Think health
No. 1 – NOVEMBER 2013
/ IMMUNOTHERAPY / FLASH BEAM IRRADIATION
NEW WEAPONS IN THE BATTLE AGAINST
CANCER / PERSONALISATION / NANOMEDICINE
LUC FERRY “I claim the right to weakness” SENSORS Self-tracking, to the point of obsession NEUROSCIENCE Coma: predicting wake-up Published by the CHUV www.invivomagazine.com IN EXTENSO THE SCIENCE OF RUNNING
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IN VIVO / Number 1 / November 2013
CONTENTS FOCUS
17 / research New weapons in the battle against cancer
Recent clinical studies have revealed promising prospects by daniel Saraga and melinda marchese
MENS SANA
26 / Interview Luc Ferry gives his view on euthanasia by bertrand tappy
30 / decoding Organ donation: information campaigns are too neutral
by clément Bürge
42 / Prospecting The dangers of the 200 franc DNA test
An n
Watson plays doctor
ome Im , Wellc
38 / Innovation
I, CRUK
by Julie Zaugg
on, LR e West
34 / trends Barcode bracelets for patients
ages
by SYLVAIN Menétrey
by sophie gaitzsch
A coloured high-resolution scanning electron micrograph of lung cancer cells
CONTeNTS
56
56 19
04 COrPOrE SaNO
IN SITU
46 / dECOdINg
07 / hEaLTh vaLLEY
Coma: predicting wake-up by geneViÈVe RuiZ
At the heart of cardiovascular technology
51 / TrENdS
12 / arOUNd ThE wOrLd
New media, new addictions
iKnife, the intelligent scalpel
by SylVain menétRey
The deep freeze by melinda maRcheSe
70 / COMMENTarY
62 / INNOvaTION
Delving into the heart of life
Medical progress in print by Julie Zaugg
66 / TrENdS Self tracking, to the point of obsession by benJamin KelleR
2
CUrSUS
72 / POrTraIT Microbiologist Onya Opota’s career thus far
74 / TaNdEM A duo driving research forward
sHeA RoggIo, moRgAne RossettI, JÉRÉmIe meRCIeR, UsA goV
42
56 / IN ThE LENS
editorial
BUMPING ZONE
PAtRICK DUtoIt
BÉaTrICE SChaad Chief editor
3
At the centre of the building that will house the swiss Cancer Center on the Lausanne University Hospital (CHUV) campus, the architect has created an area dubbed the bumping zone. During the day, professionals from diverse backgrounds will ‘bump’ into each other in this area: this holds true for the It specialist educated at the University of Lausanne, the specialist in tumour cells back from an internship at Harvard medical school, and the materials specialist newly graduated from the swiss Federal Institute of technology Lausanne (ePFL). the tremendous progress made in the last 24 months in cancer research, which you will learn about in this first issue of “In Vivo”, perfectly illustrates the now essential conditions for innovation in medicine: intense permeability – close collaboration between previously separated research areas. such reconciliation endeavours to pool knowledge that has been kept apart throughout the history of science – such as medicine, humanities and social sciences – and to help drive technological progress. these developments are underway and can be seen in the work conducted by medical students on the quality of the diagnosis announcement (see p. 21). Within this new context, it is therefore not only the architectural basics that are being actively reconsidered – labs with opaque walls and closed doors – but also those of medical science and treatment. Yi Zuo, a 50-year-old American who discovered in 2009 that she had advanced ovarian cancer, is living proof of this. As she recounts on page 19, she received immunotherapy treatment as part of a clinical trial. twelve months later, her cancer was in remission. this feat would not have been possible without the many specialists able to pool their knowledge. they were led by george Coukos, who left Pennsylvania last summer for the CHUV campus and now runs the swiss Cancer Center – another perfect illustration of vanishing borders since it is the result of the pooled resources and expertise of ePFL, the University of Lausanne, the Ludwig Institute for Cancer Research, CHUV and professionals from around the world who this competitive spirit now attracts to Lausanne. “In Vivo” wishes to be the impassioned reporter of this reconciliation of knowledge between labs, the Health Valley professionals and those of the leading universities and hospitals around the world. Its journalists are explorers of this new world opening up to the patient; in short, they are reporters of a vast bumping zone, a communal space for debate, which we hope will be an exciting contributor for all those who like to think about health. ⁄
Thanks to its university hospitals, research centres and numerous start-up specialising in healthcare, the Lake Geneva region is a leader in the field of medical innovation. Because of this unique know-how it has been given the nickname “Health Valley”. In each “In Vivo” issue, this section starts with a depiction of the region. This first card was created by the Genevan graphic designer Jérémie Mercier.
in situ
Health Valley Safety sensors, smartphone applications, cardiac devices, but also the construction of prestigious research centres, new developments in the field of healthcare… all of these are manifold in French-speaking Switzerland. A panorama of the latest innovations.
4
in situ
neuchâtel
HEALTH VALLEY
P. 06
Bioindenter, an innovative device that can increase knowledge on tumour staging.
Lausanne
P. 09
At the EPFL, molecules have been discovered which could improve the treatment of Alzheimer’s disease.
Montreux
P. 09
An international conference dedicated to nanotechnology begins on 18 November 2013.
Martigny
sion
Meyrin
P. 07
Health Valley is strengthening its leadership position in cardiovascular technology with the arrival of US giant St. Jude Medical. 5
P. 08
Construction work has started on the future EPFL Campus that will host 300 researchers in 2015.
P. 10
Twelve new molecules are currently being developed at Debiopharm.
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HEALtH VALLEY
STArT-UP SENSORS
“It isn’t up to medical technology to pay the bill.”
the lausanne-based company domo Safety has developed a system of sensors to prevent domestic accidents among the elderly. the sensors are installed in the home and detect decreases in mobility. if necessary, an alarm warns relatives. the start-up recently raised 935,000 swiss francs for its project.
urs GascHe, PresiDent oF tHe FasMeD FeDeration oF swiss MeDical DeVices’ traDe anD inDustry associations, talKinG aBout tHe HiGH cost oF HealtHcare.
APPOINTMENT
Exxact, a start-up based in Preverenges, has developed a system for doctors to make appointments online. Patients can consult the available timeslots. the platform is also equipped with a function that sends a reminder message to the patient’s mobile phone. the system has been adopted by Hôpital de Morges and the permanent medical facilities at the lausanne university Hospital (cHuV).
DIAGNOSIS
the Simplicity Bio start-up, in Monthey, is working on a system that will make it possible to analyse several biomarkers in order to identify the presence of a disease. an algorithm analyses the biological characteristics and detects traces of disease, thus facilitating diagnosis. the system is currently in the test stage at the Geneva university Hospitals (HuG).
VIRUS
Viroblock, based in Plan-lesouates, has designed a mask that traps and kills pathogenic viruses such as those which cause swine flu, bird flu and coronavirus. according to Viroblock, this product is a hundred times more effective than other masks on the market.
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THE word
radioisotoPes radioisotopes are atoms with a radioactive nucleus. in medicine, they are used to detect the position of specific molecules present in tissue. By 2015, the cern MeDicis research platform will be producing radioisotopes for medical use, initially for hospitals and research centres in the lake Geneva region.
A checklist to reduce surgical incidents
THE dEVICE
Bioindenter in neuchâtel, the swiss electronic and microtechnical centre (cseM) and csM instruments have developed an innovative device that measures the elasticity of biological tissue such as cartilage, ligaments, tendons and muscles. the device helps to increase knowledge on tumour staging and diseases including arteriosclerosis and to optimise implants in tissue engineering.
Since the start of autumn, ten Swiss hospitals have been testing a new system to improve patient safety: the systematic use of a check-list in surgery. Three of the hospitals are located in French-speaking Switzerland: Lausanne University Hospital (CHUV), Hôpital Fribourgeois and La Tour Réseau de Soins. The pilot project aims to reduce the number of adverse events occurring in surgery. According to the Swiss Foundation of patient safety, current results show that a foreign body is forgotten in a patient’s wound in 14 out of every 100,000 operations. It is hoped that the checklist will be used in all hospitals within the next few years.
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HEALtH VALLEY
At the heart of cardiovascular technology The US giant St. Jude Medical recently bought the Geneva-based heart surgery specialist Endosense. This is an asset for the region which already hosts two leading companies in the sector, Medtronic and Edwards Lifesciences. CArdIoloGy A new giant of innovation in cardiac surgery has been established on the banks of Lake Geneva. At the end of August, St. Jude Medical, worth $5.5 billion, announced it was buying out Endosense, a small company based in Meyrin (Geneva) and founded in 2003. Endosense’s flagship product is an ablation catheter used to treat cardiac arrhythmia, the most common heart condition. The takeover, for more than 300 million Swiss francs, demonstrates that the region is becoming increasingly specialised in cardiac surgery technology. The trend is demonstrated by a surprising figure: a quarter of pacemakers in the world are produced in French-speaking Switzerland by the American company Medtronic. Based in Tolochenaz (Vaud), Medtronic controls more than 50% of the global pacemaker market. Edwards Lifesciences, another US medical technology giant and the world’s number-one manufacturer of artificial heart valves, is located just a few kilometres away. The multinational built a new EMEA (Europe, Middle East and Africa) head office in Nyon in 2009. “We have developed very strong relations with the region’s leading doctors,” says Eric Gasser, spokesperson for Medtronic in Switzerland. “This dialogue allows us to continually develop our products and treatments. We are not scientists, isolated in a laboratory!” Four years ago, for example, the company helped to launch the MD Start think tank, on the Swiss Federal Institute of Technology Lausanne (EPFL) campus. One of MD Start’s missions is to follow up on projects initiated on Medtronic’s online discussion forum, the “Eureka” platform. In pacemakers, one of the most important advances made over the last few years was the launch of models 7
text: serGe MaillarD
HiGH-tecH DeVices to treat Heart Disease – Below, tHe MeDtronic PaceMaKer, tHe eDwarDs liFesciences ValVe anD tHe enDosense catHeter – are ProDuceD in tHe laKe GeneVa reGion.
compatible with MRI scanners. “Previously, patients with a pacemaker could not have an MRI scan owing to potentially fatal electromagnetic interference,” explains Eric Gasser. Medtronic is now working on making pacemakers smaller so that they can be fitted directly on the heart without metal connectors. Avoiding open heart surgery According to Enrico Ferrari, Associate Physician at the Department of Cardiovascular Surgery of the Lausanne University Hospital (CHUV), the most important innovation in the field in the past few years is the development of artificial heart valves for percutaneous implantation. By avoiding open heart surgery, the new technique, introduced by Edwards Lifesciences, makes it possible to treat high-risk surgical patients who were previously inoperable. One of the minimally invasive techniques consists in using a catheter to insert a valve into the femoral artery and guide it to the heart to replace the diseased valve. “Other possible access routes exist to avoid open heart surgery, for example through the apex, the tip of the heart, or the ascending thoracic aorta,” says Enrico Ferrari. “The procedure is very quick and guarantees excellent results.” Announcing the long-awaited launch of the third generation of this product, Edwards Lifesciences spokesperson Richard Harbin said: “It will facilitate the positioning of the valve and help to reduce the number of complications, such as bleeding or leaks.” Every year, Edwards Lifesciences also hosts hundreds of doctors from all over the world at its offices in Nyon, teaching them how to insert these valves. This is yet another way of placing Health Valley on the world map. ⁄
in SITU
HEALTH VALLEY
GENEVA CAMPUS SANTé will host researchers from the Global Fund to Fight Aids, Tuberculosis and Malaria and other healthcare organisations. Construction work will start at the end of 2014. Employees Project cost Surface area
1,200 100-120 million Swiss francs 25,500 sq. m
CAMPUS BIOTECH, a neuroengineering research centre, will be established on the site of what was previously the head office of Merck Serono at Genève-Sécheron. Work will start in autumn 2013.
Health Valley, under constant construction
Employees Project cost Surface area
Several large construction sites in French-speaking Switzerland will become buildings dedicated to research and medical innovation.
1,500 – 2,000 Approx. 300 million Swiss francs 29,000 sq. m
Hôpital de la tour, in Meyrin will be transformed in 2014
and doubled in size. Employees Project cost Surface area
150 100 million Swiss francs 20,000 sq. m
HôPITAL INTERCANTONAL RIVIERA CHABLAIS is currently being built. It should be inaugurated in 2017. Employees Project cost Surface area
2,800 293 million Swiss francs 63,493 sq. m
THE EPFL Valais-wallis campus, in Sion, will bring together 11 Chairs, two of which will be dedicated to neurosciences and two others to biotechnology. Researchers will be able to move in in autumn 2014. Employees Project cost Surface area
The construction sites in progress on www.invivomagazine.com
300 115 millions Swiss francs 15,000 sq. m
Hôpital psychiatrique de Cery, near Lausanne, will be completely rebuilt between now and 2019. Employees Project cost Surface area
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320 106,6 million Swiss francs 13,500 sq. m
in situ
HEALTH VALLEY
Nanotechnology in the spotlight
3 questions for
Diary The 7th edition of the Nanotech-Montreux conference will be held from 18 to 20 November 2013 at the Hotel Eden Palace. Worldrenowned speakers will address the application of micro- and nanotechnology in biology, chemistry, and medicine. Posters created by students will present innovations in the sector. www.nanotech-montreux.com
A new School of Public Health
TRAINING Six institutions based in Geneva, Lausanne and Neuchâtel plan to form a School of Public Health in French-speaking Switzerland. Geneva (UNIGE/HUG) will in particular deal with the issues of international healthcare. In Lausanne (UNIL/CHUV/IST) teaching will focus on cardio-metabolic diseases among other things. The Neuchâtel site (UNINE) will take charge of healthcare law.
Patrick Fraering
His laboratory has made a discovery which could revolutionise the treatment of Alzheimer’s disease. What have you discovered about Alzheimer’s disease?
The disease is caused by the overproduction of a molecule in the brain, amyloid beta peptide (1-42). The molecule forms plaques on the brain that kill neurones and cause the disease. We have discovered that two groups of molecules reduce the formation of this peptide. These molecules act on the protein APP which, after the natural process whereby it is cleaved by the enzyme gamma-secretase, will cease to produce, or produce less of, the peptide in question.
2
This character is several microns in size, and has been printed in 3D by nanotechnology researchers in Vienna. Miniscule biomedical elements could also be created using this method.
What makes this procedure revolutionary?
Previously, clinical research was focused on the enzyme gamma secretase. We already knew that it produced the peptide after cutting the APP protein, so tests focused on enzyme inhibitors. The problem was that there were numerous adverse effects as other elements essential to cell regulation are also produced by the cleavage of APP. The molecules at the centre of our research do not cause these adverse effects; they allow the production of the “good” molecules.
3
reuters
1
Can Alzheimer’s disease be cured?
Not exactly. When the cause of the disease is congenital, patients could take the medicine as a preventative measure provided that clinical tests are successful. As for other Alzheimer’s patients, if the disease is diagnosed early, the treatment could prevent it from developing further and therefore extend life expectancy. ⁄ Patrick Fraering is a lecturer at the School of Life Sciences and researcher at the EPFL’s Brain Mind Institute, in Lausanne.
9
In square metres, the surface area of the new production unit of UCB, a biopharmaceutical company located in Bulle. It is one of the biggest production sites of medicinal products in Europe.
32
million Swiss francs, the sum raised by ObsEva. The Genevan start-up, founded at the end of 2012, develops medicinal products used to counteract the risk of premature birth.
in situ
HEALtH VALLEY
First stoP
MartignY
DeBioPHarM researcH anD ManuFacturinG sa. on tHe road
in each issue, “in Vivo” travels to meet with companies based in Health Valley. First stop: Martigny in the Valais.
Local know-how, global network For 35 years, Debiopharm has been developing drugs and licensing them out to large pharmaceutical firms. text: BertranD taPPy
Debiopharm Research and Manufacturing, a branch of the Lausanne-based Debiopharm group, notably produces the prostate cancer drug Triptorelin. Together with another Debiopharmdeveloped drug, Oxaliplatin, Triptorelin has generated several billion dollars in revenue since launch. “The world is our laboratory,” says Thierry Mauvernay, delegate of the board. “Where we are able to add value to a molecule, we develop it and then sell it to a large pharma group which can market it more effectively than ourselves.” It has to be said that developing a drug is a long and costly process, requiring an average 12.7 years and $4 billion, Thierry Mauvernay tells us. The task of the Martigny site, then, is to “inject innovation” into complex products using chemistry and nanotechnologies able to solve the knotty problems of product solubility and harmfulness. The firm’s latest development is 10
a drug that can be administered just once every six months, compared with an injection every month or three months previously. The offices are still in the same premises that have housed the company since its inception 35 years ago, with a few extensions having been made to the production area and biochemistry lab, which is staffed by 45 researchers. “Currently, twelve new molecules are under development for a hepatitis C treatment licensed to Novartis,” says Cédric Sager, CEO of Debiopharm Research & Manufacturing, managed independently of the Debiopharm Group and with a 130-strong workforce. “And we will soon be starting a clinical study at the Lausanne University Hospital (CHUV) of with one of its most promising oncology molecules.” The company’s local know-how and global network is a perfect starting point for our journey. ⁄
in situ
HEALtH VALLEY
BenoÎt duBuis Director of the Campus Biotech site and Chairman of BioAlps
In Western Switzerland, the life sciences industry is going through big changes—an opportunity for the players involved to be that much more creative.
News of the closure of the Merck Serono head office left a deep impression, both in terms of the economic and human consequences and the symbolic value of this fatal end. A dramatic glitch, but a glitch nonetheless. Western Switzerland remains a land of opportunities, of which Serono took full advantage, evolving from a start-up with just a few employees when it arrived in 1980 to several thousand employees before it closed. Our region continues to use its assets to help develop the industrial sector of life sciences. It has allowed a number of companies, for example Ariad, Shire and Alexion, to experience exceptional growth, thus justifying the huge sums of money invested over the past few years by companies such as UCB (which invested about 300 million Swiss francs in its production site in Bulle). Its assets are the basis of the success of companies including Ferring, Debiopharm, Celgene and many others.
