concerns all segments of the population, from the elderly to children, including those actively employed who sit for long hours in front of their screens. A study by the Swiss Federal Institute of Technology in Zurich shows that standing for long periods also causes muscle fatigue. After several days it can lead to musculoskeletal disorders and back pain.

THE BACK

bit of patience and physical activity, the pain would disappear on its own.” “People are in so much pain that they ask us to operate, even if they have no serious pathology,” says the neurosurgeon Viktor Bartanusz. “As specialists, we must study the test results and decide whether the operation would be useful. If surgery won’t help or risks making the pain worse, we have to be able to say no. Only 10% of people with back pain really need an operation.” This less-is-more approach is not yet systematically applied by professionals or taken into adequate consideration by researchers. Viktor Bartanusz takes an example from the study conducted by the Department of Neurosurgery at the University of Texas reported in the scientific publication The Spine Journal in 2013. “It shows that between 1993 and 2012 the number of trials performed to compare the choice of surgical instruments far exceeded “You should sleep on a firm the number of trials to determine mattress to prevent or relieve the effectiveness of surgery,” the exback pain.” pert laments. FALSE A mattress that is too

TRUE OR FALSE?

firm can cause stress for the vertebrae. But a mattress that is too soft fails to support the body adequately. If the shoulders and hips dip into the mattress, the spine is arched. The best option is a mattress that is neither too firm nor too soft and can support and relax the back. “Back pain definitely means a serious illness.”

FALSE 85% of pain is “non-specific”, meaning it is not due to any particular organic cause such as a fracture, tumour or inflammation. If it’s not related to an injury or disease, this is good news. “Drugs are used for quick relief.”

TRUE/FALSE Taking anti-

inflammatory drugs for acute pain can offer relief within a few hours. However, medication should not be the only treatment. It is merely a temporary remedy. For people who are inactive for long periods of time or do not do enough physical exercise, the discomfort is likely to come back. As soon as the pain subsides, people should take care of their backs by staying as active as possible.

MORE PRECISION, MORE RELIABILITY When dealing with certain organic causes of back pain, such as a tumour or fracture, surgery is in fact likely to improve the patient’s health. “Tremendous technical advances have been made in recent years,” says Viktor Bartanusz. “With smaller instruments and ever more accurate imaging, surgery is being optimised and becoming more precise. Statistically speaking, it is now safer to have herniated disc surgery than to drive on the motorway!” Viktor Bartanusz predicts another change over the next ten years. “Orthopaedic surgeons will work jointly with neurosurgeons on spinal disorders. These two specialities will eventually become one and further improve the quality of our surgical procedures.”

GROWING USE OF ROBOTICS In the future, back surgeons will increasingly benefit from the assistance of robots. In December 2015

FOCUS

THE BACK

Atlas and axis

Spinal canal

The two vertebrae at the top of the vertebral column. The atlas holds up the skull and the axis enables it to pivot.

The vertebrae are stacked up on top of each other, all with a hole in the middle, forming a cavity which encloses and protects the core of the nervous system, the spinal cord.

Intervertebral discs Cartilaginous and fibrous structures located between the vertebrae that act as shock absorbers. Curvature of the spine A healthy adult vertebral column features four curves when viewed from the profile, two lordotic, or inward, curves â&#x20AC;&#x201C; the cervical and the lumbar â&#x20AC;&#x201C; and two kyphotic, or outward, curves in the thorax and the sacrum. This sinuous shape gives the skeleton stability and helps it absorb shocks. Coccyx This bone is located at the bottom of the vertebral column. Also referred to as the tailbone, the coccyx is believed to be a vestigial leftover of the tail that ancestors of human beings eventually lost through evolution.

Sacrum

ERAXION

This bone shaped like an upside down triangle is part of the pelvis and is formed by five fused vertebrae.

THE BACK

at the Amiens-Picardie University Hospital in France, a robotic surgery system developed by the French company Medtech was used to operate on a herniated disc for the first time. The Rosa Spine machine features an articulated arm guided by the surgeon for greater safety and dexterity in movement. The Lausanne-based company KB Medical is also preparing for the commercialisation of its spine surgery robot AQrate. “We are currently in talks with large distributors in Germany and the United States,” says the CEO Jean-Marc Wismer. “Minimally-invasive, robotassisted surgery is used to make smaller, more precise incisions. That means that the patient recovers more quickly. And in general, the risks that can occur during surgery are reduced.”

HIGH-TECH INNOVATIONS

SMART T-SHIRTS AND BACK PACEMAKERS

❸

he “back pain market”, with its many potential customers, has sparked innovation from start-ups to develop ways of relieving pain. The Paris-based Percko attracted a lot of attention with its sensor-embedded T-shirt that corrects poor posture. This lightweight garment fits like a second skin and alerts its wearers when they start to slouch, encouraging them to adjust their posture with its string of tensors fastened into the fabric along the spine, shoulders and thorax. “We hope to sell 10,000 shirts in 2016 to bring in about €1 million in revenue,” say Quentin Perraudeau and Alexis Ucko, the two young engineers who launched the project. The target seems feasible as the Percko T-shirt, sold at €129 apiece online and at selected points of sale, garnered immediate interest. By the end of 2015, the start-up had raised more than €385,000 pledged by 3,325 backers on the crowdfunding website Kickstarter. Backers include ten or so companies that view the product as a useful tool to improve their employees’ well-being. The posture of employees, sitting physically inactive for long hours in front of their screen, is often called out as one of the main causes of back pain. “In a seated position, tension increases in the deep muscles of 18

Taking care of your back

BUILDING MUSCLE

There are a number of strength training exercises to build muscle in the back. Strengthening the core targets deep muscles and, when practised properly and regularly, guarantees results. The classic version involves facing the floor with your body weight distributed between the tips of your toes and your forearms bent at a 90-degree angle to the shoulders. The longer you hold the position, the more muscle you build.

RELAXING

The back muscles must be relaxed regularly. For example, to relax the lumbar region, lie down on your back with your legs elevated and bent onto a structure, such as a stool. The arms should lie alongside the body with the palms down. This position is beneficial because it takes all pressure off the back. The tilt of the pelvis stretches the lumbar muscles and removes any tension.

WARMING UP

Before beginning any activity that will put strain on your back – be it gardening, ironing or of course muscle building – you should warm up your back muscles. Kneeling on all fours with your hands resting on the floor, switch from a rounded back to an arched back about 30 times. Keep your head aligned with your spine so it can follow the movement.

SITTING PROPERLY

Remaining seated for many hours in front of a screen can cause muscle contractions. Your heels should be placed under your knees (legs should not be crossed) with the lumbar region resting firmly against the back of the chair and the weight of the body on the ischia bones that make up the lower pelvic region. The middle of the back is naturally slightly forward. The shoulders are relaxed and the elbows free. It is also highly recommended to get up and move around regularly.

