In Vivo #8 ENG

Published by the CHUVwww.invivomagazine.com

Think healthNo. 8 – MARCH 2016

BACTERIA The hunt for multidrug-resistant germs has begun

INNOVATION Using video games to get well

REPORT Corneal transplant in the operating room

IN EXTENSO ALL ABOUT VITAMINS

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

UNDERSTANDING YOUR

BACKNO MORE PAIN

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FOCUS

11 / CARE

Stopping back painReducing the pain and the costs. BY MELINDA MARCHESE

MENS SANA

20 / INTERVIEW

Patrick Woo: “I hunt viruses around the world”BY JULIE ZAUGG

24 / DECODING

Super-bacteria are gaining groundBY JULIE ZAUGG

27 / INNOVATION

Playing for healthBY SÉVERINE GÉROUDET

CORPORE SANO

31 / PROSPECTING

Fixing a damaged heartBY RACHEL PERRET

34 / INNOVATION

Say cheese, you’re about to be intubated!BY PAULE GOUMAZ

36 / IN THE LENS

Transplant in micrometresBY MELINDA MARCHESE

IN VIVO / NUMBER 8 / MARCH 2016

CONTENTS

DR,

SÉB

ASTI

EN M

ARTI

NERI

E, C

LÉM

ENT

BÜRG

EIN SITU

07/ HEALTH VALLEY

Hospitals turn to 3D printing

CURSUS

42 / COMMENTARY

Money and questions

44 / TANDEM

A pair of eating disorder experts

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

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YANN BERNARDINELLI

This former neuroscience researcher now puts his

scientific expertise to use as a freelance writer.

For this issue of “In Vivo”, Yann Bernardinelli

contributed to the Health Valley section (p. 06).

SÉVERINE GÉROUDETAs a staff writer for

LargeNetwork, Séverine Géroudet contributes regular

articles on major cultural, social and technological

issues affecting our society. She reported on the success of serious games in medicine

for “In Vivo” (p. 27).

The journalist Melinda Marchese, head of

production for In Vivo at LargeNetwork, won the

Suva Media Award in the press category for her article

“The gut, your other brain”, published in March 2015.

The panel of judges described

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

“IN VIVO” WINS THE 2015 SUVA MEDIA AWARD

THIE

RRY

PARE

L, D

R

2

FOLLOW US ON: TWITTER: INVIVO_CHUVFACEBOOK: MAGAZINE.INVIVO

CONTRIBUTORS

AWAR

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3

A few million years ago, man decided to stand upright. We may never know why he did that, but our back is the direct result of the thousands of years of “bipedalism” since he made that choice. The human back is an incredibly complex organ featuring intricate biomechanics that have enabled us to defy gravity. The spine is like a mast, supported by dozens of muscular stays, offering both resistance and mobility. However, behind this wonderful evolutionary triumph is a fragility that never ceases to fascinate me as an orthopaedic doctor.

This fragility exposes our spine to a wide range of injuries, dis-orders and diseases. Research fights day after day to find ways to remedy back problems, producing reams of publications every year. And that research has paid off. Fifty years ago, herniated disc surgery was a medical adventure, with patients spending weeks in hospital for irregular results. These days, the same procedure can even be per-formed on an outpatient basis!

And that’s just the tip of the iceberg. The number of patients suf-fering from back issues is clearly rising, even when no evidence of any anatomical disorder is found. That’s because our back can bear the brunt of psychosocial factors that are harder to detect. To understand what’s going on, we need to look beyond X-rays and MRI scans into lifestyle factors, such as posture at work, the exercise we get (or don’t get) and psychological problems.

Hospitals now understand that doctors are no longer enough. A whole armada of professionals – physiotherapists, ergotherapists, psychotherapists, ergonomists, radiologists, etc. – is needed to treat back issues properly. Nowadays, these experts are brought together in multidisciplinary facilities like the new Centre for Spinal Surgery at the Lausanne University Hospital. This vast range of expertise is reflected in the number of different specialities that have contributed to this magazine’s special report.