But if I only had to retain one strength, it would be the human factor: these men and women are highly qualified and represent the bedrock of this industrial and entrepreneurial dynamism. We live in a period of change, and when things change there are opportunities to make things better: better assist clients, better manage resources, develop more effective strategies, better organise the links between economy and research centres, better fill the technology gap. By technology gap, I mean the difference between an existing product and a new product, or between a certain way of working and a new way of working. Economic opportunities are created when a better product or a better method has not yet been launched. Being the first in an industrial sector or a pioneer in a specific region allows this technology gap to be filled. It is precisely during these turbulent periods, when people are less adventurous, that there are the greatest number of opportunities. Everyone has to look for ways to get by. And the more people who do hesitate, the better the opportunities are for those who don’t. ⁄
Whether we look at the competitiveness-cost situation or the level of investment, the demand perspectives of our products, the financial situation of industrial companies, the technological level, the level of training or entrepreneurial drive: for MorE INforMATIoN all of the indicators are positive. www.bioalps.org
Dr
the platform for life sciences in western switzerland www. republic-of-innovation.ch current life science news in western switzerland
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in SITU
world
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AROUND THE WORLD
Sang Tan / AP Photo
Because research doesn’t stop at borders, In Vivo also provides information on the latest medical innovations around the world.
An intelligent scalpel surgery A revolutionary instrument has been developed by scientists at Imperial College London: the iKnife, an intelligent scalpel capable of distinguishing between healthy and cancerous tissues. The principle: it uses a small electrical current to create vapour upon incision. It then analyses the vapour using a sophisticated mass-spectronomy technique and compares the data collected with a database of more than 3,000 specific tissues, which are the fingerprints of several types of cancer. This gives the iKnife the ability to determine whether the tissue that it has just cut is cancerous or healthy. The number of vaccines currently being developed at the Pharmaceutical Research and Manufacturers of America, a US association of pharmaceutical researchers and manufacturers. 137 are for the treatment of infectious diseases, 99 for the fight against cancer.
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THE WORD
Pandoravirus A new type of virus was discovered this summer. Very complex, it comprises between 1,900 and 2,500 genes. The name refers to Pandora’s box. “Opening this box will without doubt destroy the foundations of everything we thought we knew about viruses,” says Jean-Michel Claverie, Head of Research at the CNRS (French National Centre for Scientific Research) in Paris, which led the study.
in situ
worLd
(1)
(2)
(3)
(4)
dwArfISM Restarting bone growth in people suffering from achondroplasia, the most well-known form of dwarfism. This is the feat researchers from INSERM (French Institute of Health and Medical Research) in Paris hope to accomplish. They have already done so in mice. By means of protein injections, the members of these rodents (1) returned to their normal size (2). The bones of mice suffering from achondroplasia (3) also grew (4). If we consider the most optimistic hypothesis, a medicinal product capable of treating children suffering from achondroplasia will be available in around ten years time.
sci. transl. MeD. 5
Hope that growth can be restored
S Vo ICk I V P IN EST Inside National Slow ideas B atul GawanDe’s coluMn, Health Reform “tHe new yorKer”
JoHn e. McDonouGH, uniVersity oF caliFornia Press, sePteMBer 2012
In 360 pages, John E. McDonough, lecturer in public health at the Harvard School of Public Health (Boston), gives us a comprehensive overview of the challenges – and the flaws – of the health reform launched by Barack Obama in the United States. This perfectly accessible, well documented work allows us to understand a complex system considered to be the biggest social policy reform in America for many generations.
In this column the American journalist and surgeon Atul Gawande presents an enthralling analysis of the difficulties of implementing hygiene measures and care techniques in the most disadvantaged countries, despite the fact that they could save many lives. He points out in particular that, even at a time when technology allows the rapid diffusion of ideas, human contact remains the only way of helping the situation to evolve, even though it may be a slow process.
The hidden influence of social networks
Neuroscience & Philosophy: An Exchange
teD conFerence By nicHolas cHristaKis
DeBate Between Jean-Pierre cHanGeux anD colin McGinn, “tHe new yorK reView oF BooKs”
“I’m excited about tackling aging” larry PaGe, GooGle ceo, PresentinG calico, a new coMPany launcHeD By tHe internet Giant to analyse HuGe quantities oF Data collecteD FroM Patients witH tHe aiM oF iMProVinG tHe treatMent oF Diseases associateD witH aGinG.
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What do neurones have to teach us? The French neurobiologist Jean-Pierre Changeux and British philosopher Colin McGinn discuss the issue. They do not exactly share the same point of view, with each one defending his discipline. Changeux points out that “Philosophers have nothing to teach us, in particular scientists.” To which McGinn replies, “You’re right. It is not the role of philosophers to teach science to scientists, but they are perfectly capable of teaching scientists philosophical theories and concepts.” ViDe s an D entarie M coMM o .c to e s n K lin aGazi nViVoM www.i
People now talk about an “obesity epidemic”. Is the disease contagious? Nicholas Christakis thinks so. A lecturer in medical sociology at Harvard Medical School, he gives a convincing TED conference on the influence of social networks of friends, family and colleagues on an individual. Other behaviour, actions and mental states, such as smoking, alcoholism, divorce and happiness, can spread from one person to another, proving that an individual’s social network can have an impact on their life without them even realising.
os o n
in SITU
the electronic cigarette dilemma Should e-cigarettes be defined as a medical product, and therefore only sold in pharmacies? European institutions and member states have clashed over the question, but should come to a decision early 2014. Invented in China some 10 years ago to help smokers kick the habit, the e-cigarette releases vapour with an optional nicotine add-in. However, medical authorities are still unaware of its health effects. Its extraordinary success has led to fears that the product will become fashionable with adolescents, and a US study conducted by the Centre for Disease Control and Prevention shows that increasing numbers of secondary-school students are using the e-cigarette. Jason Cropper (opposite), former CEO of the electronic cigarette company Totally Wicked, “vaping� in Canary Wharf, London. SIMON NEWMAN / REUTERS
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UP-TO-DATE INFORMATION All you need to know about life sciences and innovation in the region. Sections that are designed for you: What’s on, Innovation, People, Science. It’s a one-stop site for news about companies, higher education, and sponsors of innovation.
D republic-of-innovation.ch
“The joys of discovery are made all the richer when shared. Learn about innovation and experience that goes beyond everyday lives.” BENOIT DUBUIs Founder BioAlps, Eclosion, Inartis
“The Republic of Innovation website is informative, smart, open, and easy to read. It’s a true delight and a real help.”
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ThIERRy MAUvERNAy Delegate of the Board Debiopharm Group
REPUBLIC OF INNOVATION
focus
Cancer
research
New arms in the fight against cancer /
Clinical trials have enabled major discoveries to be made in cancer treatment. Although it is likely that these treatments will only be available in several years time, the future is bright.
/ BY
DANIEL SARAGA and melinda marchese Illustrations
Diamantis Seitanidis / Dreamstime
sĂŠbastien fourtouill
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focus
cancer
“Y
ou have just a few months to live, a year at best.” So many patients suffering from advanced cancer are still handed this terrible sentence. But soon it may be replaced by a more optimistic message. Discoveries made during clinical trials have revealed excellent prospects in terms of the treatment of this disease. Patients who have taken part in such trials have responded well to new therapies (see Yi Zuo’s account opposite). “Some advances are so impressive that I feel we have every right to be enthusiastic about them, said a delighted Olivier Michielin, oncologist at the Lausanne University Hospital (CHUV), on his return from the annual meeting of the American Society of Clinical Oncology in Chicago in June 2013. Everyone I met there was so optimistic.”
If these potential treatments are approved within the next few years, they will join the list of major developments made in the treatment of cancerous tumours. The therapeutic arsenal to which physicians have access is constantly growing; this makes it possible for them to tailor treatments to their patients’ specific needs, an approach which can already be observed in the field. “The way in which we manage cancer care has changed considerably over the past few years, from diagnosis through to choices of therapy, highlights Roger Stupp, director of the Oncology Department at University Hospital Zurich. There isn’t just one approach: it is often by combining different strategies that significant progress is made.”
soMe fIgures
Nevertheless, we will have to wait several years before these treatments are granted marketing authorisation. Before being administered to patients in a clinical context, a drug must first go through several validation phases (see: “The birth of a drug” p. 21)
1
IMMunotherapy DEfENcE IS thE bESt foRm of AttAcK
37,000
The number of new cancer cases diagnosed each year in Switzerland. /
16,000
The number of people who die every year from cancer in Switzerland. /
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For the moment, surgical removal of the tumour remains an indispensable part of treatment for the vast majority of patients. “When an operable tumour is removed, cancer cells can remain and could lead to a relapse, explains Professor Stupp. These new approaches give us hope of one day eradicating the disease for good.”
blood cells, known as the soldiers of the immune system. The molecule Nivolumab, which is still in the testing stages in the USA, works in this way and was found to reduce tumour size in one third of patients whose melanoma did not respond to prior treatment. This is a strategy that oncologist Olivier Michielin believes could work in a large variety of cancers.
In millions of Swiss francs, funding allocated in 2012 by “Recherche Suisse contre le cancer” (Swiss cancer research foundation) to researchers and organisations seeking to improve cancer treatment.
Immunotherapy involves using a variety of strategies to boost the patient’s immune system. “We are finally seeing sound results, says Roger Stupp. This approach still mainly concerns very advanced cancers, but should eventually prove useful in the treatment of intermediate-stage cancers.”
The first of these strategies is aimed at directly stimulating the immune response. This is the role of Yervoy, used to treat melanoma (a very aggressive form of skin cancer). This immunotherapy drug was the first to be approved by the US Food and Drug Administration (FDA) in 2011, and is also available in Switzerland.
A combination of these two approaches can produce even more spectacular results: in a recent clinical trial, sponsored by the American pharmaceutical company Bristol-Myers Squibb, which combined the use of Yervoy and Nivolumab, tumours shrank by 80% in over half of the 53 participants with metastatic melanoma.
A second strategy is to block the action of certain proteins found on the surface of cancer cells. These proteins inhibit the defensive activity of the white
tRAINING thE whItE bLooD cELLS – Therapeutic vaccination is another approach used in immunotherapy. Provenge, approved by the FDA in 2010 for the
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focus
cancer
“My stage III cancer is now in remission” Fifty-year-old Yi Zuo firmly believes in the potential of immunotherapy. She herself benefited from it in 2011, in the framework of a clinical trial, when she suffered a recurrence of ovarian cancer. by melinda
marchese
shea roggio
A
dentist by profession, this resident of Philadelphia (USA) discovered in 2009 that she was suffering from a stage III cancer. “Initially I went to see my physician about constipation problems, she recalls. He prescribed laxatives and encouraged me to eat more vegetables. But that changed nothing. When I felt a lump below my navel, I immediately went back to see him.” An ultrasound revealed the presence of a malignant tumour. “I could see on the faces of the radiologist and technician that the news was not good. It was a Friday afternoon. The following Wednesday, I underwent surgery to have my ovaries and uterus 19
removed.” She was then given chemotherapy, but this did not prevent a relapse two years later. “When I discovered on the internet site of The Penn Ovarian Cancer Research Center that they were looking for women with ovarian cancer to participate in clinical trials, I didn’t hesitate for a second. I applied and was happy to have been selected. I have always been aware of the severity of my illness, and to
benefit from a new therapy was a real opportunity for me. I was also hoping that by serving as a guinea pig I could help other women”. In May 2012, Yi Zuo began immunotherapy. “The physicians took healthy cells from my body which they then put into culture with cancer cells so that they could learn how to recognise them and fight them.” The vaccine is re-injected in several stages with the aim of boosting the patient’s immune system. “Unlike with chemotherapy, this treatment had no side effects on me.” Although she has not yet returned to work, today Yi Zuo regularly participates in charity sports events for cancer research. “Today I feel good and, above all, my latest tests have revealed no trace of my cancer.”
focus
cancer
treatment of prostate cancer, falls into this category. It is now available on the American and European market, but is not currently approved for sale in Switzerland. The objective is to “train” lymphocytes (a type of white blood cell) to recognise cancer cells by putting them in vitro with antigens extracted from the patient’s tumour. Unlike conventional vaccines against influenza or polio, this type of vaccine has no preventive purpose but is administered once the cancer has been diagnosed.
2
natural immune cell
3
1
simulation substance
tumour
Immunotherapy Immunotherapy boosts the immune system so that it can fight cancer more efficiently.
George Coukos, currently head of the Oncology Department at the Lausanne University Hospital (UNIL-CHUV) (see interview p. 24), led studies into the development of a vaccine against ovarian cancer in the framework of his research at the University of Pennsylvania, which now works in partnership with Lausanne. When combined with Avastin (see point 2, Targeted drugs), immune therapy was found to stabilise progression of the disease in patients with advanced cancer. According to Professor Coukos, this treatment could be made available to Swiss patients within the next two years. Another promising experimental vaccine, developed to treat brain cancer, has been submitted for approval to Swissmedic, the Swiss Agency for Therapeutic Products. “We have been able to develop a vaccine by identifying the molecules present on the 20
surface of tumours”, explains Pierre-Yves Dietrich. In recognition of his discoveries, the director of the Centre of Oncology at Geneva University Hospitals (HUG) was awarded the inaugural Annual Cancer Researcher of the Year Award by the American organisation Gateway for Cancer Research. “A handful of treatments have already been put on the market, but the majority of them are only accessible at the moment through clinical trials,” notes Roger Stupp. “Swiss patients should get information on this treatment and ask their physician whether participating in a trial could help them in their fight against cancer.” Towards gene therapy –1 Finally, gene therapy is the 2 most ambitious approach. This involves adding a spe- genetic tumour cific gene from the cancerous tumour to white blood analysis cells extracted from the patient’s body. A spectacular case was reported in a study published in “Science Translational Medicine” in March 2013: the lightning cure by gene therapy of five patients suffering from leukaemia, with the most rapid cure taking only eight days. But this approach, used by researchers at the Memorial Sloan-Kettering Cancer Center (New York) is still in its experimental stage and, for the moment, the European Union has only authorised a single 3 gene therapy, used to treat a rareselection genetic disease not related to cancer (lipoprotein lipase deficiency). of most effective drug
2
Targeted drugs The hopes for personalised medicine
There are cancers and cancers. Once classified according to organs, tumours are now identified according to their biochemical modes of action or, in other words, the way in which cells react to other cells. Personalised medicine, the aim of which is to recognise each type of cancer and to attack it in a selective manner, is playing an increasingly important role in therapies. “Revolutionary results have been obtained with Glivec (see p. 50), one of the first targeted drugs,” points out Martin Fey, director of the Department of Medical Oncology, Inselspital, Bern University Hospital. “This treatment can cure chronic myeloid leukaemia, a disease that used to be incurable.” Among the better-known targeted drugs are Herceptin, for certain breast cancers (authorised in Switzerland since 1999), and Avastin (authorised since 2004), which inhibits the vascularisation that nourishes the growth of tumours.
1
tumour
focus
cancer
IMPORTANCE OF PSYCHOLOGICAL IMPACT Advances in research have not yet set people’s minds at rest about cancer: “Even though patients may have learned from the press or 2 the internet that cancer management has nanobox improved immensely over the last few years, they still strongly associate the disease with death, notes Friedrich Stiefel, head of Liaison Psychiatry at the CHUV. Diagnosis and cancer treatment are still highly stressful ordeals for which no-one can really be prepared.”
2
1
genetic analysis
tumour
Targeted drugs The exact type of cancer is identified so that an appropriate drug can be used.
3
selection of most effective drug
These drugs act on precise molecular targets, unlike conventional chemotherapy treatment that attacks healthy tissue at the same time. “Some tumours, which are activated by DNA mutations, may be identified by genetic analysis,” explains George Coukos. “It is thus possible to identify a large number of new targets for targeted therapies that operate by blocking the defects generated by mutation. Some results are spectacular.” Before drugs can be used in therapy, diagnostic tests are conducted to ensure that the tumour is of the type that will react to the medication. Targeted drugs developed over the past fifteen or so years for use in oncology constitute new weapons in the arsenal available to physicians. Moreover, physicians sometimes use these strategies in combination with other approaches: surgery, chemotherapy, radiotherapy. This is another way of making the treatment for each patient more personalised.
1
mour
Professor Stiefel 1 emphasises the importance tumour of good communication between patient and medical staff. “Scientific studies have shown that the better the physician handles meetings with the patients the more satisfied these patients will be and the better they will adapt to the treatment.” Switzerland is the only country in the world where, since 2005, oncologists are obliged to attend communication seminars. “Everyone involved in the care of patients must be responsive to patients’ needs and offer them psychological support.” In certain cases, additional support may be needed. “About 20% of cancer patients suffer from major psychological problems, such as severe depression or extreme anxiety. All cancer centres now have psychooncologists whose role is to help patients adapt to their situation.” Psychological issues may also emerge during periods of remission. “Emotional scars remain. And the after-effects of treatment – notably fatigue – should not be treated lightly. This is why health care professionals must remain alert to the psychological issues of patients over the long term.”
The birth of a drug Before a drug is granted marketing authorisation a clinical trial is carried out to ensure the product is effective and safe for patients. Clinical trials can last around ten years and are divided into several phases:
Phase I
The test is carried out on a small group of people, both healthy and with the disease in question, in order to evaluate treatment tolerance and to identify side effects.
21
Phase II
The trial is extended to several hundred people with the disease in question: one group is treated with the molecule and the other is treated with a placebo. The efficacy of the treatment is analysed and the optimal dose for administration is determined.
Phase III
The trial now involves a very large number of subjects and aims to compare the efficacy of the new treatment with another existing treatment or a placebo. The results of this phase will determine whether the drug is granted marketing authorisation.
Phase IV
This entails monitoring the treatment over the long-term, after marketing authorisation has been granted. Side effects and possible complications are identified.
3
ac m
focus
cancer
3
active molecule
2
nanobox
1
tumour
1
tumour
3
Chemotherapy Active molecules are enclosed in nanoboxes that have the advantage of accumulating only in the tumour. The chemotherapeutic agents thus attack the cancer cells but leave healthy tissue unharmed.