BENJAMIN SCHULTE

FOCUS

The Irish company Mainstay Medical developed a system, ReActiv8, to relieve chronic low back pain. The implant works like a pacemaker, with two electrodes placed on either side of the vertebral column. The electrodes are connected to a device that sends out small electric impulses to stimulate the nerves responsible for contracting the key muscles that stabilise the lower back. Mainstay Medical announced positive results to its clinical trials and plans to initiate the commercialisation phase shortly. “That’s great if these innovations relieve pain,” says the rheumatologist Iohn Norberg. “But we shouldn’t rely on these devices and forget the most natural and most effective way to prevent and treat back pain. Moving!” ⁄

30° kg

45 °

the spinal column and puts pressure on intervertebral discs,” says the posture therapist Olivier Girard, head of the Ergonomics Services Unit at the Institute for Work and Health of French-speaking Switzerland (Institut universitaire romand de santé au travail or IST) in Epalinges. The expert believes it is essential for people to sit in a comfortable, ergonomic position (see opposite). “It’s not enough to protect your back,” he adds. “After 30 or 40 minutes, you need to change position. That doesn’t mean stop working. Consider making a phone call while standing, printing a document on a machine a few metres from your desk or going to see your co-workers nearby rather than writing an email or calling them.”

15° 12 kg

THE BACK

0° 5 kg

FOCUS

me ts o r c ynd addi s e Th SMS Nearly two hours of and 30 minutes per day.

That’s the average amount of time that people spend on their smartphones, according to the American market research company Millward Brown. During that time, as users enjoy writing text messages or browsing through their favourite blog, the neck suffers in silence. A study recently published in the scientific journal “Surgical Technology International” reports that when people tilt their head forward – the typical position for looking at their smart phone – the stress on the cervical spine increases. The author of the study, the American spine surgeon Kenneth Hansraj, describes how the further forward the head is tilted, the greater the weight exerted on the neck. He writes that the adult head weighs 4.5 to 5.5 kg. In a neutral position, this weight is naturally distributed and supported by the spine. But by tilting the head forward 15 degrees, “the forces on the neck surge” to more than 12 kg. At 30 degrees, the head weighs 18 kg, at 45 degrees 22 kg and at 60 degrees nearly 30 kg. Due to that excess weight, many smartphone addicts complain of neck pain. This rapidly growing phenomenon has been coined “text neck syndrome”. Doctors clearly advise people to avoid tilting their head for several minutes in a row and to make sure their ears are aligned with their shoulders when using their smartphone. ⁄

° 60 kg 30

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Nearly 30 coronaviruses, a tiny fraction of those out there, have been discovered since 2003.

CLÉMENT BÜRGE

PATRICK WOO

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INTERVIEW

PATRICK WOO The Chinese researcher is spearheading the search for new virus strains. He sat down with In Vivo to discuss his work.

INTERVIEW: JULIE ZAUGG

“I hunt viruses around the world” Patrick Woo, a professor with the Department of MicrobiolIV How are these samples analysed? ogy at the University of Hong Kong, has set out to uncover PW There are two ways of studying them. The new viruses that can spread from animals to humans. Profirst involves using traditional molecular techfessor Woo was a member of the team that discovered the nology. We use highly conserved DNA sevirus that caused the severe acute respiratory syndrome quences to amplify certain fragments of the (SARS) epidemic in 2003. He tells us about his quest, at virus genome. Then we can sequence these a time when the deadly new bird flu virus H5N6 has snippets of DNA. The second method, metagenkilled its first victims in China. omics, is a more recent technique which is used to sequence all the genetic material in the sample IV How do you go about finding new viruses? PATRICK that interests us. In both cases, we feed these DNA WOO I travel through Hong Kong, China and other sequences into a computer to analyse whether it’s a countries looking for animal and human samples that new virus. I can analyse at a lab. I specialise in coronaviruses [a large family of viruses that can cause a wide variety IV How does it detect a new virus? PW The computof diseases in humans], which has led me to focus er compares the DNA in our samples with the geon species that carry these viruses such as bats. I nomes of all known viruses. They’re then listed in also study animals that have the most contact with GenBank, an American open access database for rehumans and mammals, because the chances are searchers reporting a new DNA sequence. This analysis greater that viruses infecting these species will produces a list of viruses whose genome is similar to our spread to humans. Hospitals sometimes inform samples, indicating the percentage of similarity. We then me when they have a patient with pneumonia decide if that percentage is low enough to confirm that and they haven’t been able to identify the viral we’re dealing with a new virus. cause in the laboratory because it doesn’t resemble any known virus. So we take a sample IV Can you give us an example of a recent discovery? from the patient and analyse it. PW Following the outbreak of the coronavirus that caused

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INTERVIEW

Middle East respiratory syndrome (MERS), I decided to go to Dubai to collect samples from camels, the animal that transmitted this new virus to humans. In analysing the samples, we discovered a whole series of new viruses in camels. One of them causes a form of hepatitis E. Shortly afterwards, a case of the disease was reported in Singapore. The victim had undergone a liver transplant and had a regular diet of camel milk and meat. It’s too early to confirm if there’s a correlation between these eating habits and the hepatitis he developed, but we suspect there is.

them. Many animals have never been screened for coronaviruses.

“THE GENETIC MATERIAL OF A VIRUS CHANGES ALL THE TIME.”

You contributed to the discovery of the SARS virus. Tell us how you did that. PW When the epidemic broke IV Do we know how viruses spread from aniout 12 years ago, we didn’t know what caused it. We startmals to humans? PW Yes. The genetic material ed working on samples taken from several patients sufferof a virus changes all the time, either by mutaing from the disease, including a man who came to Hong tion or by recombination. The function of the Kong after contracting it in China. We cultured the virus virus proteins can be altered. They develop the from his sample by maintaining a cell line. That helped ability to latch on to human cell receptors, and us establish that it was a new coronavirus and determine that’s when the virus can be transmitted from anits genetic structure. imals to people. This jump from species to species sometimes goes unnoticed. We think we’re dealing IV What were the consequences of this advance? with a new virus, while in fact it spread to humans PW At the time of the SARS outbreak, not many reages ago. That’s what happened with the two new searchers were looking for new viruses. The only techhuman coronaviruses discovered in 2004 or 2005. nique available was to breed the pathogen in a lab setting. But it was slow and ineffective. IV How can we overlook something so Some viruses are very difficult to culture us- BIOGRAPHY important? PW We’re far from knowing ing a cell line because they need an organism Patrick Woo everything that goes on in hospitals and to reproduce. When the epidemic subsided, joined the even less in the general population. The viscientists realised that there were still many Department of rus that causes pneumonia is identified less Microbiology at viruses that we didn’t know existed. More the University of than half the time. In the rest of the cases, efficient molecular and metagenetic tools Hong Kong in we don’t know what triggered the disease. were then developed to identify them. The 1997. Eight years But as patients generally recover, we don’t number of new viruses exploded at the time. later, the scientist investigate any further. Most of these mystraced the source Before 2003, we only knew about two hu- of the SARS terious cases of pneumonia are probably man coronaviruses discovered in the 1960s. epidemic to the caused by viruses that haven’t yet been reBut in 2004 and 2005 alone, we found two rhinolophus, a ported. The same goes for other types of inothers, including one that was discovered by species of bat pre- fections, like diarrhoea. sent in China, and the University of Hong Kong. discovered HKU1, IV And once the new virus is discovered, a human coronavirus that causes IV Where is our knowledge lacking the what can we do? PW That depends on the most? PW In coronaviruses. Before SARS, pneumonia. virus. If it only infects animals, most likely Professor Woo we had only sequenced the genome of also conducts nothing. However, if it’s a highly pathogenic about ten of these pathogens. Since 2003, research in other virus for humans, we’ll study it to understand we’ve discovered 20 or 30 more. But we countries. In how it spreads, how it causes the disease and still only know about a small portion of 2013, he went what symptoms it induces. Eventually, we IV

to Dubai to take samples from camels, which is how he identified five new viruses. He reported another type of coronavirus in dolphins in 2014.