Chemotherapy the nano revolution
Chemotherapy destroys cancerous tissues using powerful molecules, but it may also damage healthy tissue. New techniques developed in nanomedicine are aimed at using this type of therapy in a more selective way. One ambitious idea which is currently being developed in research laboratories involves encapsulating chemotherapy molecules in a nanobox comprising a fatty membrane and onto which it is possible to attach proteins that are able to bind to cancer cells. The box is then “swallowed” by the tumour and delivers the chemical agent into the cancer cell – a microscopic Trojan horse. The first FDA-approved nanodrugs, such as Abraxane or Doxil, work in a simpler way. Doxil, which is marketed in Switzerland, accumulates naturally in tumour tissue since the nanoboxes are exactly the right size to pass through the porous walls of the blood vessels leading to the tumours. With other more conventional techniques drugs can be injected directly into the tumour. Francis Munier of the Jules Gonin Eye Hospital (Lausanne) has developed a method for treating children with advanced retinoblastoma (cancer of the retina). This procedure, which is practised in Switzerland, con22
sists in the intravitreal injection of chemotherapeutic agents without risk of tumour spread, thanks to 1 2a fine needle cooled to -70°C. The eye was conserved tumour natural in 20 cases out of 23, with no recurrences two years immune after the procedure. cell
4 3
simulation Radiation Therapy substance Greater precision and better-adjusted doses Some predicted the decline of radiotherapy – but they were wrong. The use of radiotherapy dates back to the 19th 3 century and has seen tremendous progress selection over the last few years: highly-targeted X-ray of most doses can now reach cancer cells with increas- effective drug ing precision, thereby avoiding damage to adjacent healthy tissue.
Generally speaking, progress in radiation therapy is inextricably linked to advances in imaging (scanners, MRI, PET), according to Stephan Bodis, expert in radiation oncology at the Cantonal Hospital Aarau. These devices provide highly refined images making it possible to target very precise areas of the body. “In certain cases, a single radiation dose in a very small volume may be sufficient to destroy the tumour.” This technique, known as stereotactic radiotherapy or radiosurgery, requires high-precision equipment such as the gamma knife system. The potential of radiotherapy can be further enhanced through new approaches, including flash radiation therapy. “This innovation is based on a very intense and extremely rapid radiation technique,” exRadiation therapy Radiosurgery works by focussing radiation beams on the cancer cells. Radiation destroys the tumour but preserves surrounding tissue.
1
tumour
3
point of convergence of radiation beams
2
beam
cancer
5, 4,
3
19 18
23
16 1,2 15 14
2
24
,7
28
,1
31
,6
38
39
2
LUNG, BRONCHUS, TRACHEA
Disease selfmanagement
,2
,2 23
27
25
,2
34
36
,2
PROSTATE (MEN)
5 4,
1 5,
5
6
6,
2
BREAST (WOMEN)
2, 8 2, 6 2, 8
8
2,
2,
9
LEUKAEMIA
13
,8
,6 16
15
19
,6
,6
MELANOMA
21
Currently, scientific progress has not provided the means to cure all cancers. But, importantly, it has helped prolong the lives of people with cancer. Hospitals therefore now have to respond to a new need: they must help patients to live from day to day with the disease. “Thanks to improvements in patient care, more and more people can now leave the hospital on the day of treatment,” explains Andrea Serena, specialised clinical nurse at the University Hospital of Lausanne (CHUV). “We must ensure that their return home goes smoothly, that they know how to take their medication, but also, for example, that they can manage fatigue, a common symptom in people undergoing cancer treatment.” Psychological and psychosocial support – aimed for example at helping patients manage family relations – is also a vital part of follow-up care. This new approach to patient care and the complexity of treatment means that specialised healthcare personnel are needed. “Nurses have to help patients to develop self-management skills and ensure that they play an increasingly active role in their treatment.” In the future, there will be fewer trips to the hospital. “Nurses will be able to advise patients remotely thanks to advances in telemedicine. This topic is already being discussed today, the main objective being to help patients learn to live with chronic disease.”
Source: FEDERAL STATISTICAL OFFICE (FSO)
4
30 ,6 29 ,7 28 ,7
,1
33
,7
Mortality rates for 100,000 men/women
,2
The first tests will concern only shallow tumours, more specifically head and neck tumours. “In the long term, flash radiation therapy will likely be used for all types of cancer,” predicts Professor Bourhis. “It has the advantage of minimising inflammation of adjacent healthy tissue, enabling us to use higher doses of radiation. It could therefore be used to treat the most resistant cancers.” ⁄
NUMBER OF DEATHS IS IN CONSTANT DECLINE
,4
plains Jean Bourhis, head of the Radiation Oncology Department at the University Hospital of Lausanne (CHUV), where this autumn he will start conducting the first programme in the world to test this approach. “The radiation dose currently delivered in five minutes will be delivered in 0.1 second.”
35
focus
COLON-RECTUM
1986-90 1991-95 1996-2001
ALL CANCERS
2006-10 2001-05
focus
cancer
INTERVIEW “To see certain patients in remission is truly a miracle”
BASED ON AN INTERVIEW WITH
daniel saraga
Things have changed: in the case of cancer, the hope is not simply to delay the inevitable – but to cure it. George Coukos, one of the world’s leading specialists in immunotherapy, talks about the current state of cancer research.
In 1971, US President Richard Nixon declared war on cancer. Forty years later, the war is still not won.
IV
more than five years after diagnosis is truly a miracle.
No, of course not. But spectacular results have been obtained with new approaches such as targeted therapy and immunotherapy. And the combination of One of the world’s different treatments – leading figures in drugs, chemotherapy immunotherapy and radiotherapy – For 20 years George sometimes multiplies Coukos worked in the field of immunotherapy the beneficial effects.
IV Why is there still only a handful of immunotherapy treatments available? Researchers first focused their attention on a difficult target: therapeutic vaccines that seek to educate the immune defence system by putting it into contact with markers related to cancer. We also discovered the Research and clinical mechanisms used by practice brought cancer to neutralise together the defences of the With its new Swiss Cancer human body, and we Centre, Lausanne wants recently managed to to focus on access to new thwart this strategy experimental therapies and and neutralise it. It’s a to become known as an real game of chess. important site for clinical
GEORGE COUKOS
at the University of Pennsylvania. Since January 2013 he has been head of the Oncology Department at the University Hospital of Lausanne (UNIL-CHUV) as well as director of the Swiss Cancer Centre in Lausanne. The excellence of his work has recently been recognised by an Advanced Grant from the European Research Council, with funding of 2.5 million euros. This funding will be used to support a cancer immunotherapy project aimed at elucidating the interactions between tumour vascular endothelium and T lymphocytes programmed to destroy the tumour vascular network.
Your field, immunotherapy, is today hailed as the most promising approach.
IV
We have made enormous progress. We now know that helping the body to defend itself can have a very important impact on fighting disease. It is possible, for example, to conduct surgery to extract white blood cells (the cells that make up our immune defence system), boost their efficiency and re-inject them into the patient’s body. This technique makes it possible to act even in cases that were previously considered hopeless, such as in patients with metastatic melanoma. To have patients in remission for 24
trials in Europe. The aim
is to develop a centre for Have the early translational research that promises of genetics brings together researchers and personalised and oncologists. Together medicine been they can then more easily fulfilled? Treatment find patients who can programmes benefit from the latest sometimes prove developments in research. to be less effective than predicted and Founded by the CHUV, UNIL, EPFL, ISREC and their extremely high the Ludwig Centre for cost is not well Cancer Research, the accepted. Swiss Cancer Centre is One shouldn’t be already operational. so pessimistic. A new building planned There are dozens of for 2016 will eventually targeted treatments house 400 researchers. that have been developed recently, and they are saving lives. Cancer is a complex and heterogeneous disease. Treatment does not always work for everyone. IV
focus
cancer
It is crucial to first analyse the cancer to determine its type.
IV How long does it take today before a new treatment is used on patients? At best, we can have the first clinical trials after five years and the authorisation to market a treatment for all patients after ten years.
christophe voisin
IV Every day, the papers announce encouraging results for experimental therapies, but in general it takes several years before the treatments are approved for use. Are patients really benefiting from these developments? This is the main objective of so-called translational research centres that bring together researchers and oncologists in a radical manner. Together they can then rapidly identify those patients who could benefit from a new therapy and recruit them for a clinical trial. This is the strategy adopted by the Swiss Cancer Centre, launched in May 2013. We will thus be able to recruit participants far more quickly, which can save lives and also help the therapies mature more quickly.
George Coukos, in the district of Vallon, where the new building of the
Can Swiss patients participate Swiss Cancer Centre Lausanne will be built by 2016. The head of the Oncology Department at UNIL-CHUV is director of this centre, which in clinical trials abroad to test will eventually house some 400 researchers. new molecules? This is possible, but for the moment it is difficult. An I am not a specialist in spiritual matters, innovative treatment is most often accompabut I know that these aspects play a role nied by conventional therapy, and insurance in the patient’s experience and recovery. companies may refuse to cover it if it takes What’s important is that the patient feels place abroad. We are developing this kind good. This is why we have begun to set up of collaboration programme in Switzerland, a transversal organisation that brings together bringing together quite a number of research different specialists – from the surgeon, the groups and already providing opportunities psychologist and nutritionist to the oncologist for participation in innovative trials – around different professional bodies. The IV Cancer treatments are extremely technical. patient no longer has to be concerned with Is there still a place for psychological and different contact points, and information sociological aspects of the disease? circulates better. ⁄ IV
25
mens sana
“Who can claim in all certainty that death is the right answer to a call for help? Allow me to doubt it. We only have to think about those we love to shudder at the idea that they could fall in the hands of those terrible doctors delivering the quick and painless “exit”…” LUC FERRY
26
MENS SANA
INTERVIEW
Luc Ferry Should patients be kept alive against their will? Is assisted suicide defensible? The philosopher, and former French Minister of Youth, Education and Research, sounds off on euthanasia. interview: BERTRAND TAPPY photo: philippe gétaz
in addition to the necessity, in such cases, IV Public opinion is divided on the questions of euthanaof advocating understanding and support, sia and therapeutic obstinacy. What is your position in even love, rather than trying to make others this regard? LF The concept of “dying with dignity” seems understand that it is better to make a clean very fragile to me, not to mention that it often carries very sweep and stop bothering the world… distressing connotations. It seems to imply that human dignity is related to autonomy, and that such dignity can More generally, one could hope that society be lost through the extreme mental and physical dewould stop being encouraged to consider old pendence that old age and illness can sometimes thrust age as an “illness” that responds only to two upon us. Quite frankly, I find the idea of drawing any treatments: DHEA (dehydroepiandrosterone, a equivalence whatsoever between “dependence” and hormone known for its anti-ageing effects, earning “indignity” to be morally intolerable, as if a human it the nickname of “the hormone of youth”, editor’s being could “lose his dignity” on account of being note) to begin with, and euthanasia to end with… weak, ill, old, and why not ugly, for that matter, I would say the same thing to “pro-suicide” arguand therefore thrust into a situation of extreme dements: the very notion of assistance indicates that we pendence. My question is: can a human being ever are not dealing with the exercise of a purely individual lose his dignity in such a way? He can probably freedom. Assistance implies a relationship with others. lose it in another way, by becoming a scoundrel, Suicide supporters focus on the request for assistance but certainly not by being weak and dependent. and the guarantees offered by checking the merits of said request. However, by focusing mainly on the request, we IV You then argue in favour of respect for almost forget the other half of the agreement: the answer life, whether or not it is difficult. LF I argue to such a call for help. Far from arguing in favour of the for a patient’s absolute right to even the most ideal individual autonomy that all supporters of assisted extreme form of dependence and weakness,
27
MENS SANA
INTERVIEW
suicide hold sacred, the truly desperate appeal on the other would be absurd! The truth is that human party shows that, in this case, the person making the apdignity is not a quantitative question; it peal is essentially dependent – since he would otherwise does not form part of the scale by which simply commit suicide without assistance. As a result, it one measures – how, exactly? – pleasure is the ethical problem of the answer provided which must and pain. The human being has something be considered essential, and not the obsessive checking of which surpasses the mere man: a certain the quality of the request. Who can claim in all certainty transcendence that forces respect and dethat death is the right answer to a call for help? Allow me serves to be fought for. Some might say that at least to doubt it. We only have to think about those we this premise cannot be proven. Perhaps, as is love to shudder at the idea that they could, one desperate always the case in matters of morality, which day, fall in the hands of those terrible doctors delivering is not an exact science. But if I had to choose the quick and painless “exit”… between a so-called humanitarian act consisting of killing and another consisting of saving and loving, you will forgive me for choosing the second option.
IV But hospitals are not for desperate people, rather patients at the end of their lives… LF That is not true today: these clinics end the lives of people in perfect physical health who are only, as they say, “tired of life”. They are mostly the elderly, both men and women… But what proves to us that a lonely and slightly depressed old lady has more freedom to desire death than a young girl who is struggling to get over her cheating fiancé? So much has been said and done to make us think of the elderly person as useless, a burden, a piece of rubbish, less attractive and less independent than before; in short, undignified! In the end, the patient has no other choice but to die with this famous “dignity”, which ultimately becomes another word for indifference.
So, where is the dividing line? LF In any case, it is not merely a question of age, that
IV
28
IV You have had the opportunity to work with many health professionals on the issue of therapeutic obstinacy. What struck you most during your discussions? LF Surveys conducted among doctors from some twelve Western countries show that over 40% of them admit to having been faced with euthanasia requests. Nobody knows how many responded favourably, but at a minimum, these figures show that the practice of euthanasia could easily become standard. BIOGRAPHy Born in 1951, Luc What struck me most? First and foremost, Ferry studied the real and prevailing concern for humanphilosophy and ity among health professionals, followed by political science. He has written their lack of a reliable reference framework several books, in for making decisions and, as a result, their particular The request for clarification of all the different new ecological positions taken… order, translated
into 15 languages and for which he was awarded the Prix Medicis and the Prix Jean-Jacques Rousseau. His initially discreet career entered the fast track in 2002 upon his appointment as French Minister of Youth, Education and Research. He is currently Chairman of the conseil d’analyse de la société français (CAS – French society analysis council).
IV You often talk about different views on therapeutic obstinacy, which are necessary to understand requests from families. LF Yes. The first position is the one held by religions, which are mostly all hostile to euthanasia, all the more to assisted suicide, and also to therapeutic obstinacy. However, their definition of the latter is highly minimalist. Why? Because they are much more hostile to euthanasia than to therapeutic obstinacy and the two problems are related like two sides of the same coin.
MENS SANA
INTERVIEW
Do you have any examples? LF For one, there is the Catholic Church, which has always been most radically opposed to euthanasia in all forms. The Church bases its position on a simple principle (which, moreover, should have opposed it equally to the death penalty, to which it has nevertheless always been favourable). This principle is expressed very clearly in paragraph 2280 of the official Catechism of the Catholic Church: “We are stewards, not owners, of the life God has entrusted to us. It is not ours to dispose of.” The is not a doctrine which glorifies selfishness and the purChurch naturally distinguishes between active suit of private interests. On the contrary, it is an altruiseuthanasia, which it strictly rejects, and the legittic theory whose supreme principle could be expressed imate refusal of therapeutic obstinacy. However, as follows: an action is good when it strives to achieve “leaving to die” is only justified in extreme borderthe greatest amount of happiness for the greatest posline cases, such that the decision to stop treatment sible number of beings concerned by the action. Once may be very difficult to define in practice. this has been clarified, we can understand that based on such premises, utilitarianism not only justifies euthanasia, but also justifies any IV Illness also plays a unique role in this form of opposition to therapeutic obsticase. LF Most definitely. On the one hand, READ nacy: to the extent that utilitarianism enthe illness could be a “road of conversion”: “Faut-il légaliser l’euthanasie?” tails a “calculation of pleasures and pains”, it can, once again according to the “Cate- Axel Kahn it goes without saying that, from the mochism”, “make a person more mature, help- and Luc Ferry, ment when a life consists of infinitely more ing him discern in his life what is not essen- published by Odile Jacob, 2010 pain than pleasure, without the possibility tial so that he can turn toward that which of foreseeing the slightest improvement is. Very often illness provokes a search for in the future, action must be taken and God and a return to him.” The typically recourse to euthanasia granted as soon as the pamodern ideal of a quick and gentle death, if possible tient clearly requests it. in a state of unconsciousness, is therefore not that of the Church which is keen to remind us how, in ancient times, people were less afraid of death than of what was IV In that case, is there no ideal approach to supposed to follow it, such that the agony, far from beillness and death? LF Certainly not! As you can ing cut short, was an opportunity to make peace with see, these positions are completely irreconciloneself, others and God. able. For example, there is no practical way of balancing the demands of a fundamentalist Catholic family with those of a medical estabIV What other views of therapeutic obstinacy would lishment converted to utilitarianism, and vice you mention? LF That of utilitarianism, which is nearly versa. We are forced to proceed by trial and completely predominant in the Anglo-Saxon world. Acerror, to navigate the pitfalls and try to undercording to these views, therapeutic obstinacy begins with stand the logic motivating all parties. Why? the refusal to meet a patient’s request for euthanasia or Because there are highly divergent philoassisted suicide. sophical and religious positions and none of them can seriously claim to prevail over the IV Where does this idea come from, which is radically difothers – that is why I am always dubious of ferent from the previous one? LF It should be remembered strict legislation on the subject. ⁄ that, contrary to what the French word suggests, utilitarianism IV
29
MENS SANA
DECODING
ORGAN DONATION
CHANGING THE HEADLINE In Switzerland, the lack of donors can be explained by the uninspiring public information campaigns. But not for long.
Manuel Pascual, Chief of Service at the transplantation centre at the Lausanne University Hospital (CHUV), explains that the increase is
30
Manuel Pascual, Chief of Service at the transplantation centre in the CHUV
caused by a rise in the number of people waiting for an organ transplant rather than by a decrease in donor numbers. “We have an ageing population. This means we are seeing more patients, with vascular problems in particular, who require an organ transplant.” Moreover, medical progress is making transplants possible for a growing number of people. Meeting this growing need will demand a high level of community solidarity. However, the number of donors has remained stable over the past ten years, while the waiting list has virtually doubled in length over the same period.
Hailed by advertising professionals for its artistic qualities, the 2013 campaign entitled “The Decision” does not really encourage people to donate their organs. The short film, produced with a budget of 80,000 Swiss francs, features two men in a car that swerves off the road and ends up teetering on the edge of a cliff. A life-or-death situation that sparks a conversation about organ donation. The film does not aim to influence the decision of the public but to encourage them to think about this issue and to make a decision by carrying a donor card before they find themselves in a situation as dangerous as the one faced by the two men. This impartial approach to the issue does not promote organ donation as much as it should. “The message remains too neutral, organ donation should be actively promoted,” insists Manuel Pascual, Chief of Service at the transplantation centre at the CHUV.
PATRICK DUTOIT
L
ast year in Switzerland, 53 people on the transplant waiting list died owing to the lack of donors. The situation has not improved since. In June 2013, 1,208 people were waiting for an organ transplant in Switzerland, a rise of 3,7% on the previous year. To raise awareness on this issue, the Swiss Federal Office of Public Health (FOPH) regularly runs national information campaigns. With little success. According to the SwissPOD (Swiss Monitoring of Potential Donors) survey conducted in Switzerland in 2011 and 2012, 53% of relatives refused to donate organs, compared to 30% in Europe as a whole.
TEXT: SYLVAIN MENÉTREY
MENS SANA
DECODING
Compared to other European countries, statistics in Switzerland are among the lowest. According to Swiss-transplan, the Swiss national foundation for organ donations and transplants, the number of deceased donors per million population was 12,8 in Switzerland in 2011, compared with 14,7 in Germany, 23 in Austria and 35,3 in Spain, the European champion for organ donation.
SWITZERLAND HAS SOME OF THE MOST WORRYING STATISTICS
Are the Swiss selfish? “I don’t think so. If you look at the figures for organ donation by living donors, the Swiss are at the top of the rankings,” says Manuel Pascual. Every year, over one hundred living donors give a kidney to a family member or friend. And they make this decision despite the risks linked to the operation, although these are now minimal. In addition to the logistical obstacles to organ donation and the difficulties of putting in place a regional organisation to identify all potential donors across Switzerland, Manuel Pascual believes that the problem lies in the information campaigns organised in Switzerland until now. “They have a destabilising impact on the public because they do not come out
clearly in favour of organ donation. One of them featured people expressing their opinions, and most of them seemed to be against the idea. This does not reflect public opinion when people have all the facts. For example, when we go to see students and explain the situation, almost all of them support the idea. Even from a religious standpoint, organ donation is widely accepted today, but there are a few exceptions.” Although campaigns vary in terms of form, distribution channel and target audience, they appear overall to be purely informative and neutral. Raphaël Hammer, a Lausanne-based sociologist who has studied the impact of media coverage on organ donation in the local French-speaking press, believes that the FOPH could adopt a more incisive approach to its campaigns. “The information content relates mainly to procedures and has little substance. Campaigns could give more facts, ‘for and against’, while still respecting the principle of ‘public information’. This would help people form their own opinion.” In reality, the FOPH campaigns respect the Act of 2004 to the letter. The second paragraph of the first article of this Act says that the role of the State is to ‘contrib-
SWITZERLAND
OFSP
“La Décision” 2013
31
MENS SANA
DECODING
ute’ to making organs, tissues and human cells available for transplantation, and not to 'promote’ the act of donation. As a result of this semantic subtlety, the State limits its actions to information and control. CHANGE IS IN SIGHT
This stance could shortly change. At the beginning of 2013, the Federal Council launched an action plan christened “Plus d’organes pour des transplantations” (More organs for transplants). This may reflect a desire for more efficient information campaigns. Manuel Pascual will be part of the steering committee. “I am delighted to see this collaboration with the authorities,” he says. “I hope that between now and next spring we will be able to run a campaign that truly encourages organ donation.” Why was this restriction introduced in the first place in 2004? “Pascal Couchepin, the federal advisor who introduced the Act, believed that it was important not to create panic among the public or to give the impression that the State could take organs from its citizens,” explains Nicholas Stücklin, graduate assistant in social sciences at University of Lausanne (UNIL), specialised in body
Germany
anthropology. “This impression was not entirely unfounded. For the first heart transplants in Zurich in the 1960s, organs were removed without informing the families, and that made the issue controversial. The idea was to avoid sparking a public debate on the role played by the State in the supply of organs for fear of damaging what Pascal Couchepin called a ‘climate of trust’”. The aim of the organ transplantation act was first and foremost to inform the public and to encourage more people to carry organ donor cards. From this standpoint, the public information campaigns have been relatively effective, since between 20% and 30% of the Swiss population now carries a completed organ donor card, compared to 12% before the campaigns. “However, it will be some time before this increase in card carriers translates into an increase in donors because brain death – the condition required to be a donor – remains rare. It occurs no more than 200 times a year in Switzerland,” states Karin Waefler, head of FOPH information campaigns. The hope is that most of the people taking cards will be potential donors. So what is the best way to convince more people to become donors? Is it a good idea to play on their emotions by showing people waiting for organ transplants? Or to communicate more widely? According to Christophe Girard, Artistic Director with the MC Saatchi Agency in Geneva, the subject requires some media hype, “Campaigns should take their inspiration
spain
“The waiting Time experiment” 2012
“Eres perfecto para otros” 2012
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DECODING
from road safety initiatives such as ‘Slow Down’, which was seen everywhere. Extensive advertising, based on the model used in English-speaking countries, works very well for this type of social issue.” However, sociologist Raphaël Hammer warns against the limited long-term impact of campaigns that appeal to the emotions. “Studies have shown that fear and emotion do not have long-lasting effects. You need to go deeper to change attitudes on issues as sensitive as organ donation.” Manuel Pascual would like to see a clear, straightforward message, “We need to remain pragmatic by explaining that Switzerland has high-quality transplantation technology and that the chance of receiving an organ is ten times higher than the chance of donating one. We need to communicate plainly, by saying ‘I am in favour of organ donation. I have told my friends and family and I carry a donor card.’” Yves Rossier, Assistant Head of Strategic Projects and Organisations at the CHUV, has studied how best to promote organ donation. He believes that campaigns should refute a number of common misconceptions. “We need to remind people that the family’s consent is still required, even if the person has an organ donor card. Also, the concept of brain death is not clearly understood. Some people are still afraid that their organs will be removed while they are still alive. Others think that the costs of organ removal will be paid by the family or
that donors’ bodies will be used in medical research.” Yves Rossier also suggests creating communities in the media and on social networks to open up a wider debate on this issue, which still has limited visibility. “We could even set up a travelling theatre, with a play that could be staged in hospitals, schools and associations around Switzerland.” Some of these ideas will be discussed in Bern over the next few months. “In 2010, Switzerland signed an international treaty that required it to adopt a favourable position on organ donation,” says Manuel Pascual. “It is time for this to be reflected in federal law.” The Swiss Parliament is also debating the possibility of changing the law, by making every adult a “donor by default”, unless they specifically state that they do not want to donate their organs. All of these initiatives demonstrate an awareness that things need to change. It remains to be seen whether these efforts will bear fruit. Manuel Pascual, Chief of Service at the transplantation centre at the CHUV. ⁄
brazil
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“Immortal Fans” 2012
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5 PRECONCEIVED IDEAS ON ORGAN DONATION “Organs could be removed before the donor’s death” False Organ removal occurs only in the event of brain death, verified by two doctors and confirmed through neurological tests. “Beyond a certain age, you can no longer be a donor” False There is no lower or upper age limit for donors. “You can say in your will that you want to be an organ donor” False The reading of the will is usually too late for the organs to be viable. “Agreeing to be a donor means agreeing to donate all your organs” False You can specify any organs you do not wish to donate on the card. Many donors say ‘anything but the eyes,’ since they are uncomfortable with the idea that something so closely linked to who they are could be transferred to another person. This is also false since only the corneas are removed. “The costs of transplantation are paid by the donor’s family” False The costs are covered by the recipient’s basic health insurance.
trends
Text: Julie Zaugg Illustration: Tang Yau Hoong
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n November 2012 two men visited a hospital in Isère in France for a medical examination. One of them had an aneurism that needed to be operated on straightaway. But he was sent home and the other man was operated on for an inexistent aneurism. Fortunately, there were no serious consequences for the two patients. But the case of mistaken identity could have ended tragically. To avoid this kind of error, some hospitals have started to fit their patients with electronic bracelets equipped with barcodes for 100%-sure identification. Since the mid-2000s, most Swiss hospitals have fitted patients with paper bracelets, marked with their name. But the computerisation of the system is still in its infancy. Geneva University Hospitals (HUG) began a pilot project in 2006 to test electronic bracelets in some oncology departments. “Caregivers now systematically scan the barcode
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Electronic files in all Swiss hospitals The end is near for the printed patient file. By 2017, all Swiss cantons are required to introduce the electronic file system, through which individuals may choose to enter their medical information online. They will then be able to decide who, apart from themselves, is allowed to view this data. The goal is to enable access to patient information anytime, anywhere, greatly assisting specialists and medical establishments.
on the patient’s bracelet to check that it matches the barcode printed on the pack or syringe to be administered to the patient. The idea being to not give them the wrong medication,” explains Pascal Bonnabry, head pharmacists at HUG. A test study with imaginary patients showed that using a scanner identified 100% of potential mistakes, compared with 98% for a checklist on paper and 85% with neither of these tools. The project is to be extended to the rest of the establishment by 2014 or 2015. “As well as preventing medication mistakes, electronic bracelets could be used to avoid errors in administering blood packs and fitting equipment such as prosthetics and pacemakers,” adds Pascal Bonnabry. But what happens if the patient gets the wrong bracelet? Dartmouth University researcher Cory Cornelius has solved this problem by developing a bracelet that
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To guard against this information falling into the wrong hands, the device would only work within range of an identification beacon worn at all times by the doctor and activated by Bluetooth. “No information on the patient is stored on the phone,” says Olivier Hugli. SAVER would take on its full meaning with the introduction of the patient’s electronic file, centralising all the data on the patient in electronic format. This is planned for 2017 at Federal level in Switzerland (see p. 34).
“recognises” the person to whose arm it is attached. “When a slight electric charge is applied to the wrist, it reacts according to tissue and bone density,” he explains. This is what is known as bioelectrical impedance analysis, or BIA. “The impedance, or resistance, establishes a ‘print’ that is unique to each human being and informs the bracelet of the identity of the patient in question.” intElliGEnt Data sortinG
Olivier Hugli, head physician at the emergency service at the Lausanne University Hospital (CHUV), is looking even further into the healthcare future, one in which electronic bracelets are just the starting point for a huge network of patient data. “Three or four years ago, when the hospital replaced doctors’ beepers with mobile telephones, I began asking myself how we could make better use of handsets in our day-to-day work,” he says. The result of that thinking is the Smart Access to Versatile Emergency Resources (SAVER) project, co-developed with the Haute École d’Ingénierie engineering school in Yverdon.
At the CHUV, patient data have been entered electronically since 2010 as part of the “Dophin” project (“Dophin” being short for institutional and electronic hospital patient file in French). “Between now and 2015, caregivers will also start entering instructions for patient treatment, including orders for medication and x-rays,” says Pierre-François Regamey, head of IT systems at the CHUV. A pilot project on accessing patient files via electronic tablets will be rolled out by the end of the year. In the long term, Dophin could be connected to SAVER, the implementation date for which has yet to be set. “The two projects tie in,” stresses Pierre-François Regamey. “Electronic bracelets generate automatic patient identification, creating an instant and reliable link with their file, saved in electronic format.”
The aim is to fit patient bracelets with RFID (radio frequency identification) chips. “When caregivers approach a patient’s bed, information on the patient is displayed on their smartphones,” says Olivier Hugli. The information is “intelligently” sorted according to the caregiver’s needs and function (doctor, nurse, etc.). They can then access information on the patient using their phones. “We’ve developed software that makes it easier to enter these data in a smartphone. For example, pain intensity would be indicated by a cursor from one to ten, while blood pressure could be illustrated via a dial.” Away from the patient’s bed, doctors could receive alerts about them on their telephones.
survEillancE tool
In the United States, some hospitals are delving deeper into the possibilities of artificial intelligence. El Camion, a 411-bed establishment in Silicon Valley, is one of the most “connected” hospitals in the world. Doctors can check their patients’ electronic files at any time and analyse exam results using one of the terminals located around the facility or froM patiEnt to carEGivEr information is sent from the patient’s wrist to the caregiver’s smartphone via a chip in a key ring. The telephone is connected to the hospital’s iT system.
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via their smartphones. Patients are hooked up to the system via electronic bracelets, which are equipped with a biometric ID (an ultrasound of the vein network of their hand taken on admission) and enable doctors to check where they are in the hospital in real time. And so an electronic bracelet can also be used as a surveillance tool. “Providing it is equipped with a RFID chip or GPS, we can monitor the patient’s movement, from one service to another and from one caregiver to another,” says Pascal Bonnabry. “This can be useful in a psychiatric environment or for fighting baby theft.” Newborns are fitted with such bracelets in a number of hospitals in Texas, California and Colorado. An alarm goes off and the hospital doors lock shut automatically if an infant is taken from the nursery by a non-authorised person. “Electronic bracelets could also be interesting for people with Alzheimers or other forms of dementia,” says Birgitta Martensson, director of Association Alzheimer Suisse. “When they first arrive at hospital, they are often very disoriented, don’t understand why they are there, and try to leave. Bracelets can help to find them. In nursing homes, it gives them a welcome dose of independence, since they can move around freely in a secure perimeter instead of being stuck behind a locked door.” ⁄
interview “It is crucial to set clear rules” Christian Raetz, data and information protection commissioner for the Vaud canton, talked to us about the big issues in medical data security. What are the risks involved in the increased digitalisation of patients’ medical records? CR The advantages of digitalising patients’ records are undeniable, but, yes, there are dangers involved, too. The main risk stems from the volatility of IT data, which are easy to transport, share and modify. Concerted efforts need to be made to ensure that the data are not meddled with or accessed by unauthorised people. We also need to make sure that the information is used purely for the original aim, that of bringing patients the best possible care. IV
What measures need to be taken to safeguard the security of patients’ records? CR The first, naturally, is to ensure the physical security of the data, mainly through encryption, in other words, making a document unreadable to all those without a decryption code. Another key issue is access rights. Not all hospital staff should be able to access all the medical data of all the patients. IV
What about information leaks at hospitals? CR Healthcare personnel are bound by medical confidentiality and well aware of that fact. But unlawful treatment can’t be ruled out, so a set of basic conditions needs to be implemented to limit risks. It is also important to distinguish between two types of records: the computer records drawn up by each healthcare provider (hospital, GP, etc.), which in principle are accessible only in the hospital or doctor’s office where the patient is treated; and the records as envisaged by the federal bill on electronic patient records, containing data that can be potentially accessed by all healthcare providers. In both cases, it is vital to set clear rules on who can communicate what to whom. BS IV
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INNOVATION
_watson _T
ucked away in the Thomas J. Watson Center, IBM’s research headquarters in a small northern suburb of New York City, an unremarkable door leads to a large room. The room houses one of the world’s most powerful computers. Servers fill the space, covering several hundred square metres and cooled by a battery of loud fans. The dark mass of electronic circuits represents the latest and greatest hope of US physicians and promises to transform the country’s healthcare system. The machine became a celebrity in January 2011 when it won the
famed televised game show Jeopardy. Capably answering questions put by the presenter, Watson – for that is its name – systematically crushed the human competition. “We wanted to show that our computer was capable of speaking and understanding English, not just deciphering codes and raw data, like other computers,” explains Adam Lally, one of the 12 members of the computer’s original development team. “For the contest, Watson read and assimilated nearly 200 million pages of text, including all of Wikipedia.” The day after the televised victory, IBM went to work on finding a commercial outlet for the
machine. “We decided the logical next step was to put it to use in medicine,” Mr Lally recounts. Marty Kohn, in charge of Watson’s medical programme, states the starting point of the new project: “The number of data points and scientific articles is increasing every year at an ever-faster rate. No care provider can use all this information, or even access it all”. The supercomputer, on the other hand, is able to read 60 million pages of text per second and can instantaneously manage the new information. IBM’s objective is to assist physicians in making diagnoses and suggest the most appropriate treatments. IBM hopes to market its service within a few years. Watson and similar computers should become
david korchin
Text: Clément Bürge
_With its unparalleled diagnostic ability, the Watson supercomputer is radically transforming the role of the physician. We spoke with scientists who are learning to work with a machine that “outdoes” humans.
_One in five diagnoses is incorrect or incomplete.
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plays doctor_ accessible to every doctor on the planet thanks to cloud computing, a system of online storage and viewing. The machine’s medical skills are currently being tested at the Memorial SloanKettering Cancer Center, a New York cancer treatment and research hospital, and the Cleveland Clinic, a hospital in Ohio. US insurer WellPoint plans to call on Watson’s talents soon to analyse the effectiveness of the treatments it pays for its customers to receive. A bespoke diagnosis
Herbert Chase, MD, professor of Clinical Medicine at Columbia University, is working with IBM on the project. He details Watson’s advantages: “The machine will allow patient treatment to be personalised as never before”. Beyond accessing the most relevant medical literature, Watson will be able to use a patient’s individual data: “The hospitalised person’s diagnosis will be customised based on their history. Watson will read their medical file and will know their allergies, the medications they have taken
Adam Lally, a member of the team that developed Watson, pictured with the 90 servers making up the supercomputer.