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INTERVIEW

should be able to develop a treatment, along with diagnosis and prevention methods.

What do we know about the new H5N6 flu virus? PW We know very little about it because we’re just now seeing the first cases emerge. It’s still too early to determine how and IV Do you have an example? PW Ten years how fast the disease spreads in humans. We don’t even know ago, we discovered a new human coronavirus what its animal reservoir is. We’re in the same situation as at the University of Hong Kong called HKU1, Saudi Arabia three years ago, when the first cases of MERS which was very close to the hepatitis virus in were reported. mice. Researchers in other countries began to look for it in their population pools. We found IV How did this new flu virus develop? PW The genome of it in Connecticut in the United States, Australia the flu virus is segmented, meaning that it is divided into and France. Due to this broad geographical diseight different pieces of DNA, while the genome of corotribution, we began researching a treatment and naviruses is in a single piece. Two strains of flu virus often diagnosis for the virus. exchange genetic material when they infect the same cell. For example, if the H1N1 virus meets the H2N3 virus, they could exchange DNA and form a H1N3 virus. And that would be a whole new virus. This genetic recombination frequently occurs in birds, which are the natural reservoir for influenza. And the new virus that results from these exchanges can sometimes be transmitted to humans, such as H5N6. IV

“THE ONLY WAY TO PROTECT PEOPLE IS TO LIMIT THEIR EXPOSURE TO THE VECTORS THAT SPREAD THE DISEASE.”

IV H5N6, SARS and H5N1 all came out of southern

China. Is there a reason for that? PW We can’t be sure. All we have are hypotheses. One of them is related to people’s eating habits in southern China. They eat lots of meat and prefer fresh food. That means that the food markets in this region of the world are full of live animals, increasing the chances of contact between humans and animals and therefore the species-to-species transmission of viruses.

How did you get interested in discovering new viruses? PW When I joined the Department of Microbiology at the University of Hong Kong 20 years ago, I specialised in studying infections IV How can we prevent a new virus from spreading? PW in patients who had undergone a bone marrow When there’s no vaccine or form of prevention, the only transplant. One day, I came across a bacterium way to protect people is to limit their exposure to the vecthat we couldn’t identify. I decided to use a motors that spread the disease. For example, if we know that a lecular method to list it. That made me want to virus is transmitted by mosquitoes, we’ll encourage people go out looking for other new bacteria. I started to protect themselves. In the same way, the authorities out using various samples kept at the hospital launched a public campaign during the SARS epidemic to that had been collected from patients infected convince people not to eat certain wild animals, such as civwith an unknown pathogen. These “archives” ets, the source of numerous infections. And with the H5N1 led me to discover 10 or 20 new bacteria. outbreak in 1997, the government of Hong Kong had all the And when the SARS epidemic hit in 2003, I chickens in the city slaughtered. traded in bacteria for viruses. ⁄

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DECODING

Super-bacteria are gaining ground TEXT JULIE ZAUGG

New drugs won’t be enough to fight multi-resistant bacteria. We also need to prescribe antibiotics more intelligently.

ve seen patients die of an infection, especially in the service that treats severe burn victims, because no antibiotic would work on them,” says Yok-Ai Que, head of Education and Research at the Department of Fundamental Microbiology at the University of Lausanne. “Sometimes we have to put patients on an IV just to treat cystitis (inflammation of the bladder).” What causes these tragedies? The growing number of antibiotic-resistant bacteria in Swiss hospitals. E. coli, a common intestinal bacterium that can cause gastroenteritis and urinary infections, no longer reacts to fluoroquinolone, the antibiotic usually used to kill it off, in

“When you attack bacteria with antibiotics, they will almost invariably develop resistance to it. It’s a survival mechanism,” says Didier Pittet, head of the Service of Infectious Diseases at the Geneva University Hospitals (HUG). “Resistance to penicillin first emerged just nine months after the drug was discovered in 1947”, and resistance has only become worse with the overuse of antibiotics. At Swiss hospitals, the number of daily doses administered jumped 36% between 2004 and 2013. “They’re often mistakenly used for diseases caused by viruses instead of bacteria, like colds,” he says. Outside Switzerland, the situation is no more reassuring. Turkey, Greece, France and the United States are the champions of antibiot-

CDC / MELISSA BROWER / SCIENCE PHOTO LIBRARY

“I’

20.5% of cases according to the Swiss Centre for Antibiotic resistance (Anresis). In 2004, the percentage stood at 10.3%. Another example is K. pneumoniae, a bacterium that causes respiratory infections, has become unresponsive to third-generation cephalosporins, a more recent antibiotic, in 11.2% of cases, up from 1.3% in 2004.

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DECODING

ics consumption, according to the European Centre for Disease Prevention and Control. “In countries where poor hygiene is widespread, like India, or common in hospitals, like in Italy and Greece, patients are often given antibiotics as a preventive measure”, says Patrice Nordmann, a professor from the Microbiology Unit at the University of Fribourg. The use of antibiotics on chicken, pig and fish farms – to prevent the spread of infections when animals are kept in cramped living conditions – also builds resistance, as have globalisation and the growth in medical tourism. Patients are increasingly transferred between countries, and that spreads germs. “We think that the first extended-spectrum beta-lactamases [enzymes that cause resistance to antibiotics] first came to French-speaking Switzerland when the victims of the 2002 Bali bombings were brought to the Lausanne University Hospital (CHUV),” says Didier Pittet. “Travellers who go to countries like India often bring back resistant germs in their gut flora,” says Thierry Calandra, head of the Infectious Diseases Service at CHUV. These healthy carriers have no symptoms, but they can pass these bacteria on to other people with weakened immune systems.

THE MOST DANGEROUS BACTERIA ESBL

Extended-spectrum beta-lactamases, here covered in pili (hair) and flagella, are enzymes that can develop resistance to certain antibiotics.

Extended-spectrum beta-lactamases are enzymes produced by certain gut bacteria such as E. coli and K. pneumoniae. Discovered for the first time in France and Germany in the mid-1980s, ESBL provide resistance to beta-lactam antibiotics, which are the most commonly used. These enzymes appeared in Switzerland in the early 2000s. In 2010, 4.8% of patients admitted to the Geneva University Hospitals and 5.8% of those coming to the Zurich Hospital were carriers.