Watson will change that... the institute of medecine, Washington, DC
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throughout their life, and even the specifics of their genetic makeup. It will be able to foresee drug interactions, even when thousands of drugs are involved or when they are nearly undetectable. The patient will also be able to indicate his treatment preferences and what side effects he is willing to put up with.” Watson’s diagnoses should thus prove more precise than any contemporary doctor’s. According to the Institute of Medicine, a US NGO that deals with health matters, one in five diagnoses is incorrect or incomplete, and nearly 1.5 million medication errors are made every year in the USA. “Watson helps us to improve our aim,” says Daniel Kraft, a professor at Singularity University in the heart of Silicon Valley and Executive Director of FutureMed, a programme that explores the use of new technologies in medicine. In the USA, the Watson project’s announcement has had a spectacular impact. The question for the academic world and media is: will the robot replace the doctor?
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Vinod Khosla, one of the best-known investors in new Silicon Valley technologies, thinks so. He predicts that computers and robots will be able to handle most tasks performed by doctors – even surgical operations – and will replace four out of five physicians in the USA. Stanford University author and physician Abraham Verghese fiercely challenges this view: “People who say that don’t understand what treatment is. A physician’s work does not begin and end with diagnosis. It’s all about providing psychological support for our patients. And that’s something no robot can do.” IBM’s Mr Kohn adds reassuring words: “Watson doesn’t pretend to be anything but a helpful tool. It will never replace the physician”. But even as a mere assistant, the supercomputer seems to be redefining the role and working methods of medical personnel. “The physician will spend less time and energy in diagnosing his patient. He will be able to concentrate on psychological follow-up,” says John Eric Jelovsek, who heads the Cleveland Clinic’s Simulation Center. In the eyes of Thomas Gauthier, a specialist in new medical technologies at Geneva’s Haute Ecole de Gestion, the transformation has already begun. “More often these days,” he says, “the physician is involved in mediation or negotiation. Patients frequently arrive at their doctor’s office with a handful
INNOVATION
of Wikipedia printouts. They have the illusion that they know what is wrong with them and sometimes refuse the treatments their doctor offers”. For Francesco Panese, Associate Professor of Social Sciences and Medicine at the University of Lausanne, the culture of medicine is in the midst of transformation. “The paradigm of the 1960s, when a doctor would diagnose his patient and decide his treatment, no longer exists. We are going to enter the era of the ‘negotiated clinic’. Patients have more and more access to information. They want to know what is happening to their bodies.” Mr Kohn is counting on Watson to facilitate the transition to negotiated medicine: “The machine can explain, in English, precisely what the patient is
suffering from and what the treatment options are. It has been proven that a treatment chosen with the patient’s agreement is more effective. We want to encourage that.” But there is still the fear that Watson will threaten the relationship between patients and caregivers. “The supercomputer could disrupt the trust placed in the practitioner,” says Mr Gauthier. “When world chess champion Gary Kasparov lost against the Deep Blue computer, the human race realised for the first time that a machine could outperform a human being. It was a shock. The patient may be tempted to turn to the machine and reject the physician’s diagnosis in the belief that it is of lower quality.”
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million: The number of pages ThaT waTson can read and undersTand per second. —
11,520
The number of Tasks ThaT waTson can process aT The same Time —
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in TerabyTes, waTson’s random-access memory. This eQuals The memory of abouT 3750 deskTop compuTers. 40
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Watson’s arrival on the market will also have an impact on physicians’ training. “The doctors of the future will need different skills. Memorisation will be less important, and the analytical skills to understand the information computers provide will be more so,” says Mr Kraft. “The computer will be the one who takes on memorising all the side effects of medications, which are too many for a single physician to know them all.” sHARed ResponsibiLiTies
Benoit Dubuis, Chairman of Swiss association BioAlps, warns of another effect: “With the everwidening use of new technologies, there are more and more actors in the medical chain. Engineers and mathematicians are joining
INNOVATION
the physicians and life scientists. We must be careful not to end up in a Tower of Babel, where each person speaks a language specific to his own specialty.” To avoid this pitfall, the EPFL institute of technology in Lausanne has opened a school of life sciences, which aims to promote communication between engineers and biologists. The increasing number of players is a challenge to physicians’ area of responsibility. “Currently, the doctor bears full medical responsibility. But what will happen in a few years?” asks Dr Panese. “The responsibility will also be borne by the person who inputs the data to the information system, or the creator of an algorithm. In future, it will not be out of the question for a mathematician to
big daTa _ a challenge for medicine_
The data explosion now affects every corner of our society. But it is in the field of medicine that it has raised the greatest hopes. how will it be possible to store, share, analyse and view this mass of information (also called “Big data”) to improve patient treatment? iT processing of gigantic mounds of data presents several advantages for the healthcare sector. according to consulting firm mckinsey, the information revolution will result in savings of $300 billion to $450 billion annually for the US healthcare system, representing a decrease of 12% to 17% in costs. But hopes go beyond the merely financial advantages. “Combining the data from a patient’s file with global medical information will result in continuous improvement in diagnoses,” says Francesco Panese, associate Professor of Social Sciences and medicine at the University of lausanne. “in future, it will be possible to predict what type of disease someone may contract many years in advance.” But there is another side to the coin: “We are going to move from an era of uncertainty to one of worry. We will know our ailments in advance, but in some cases, medicine will not know how to treat them”.
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testify in a court of justice when a medical error has occurred.” May even Watson be incriminated? “The physician must absolutely stay in control of his diagnosis. Watson is there merely to help him, not to take responsibility for anything,” comments Mr Kohn. For Mr Gauthier, the danger is in the mathematical formulae of
ibm ≥ hal? Back in the 1980s, British writer arthur C. Clarke, author of the «Space odyssey» saga, imagined the hospital of the future. «it seems that the computer has virtually unlimited capacities. Could it replace the doctor one day? (...). it’s more likely that the computer will play the role of advisor. The doctor will use it to gain a second opinion». Clarke’s supercomputer was called hal, an acronym that corresponds to a one-letter shift on iBm. a link that the author always said was coincidental.
the new systems. In his view, “If machines like Watson are transformed into ‘black boxes’ and no one knows how they work, there will clearly be a problem of responsibility.” The expert throws down the gauntlet: “Physicians and society as a whole must think about the importance of machines in medicine, and clearly define their role.” ⁄
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prospecting
The hazards of low-cost dna testing Having ones genetic makeup analysed to detect health risks is a practice that is winning over consumers. But it is not without risks. Here are four concerns to keep in mind.
Text: Sophie Gaitzsch
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T
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echnological advances and genetic finds in this century have created a burgeoning new market: direct-to-consumer DNA testing. Several dozen firms, mostly US-based, now operate in this sector. For prices ranging from 200 to 1,000 Swiss francs, they promise to tell their customers where their ancestors came from, whether they are predisposed to certain illnesses or whether they have the “warrior gene” – a higher-than-average propensity for risk-taking, which confers above-average chances of success. And consumers can get all this information without leaving their armchairs. They order the test online, receive a sampling kit and send a saliva sample by post for analysis. As the founder of three firms that offer tests of this kind in Switzerland, biologist Joëlle Apter confirms the public’s lively interest. “Demand just keeps growing. We’re selling 3,000 tests a year. The vast majority are designed to determine origins. I believe everyone should be able to decide for himself whether he wants to have access to this information.” But the testing craze worries healthcare professionals.
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1 The analYses are incoMPleTe
“These companies – the bestknown is called 23andMe – analyse one or two million variations
andrew kelly / reuters
Jared rosenthal drives around new York in his van, encouraging passers-by to take a variety of genetic tests for a few hundred dollars. he sells around one hundred tests a month. he says that his aim is to help people establish their identity. “our van offers greater privacy than a clinic. so our customers tend to talk more freely. we are right there with them at a key moment in their existence.”
The presence of the “warrior gene”, a higher-than-average propensity for risk taking Relational compatibility with a partner The ability to avoid mistakes Ancestral origins, Vikings or Celts
a single genetic dataBase
for medical research, genetic information is of the utmost importance. it leads to a better understanding of disease mechanisms and helps in developing new treatments. the lausanne university Hospital (cHuv) is leading the only project of its kind in switzerland. early in 2013 it began collecting genetic data from consenting patients. the data will be stored and may be used for research. eight months into its work, the lausanne institutional Biobanque already has 4,500 samples. on a long term, it expects to gather 15,000 annually.
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that occur with relatively high frequency in the human genome,” explains Vincent Mooser, head of the testing department at the Lausanne University Hospital (CHUV). “Certainly, variations are informative for someone interested in genealogy, but they have limited predictive value for health. For example, through precise investigation in a medical environment, Angelina Jolie was found to be at high risk of someday suffering from breast cancer. Her risk would not have been detected with one of the tests available online. Also, these analyses do not take an individual’s environment into account, even though illnesses always stem from multiple factors.”
proSpEctiNg
customers in detail about the products, their limitations and their potential consequences.”
3 daTa ProTecTion is noT gUaranTeed
Some experts also highlight the lack of guarantees regarding data protection. Industry firms store large amounts of their customers’ information. In Switzerland, the manipulation of genetic material is considered sensitive and is subject to very strict organisational and technical measures. But many countries, including the USA, do not have such high requirements.
4 no PsYchological sUPPorT is offered
2 The firMs are noT MoniTored
For Dr Mooser, the lack of monitoring is also worrying. “Although certain laboratories like 23andMe have a good reputation in the scientific community, we have no idea how they actually do their work.” Armand Bottani, a geneticist and member of a Swiss Federal commission of experts for human genetic analysis, sees the market’s take-off as inevitable. “This is a reality we cannot really fight. We want better oversight, with the companies operating transparently. They should operate under Swiss Federal authorisation and they should inform
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Ruth Baumann-Hölzle is head of the Dialog Ethik Foundation, a Zurich institute for ethics in healthcare, and a member of the Swiss National Ethics Commission on Human Medicine. For her, the DNA testing phenomenon raises a host of questions. In clinical settings, physicians may perform DNA tests to confirm diagnoses. However, online offerings arbitrarily point to a vast array of diseases. “Customers sometimes receive disturbing indications that may have serious consequences for their emotional well-being and that of their friends and families. What is an individual supposed to do with information like
that? What does the company do with it? What happens if health insurance companies and employers gain access to it?” These questions will no doubt gain in urgency as the techniques gather momentum. In a few years, online genetic testing firms will surely have access to complete genome sequencing and will be able to provide their customers with even more information. ⁄
flYing Under The legal radar
swiss law prohibits the sale of genetic tests to individuals. But offers from firms outside switzerland are readily available online. despite legislation, three zurich-based firms – igenea, gentest and genepartner – also sell services of this type. they skirt the prohibition by having the analyses done in laboratories in other countries. they take responsibility only for explaining the results and for customer contact. switzerland is trying to adapt to this fast-changing environment. in february 2013 the swiss federal commission of experts for human genetic analysis made a statement favouring a “prudent opening” of this market. it recommended authorising the tests when there is no direct health concern, and advising the general population to avoid such testing. But a revision of the law may be in the works. the swiss parliament rules on such questions, and it casts a wary eye on any liberalising moves. when the parliament last voted on the question, in 2012, it refused by a very wide majority to authorise dna tests without medical support.
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coMMENtArY
luc montagnier 2008 Nobel Prize winner in Physiology or Medicine, for his work on the HIV virus
A change in mindset is necessary, by both doctors and patients, if we want to improve the prevention of chronic disease. Human life expectancy is continuing to increase and medical progress can take much of the credit for this. However, the incidence of age-related chronic diseases is also increasing. We are nearing a time when the number of people suffering from these diseases will outstrip the number of working people in good health. Health expenditure is highest and most prolonged during the last years of life and a number of the chronic diseases treated, neurodegenerative diseases in particular, often become incurable. Clearly, we need a new approach to medicine, aimed at keeping people in good health for as long as possible. To this end, I have lent my voice to others in the US and in Japan in promoting a new form of medical practice, P4 medicine, based on four key attributes: Preventive, Predictive, Personalised and Participatory.
Of these tests, some will detect established situations, such as infections, where the infectious agent(s) can be destroyed. Although these diseases have many contributing factors, the ability to identify infectious agents will make it possible to take early action that will stop the disease developing and prevent irreversible consequences.
Personalisation and participation: each individual has a genetic heritage common to the human species, as well as variations that are transmitted genetically or picked up by the organs as a result of exposure to environmental factors: chemical or food pollution, or radiation of any sort. It is therefore important for a far-reaching dialogue to be established between patient and doctor, and – first and foremost – for the patient to consult his/her Prevention and prediction: current information doctor on a regular basis before the disease campaigns (smoking, alcohol, obesity,) must can take hold. The doctor must then establish a naturally be maintained and developed. global profile of the patient by means of laboraAlso, a growing number of laboratory tests will tory tests and this dialogue. This means that the make it possible to identify risk factors. These consultation should last at least one hour, rather tests will become increasingly sensitive than an over-hasty ten minutes! and precise, drawing upon molecular biology and biophysics to replace or complement We must therefore encourage a change in mindset. serological and biochemical tests. This could be done through financial incentives, but it is up to each person to act responsibly. Each Profile individual is free to choose a low-risk life – life is Luc Montagnier, a French a risk in itself – or to subject his/her body to an virologist and professor excessive load and die earlier than expected! ⁄ emeritus at the Institut Pasteur, is currently engaged in research into DNA and chronic diseases in Europe and Africa. read
dr
“les combats de la vie: mieux que guérir”, luc montagnier, editions Jc lattès, 2008 luc montagnier develops the content of this column, written for “in vivo”, in a text published on www.invivomagazine.com
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COMA: PREDICTING WAKE-UP teXt geneViÈVe rUiZ
doctors are managing to predict with ever more accuracy whether or not a comatose patient will wake up one day. We explore a world that is still rife with the unknown.
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ill a patient wake up one day from a coma? answering this question is a considerable challenge for doctors, given the complexity of this brain dysfunction. through extensive research and increasingly precise equipment, the coma is gradually being demystified. “Since 2010, we have performed a battery of tests using a sophisticated eeg, which allows us to develop a detailed map of the brain,” explains Mauro oddo, head of the neurointensive care Unit at the Lausanne University hospital (chUV). “We subject patients to a series of sensory stimuli and observe their reactions. on that basis, it is possible to predict whether a patient will remain comatose with a probability of over 80%, particularly in a post-cardiac arrest coma.” this probability could improve significantly following recent advances in research. in france, at the pitié-Salpêtrière hospital in paris, a team created a bank containing the data of hundreds of seriously injured people seriously whose prognosis at one year was known. When a new patient arrives in the intensive care unit, the results of his Mri scan are compared with those of the bank using special software. So corpore Sano
far, predictions thus obtained, pertaining to the likelihood of patients waking up or the after-effects they may suffer, have proved to be reliable. however, the real revolution could come from a recent study at the centre for biomedical imaging (cibM) in Lausanne, the joint work of Mauro oddo and andrea rossetti, head doctor of the epileptology Unit at the chUV. the results, published in the “brain journal”, have exceeded expectations: “for now, we have obtained predictions that were 100% accurate,” says a delighted Mauro oddo. “Since 100% obviously does not exist in medicine, we need to confirm these results with a larger group of patients,” he specifies. the test consists of subjecting patients to different auditory stimuli, then observing the reaction of their brains with an eeg. “in the intensive care phase, we place the patient in a state of hypothermia for 12 hours and we lower body temperature to 33 degrees,” explains Mauro oddo. “this treatment helps preserve brain function. this is when we begin to look at the person’s brain, observing his reaction to a series of monotone sounds that vary in
coMa a patient in a coma cannot be awakened by any stimulation, even involving pain. his eyes remain closed and he has no sleep-wake cycle. the only movements he makes are reflex ones.
Zephyr / Science Photo Library
This coloured tomogram represents the brain of a 42-year-old coma patient. The lesions, in particular on the mesencephalon (white marks), a region controlling functions such as concentration, sleep, waking up, and movements of the head and neck, are caused by a lack of oxygen.
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BeTween FiCTiOn and eXCePTiOn /
intensity and duration.” twenty-four hours later, when the patient has been warmed up and returned to a normal temperature, the medical team repeats the test. if it observes an improvement between the first and second session, the comatose patients have so far always woken up. Major ethical issues “to date, we have tested only 30 patients, which is not enough,” says Mauro oddo. “We are in the process of testing others, but VegetatiVe we would like to test State hundreds to confirm this state is characterised by our results.” this promthe preservation ising experiment has of certain funconly been conducted tions: breathing, on people for whom thermoregulathe cause of coma is tion and sleepprolonged cardiac wake cycles. arrest. the researchers the patient may would also like to apply spontaneously it to brain injury victims. open his eyes, “We are beginning to but does not study this section of the communicate with the outside population, since the world and does people involved are not respond often younger than 40 to stimuli. his years old. this is espemovements are cially true since, even if reflexes. the chances of waking up are practically nil, it is still very painful to disconnect a young person in a coma.”
said the name of his mother after 20 years spent in a coma.
When faced with comatose patients, ethical questions frequently arise. “in Switzerland, when we know that a patient is not going to wake up, we do not keep him on life support,” says andrea rossetti. “a case like ariel Sharon, the former israeli prime Minster, who has been in a vegetative state for seven years following a stroke, could not exist here. these questions are highly cultural and in countries such as italy, Japan and israel, it is very difficult to stop treatment for a person, even if there is no hope.” there are tragic situations, such as the one concerning terri Schiavo, whose fate divided america in 2005. this 41-yearold woman was in a vegetative state for 15 years following a stroke. her husband was resigned to ending her suffering. her parents did not agree, and a series of conflicting court rulings ensued. on two occasions, terri Schiavo’s artificial feeding tube was removed, then reinstalled, first in 2001, then in 2003, and permanently disconnected two years later. ⁄
the results of these tests will facilitate decision-making that is often very distressing for families and medical staff. CORPORE SANO
UnUSUal the american terry Wallis
dECOdiNg
MiniMaLLy conScioUS State (McS) the patient shows some awareness of his environment: he looks at an object, follows his reflection in a mirror, sometimes reacts to emotional stimuli (he may cry or smile when he sees a loved one) and can answer requests, for example, by moving. but this behaviour is fleeting and unstable. the patient is unable to communicate consistently.
eMiLio Morenatti / Upi / neWScoM, ron phiLipS
COnVenTiOnal the former israeli prime Minster, ariel Sharon, has been in a vegetative state for seven years.