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DECODING

There are a few ways to fight these superbugs. Simple measures, like improving hand hygiene and vaccinating high-risk patients, would prevent 30% of the 70,000 infections contracted every year at Swiss hospitals. We also need to reduce the consumption of antibiotics. “In Switzerland, antibiotics cannot be sold without a prescription,” says Karin Wäfler, an antibiotic resistance project leader at the Swiss Federal Office of Public Health (FOPH). “But there are no binding guidelines that define when antibiotics should be prescribed or which one is the most appropriate.” NEW NATIONAL STRATEGY

To combat resistance, we have to better understand its prevalence and its distribution among the population. Since 2004, Anresis has been collecting information on resistant bacteria and antibiotics prescribed at hospitals, but not in outpatient care. Antibiotic-resistant bacteria in livestock such as pigs, chickens, and cows have been reported since 2006, but not the amounts of antibiotics administered. The Swiss Antibiotic Resistance Strategy (StaR), launched by the Federal Council in early 2016, “will fill those gaps by systematically recording all of that information,” says Karin Wäfler.

bacterium in less than two hours, as opposed to the previous two-day wait. A Geneva-based team has designed a tool used to detect tuberculosis strains resistant to the antibiotic rifampicin in two hours instead of two to eight weeks.

But to really finish off these super-bacteria, we need new antibiotics. And unfortunately, the pharmaceutical industry seems to have other priorities in mind. “Drug manufacturers haven’t developed any new products for years, because it doesn’t bring in enough money,” says Didier Pittet. “It’s much more profitable to develop drugs for Alzheimer’s or diabetes, which patients will have to take for the rest of their lives”.

Didier Pittet believes we’ll eventually need to create new funding models. “Antibiotics could be listed as UNESCO Intangible Cultural Heritage, which would draw in subsidies from the World Bank or European Union”, he says.

But that won’t be enough to stop the spread of these super-bacteria. “To do that, we have to identify the presence of resistant germs in hospitals as quickly as possible. One way to do that is by systematically screening all patients who’ve been abroad and then isolating carriers,” says Thierry Calandra. That is what has driven Patrice Nordmann and his colleague Laurent Poirel to develop a diagnostic test that can detect resistant strains of the Acinetobacter baumannii

In 2015, the Swiss Confederation announced its new National Research Programme on Antimicrobial Resistance backed with total funding of 20 million Swiss francs. “This programme aims to develop new ways of treating resistant bacteria”, says Karin Wäfler. The FOPH said that it would provide further details between now and midGOLDEN STAPH 2016 while keeping the public regularly informed Staphylococcus aureus is a bacterium found in the skin of of its progress. The fight 30% of the human population. against super-bacteria It can cause infections in the has begun. Now all we bloodstream, soft tissue and have to do is win it. ⁄ joints. The bug has developed

resistance to the first-line antibiotic meticillin, making it one of the most common causes of hospital-acquired infections. Its incidence has begun to subside over the past ten years, however, with the prevalence of resistant strains dropping from 12.7% in 2004 to 5% in 2013. 26

CARBAPENEMASES Carbapenemases is another enzyme produced by intestinal microflora that deactivates carbapenems, the latest generation of antibiotics. Patients infected with this superbug are left with only one option, colistin. Discovered in 1949, this drug is used as a last-resort antibiotic due to its toxicity. For the time being, all cases of carbapenemases reported in Switzerland have been imported from either Mediterranean countries or the Indian sub-continent. But the number of strains present in Switzerland has exploded from less than 15 in 2009 to more than 400 today.

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INNOVATION

PLAYING FOR HEALTH Serious games are increasingly used by patients and health care professionals. More serious games are being developed in Switzerland, with the support of the country’s hospitals and leading schools.

TEXT: SÉVERINE GÉROUDET

THAT DRAGON CANCER

BASED ON A TRUE STORY, THE GAME “THAT DRAGON, CANCER” EXPLORES THE DAY-TO-DAY LIFE OF THE GREEN FAMILY, WHOSE YOUNG SON JOEL WAS DIAGNOSED WITH CANCER.

In a fictitious town, Alex London is conducting an investigation. He has to find the kidnapped scientist Professor Birman. Clues keep coming, while the hero, a diabetic, has to monitor his blood sugar throughout his adventure. This video game, called The Birman Affair, available from the online platform Gluciweb, is an educational tool designed to support patients in managing their insulin therapy. Players have an insulin pen, a glucose meter, a sugar reserve and different snacks. Diabetic patients learn about their own treatment by managing their character’s blood sugar through the story. The Birman Affair is what is called a “serious game”, a programme that uses the context of a game to reach a serious objective, such as educating or informing players. “Serious games have been around for many years, especially in management, but they’ve only recently been applied to medicine,” says Dominique Jaccard, director of the research team at AlbaSim, a laboratory at the School of Business and Engineering Vaud (HEIG-VD) that develops a variety of serious games. “It took a while for the appeal of using entertainment to gain ground in health care due to preconceived notions. Many people have trouble associating games with a serious purpose.” THE MOTIVATION FACTOR

Video games are garnering support in medical training. “We’re trying to combine traditional teaching with serious games,” says Dominique Truchot-Cardot, a

INNOVATION

EVERY GAME HAS ITS “SERIOUS” PURPOSE Different types of serious games are used in health care:

3 4

ADVERGAMING objective: Prevent and educate. example: “Ce soir il conclut”, designed for young adults aged 18 to 25, presents the risks of excessive alcohol consumption. www.cesoirilconclut.com

EXERGAMING objective: Train and rehabilitate. example: “Voracy fish”, a fun rehabilitation programme for stroke victims. The main character is a little fish guided by the player’s arm. www.voracy.com

IMMERSIVE GAMING objective: Immerse the player in a virtual environment to deal with a situation from the real world. example: “Ludomedic” immerses the patient in a hospital environment. www.ludomedic.com

HEALTH CARE GAMING objective: Educate and train. example: “Théo et les psorianautes” is designed to help children deal with psoriasis. www.theoetlespsorianautes.fr

CE SOIR IL CONCLUT, VORACY FISH, LUDOMEDIC, THÉO ET LES PSORIANAUTES

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physician and full professor at the Institut et Haute École de la Santé La Source in Lausanne. “Our students are digital natives. They love these types of programmes, which they find stimulating and motivating.” The software is used to confront students with real-life situations of their profession through virtual representations. Pulse!!, the leading American game, was one of the first serious games for health care professionals in which future doctors have to make the right decisions to save a virtual patient’s life. The La Source school currently uses a serious game on clinical cardiac evaluation developed jointly with the AlbaSim laboratory. A virtual simulation forces the player to deal with a patient who comes to the Accident and Emergency department with chest pain. “The programme aims to develop the ability to care for the patient holistically,” says Dominique Jaccard, the laboratory director. “The player can ask the patient questions and run tests, and then determine what action to take.” The use of entertainment has also proved beneficial for patients. They get more involved in their treatment and more serious about taking it. “We’re currently seeing a change in paradigm,” says Dominique Truchot-Cardot. “Patients want to take an active role in their health and be independent with their care. Health care professionals need to adapt to that demand and integrate it into their practices.”

INNOVATION

Many of these “serious” video games target young patients with chronic diseases, such as diabetes or psoriasis, to help them better understand their treatment and live with their disease day-to-day. These games are often available online or can be downloaded, making them ideal for self-managing their treatment. Most games feature the option of compiling the player’s treatment behaviour, which can then be exported to their medical practitioner. Serious games are not just for children. Many are also designed for adults and the elderly, with many programmes developed to prevent falls. MOVING INTO THE MAINSTREAM

Some games initially designed without a “serious” purpose are then adapted to achieve a therapeutic goal. The Wii Fit Board, an accessory for the Nintendo Wii console, has turned out to be useful in motor-skill rehabilitation. Lara Allet, a physiotherapist and researcher at the University of Applied Sciences (Haute école de santé) in Geneva, studied how this tool could be used to recover from ankle sprains and prevent future

ankle injuries. “The Wii Fit Board features several games that are effective in rehabilitation,” she says. “It can be used to vary exercises and better motivate some patients. But it’s only a tool. Recovery requires medical treatment and the Wii Fit Board can’t substitute that.” Most serious games available have been developed abroad. This can sometimes be a problem, especially when patient care rules and procedures differ from one country to another. Some games can’t be used in Switzerland. But more Swiss games are being developed. “Technology is advancing, and development costs are falling. Costs are now one-fifth of what they used to be ten years ago,” says Dominique Jaccard. “The development of serious games will grow.” The games available today are expensive and under licence, “but they’re moving into the mainstream,” says Dominique Truchot-Cardot. Switzerland’s hospitals and specialised schools are beginning to develop their own serious games to improve medical training, treatment and patient care.” ⁄

UNDERSTANDING THE FIGHT AGAINST CANCER “That Dragon, Cancer” is a game developed by Ryan Green based on his young son Joel’s fight against cancer. This serious game explores Joel’s day-to-day experience in dealing with the disease and the hardships his family faced with him. The player has to react in a series of scenes, interacting with doctors, nurses and members of Joel’s family to help him during his treatment. The project was developed based on a text by Amy Green, Joel’s mother, written to explain her son’s disease to her four young boys. The Green family wanted to help patients and their loved ones going through the same turmoil to better understand and live with the disease. SEE MORE ON WWW.INVIVOMAGAZINE.COM

MENS SANA

COMMENTARY

PATRICK LÉGERON Psychiatrist at Sainte-Anne Hospital and Founder of Stimulus (Paris)

Companies must act to reduce work-related stress.

Spice of life or kiss of death. The title of the first major report on work-related stress published by the European Commission in 1999 presented the problem well. Stress has been studied scientifically for more than 80 years. It is the natural response triggered when we are faced with a challenging, frightening or threatening situation. This reaction is complex, combining changes in our hormone levels and our bodies, aggravating our emotions and our behaviour. The sole purpose of stress is to help us adjust to the situation, to face it effectively. But beyond a certain threshold, when this response becomes too intense or chronic, stress loses its primary function and endangers our health.

The sources of work-related stress have changed. These days, its root causes are in the new “psychosocial” demands of the work environment, including an excessive focus on performance and productivity, loss of independence and the meaning of tasks required, being constantly connected, faulty managerial practices and poor relations with others, to name just a few. Companies must urgently act to reduce work-related stress. In addition to the human suffering, it is a huge economic waste due to the high costs it generates for companies and governments. The International Labour Office has defined three levels of stress management interventions: primary (reducing sources of stress), secondary (developing stress management skills) and tertiary (treating and rehabilitating workers suffering from stress).

LEGOUHY

Between 20% and 25% of employees currently suffer from work-related stress. The condition affects all sectors and all categories of people: workers, office employees, managers and executives. “Hyperstress” is responsible for Our professional lives are increasingly complex, causing a number of disorders that can be either uncertain and often challenging. Meanwhile, we psychological (depression, burnout, suicide) or have much higher aspirations of well-being but physical (cardiovascular diseases). tolerate adversity significantly less. Is it a sign of weakness on the part of our contemporaries? That’s a tough question to answer. Do these demands reflect the progress of our civilisation? Whatever the answers to these questions, the companies with the greatest chances of success PROFILE will be those that help people deal with stress Psychiatrist at Sainte-Anne and organise the work environment in line with University Hospital in Paris, human aptitudes and aspirations. ⁄ Patrick Légeron founded the consulting firm Stimulus which helps businesses develop well-being in the workplace. He has authored several books, including La peur des autres, Le stress au travail and La gestion du stress.

READ

“Le stress au travail: un enjeu de santé”, Odile Jacob, 2015.

TEXT: RACHEL PERRET

FIXING A DAMAGED HEART SCIENTISTS AND DOCTORS HAVE LONG DREAMT OF BEING ABLE TO REGENERATE CARDIAC CELLS. NOW, SWITZERLAND IS THE SETTING FOR CUTTING-EDGE RESEARCH TO MAKE THAT DREAM REALITY.

xperts long believed that heart cells could not regenerate. But that’s only true up to a certain age. “Cardiac cells proliferate in children and up to age 20 before gradually losing that ability,” says Marie-Noëlle Giraud, biologist and cardiology researcher at the University of Fribourg. But can that process be reactivated? Researchers have been exploring potential solutions for about fifteen years. CORPORE SANO

Should they succeed, the repercussions would be huge. Today, heart failure affects some 26 million people worldwide. “This condition is almost as common as cancer,” says Roger Hullin, a cardiologist at the Lausanne University Hospital (CHUV). “It’s also extremely severe, with a mortality rate of nearly 50% within the five years following diagnosis.” The term heart failure is used because the heart loses its ability to pump enough blood through the circulatory system. This condition often arises as a result of a heart attack. Cardiac muscle cells are deprived of oxygen and die, leaving scar tissue. The heart’s “contractility”, or ability to contract, is reduced, and the organ can no longer properly fulfil its pump function. Today,

thanks to the work of interventionist doctors, heart attack survival rates are high. That’s great news, but the downside is that the number of patients suffering from heart failure is increasing. TRANSPLANTS AND ARTIFICIAL HEARTS

Drugs can slow the deterioration of the cardiac function, but the only real way to treat severe heart failure is a transplant. That’s not really a solution though, because patient waiting lists are long and the number of available organs is small. Artificial hearts offer a more viable option. Recent innovations promise to improve the fate of patients with a severely slow heart rate. For example, CHUV has recently implanted a new

centrifugal pump which is expected to reduce the risk of infection and blood clots. But since the heart has been found to have a dormant regeneration programme encoded somewhere in its cells, researchers have been moving away from mechanical assist devices towards cell therapies.

heart tissue. Implanted stem cells don’t survive. However, they produce a cocktail of signals that cause positive changes in their surroundings, especially the heart’s own stem cells. That’s what is called a paracrine effect in cellular biology, a form of cell-cell communication.