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IMPROBABLE Alicia, the heroine of the film «Talk to Her», becomes pregnant during her coma.
Between myth and reality A patient is in a coma for four years and becomes pregnant. She wakes up after giving birth to a stillborn child and then goes on to lead a completely normal life. Alicia, the heroine of the film Talk to Her (Hable con ella) by Spanish director Pedro Almodovar, would certainly not know the same fate in real life. “Most patients do not remain in a coma for more than four to six weeks,” explains Mauro Oddo, head of the Neurointensive Care Unit at the CHUV. “And it seems very unlikely that a woman in a coma could fall pregnant, given that her hormonal cycles are disrupted.”
Comyper, Gilles Weber
Beyond fiction, beliefs about comas are also influenced by exceptional cases reported in the media, such as the American Terry Wallis, who in 2003 said the name of his mother after 20 years in a coma. Moreover, the term “coma” is often used carelessly. There are actually different stages of brain dysfunction, characterised by clear signs. “Between coma and waking, the patient often goes through a vegetative state, then enters a minimally conscious state,” clarifies Andrea Rossetti, head doctor of the Epileptology Unit at the CHUV.” In the latter state, patients are more responsive to external stimuli. For example, they are able to smile or to follow their own reflection in a mirror. Even if they cannot communicate with those around them continuously, there is still a likelihood that they may come out of their state one day. The more weeks go by, however, the slimmer the chances...” CORPORE SANO
«We must use the formal form (‘vous’ in French) when addressing a person in a coma» interview Karin Diserens, head of the Acute Neurorehabilitation Unit at the CHUV, talks about the ethics of care given to patients in a coma.
It is now possible to predict the progress of some comatose patients. What are the ethical implications of these findings? These new tools are going to influence the initial decision of whether or not to continue therapy for a patient in a coma. A multidisciplinary team shall discuss each case. The team shall comprise intensivists, neurosurgeons, neurophysiologists, neurorehabilitators and other consultants if necessary, depending on the pathology. Are families also involved in this process? Yes, their viewpoint is essential. Moreover, since early 2013, they possess an absolute right to decide on the fate of their relative.
decoding
Does the medical team treat a patient in a coma as if he were awake? That is our goal, but the main difficulty lies in the fact that we are unable to communicate with the patient. However, the team is required to use the ‘vous’ form when addressing the patient and to talk to him as if he understands everything. We have also set up a rating scale of pain based on the observation of patients. We can identify those who are suffering and address their pain through early neurorehabilitation. This last point is important: clinical research has shown the beneficial effect of very early treatment during which patients benefit from a programme with many neurosensory stimuli. CHUV is also the first research hospital to take care of these patients in a neurorehabilitation unit so early on.
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Imatinib C 29H 31N 7O
C 29H 31n 7 o A moLeCuLe, A StorY text: bertrand tappy
glivec, the brand name of the drug imatinib, is a breakthrough medicine that halts the advance of a rare form of leukemia, chronic myelogenous leukemia, by accurately inhibiting its reproductive mechanism. it was the first in a fastgrowing series of special new cancer drugs, the most recent of which address kidney, lung and liver cancer. on launch in 2001, glivec made the headlines because of its price: 50,000 swiss francs a year for lifetime treatment. the manufacturer argued that the development of the drug required a sizeable investment given the relatively modest number of chronic myelogenous leukemia sufferers (with
Glivec, a drug used to treat a rare form of leukemia, costs each patient 50,000 Swiss francs a year. By adapting the dose to each person’s particular needs, that expenditure can be reduced and the benefits of the medicine increased.
around 50 cases diagnosed a year in switzerland). “but in the last ten years, on the strength of a growing number of successfully treated patients, glivec has become an extremely profitable product, worth 4 billion swiss francs in annual revenue worldwide,” says thierry buclic, head of clinical pharmacology at the lausanne university hospital (chuv). and the manufacturers have equally high financial hopes for other new cancer drugs. another striking fact with drugs such as glivec is that
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just one dosage regimen is recommended, even though blood concentration levels vary significantly from one patient to the next. that aspect raised a vital question at the chuv: would it be possible to improve the cost-benefit ratio of these products by working out a specific dosage for each patient? “obviously manufacturers are somewhat reluctant to finance research aimed at reducing the doses of some patients since it also reduces sales,” says thierry buclin. “but we
had to launch research on the topic, because the lack of data on the possibilities of individual dosage was simply unacceptable. any drug can be ineffective, or do more damage than good, if the dose isn’t right.” after several years’ research on measuring blood concentration levels with glivec, the efficacy of the approach appears to have been confirmed, providing that dosages are individualised in consequence. similar work now has to be done with other cancer drugs in the same family that are still prescribed with one dosage for all, as it seems quite clear that different patients need different doses. ⁄
ZOOM
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new media, Online communication occupies an outsized place in our lives. And what we once called “virtual” contact must now be considered real, as are the various forms of dependency it engenders.
new
addictions?
Text: Sylvain Menétrey Photos: Anthony Leuba IN CORPORE SANO
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n a recent press interview, Arnaud Cerutti, a young Geneva-based journalist, talked about how Facebook had “almost saved his life”. Arnaud joined Facebook in the midst of a serious depression. The social network allowed him to get in touch with old friends and helped him realise from the depths of his solitude that people showed an interest in him. But it was when he published a photo of himself, showing how physically wasted away he had become, that the online relationship took on real-life form. When his estranged family saw the picture, they grasped the full extent of his condition and called the Swiss psychiatry supervisory council to have him treated. Arnaud says that he has since rediscovered his lust for life and now has friendships on and off line.
„People addicted to online gambling and seeking help arrive in a state of deep anxiety and depression.“ Olivier Simon, Associate Physician at the CHUV
For better – as in Arnaud’s case – or for worse, new technologies have come to occupy a considerable place in our lives. To the extent that it has become practically absurd to refer to life on line as “virtual”. “Relationships formed on the internet are real, a part of everyday life,” says French psychologist Yann Leroux, author of several works on the influence of new media on psychology. “In my consultations, people tell me about what they do on Meetic and Facebook while making no distincCORPORE SANO
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Web pathologies
tion with other parts of their lives.” The web gives many shy people a window on the world and a more comfortable way to interact with others. “People aren’t physically exposed on the internet. They can play any number of roles because the other person can’t see them,” says Sophia Achab, head of the addiction unit at the Geneva University Hospitals (HUG). “You can hone your skills on the web before expressing them in real life.” While freeing some people from their inhibitions, new technologies also have a dark side, trapping users in a web of dependency. The “bible of psychiatry”, The Diagnostic and Statistical Manual of Mental Disorders, or DSM, has yet to classify cyber-dependency as a known disorder, but more and more people are seeing doctors for problems stemming from excessive use of new media. “We get this kind of case regularly, especially with gambling addicts, often involving several individuals,” says Olivier Simon, Associate Physician at the Centre for Excessive Gambling at the Lausanne University Hospital (CHUV). Research on this type of mental problem is still in its infancy and a clear consensus as to the reality of the addiction has yet to be established among psychiatrists and psychologists. Yann Leroux has a sceptical view. “It’s a holy grail that people have been looking for in vain for years. In my opinion cyber-addiction doesn’t exist. People with psychopathological problems express them through the social networks and internet.” In other words, the technological tools have no addictive properties in themselves, unlike substances such as nicotine. They are simply outlets through which people with mental illnesses express their problems.
New technologies can exacerbate certain personality traits and lead to behaviour that is harmful for oneself and others. Hikikomori Hikikomori, literally “pulling inward, being confined” in Japanese, is used to describe teenagers and young adults who refuse contact with everyone apart from their online friends, locking themselves in their rooms amid empty soda bottles and only leaving their lairs to forage for food. FOMO FOMO, or the “fear of missing out” syndrome, is the constant anguish of worrying that you’ve missed out on something great, like a party or event. The fear is magnified by the countless photos of parties posted in the social networks. This syndrome may signal an inferiority complex.
Yann Leroux cites the example of FOMO, or the “fear of missing out”. FOMO CORPORE SANO
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sufferers are under the impression that other people are having more fun than them and are worried about missing the “unmissable” party. FOMO, which can paralyse an individual in asserting a preference, is caused by the non-stop comparison of personal choices and those of others, aided and abetted by posts on the social networks. “But really it’s just an old fear dressed up in modern clothing, the fear of not having bought the right car or not getting good marks,” says Yann Leroux. “In today’s world, where everyone is interconnected, a person can feel left out simply by having failed to follow a particularly heated discussion on line.” While caution should be taken before declaring the appearance of new syndromes, a substantial amount of research shows that there is a link between new media and addiction. “Even if the causality hasn’t been formally established and test samples are still limited in scale, brain imaging data demonstrate similarities between addiction to the internet and addiction to a substance,” says psychiatrist Sophia Achab. Head of the “New Addiction, New Treatment” programme launched in 2007 in Geneva, Sophia Achab took part in a study sketching out a parallel between web and cigarette addiction. “Internet use activates parts of the brain associated with the idea of reward. We noted the secretion of dopamine and serotonin, for example. Even with the absence of a substance an addiction may develop, as it does with gambling.” Surprisingly, the same mechanisms are involved in the two cases. “For example, multi-player online video games bring players a consistent and immediate dose of wellbeing after the game. Players
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moving up to higher game levels experience an even better feeling, as they set their aim on new goals and receive acknowledgement from their peers.” These mechanisms, combined with the 24/7 access, low cost, high speed and anonymity of the web, favour the development of addiction. Addiction is diagnosed by psychiatry departments from the moment a form of suffering is expressed, not just by the person’s friends and family but by the person himself. The latter is forced to put other parts of his life on hold – work or social relations, for example – in order to get his dose of satisfaction, much like cocaine-addicted mice willing to pedal forever to obtain their drug. “People seeking help at this level generally arrive in a state of deep anxiety and depression,” says Olivier Simon.
Trolling Trolling is the provocation of chat forum members through insults or contrary opinions, motivated by jealousy or the desire to reveal participants’ hypocrisies. Trolling can also be a form of harassment.
Unlimited access to electronic media may contribute to the addiction, but it is the content in itself – chat sessions, social networks, porn sites, games – that works as a catalyst. “In the prehistoric era, the more humans grouped together, the higher their chance of survival. Some spheres of the web call on these same primal instincts,” says Olivier Simon. By strengthening the feeling of belonging to a community, the social networks have a reassuring effect. “Also, sites with strong and hard-hitting stimuli elicit reactions related to survival, sex and social interaction.” Given the extent of the stimuli, specialists talk about cyber-addictions in the plural. Cyber-dependents also include subgroups with a variety of profiles. “Women are more addicted to the social networks, mature men to cyber-porn and well-integrated young people to video games. But these categories are shifting CORPORE SANO
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with the arrival of new technologies,” says Sophia Achab. The disconnect between online and offline behaviour can also be credited to the recognition of cyber-dependency. “In my practice I have never encountered people addicted to both sex and porn sites or to real-life gambling and online poker,” says Sophia Achab. “People visit virtual casinos in search of different sensations. Sociability and chatting while playing on slot machines, which may play a role in entrenching problem gambling, do not exist online.” Treating these addictions is complex because sufferers cannot be weaned completely, as they can with addictive substances. As a result, treatment often involves individual or group therapy. “The idea is to help the person find a life objective. They have to re-learn how to consume multimedia content. We also try to find out to what extent the addiction is linked to family issues and how the evolution of the addiction is affecting the sufferer’s family and friends.” Experts all agree that the web should not be demonised. “It’s a working tool that only becomes problematic for a small minority,” says Sophia Achab. Internet is a life preserver for some and a new way of living their sexuality and social life for others. It is a place for interaction, generally positive but sometimes destructive. The key is educating find out more people on how to limit “Les jeux video, the risk of ill use. ⁄ ça rend pas idiot!”, Yann Leroux, FYP ed., 2012 “Mon psy sur internet” Yann Leroux, FYP ed., 2013
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hélÈne brioschi levi Director of Healthcare, CHUV
the working population in the healthcare sector contribute to the swiss success, both from an economic and human point of view. it is therefore necessary to invest in the training of medical staff. the social and physical environment of individuals, but also their level of education and culture, and whether they have access to healthcare, for example. switzerland has been ranked as the world’s most competitive economy for the second consecutive year, as reported recently in the press. these rankings, established by the world economic forum identified the keys to success: excellent national innovation capacity – supported by high-quality research institutes and continuous cooperation between the academic and business worlds – and public institutions that are among the world’s most efficient and transparent. further, of the 148 countries surveyed, switzerland also ranked first for training.
the health sector supplies not only products, therefore, but also services delivered by professionals in this field. however, this human capital is becoming scarcer, owing to population changes, in particular. and in the field, healthcare professionals are facing new developments, such as ageing, migratory trends or epidemiological transitions to chronic and degenerative diseases. in this context, and in my capacity as director of healthcare at the chuv, i consider as essential the professional expertise and attention given to each individual in his/her full globality and complexity.
matthieu martin
health also makes an important contribution to switzerland’s success. it is not only an economic sector in its own right – 8% of the swiss working population exercises an activity in the fields of healthcare or therapy – but a factor in the smooth running of the whole. technological and pharmaceutical progress springs immediately to mind, in view of its clear market benefits. however, this progress can express its full potential only if it is backed up by efforts on at least the same scale in other fields. if we look at the full range of factors with a decisive influence on health, we need to consider not only
all this has been clearly understood by “health valley”. by joining forces to create the lausanne university institute of healthcare research and training, our leading swiss schools and their partners perpetuated the virtuous circle that is at the root of switzerland’s success. and i am delighted that the university course in nursing sciences created by this entity is now seeking to promote innovations that encompass all the factors with a decisive influence on human health. /
find out more
www.unil.ch/sciences-infirmieres
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COMMENTARY
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The deep freeze: from 22째 to -196째 C Fertility Oocyte cryopreservation allows female gametes to remain frozen for years. This advanced technique gives patients whose fertility is at risk the hope of one day becoming pregnant. Texte: Melinda Marchese reportage pHOTO: Morgane Rossetti
Unlike sperm cryopreservation, which became a routine procedure in the 1980s, oocyte cryopreservation (which is more complex) remained in the experimental stage for some time. Today, the technique has been mastered: reproductive specialists are able to freeze female gametes for several years, while preserving their properties. In Switzerland, women whose fertility is put at risk, particularly by treatment for cancer, may have recourse to this technique. Oocytes that have been retrieved for in vitro fertilisation may also be stored in this way. Fertilised by sperm before or after their rapid freeze, cryopreserved cells are able to produce embryos capable of implanting in the womb, and subsequently resulting in the birth of a child. Details in images.
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in the lens
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1/
OOCYTE RETRIEVAL Oocyte retrieval takes place in the operating room, under mild general anaesthesia. The patient followed two weeks of medical treatment before the procedure in order to increase oocyte production. A reproductive medicine specialist draws off the follicular fluid containing the oocytes using a fine ultrasound-guided needle inserted into the vagina.
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UNDER THE MICROSCOPE After transfer to the laboratory, the oocytes are identified and extracted from the follicular fluid under a stereoscopic microscope. The biologists must retrieve them carefully and place them in a culture tube containing a nutritive medium.
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in the lens
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3/
IN THE INCUBATOR
The cells are stored for a whole night in an incubator at 37°C, the human body’s normal temperature.
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in the lens
4/
IN VITRO FERTILISATION
Two in vitro fertilisation techniques can be used. The conventional method consists of placing oocytes and sperm together in a test tube. The sperm must penetrate the oocyte by itself. Where the sperm count is low or the sperm is not strong enough, the biologist manually performs ICSI (intra-cytoplasmic sperm injection), which consists of injecting sperm into the oocyte using a needle.
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5/
Le dĂŠveloppement du prĂŠ-embryon
/5
PRE-EMBRYO DEVELOPMENT Around 17 to 18 hours after in vitro fertilisation, the result is assessed under a microscope. The procedure has a 60 to 70% success rate. As we can see on the screen, the two nuclei are clearly visible, but have not yet fused. This pre-embryo must be frozen without delay because after fertilisation it will become an embryo (the maternal or paternal chromosomes having paired up), and at this stage it is illegal to freeze it.
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in the lens
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6/
IN THE PROGRAMMER
The pre-embryos are immersed in a cryoprotective substance (which protects them against the cold) and placed in small tubes called “straws”, which are stored in a computerprogrammed freezer designed to gradually lower the temperature. The temperature drops from 22°C to -7°C in 15 minutes, continuing to fall by 1 degree every three minutes until it reaches -150°C. Vitrification is another method, enabling a more rapid freezing process in which the temperature drops by around 2,000 to 20,000°C per minute. In both cases, controlling the drop in temperature is important to prevent the formation of ice crystals, which may damage the oocyte.
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IN LIQUID NITROGEN
At this stage, the straws are sealed inside tubes labelled with the patient’s date of birth and the date of freezing. The tubes are placed in containers filled with liquid nitrogen at -196°C. The pre-embryos can be stored this way for several years.
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in the lens
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Cryopreservation for personal convenience: should it be prohibited? Ethics A 35 year-old English woman, not yet wishing to become pregnant, without however giving up on motherhood entirely, can freely choose to have her oocytes frozen. She will therefore be able to become pregnant after the age of 40, using her own reproductive cells, which will not have aged even after several years. Like England, the US, Canada, Italy and Spain also authorise cryopreservation for personal convenience.
The subject is controversial in France. The National College of Gynaecologists and Obstetricians supports cryopreservation for personal convenience, “as the average age of motherhood is increasingly delayed” and because “cryopreservation for personal convenience is available to men. There is no specific reason why it should not be allowed for women.” Opponents fear that legalisation may encourage late pregnancies, which carry the risk of potential harmful effects for the mother and child, such as hypertension, gestational diabetes and premature birth.