PROGRAMMING STEM CELLS IN VITRO

BUILDING A BIOLOGICAL BANDAGE

Plenty of clinical studies have been conducted on the use of stem cells to repair a damaged heart. Stem cells harvested from bone marrow are programmed in vitro to become cardiac cells. Researchers have achieved this by reproducing the protein signals that cause stem cells to differentiate into cardiac cells in an embryo. These cardiac cells are then implanted in the myocardium using a catheter.

Marie-Noëlle Giraud and her team in Fribourg have been focusing on this paracrine effect. “Our idea is to create a favourable environment so that stem cells implanted into the damaged areas of the heart can survive,” she says. “We first want to identify and then strengthen the factors with an effect on cardiac stem cells or on any other regeneration mechanism that we can demonstrate. We are making a 3D polymer matrix, which acts like a biological bandage.”

Similar experiments have been carried out with embryonic stem cells. But this method is more complex as there is a risk of rejection, which is not the case when the patient’s own stem cells are used. Other trials work with blood stem cells to promote the revascularisation of blood vessels. These methods have met with mixed results. And not one has succeeded in recolonising dead CORPORE SANO

Stem cells programmed in vitro are being combined with a matrix, and that patch is applied to the scar tissue in the heart. “We don’t yet understand all of the parameters,” Giraud says, “as we don’t know enough about the mechanisms involved. We haven’t yet come up with the right cocktail.” Which stem cells should be used? When should PROSPECTING

they be injected? And in what types of patients? All those questions remain unanswered.

REPROGRAMMING CARDIAC CELLS IN SITU Thierry Pedrazzini, director of the Experimental Cardiology Unit at CHUV, has been exploring a very different solution. He aims to control the reprogramming and differentiation of cardiac cells directly in the heart. His approach is based on a fundamental discovery involving long non-coding RNAs, i.e. the RNA molecules produced by 98% of the cell genome. As yet, their functions mostly remain a mystery. “We’ve been able to show that the long non-coding RNAs control how cardiac cells respond to stress,” says Thierry Pedrazzini. “These molecules function like switches that activate specific physiological responses in cells and trigger programmes for their adaptation to environmental factors. For example, the haemodynamic response of cardiac cells after a heart attack.” His team identified 1,500 noncoding genes that control the response to heart attack in mice. “These genes have counterparts in humans. We can try to protect the heart following a heart attack by improving its resistance. We can also give it the

VOLKER STEGER / SCIENCE PHOTO LIBRARY

This mouse heart underwent artificial cardiac arrest for research purposes. Part of the tissue is dead (in red) due to the interruption in blood flow. Researchers are now looking into different ways of restoring life to dead cells to improve the quality of life of heart attack survivors who suffer from heart failure.

ability to regenerate as the scar tissue is forming, forcing the cells to differentiate into cardiac muscle cells or by encouraging muscle cells to proliferate,” he says. “Technically, we have the CORPORE SANO

means to target these long non-coding RNAs directly in the heart and switch on or off the molecular programmes that control the fate of cells.” Thierry Pedrazzini and his team PROSPECTING

are awaiting the reply from the Swiss National Science Foundation to launch clinical trials. And who knows, maybe they’ll finally find a way to repair a damaged heart. ⁄

SAY CHEESE, YOU’RE ABOUT TO BE INTUBATED!

Facial recognition can be used to reduce the risks involved in general anaesthesia. And this technology could prove promising for other medical applications.

TEXT: PAULE GOUMAZ

he exam only lasts four minutes. Patients sit in a sort of photo booth, open their mouth, stick out their tongue, turn their head and pronounce a series of vowel sounds. Each motion is photographed and filmed by two webcams and a Kinect camera to measure the depth of their mouth. The images are then sent to a software programme

CORPORE SANO

INNOVATION

which analyses 177 precise points on the face. “The machine prepares a facial composite that predicts if intubation will be easy, medium or difficult while they are under general anaesthesia,” says Patrick Schoettker, an anaesthetist at the Lausanne University Hospital (CHUV). Intubation remains a delicate procedure. A tube is inserted into the trachea to maintain artificial ventilation during surgery. Obesity, mobility of the head and a receding chin are some of the physical risk factors. “Patients are examined based on these criteria at the pre-operative anaesthetic assessment,” says Patrick Schoettker. “But that isn’t enough. The doctor can still end up faced with unexpected difficulty in intubation and only four minutes to deal with it, because the patient isn’t breathing.” AUTOMATICALLY IDENTIFYING HIGH-RISK PATIENTS

“The idea of using facial recognition technology came to me in 2011 when I landed in the United States for the third time. The border patrol official immediately recognised me after an eye scan. I realised I might be able to use the same technique, i.e. a way of automatically detecting specific facial features and analysing them based on their morphology.”

A new version of the software measures about a hundred thousand points on the face in 3D.

When he returned to Switzerland, he tested his hypothesis with Christophe Perrouchoud, an anaesthetist at the Morges Hospital, Jean-Philippe Thiran, head of the Signals Processing Laboratory at the Swiss Federal Institute of Technology in Lausanne and nViso, a start-up specialised in emotion analytics. With a 700,000-Swiss franc federal grant, they hired two engineers to develop a software programme. “Using powerful calculations and cameras 1,000 times more precise than the naked eye, we wanted to predict unexpected difficult intubation,” the anaesthetist says.

booth. Meanwhile, new images are added to what has become the largest database of its kind, with input on more than 4,000 patients. The team is also working on a “light” version of the machine for smartphone cameras. “We plan to distribute it to other hospitals in Switzerland and abroad,” says Patrick Schoettker. “The more images we have, the better the predictions made by the software, by integrating data on the local population and the rest of the world.”

SERVICE D’ANESTHÉSIOLOGIE – CHUV

80 MILLION OPERATIONS UNDER GENERAL ANAESTHESIA

In an article published in July 2015, the team reported that the machine achieved a predictive performance comparable to the assessment by a highly experienced doctor on 970 patients. As this is a research procedure, only patients with potential complications currently benefit from it. “We’re improving both the safety and effectiveness of care. Within just a few minutes, we decide on the intubation technique best suited to the patient and the appropriate equipment and staff. With 80 million operations under general anaesthesia worldwide every year, that could save a huge amount of money.”

Several face morphology problems can be detected using facial recognition. A study is currently surveying 200 patients with sleep apnoea syndrome, which has similar predictive factors to difficult intubation, to check if the software can be adapted to identify high-risk patients. But the research goes further. Engineers are also looking into automatically examining structures at the back of the throat – uvula, glottis, vocal cords – to predict the chances of ENT surgery. The potential applications of this software seem limitless. ⁄

A patent was filed for the commercial launch of the photo CORPORE SANO

INNOVATION

TRANSPLANT IN MICROMETRES Innovation A new corneal transplant technique guarantees better results and fewer postoperative complications. Report from the operating room. TEXT: MELINDA MARCHESE IMAGES: PHILIPPE GÉTAZ

The cornea is the outer layer of the eyeball. This tissue can be damaged due to disease or during surgery, impairing the patient’s eyesight. DMEK (Descemet’s Membrane Endothelial Keratoplasty) is a new type of transplant surgery that guarantees speedier and fuller vision recovery. “With this method, we no longer transplant the entire cornea, which is made up of five layers,” says Muriel Catanese, an ophthalmologist and surgeon at the Jules Gonin Eye Hospital, where the DMEK procedure has been available since January 2016. “We remove and transplant only the deepest layer, which is called the endothelium.” There are multiple advantages to this technique. “We can very precisely reconstruct the anatomy of the eye, which reduces the risk of rejection and offers excellent results for the patient.”

EYE BANK

Corneas for transplant are kept at the Eye Bank at the Jules Gonin Eye Hospital. “Our job is to remove, store, assess tissue quality and distribute grafts,” says Michaël Nicholas, a biologist and head scientist at the laboratory. “We perform about 120 transplants every year thanks to donations. But unfortunately not even those are enough. We have some 140 people on the waiting list.” Most organs must be transplanted within hours after removal from the donor. However, corneas can be stored for 30 days if maintained in the proper environment. CORPORE SANO

IN THE LENS

CORPORE SANO

IN THE LENS

ENDOTHELIUM REMOVAL

In the operating room, the surgeon Muriel Catanese removes the graft. “The endothelium is a very flexible, elastic tissue,” she says. “It tends to roll up. Today, using carefully designed, high-precision instruments, we can handle it without damaging it.” The tissue, which only measures about ten microns, is placed in a glass container before being transplanted.

CORPORE SANO

IN THE LENS

CORPORE SANO

IN THE LENS

TRANSPLANT

Three two-millimetre incisions are enough to remove the diseased endothelium from the patient, under general anaesthesia, and to transplant the healthy corneal tissue. The procedure takes nearly one hour, during which the surgeon, assisted by a technician, will delicately position the endothelium. â&#x20AC;&#x153;To finish, we inject air to help the transplanted tissue adhere tightly to the stroma, another layer of the cornea. Over the next few days, the new cornea will become transparent again, and the patient will regain very good eyesight.â&#x20AC;?

CORPORE SANO

IN THE LENS

DANIEL JOYE

Head of Nursing, Department of Musculoskeletal Health and Department of Clinical Neurosciences

To protect our workers from developing back problems, we should invest in conscious prevention.

Put your back into it, turn your back on someone, have your back to the wall. So many negative expressions based on this part of our anatomy! Our back – much more than a simple column of twenty-four vertebrae – is a noble organ. From our early childhood, we load our national rucksack on it and set off to explore the land carrying everything we need. We use our backs constantly to make journeys long and short every day.

PHILIPPE GÉTAZ

But as with all of our organs, we only really pay attention to it when something is wrong or when we’re in pain. And that’s what ends up happening to many of us. Musculoskeletal disorders were the most common cause of hospitalisation in our country in 2014, and 25% of those cases were back-related problems.

CORPORE SANO

COMMENTARY

What we all need to do is keep our backs healthy. That means correct posture, exercise, good eating habits, i.e. conscious prevention. By “conscious”, I mean using our knowledge. “I know what position I should be in to carry this load, I know what position I should be in to work at my desk, I know what position I should be in to get out of bed, etc.” And as with all knowledge, it’s most beneficial when we learn it as children. But is our society really doing enough to teach that? Have we decided to invest in that knowledge that leads us to adopt preventive behaviour? Or do we take a more curative approach? And that is where awareness in our professional lives becomes both a public health and a productivity issue. This is evidenced in the development of robots to substitute humans for certain activities requiring physical strength, especially robotic exoskeletons that assist and relieve humans in performing certain physical activities. The technology was initially developed for construction and civil engineering, but robot assistance is now being applied to patient care and patient mobilisation. Over the next few years, we’ll see how machines and humans can work together to perform numerous tasks, even in hospitals, so that we can watch our backs. ⁄

CURSUS

COMMENTARY

Jean-Daniel Tissot Dean of the Faculty of Biology and Medicine at the University of Lausanne

Money and questions

CURSUS

CAREER AT THE CHUV

100

million Swiss francs. That’s how much fuel the Federal Council will be injecting into the Swiss education engine to increase the number of medical graduates from 800 to 1,300 per year. The Council confirmed that decision on 3 February 2016. In our previous article published in In Vivo’s December issue, we discussed how a financial boon of this size would send schools scrambling for a piece of the pie. But Bern’s resounding and stumbling response to the shortage of doctors should not be a way of avoiding the tough questions. This sum of 100 million Swiss francs should instead be sending out an electroshock, the opportunity to finally take a serious look at our health care system. And examine the time factor. Between the first year of medical school and graduation from the Swiss Institute of Medical Education, these young men and women embark on a long pilgrimage as young students, young doctors, and young heads of clinics. Young, but not so young when they hit the job market. It’s a long, arduous journey for both

future doctors and the establishments that educate them. This time scale should be considered in light of the temporary support from Bern between 2017 and 2020. The 100 million Swiss francs also reveals the importance of education in the sometimes converging and sometimes diverging strategies and interests of universities, Swiss Federal Institutes of Technology, hospitals and federal and cantonal governments. Having so many partners can be an advantage, driving cooperation and synergies, but can also become a burden due to the energy required to lift projects off the ground. Increasing the number of doctors is a simple enough objective but is easier said than done. This never-ending whirlwind, this organised chaos we’re all swept up in, can be difficult to understand. Let’s take this opportunity to unravel the mystery and think hard about medical training. However, let’s do it without losing sight of the fundamentals. At the crossroads of economic liberalism (controlled by insurers) and enlightened intervention (controlled by governments), the role of medicine should be to serve patients, the sick in our society, without creating new needs and without producing modern-day quacks. Despite the objectives set by politicians, our objective as doctors remains to heal and ease suffering. We need to take care of our sick, but this care should not be limited or affected by our financial resources. ⁄

Isabelle Décosterd Assistant Dean of Teaching and Education

CURSUS

Treating strokes

NEWS

Community immersion For the past five years, medical students have been doing a one-day observation programme at community health centres throughout the Canton of Vaud. Jean-Bernard Daeppen, chief of the Alcohol Treatment Centre and of the community medicine teaching programme, tells us more.

them that medical care primarily takes place outside the hospital. It brings them a broader view of the structure of our health care system. This initiative is also in line with a fundamental shift facing society: the ageing population. The Canton of Vaud encourages in-home care, a trend that will grow over the next few years.

What happens during this day of observation? Students in their second year of medical school are sent to one of the community health centres for one day. They follow a nurse around to patients’ homes then take part in a conference.

Five years into it, what is your view of the programme? It’s very positive. Students enjoy this immersion into the community. Given their relative inexperience, medical students are sensitive to the approach taken by these centres, which is focused on people and meeting with patients. The centres themselves are happy to share information about what they do and generate interest from future doctors. Several students have even found summer jobs as a health care assistant in these community health centres.