8/
In Switzerland assisted reproduction is authorised only if “the aim is to enable a couple to overcome infertility” (...) or if “there is no other way of avoiding the risk of transmitting a serious, incurable disease to the offspring”. Therefore when a woman’s fertility is at risk due to a treatment such as chemotherapy or radiotherapy, she may have her gametes frozen. “The Swiss Federal Law on assisted reproduction stipulates that non-fertilised oocytes may be kept frozen until the patient’s illness is considered to be cured”, explains Dorothea Wunder, Physician in chief in the Reproductive Medicine Unit at the Lausanne University Hospital (CHUV). “However, if an oocyte has been inseminated, it can only be frozen for 5 years.” The Swiss Parliament is currently discussing a possible revision of the Federal Law on assisted reproduction, which may result in this period being extended.
EMBRYO TRANSFER
When the patient wishes to become pregnant, the pre-embryos are thawed. The development process begins again, and the inseminated oocyte becomes an embryo, the cells of which start to multiply. During the days that follow, one or two embryos can be transferred. They are placed in the patient’s womb using an ultrasound-guided catheter. A blood test two weeks later confirms whether pregnancy has begun.
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teXt: JULie ZaUgg
yles bartlett will never forget his daughter Stella’s reaction the first time she attached her wreX plastic exoskeleton to her arms. “after the initial momentary shock, she picked up a paintbrush and sat painting for over an hour”, says the Canadian. His three-year old girl has spinal muscular atrophy, a genetic condition that affects the way her brain communicates with her muscles. “She is very weak, gets tired quickly and finds it hard to lift her arms”. the wreX allows her to move the upper half of her body, eliminating the effects of gravity. “now she can eat on her own, raise her hand in class and play with her pals”, he explains. “the wreX has changed her life”. CORPORE SANO
made-to-measure printing techniques are already revolutionising the production of prosthetic limbs and implants. Used with biological materials, this technology could be paving the way for artificial organ generation.
yet Stella would never have been able to benefit from this device without the help of a new technology which is revolutionising medicine: 3D printing. “the first version of the wreX, which we produced in 2005, was made of metal”, says tariq rahman, the mechanical engineer who developed the invention at alfred i. dupont Hospital for Children in wilmington, Delaware, USa. “a child this young would never have had the strength to lift it”. the engineer then made a wreX from plastic, a more lightweight material, using a 3D printer, a device which produces objects by building up successive layers of liquid plastic. “with this method we were able to cusan exoskeleton made with a 3D printer allows 3-year old Stella to move her arms. Stella, who lives in Canada with her father, suffers from a genetic condition that affects her muscles. INNOVATION
tomise the exoskeleton so it fits the size of the patient perfectly”, he continues. “we take her measurements and enter them into the computer, which generates a digital 3D model of the wreX and then manufactures it to order using the printer”. as Stella gets bigger, her mechanical arms can be continually adapted to fit. “the new parts can be sent to us by post and we simply have to screw them to the wreX using a screwdriver”, says myles bartlett, smiling. “a few weeks ago a small piece of the exoskeleton broke. i told the hospital on monday, and received the new part on wednesday. without the 3D printer, it would have taken weeks”.
Dr
meDiCal progreSS in print
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reproDuCing tHe entire BoDy
the dental, hearing aid and orthopaedic prosthetic industries were the first to grasp the potential of this new technique. Customised crowns, orthodontic appliances, audio prostheses and artificial limbs have been produced for several years now, using a 3D scan of the patient’s anatomy. more recently, it has been used to improve implants. “we can now produce synthetic, made-to-measure hip implants and spinal discs all in one piece, using the patient’s data”, explains tim Caffrey, engineer and consultant specialising in 3D printing. “they are a better fit, more solid and less expensive”. a patient in america has just had 75% of his skull replaced CORPORE SANO
with an implant made of peKK, a polymer, manufactured using a 3D printer from oxford performance materials (opm). “this material is much lighter than the metal parts normally used, which can make patients dizzy or give them headaches”, adds mr Caffrey. in 2012, a team of Dutch doctors implanted a titanium jawbone in an 83 year old woman. the fine mesh structure, which imitates real bone and makes the implant several grams lighter, was possible thanks to 3D printing technology. this technique has also made it easier to miniaturise certain processes. Kaiba gionfriddo, just two years old, owes it his life. born with a malformation of the trachea, he was unable to INNOVATION
Human bones and tissues can be made-to-measure using 3D printing. Some can already be implanted in patients.
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How to print an artery
printer lays 1. The down droplets, each
containing tens of millions of cells, into a special gel.
droplet and gel 2. The layers are built up
successively to form a three-dimensional piece of tissue.
breathe unaided. “We used an image of his respiratory tract to produce a minuscule splint using a 3D printer, which was implanted into his trachea to keep it open”, explains Scott Hollister, the doctor at the University of Michigan who performed the operation in 2012. “It is made from a polymer which will be reabsorbed by his body in about two years’ time. By then his trachea will have had time to develop properly”.
droplets fuse and 3. The the gel is absorbed.
The process does not need human intervention.
“It may not be long before 3d printing brings about even more spectacular revolutions in medicine.”
Simplifying surgery
At the MetroHealth centres in Ohio, 3D printing is used to improve patient safety. The Reconstructive Maxillofacial Surgery Unit uses it to produce a synthetic model of the face of patients requiring surgery. This allows the surgeons to practice before the actual procedure, determine the least invasive option and even predict in advance what types of bone implants will be needed. “The patient therefore spends less time under anaesthetic and in CORPORE SANO
theatre”, points out Mr Caffrey. The method was used for the first time in 2002, in preparation for a delicate procedure for separating Guatemalan twins who were joined at the skull. The surgery lasted 22 hours “instead of the 97 hours normally required for this type of procedure”, according to Eitan Priluck, founder of Biomedical Modeling, the Boston company which provided the models of the two girls’ skulls. INNOVATION
to mature 4.Left for several weeks,
the living and functional tissue is ready to use.
It may not be long before 3D printing brings about even more spectacular revolutions in medicine. Californian company Organovo, created in 2008, was inspired by research conducted at the University of Missouri and has invented a printer that works using “ink” made of biological materials such as cells. “In particular we have been able to produce fragments of liver tissue, heart muscle and arteries”, explains Eric David, one of the founders of Organovo. “Our clients are research laboratories and pharmaceutical companies wishing to test the efficacy or toxicity of new drugs. These models offer an exact replica of the architecture of human tissue as it is found in the body, unlike the 2D cell cultures normally used”. Printing organs
Ultimately, Organovo hopes to be able to print a whole organ, such as a liver or a kidney, and implant it into a patient. “This would be incredibly valuable, given the lack
infographie: Sebastian Gagin et Ale Román
With 3D bioprinting, cells are built up layer after layer to create living tissue.
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of donors”, believes mr David. each organ would be made from the cells of the patient who is going to receive it. “this would avoid the risk of rejection”, he explains. in april, the company announced it had successfully produced a fragment of liver. the tissue had a microvascular network and was able to replicate a large number of the organ’s functions, such as cholesterol production. promiSing initial reSultS
Jeremy mao, a researcher at Columbia University, is in turn interested in the possibilities of printing teeth and bones. “we make a structure from bone or synthetic enamel in the shape of the tissue we want to regenerate, and seed it with the patient’s stem cells”, explains the reconstructive medicine specialist. “it then serves as a mould for differentiating and reconstructing the missing bone or tooth”. So far, the method has only been tested in rats and rabbits, but the initial results are promising. “as the population ages, broken bones and joint replacements will become increasingly common”, notes mr mao. “if the body is able to repair these tissues using its own stem cells, it would make the process faster and safer for the patient”. the possibilities opened up by this research have caught the imagination. Some believe that we could achieve immortality by replacing organs as and when they wear out. others CORPORE SANO
dream of overcoming the effects of old age by grafting on a print-out of your face as a teenager. yet others still are discussing the possibility of saving a copy of all one’s organs and limbs on a computer, so they can be reproduced in the event of an accident or disease. However, Lee ann Laurentapplegate, head of regenerative therapy at the plastic and reconstructive Surgery department at the Lausanne University Hospital (CHUv), points out that 3D printing using live tissue is still only an experimental technique and has not yet been put to the test. “if the cells have no blood supply, they cannot survive longer than 15 hours”, she warns. “that is how long it takes to produce a 9x12 cm fragment of skin using a 3D printer”. Using this method to treat major burns would be an indulgence, “you would have to wait 4-5 weeks to print enough skin just for one leg”. “although 3D tissue printing is not a magical cure, it does pose very interesting possibilities in certain cases, for example if you wish to repair a small area of bone, cartilage or skin or if one day it were possible to print whole organs”, says ms Laurent-applegate, putting it into perspective. “Ultimately, it is up to the doctor to decide, in each individual case, whether it is in the patient’s interests to use 3D technology or whether traditional methods are best”. ⁄ INNOVATION
tHe SWiSS VerSion
the medical uses of 3D printing were pioneered in Switzerland. phonak has been using it for ten years to produce shells for its hearing aids. “we make a 3D digital model of the ear canal, using a silicon impression, which is then sent for printing”, explains Stefan Launer, vice Chairman of the company and head of science and technology. Such “large-scale made-tomeasure production”, as he calls it, guarantees “better sound quality and greater comfort for patients”. Zurich Children’s Hospital is currently developing another application of 3D technology, whereby fragments of skin are produced from the cells of burn victims, with a view to providing a graft. it uses the 3D printer developed by regenHU, a fribourg-based company which in february 2014 plans to launch “a bone substitute for transplanting into the jaw and increasing bone mass ahead of a dental implant”, describes boss marc thurner. it will be made of a synthetic material, but “with a biological microstructure that provides a sort of highway through which the patient’s cells can colonise”, he adds. eventually these implants will be customised to suit the patient’s specific requirements. “if the recipient has diabetes or osteoporosis, for example, the implants can be impregnated with drugs to treat these conditions”, says mr thurner.
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Texte: Benjamin Keller
D
o you have any idea of how many steps you take every day? Are you familiar with your heart rate? Could you say how long it takes for you to fall asleep every night? Would you be able to specify the amount of CO2 present in the air in your home? Probably not. Or at least, not unless you are one of a growing number of people following the quantified self movement. The idea is to collect data about yourself or your environment using wearable sensors or mobile apps. The term “quantified self” was coined in 2007 by Gary Wolf and Kevin Kelly, editors of “Wired magazine”, who created the site of the same name. Formerly reserved for sportspeople, diabetics or people who needed to monitor their blood pressure, the quantified self movement has become more democratic in recent years with the miniaturisation of electronic chips and the wider availability of intelligent devices such as smartphones. CORPORE SANO
TrendS
Popular devices include web-enabled scales to measure body weight index or body fat, step counter bracelets with accelerometers, and other activity trackers. Backed up by a variety of apps, this equipment is all the range. And with models made by manufacturers such as Nike and Jawbone, devices are becoming increasingly affordable. “Demand for wearable technologies is growing strongly,” confirms Christian Neuhaus, spokesperson for operator Swisscom, which markets this type of product in its range. Organised as a network, the quantified self movement has around one hundred user communities worldwide. Two groups were set up in Switzerland, last year, in Zurich and Geneva, with a total of 150 members. They discuss the latest innovations and share tips and personal experience, online or at meetings. Leaving less to chance
“Users might be motivated by health issues. They may be seeking to boost their performance levels. Or they might have precise targets in mind, such as watching less television,” explains Emmanuel Gadenne, author of the book “Guide pratique du Quantified Self” (2012) and head of the Parisian branch of the movement. Some users even order blood tests
HEArT BEAT Compatible with a range of smartphone and smartwatch apps, the Polar Wearlink+ chest strap measures your heart rate.
PrESSUrES ON Wrap the Withings Blood Pressure monitor – compatible with iPhones and iPads – around your arm to visualise your blood pressure. The data recorded on your phone can be used to monitor your health.
THE SmArT WEiGH Some scales, including the Smart Body Analyzer WS-50 by Withings, measure not just your weight but your body mass index, fat-lean ratio, heart rate, and even the quality of the surrounding air.
FiNGEr TiPS Fit on your finger, the Withings Pulse tracks your pulse rate. On your belt or in your pocket, it measures your steps and distance. CORPORE SANO
TRENdS
iSTOCKPHOTO
COUNTEr BAND rubber bracelets such as the Fitbit Flex record your steps, calories burned, distances covered and minutes of activity, as well as how much and how well you sleep.
WriST WATCH Garmin sport watches measure your running progress by recording run times, distance, speed, heart rate and GPS position.
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or a DNA analysis to guard against and identify possible illnesses (read the article on genetic testing on p. 42). Emmanuel Gadenne joined the quantified self movement in 2003, “to achieve a better life balance”. He emphasises the value of self-coaching developed by the quantified self movement. “I’ve started wearing a Fitbit bracelet to prove to myself that I can walk 2,500 km a year. If I took it off, I know that I’d drop back to between 1,000 and 1,500 km.” This approach also helps him to keep a record of his activities: “My doctor has no idea of how my weight or cholesterol levels have changed over the past twenty years. But with quantified self technology, you can easily store any item of data for an indefinite period and pass it on to your specialist.” In sport too, the quantified self movement has developed widely in recent years. “Amateur sportspeople are making greater use of instruments to analyse their performance, just like the professionals,” says Gérald Gremion, head doctor at the Swiss Olympic Medical Center and assistant physician with the musculo-skeletal unit at the Lausanne University Hospital (CHUV). “They don’t want to leave things to chance.”
TactioSanté A bona fide medical record, TactioSanté can be used to monitor and visualise a range of medical data including fat-lean ratio, cholesterol and gylcemia.
cardiograph With Cardiograph, you can measure your heart rate by simply placing your finger on your smartphone camera. Measurements can be printed and shared on line.
actipod Using the smartphone movement detector, Actipod counts the number of steps, distance and the average speed for each run.
A source of anxiety for doctors
However, self tracking can go too far. Georges Conne, a GP working in Bussignyprès-Lausanne, believes that this practice could give rise to unnecessary anxiety. He set out his fears in a column published recently in the Revue médicale suisse. “Unless people are suffering from a chronic illness requiring constant monitoring, such as diabetes, the practice of continuous tracking tends to increase patient anxiety,” he said. “Users collect personal data and then compare it to a standard. Anything above or below the standard is considCORPORE SANO
TrendS
ered to be pathological. But who sets the standard? This is where medical advice is necessary to provide a filter.” Dr Conne’s views are shared by Lilli Herzig, head of research at the Institut universitaire de médecine générale within the CHUV. She believes that the limit between intelligent and pathological use of quantified self data is fuzzy, and needs to be defined on a case-by-case basis. “Recently, we’ve seen patients arriving with their own diagnosis. That’s fine if it provides a basis for discussion with the doctor. If the data are of good quality, there’s no reason not to take them into consideration. However, the dialogue is sometimes difficult with patients who want to control the whole process. That’s when we need to check for an underlying psychiatric problem.” For Emmanuel Gadenne, measurements must always reflect set aims. “The selfcoaching process isn’t for everybody. In my case, for example, I have no need to measure my blood glucose levels. You need to set yourself three or four targets, for example, to stop smoking. And then, it’s important to discuss the results you’re aiming for with your doctor.” Taking the process to the extreme, some quantified self enthusiasts believe that they can do without a doctor, in the hope that one day they will be able to have their data analysed through algorithms. One example is American Chris Dancy (see interview opposite). Lilli Herzig takes a sceptical view of this futuristic vision: “We already have IT tools that can analyse these data to help us make a diagnosis. But their use is limited since they can only search for one illness at a time. In reality, you often have several health problems together, which makes things more complicated. Patients aren’t robots.” ⁄
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health is correlated to nine other categories that i also quantify. For example, i found that some television programmes have a negative impact on my sleep.