FORMATION

Restoring all brain functions following a stroke. The neurosurgeon Jocelyne Bloch has been working for years with the biologist Jean-François Brunet, both at CHUV, on how to achieve this. She presented an overview of their discovery at a TED Talk in Geneva in December 2015. Their research shows that our cortical cells can be cultured and reprogrammed to treat nerve cells damaged by a stroke and help the brain repair itself. NEUROSCIENCE

What are the programme objectives? Throughout their university education, students mainly learn about medicine from a hospital perspective. But the majority of them will end up in a more patient-focused field, in the patient’s environment and lifestyle. This one-day observation programme teaches

YVES DOROGI

TANDEM

LAURENT HOLZER

CURSUS CURSUS

“A

CAREER AT THE CHUV

norexics Physician Laurent Holzer and nurse This frequent need dialogue also helps Yves Dorogi form a close-knit interdevelop standard team at the Vaud Centre for vention as quickly as responses and ties anorexia and bulimia. Their goal possible,” says with partner strucLaurent Holzer, chief tures, while monitoris to help patients suffering from physician of the Child ing the health care eating disorders. Psychiatry Section of staff. These profesTEXT: WILLIAM TÜRLER, PHOTOS: GILLES WEBER the Vaud Centre for sionals are on the anorexia and bulimia front lines, and (abC) at CHUV. “Famicaring for these lies need to be closely involved in order to take patients can be gruelling. “Our role is to find part in the care process and take charge of the the best way to manage the various transition patient’s weight gain. To maximise the chances of issues,” says Yves Dorogi. “That means offering recovery, they need to put weight back on as of support for patients between their teen years the first month.” and adulthood to help them become independ ent,” he explains. “We also have to handle the The abC is a treatment centre for adults and transitions between the different levels of care, teenagers with eating disorders. Laurent Holzer especially from the hospital to the outpatient and Yves Dorogi, a clinical nurse from the day centre.” Liaison Psychiatry Service and head of patient care at the abC, work closely together overseeing Each member of the health care staff – nurses, the doctors, psychologists and health care social workers, physiotherapists, dieticians, assistants who work at the centre. This type of physicians, psychologists and nutritionists – has facility is multidisciplinary by nature and requires to bring their work into line to make sure the long-term patient care. Teamwork is indispensapatients are being monitored consistently. “Only ble, and the two experts meet regularly to after patients start regaining weight can we start discuss matters at hand. working on the causes of the problem at a deeper level, especially their relationship with their body, “We try to identify what is specific to adults or their body image and their inflexible obsessions teenagers and where any crossover might be,” about thinness and food,” says Laurent Holzer. says Laurent Holzer. “For example, mixing That is why steering current practices towards patients can encourage younger women not to more flexible and creative care could be an follow the same path as the older ones.” Unsureffective option. “And that’s where the point of prisingly, nine out of ten patients suffering from view of our health care staff is especially useful,” eating disorders are women. says Yves Dorogi. ⁄

NOMINATIONS

PACCAUD FRED POSITION Chief of the University Department of Community Medicine and Health

Biobanks getting organised A nationwide platform was launched at Lausanne University Hospital (CHUV) to co-ordinate Switzerland’s biobanks. The newly formed Swiss Biobanking Platform (SBP) aims to make it easier to access and use data and specimens. Christine Currat, the current director of Lausanne Institutional Biobank, has been appointed to head the SBP, which is scheduled to be fully operational in 2018.

LAST NAME

FIRST NAME

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CHUV wins the Salling Award CHUV’s Department of Psychiatry took home the 2015 Salling Award. This honour comes in recognition of the work by Stéphane Kolly and Ueli Kramer in psychotherapy for personality disorders. The two researchers and clinicians have developed a unique method combining brief psychiatric treatments, emotionfocused group therapy and long-term psychotherapy. ORGANISATION

VOGT PIERRE POSITION Chief of the “Cardiovascular” Department LAST NAME

FIRST NAME

A professor of epidemiology and public health at the University of Lausanne, Fred Paccaud has led the University Institute of Social and Preventive Medicine for 28 years, along with the Swiss School of Public Health for French-speaking Switzerland. He often appears in the media for his analytical views on public health issues and acts as a government advisor to come up with strategies to improve public health.

To develop its cardiovascular expertise, CHUV is bringing its cardiology, cardiac surgery, vascular surgery, angiology NOMINATIONS and experimental cardiology units together into a single service, the newly created LAST NAME GRABHERR “Cardiovascular” Department. Pierre FIRST NAME SILKE Vogt, full professor at the Faculty of POSITION Chief of the University Biology and Medicine at the UniCenter of Legal Medicine versity of Lausanne, has been apSilke Grabherr and her team are pointed to get the new department the leading experts in post-mortem up and running by 1 January 2017. angiography with their modified He will work with a team comprisheart-lung machine used to examing a project manager, a chief ine blood circulation. She has also of staff and the heads of the created a virtual database to better different services. identify bones and highly decomposed cadavers and developed an application to detect substances such as cocaine in fluids. Read the interview with her predecessor, Patrice Mangin, at www.invivomagazine.com

CHRISTOPHE VOISIN, PHILIPPE GÉTAZ, GILLES WEBER

CURSUS

CAREER AT THE CHUV

MIGRATION

Jan Harry Cabungcal came to Lausanne to do research on schizophrenia. Can you tell us about your background? I was born in the Philippines into a family of medical professionals. The idea of volunteering and giving of oneself have been dear to my heart since the days of my early childhood. When my family immigrated to the United Kingdom, I was able to follow my dream by enrolling at the University of Bristol in the biomedical sciences programme. While at school, I had the privilege of exploring Switzerland while studying for a year at the Sandoz Research Institute in Bern. So it was in Switzerland that I became seriously interested in neuroscience. I got my first research position at the Zurich University Hospital, working under Professor Volker Henn. As a doctoral student, I received a grant from the David and Betty Koetser Foundation, and I feel their investment was worth it, as I completed my dissertation with the publication of three articles.

GILLES WEBER

What motivated you to study schizophrenia in Lausanne? I decided to go into psychiatric neuroscience in Lausanne because of the reputation of the head researchers and the goals of their research. Professor Kim Do Cuénod’s laboratory is the only one of its kind. It has developed a translational programme based on close interaction between clinical and fundamental research. This approach is common in somatic medicine but is rare and even considered a novelty in psychiatry.

LAST NAME Cabungcal FIRST NAME Jan Harry AT CHUV SINCE 2007 TITLE Researcher at the Unit for Research in Schizophrenia, Department of Psychiatry

Can you tell us about your research and discoveries? At Professor Kim Do Cuénod’s laboratory, we demonstrated that mice exposed to stress when young developed irreversible brain damage in parvalbumin-positive interneurons, while later exposure causes no effect. This damage can be prevented through antioxidant treatments. We can therefore put forward the hypothesis that exposure to a traumatic injury or stress event in young children at risk can lead to damage in the brain circuits as adults. This means that schizophrenia could be related to a disturbance during a critical period of brain development that causes abnormal synaptic plasticity. Preventing oxidative stress in high-risk subjects using antioxidants could remedy this by restoring normal function to the cerebral cortex. ⁄ CR

IN VIVO

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