Dr
“i Wear haLf a DoZen sensors” American Chris Dancy has made a name for himself in the US by taking the quantified self trend to the extreme. He collects vast amounts of data, on his personal health in particular. Before 4:00 pm, Chris Dancy sets the lights in his home to “study” mode, the temperature to 21.6°C and humidity to 31%. And he avoids listening to music with more than 71 beats per minute. Dancy, a 44-year old digital technology consultant established these rules—and many others— on the basis of the extensive data he has collected about himself over the past five years. He answered inVivo’s questions from his home in Denver. iV us media describe you as the “world’s most quantified man”. What do you aim to quantify exactly? CHriS DANCY i use between 300 and 400 different systems to collect measurements covering ten categories: health, leisure, domestic environment, social network, CORPORE SANO
work, travel, opinions, content creation, money and spirituality. i wear around half a dozen sensors alternately to measure my heart beat, skin temperature and sleep patterns. my kitchen and toilets are also equipped with detectors, and the lights are connected to the wireless network in order to record their brightness. iV What is your purpose in doing this? CD Five years ago, i started to save my social networking activity to keep a record of everything i posted and measure its impact. Then i started collecting data on my body to improve my health. That’s when i realised that it’s not only the obvious factors such as food or how much sleep you get that have consequences for your health. in reality, your TRENdS
iV Do you share your data with your doctor? CD i only go to see him to keep him company (laughter). i’m not sure of his ability to monitor my health and process my data. So i monitor myself as much as i can using medical information websites such as WebmD. With tools such as Watson supercomputer (see article p. 38), patients will be able to accumulate knowledge in the same way as doctors. iV are you in good health? CD Yes. And i’ve lost around
60 pounds (around 27 kilos) since i started quantifying myself. iV are you worried about protecting your data? CD Not really. There’s always a danger of this information getting into the wrong hands. At least by quantifying myself, i know what the government can find out about me. iV Does this continuous monitoring curtail your freedom? CD Today, most of our actions are determined by our environment. When you go shopping, the shelves are not laid out at random. Your buying journey is based on precise criteria that aim to guide consumers without them realising it. Quantifying yourself means that you don’t get manipulated. ⁄
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promote innovation from the Geneva region both nationally and worldwide. The first pages of In Vivo reveal the extraordinary creativity of the Prof. Pierre-François Leyvraz region’s researchers and General director at the CHUV entrepreneurs. Furthermore, we are fortunate enough to work with Benoît Dubuis, edicine recently appointed director of the new requires Campus Biotech in Geneva, whom we are increasingly diverse pleased to have as a columnist alongside Nobel Laureate Luc Montagnier. skills. Major Faced with the shortage of health progress has professionals, we hope that In Vivo will been made through collaboration between also nurture vocations among future docscientific fields as varied as materials scitors and nurses by spotlighting the unique ence and surgery, computer science and neuroscience, genetics and the humanities. careers of young professionals. That is the The medicine practised at our hospital is at aim of the Cursus section. Published in French and English, In Vivo is distributed the crossroads of all these disciplines. to the twenty-five leading universities The CHUV is also at the centre of an worldwide, in addition to our scientific extensive network – a Health Valley, with an incredible wealth of hospitals, research embassies in San Francisco, Boston and Singapore, and to hospitals and laboralaboratories and innovative start-ups. We tories around the world with which the maintain privileged and fertile relations CHUV collaborates. with many of these partners. Moreover, In conclusion, we believe it important we work alongside the world’s greatest to stress that, based on our concern for universities on a daily basis to improve the proper use of public money, we were the treatment we provide. able to bring this project to fruition All these reasons led us to decide that through a public-private partnership our new magazine, which follows on from with the press agency LargeNetwork. CHUV Magazine, had to go beyond the We took tremendous pleasure in designing confines of our institution. It has grown the magazine and we hope you will enjoy from an in-house journal into a publication that reflects the medicine we practise: delving into the heart of life with In Vivo. Happy reading! ⁄ open and international. It strives to
M
PHILIPPe GéTAz
CUrSUS
CAreer AT THe CHUV
In Vivo, delving into the heart of life
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Providing for migrants As part of the MigrantFriendly Hospitals project operated by the Federal Office of Public Health, a group of healthcare establishments, including the CHUV, has developed structures tailored to the needs of the migrant population. The group also functions as a centre of expertise. These structures were presented for the first time to a wide audience of professionals on 19 September 2013 in Berne. BT
SoCietY
Awardwinning researchers In 2012, the Swiss National Science Foundation awarded subsidies to 46 Sinergia requests, for a total of 54 million Swiss francs. Five subsidies were awarded to researchers. Among them, Jardena Puder, PD & MER1 in the CHUV Endocrinology, Diabetology and Metabolism Department, and Amalio Talenti, Head of the University Institute of Microbiology at the UNIL-CHUV. BT SuBSidieS
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NeWs
Distinguishing normal behaviour and mental illness Philippe Conus, Chief of Service in General Psychiatry at the CHUV, shares his views on the diagnosis of schizophrenia. Why are many professionals currently focusing on the Diagnostic and Statistical Manual of Mental Disorders (DSM)? More generally, what distinguishes a disease from social distress? Many professionals are worried that the fifth edition of the DSM will excessively extend the scope of psychiatric conditions. They are concerned it will include conditions that are below the limit in terms of variations between normal behaviour and disorder. For example, the manual might encourage the diagnosis of depression in cases where, in fact, only a “normal� level of sadness is experienced.
PSYCHiAtrY
In this debate, the case of schizophrenia has not yet been classified. Why? The stage at which a patient can be considered to meet the diag-
nostic criteria for schizophrenia has become a crucial question since strategies to prevent this condition were developed. After seeking to shorten the time between the appearance of an initial episode of schizophrenia and the prescription of suitable treatment by developing specialised programmes and mobile teams, we turned our attention to identifying subjects in the prodromal phase of schizophrenia, characterised by the onset of attenuated psychotic symptoms. The question of defining a pathological threshold, both clinically and ethically speaking, was then raised. Given the lack of reliable tools to identify these states, which we currently qualify as ultra-high risk (UHR), it was decided to consider them as an entity that has not yet been validated. BT
Find out more
On the 22 and 28 November 2013, the CHUV Psychiatry department is organising two conferences, one on the risk factors of psychosis, the other on the development of the fifth edition of the diagnostic and Statistical Manual of Mental disorders (dSM). Find the rest of the interview and information on the events at www.invivomagazine.com
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career at the chuV
The microbiologist Onya Opota explains what brought him to Lausanne to pursue his career. TexTe: BerTrANd TAPPy, PHOTOS: GILLeS WeBer
n the microbiology laboratories of the Lausanne University Hospital (CHUV), the tall form of Onya Opota can easily be seen towering over the machinery that runs 24/7. A doctor of biology specialising in microbiology, cellular biology and molecular biology, Onya Opota owes his build not only to his genetic heritage but also to his former occupation as a professional volleyball player who even played for the French national team. A career pursued at the same time as his studies, “at no detriment to either, thanks to the support of those around me”. After gaining his doctorate, Onya Opota was keen to join a research group. His quest led him to Switzerland and the ePFL institute of technology. “I had already visited Lausanne during my sporting career and I loved the region straight away, with its great lifestyle
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and friendly people. Also, the strong scientific reputation of this area had already started to attract many prestigious figures who I was keen to work with. So when an opportunity came up to join the Infectology Institute at the ePFL, I said yes straight away!” Onya Opota then began his post-doctoral studies on the subject of bacterial virulence. In the course of this work, he identified a new bacterial toxin, Monalysin. “Then, as I still wanted to return to clinical work, I joined the diagnostic laboratory of the CHUV microbiology institute, where I specialised in medical microbiology. The CHUV has everything that is important in my eyes: great team spirit, workplace practices that give everybody a role, and a field of activity in constant motion. The working environment at the CHUV is really ideal. Cooperation with other
specialists – particularly doctors specialising in infectious diseases – is one of the strengths of the university hospital. It is a key advantage in our ability to act extremely quickly. We see patients suffering from a wide range of increasingly complex diseases. We are never careless in what we do. We always show maximum concentration and commitment.” In addition to pursuing his research, Onya Opota is one of the team responsible for the analyses conducted by the laboratory, from the arrival of the sample supplied by the medical team through to the handover of results to the doctors. And what about sport? “I decided to stop competing when I was doing my post-doctoral research, which marked the period of transition from student to research scientist. But after a few months, I was contacted by Lausanne Université Club, which is in Swiss League 1 and that got me out on the sports field again for two last seasons. In the first season, we finished in the finals of the Swiss Cup and the following season, we took first place!” ⁄
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career at the chuV
the microbiologist observes bacterial colonies of escherichia coli from a clinical sample. this bacterium is the source of serious infections in humans.
deNNIS KUNKeL / NeWSCOM
inside the molecular diagnostic laboratory of the CHuV microbiology institute, onya opota identifies the germs causing infectious diseases.
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JeAn-FrAnÇoiS Brunet
tAndem
JoCeLYne BLoCH
cursus cursus
Career at the CHUV
J
ocelyne conducting basic rePortrait of a duo that does right by Bloch, Associsearch cannot reason research. Neurosurgeon Jocelyne ate Physiin that way. He must Bloch and biologist Jean-François cian in the first think about the neurosurgery problem, note down Brunet. Text: Bertrand Tappy, photos: Eric Déroze department of the his observations Lausanne University and then interpret Hospital (CHUV), and Jean-François Brunet, a his findings. Actually applying the fruit of that CHUV biologist, are waiting for the go-ahead research doesn’t occur until later on.” from federal agencies to begin clinical testing for the last stage of their research. Over the years and through various publications, our two researchers have forged a close relationAlthough testing will not quite be the end of the ship, turning their differences into strengths. “If road, it is an outcome that the duo have been we had worked separately, it would have been eagerly awaiting, given the importance of what a losing battle,” says Jean-François Brunet. “Proit at stake. Bloch and Brunet are trying to restore jects like this are a real departure from previous optimal functionality to a stroke-damaged brain research, breaking down the barriers between by transplanting the patient’s own neural cells. various professions that have to learn to listen to each other. Furthermore, we wanted to show “In order to get where we are today, we had to that the therapeutic approach – as opposed to first find out which cells were concerned inside the basic approach – also has its benefits.” the biotope that is the human brain,” explains Jean-François Brunet. “So we tested over a hun“We will be able to start as soon as authorisation dred combinations before finding the right one. has been granted,” enthuses Jocelyne Bloch. Once we had found the recipe, we had to create “We have the necessary funds, thanks to the the conditions to multiply this “cocktail” over six association we created (all expenses – surgery weeks of culturing, then re-inject everything into and hospitalisation – are covered by the project).” the brain without causing any damage.” In the meantime, the neurosurgeon continues to But two skilled specialists can’t be brought implement and lead different research projects, together at the drop of a hat, however fantastic while the biologist is working in another directhe goal. The biologist and the clinician had to tion by creating a cell production centre. After all, define a language, common ground and – above research is not only teamwork; it is also a longall – a shared vision to find solutions. That was no distance race. small feat. “In the clinic, I am used to systematically looking for a solution to the problems faced by my patients,” says Jocelyne Bloch. “A scientist
Find out more
www.neurocellia.ch Website of the association for cell therapy in neuroscience
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NOMINatIONs
Hepatitis is the focus of discussion Every year, the CHUV’s Gastroenterology and Hepatology Department organises a mini-symposium entitled “Challenges in Viral Hepatitis”, which attracts participants from all over the world. The next event, on 16 January 2014, will offer simultaneous interpretation of the proceedings into French (headphones will be provided). BT
KAISer MArIe-LAUre POSITION Occupational therapist LAST NAMe
FIrST NAMe
SYmPoSium
Multidisciplinary conferences A day dedicated to the latest technical and scientific innovations in different surgical fields will be held on 22 November 2013 in the César-Roux lecture theatre at the CHUV. The visceral surgery department is giving a diverse medically-trained audience the opportunity to enjoy multidisciplinary discussions and dialogue. BT
FIrST NAMe
The CHUV aims to professionalise APPointmentS patient reception, which it considers an integral part of LAST NAMe BeHAr-COHeN treatment. Valerie Gaspoz’s mission FIrST NAMe FrANCINe is to enable the hospital to preserve POSITION Head of the University a human approach to the treatment it offers to patients and to maintain Ophthalmology department and high-quality interaction with them, Medical director of the Jules-Gonin despite its size and the level of activity. ophthalmology hospital. Professor Behar-Cohen, an ophthalmologist and retinologist with a Phd in biology, is working on the development of innovative treatments and methods of administration of eye medication, particularly for retinal diseases.
PHILIPPe GéTAz, erIC dérOze , ISABeL dIOS
SurGerY
GASPOz VALerIe POSITION Head of the institutional project to improve the quality of the CHUV’s patient reception facilities. LAST NAMe
Marie-Laure Kaiser, Head Occupational Therapist at the CHUV, was appointed Co-President of the International Society for research into developmental Coordination disorder at the 10th international conference on developmental Coordination disorder in Brazil. This multidisciplinary society aims to encourage researchers to work together, disseminate knowledge and integrate it into clinical practice.
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miGrAtion
eric Albrecht was able to take a one-year training course in Canada thanks to the CHUV. Why did you choose to spend a year in Canada? When I was appointed clinical director, I became interested in locoregional anaesthesia and above all in the method using ultrasound imagery, which was new at the time. I felt sure that this technique would have a wide range of advantages for patients at the Lausanne University Hospital (CHUV). And I knew that Toronto had a large training centre that has published widely, where I could perfect my skills. Thanks to the immediate support of my departmental head, I was able to leave quickly for Canada. I spent a year at Toronto Western Hospital between 2011 and 2012 as part of a fellowship. Can anybody do this while they’re training? yes, on two conditions. First, your training project in any given field must correspond to the hospital’s needs. There’s no point having several specialists in a cutting-edge field. Without taking account of the fact that the department and hospital provide financial support for a period abroad. Also, once a project has been accepted, you need to find a recognised skills centre willing to take you.
CHrISTOPHe VOISIN
What differences did you see between Canada and Switzerland? The main difference lies in the reversal of the pyramid of command. University hospitals have far more trained doctors than doctors in training. As a result, operations are faster and you can treat
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LAST NAMe FIrST NAMe
Albrecht eric
1999 Associate physician in the anaesthesiology ward WITH THe CHUV SINCe TITLe
more patients every day. For example, I was able to do between 15 and 20 nerve blocks per day, whereas at the CHUV, we have the opportunity to do between two and three on average. And when you’re in the theatre, you’re on your own and not working as a team with a nurse as is the case in Switzerland. And if you add the research work, it makes for a very fast pace of life, but also a fantastic opportunity to learn from both a clinical and an academic standpoint.⁄ BT
bACksTAGe
The two teams have been working together for more than five years. They notably produced around twenty themed issues of “CHUV Magazine”, an internal publication. The “In Vivo” magazine which replaces this publication has a wider vision; it hopes to relate the evolution of medicine and treatments, with particular emphasis on innovations characterising the Lake Geneva “Health Valley” region.
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The “In Vivo” magazine is published in English and French.
DAVID MAYENFISCH
Discussions, brainstorming, sketches, template adaptations… “In Vivo” is the fruit of joint efforts. The teams from LargeNetwork (Melinda Marchese, Pierre Grosjean, Sandro Bacco, left and Diana Bogsch, right) and CHUV (Bertrand Tappy and Béatrice Schaad, right) finalising the design of the magazine and the infographic supplement on the agency’s premises on 2 September 2013.
CONTRIBUTORS
MELInDA MARCHESE Melinda Marchese manages the production of “In Vivo” magazine at LargeNetwork. As a journalist she regularly works on health-related topics for magazines in Frenchspeaking Switzerland, such as “L’Hebdo”, “Hémisphères” and “Reflex”. She carried out the interview with the American Yi Zuo (p. 19) and went behind the scenes at the CHUV laboratories for her article on the freezing of oocytes (p. 56).
THE TEAM
BERTRAnD TAPPY Bertrand Tappy is responsible for coordinating the entire “In Vivo” project – both the magazine and the digital edition – as well as for establishing relations with important figures in “Health Valley”. As Editorial Coordinator within the Communication Department at the CHUV, he interviewed Former Minister Luc Ferry (p. 26) and gave the floor to CHUV employees in the “Professionals in the field” section (p. 70).
SAnDRo BACCo ET DIAnA BoGSCH Sandro Bacco and Diana Bogsch, Graphic designers at LargeNetwork, they came up with the visual identity of “In Vivo”. Together, they produced the template for the entire magazine. The duo, both graduates from HEAD, took inspiration from the precision of the medical field to create a meticulous, expressive, lively universe.
MoRGAnE RoSSETTI Morgane Rossetti is a photographer at CEMCAV (Medical Teaching and Audiovisual Communication Centre) which is part of CHUV. With the help of her colleague Eric Déroze, she created the photo essay on the different stages of the oocyte freezing process (p. 56).
PATRICK DUTOIT, DR
BEnJAMIn BoLLMAnn Journalist Benjamin Bollman headed up the production of the infographic supplement “In Extenso”. He graduated with a Masters in Biomedical Engineering from ETH Zürich and previously worked as an assistant at MIT in Boston. He co-founded the SwissInfographics platform at LargeNetwork, which explores new ways of representing information.
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In Vivo
Magazine published by the Lausanne University Hospital (CHUV) and the news agency LargeNetwork www.invivomagazine.com
publisher
CHUV, rue du Bugnon 46 1011 Lausanne, Switzerland T. + 41 21 314 11 11, www.chuv.ch redaction@invivomagazine.com EDITORIAL AND GRAPHIC PRODUCTION LargeNetwork, rue Abraham-Gevray 6 1201 Geneva, Switzerland CHIEF EDITORS T. + 41 22 919 19 19, www.LargeNetwork.com Béatrice Schaad and Pierre-François Leyvraz PROJECT MANAGEMENT AND ONLINE EDITION
Bertrand Tappy Thanks to
PUBLICATIONS MANAGERS
Gabriel Sigrist and Pierre Grosjean PROJECT MANAGER
Melinda Marchese Alexandre Armand , Aline Hiroz, Anne-Renée Leyvraz, Anne-Marie Barrès, Annemarie Vuillaume, Cannelle Keller, Céline Vicario, Christian Sinobas, GRAPHIC DESIGN MANAGERS Christine Geldhof, Dominique Gerardi, Elena Diana Bogsch and Sandro Bacco Teneriello, Elise Méan, Emilie Jendly, Enrico Ferrari, Fiona Amintrano, Francine Billotte, Gilles Bovay, EDITORIAL STAFF Jean-François Noble, Jeanne-Pascale Simon, LargeNetwork (Benjamin Bollmann, Clément Bürge, Sophie Gaitzsch, Katarzyna Gornik Verselle, Laurent Meier, Lauriane Benjamin Keller, Serge Maillard, Melinda Marchese, Sylvain Menétrey, Bartek Mudreki, Bridel, Manuela Palma de Figueiredo, Marie-CéGeneviève Ruiz, Barbara Santos, Daniel Saraga, Julie Zaugg), Bertrand Tappy cile Monin, Marie-Hélène Ros, Massimo Sandri, Mirela Caci, Muriel Cuendet Teurbane, Muriel Faienza, Nadine Haller De Crousaz, ICONOGRAPHIC RESEARCH Nathalie Jacquemont, Nicolas Jayet, Odile Sabrine Elias and Olivia de Quatrebarbes Pelletier, Pauline Horquin, Philippe Coste, Philippe Dosne, Serge Gallant, Sonia Images Ratel, Stéphane Coendoz, Stéphanie CEMCAV (Eric Déroze, Patrick Dutoit, Philippe Getaz, Morgane Rossetti, Christophe Voisin, Dartevelle, Thuy Oettli, Valérie Blanc, Gilles Weber), Sébastien Fourtouill, Sebastian Gagin et Ale Román, Anthony Leuba, Virginie Bovet et le Service de David Mayenfish, Jérémie Mercier, Tang Yau Hoong communication du CHUV. layout
DISTRIBUTION PARTNER
Diana Bogsch and Sandro Bacco
BioAlps
TRAnslation
Technicist printing
PCL Presses Centrales SA The views expressed in “In Vivo” and “In Extenso” are solely those of the contributors and do not in any way represent the views of the publisher.
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EMPATHY
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EDUCATION COMPETENCE