In deciding to stand upright, our prehistoric ancestor probably had no idea of the adventure he was taking us on. But considering the amazing progress in medicine to better understand our spine, can we really hold it against him? ⁄

Editorial

THE SPINE: A COMPLEX AND FRAGILE ORGAN

PHIL

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PIERRE-FRANÇOIS LEYVRAZGeneral Director at the CHUV

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Thanks to its university hospitals, research centres and numerous start-ups specialising in healthcare, the Lake Geneva region is a leader in the field of medical innovation. Because of this unique know-how, it has been given the nickname “Health Valley”. In each “In Vivo” issue,

this section starts with a depiction of the region. The accompanying map was created by the Spanish illustrator Iván Bravo.

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LAUSANNE P. 10

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

IN SITU

HEALTH VALLEYPanorama of the latest innovations.

GENEVA P. 08

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

PLAN-LES-OUATES P. 08

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

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IN SITU HEALTH VALLEY

MARTIGNY P. 08

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

FRIBOURG P. 10

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


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START-UP

CONTRACEPTIONGene Predictis, based at the

EPFL, has approved a new test that assesses the risk of blood

clotting in women on birth control pills. Today, 400 out of the

350,000 Swiss women taking this form of contraception develop deep vein thrombosis. The test could identify eight times more

women at risk than standard care based on the analysis of a series

of genes involved in forming blood clots.

STERILISATIONSterilising surgical equipment

anywhere in the world and at a lower cost? That’s what Sterilux

hopes to achieve with its autono-mous UV irradiation system,

the SteriBox. The SteriBox was in-vented by a team of students from

EPFL and from the University of Art and Design (ECAL), the former responsible for technical aspects

and latter for art and design.

OCULOMETRYEyeware, a Swiss start-up based

in Martigny, is on its way to developing software that can track

the eye and facial movements of people who have lost the use of their arms and analyse these

movements to control computers. The company plans to release its

invention to market in 2016.

IN VITROHow can new lung cancer treatments be tested while

limiting trials on live animals? The young Geneva-based company OncoTheis has addressed that

dilemma by developing three-dimensional cell culture

models that imitate both healthy and diseased lung tissue. Their system was awarded the 2015

Lush Prize for Science.

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“We need to instil the entrepreneurial

spirit at schools”PHILIPPE LEUBA

HEAD OF THE DEPARTMENT OF ECONOMY AND SPORTS IN THE CANTON OF VAUD, AT THE 20TH

ANNIVERSARY CELEBRATION OF THE FOUNDATION FOR TECHNOLOGICAL INNOVATION (FIT). SINCE ITS SET-UP, FIT HAS AWARDED 21 MILLION SWISS FRANCS IN LOANS AND GRANTS TO START-UPS

IN FRENCH-SPEAKING SWITZERLAND.

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

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

THE DEVICE

SMART BANDAGE

Theran Optics, a company started by two EPFL engineers, won

the AXA Innovation Award for its futuristic smart bandage developed to diagnose and

monitor chronic wounds.

60,000,000

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INNOVATION In December 2015, the Geneva University Hospitals (HUG) per-formed ankle replacement surgery using 3D printing for the first time in Switzerland. This technique is used to design guides to cut and position the implants, which are then placed directly on the patient’s tibia and talus during the operation. What are the advantages of 3D printing? Greater pre-cision and customisation while reducing surgery time.

“A traditional ankle replacement proce-dure lasts an hour and a half,” says Nicolas de Saussure, the spokesperson for the hos-pital. With 3D printing, the operation takes only 45 minutes, considerably alleviating the patient’s stress.” Victor Dubois-Ferrière, head of the foot and ankle surgery team, brought the technique back from Canada after taking a special training course. This application of 3D printing is still scarcely used in Europe. At HUG, 3D printed cut-ting guides are now used in most ankle replacement cases, and the new procedure could eventually be applied to shoulder, hip and knee replacements.

An eye socket for 550 Swiss francsThis event reflects the growing impor-

tance of 3D printing at Swiss hospitals. HUG also use it to prepare for certain orthopaedic, plastic and oral and maxil-lofacial surgical procedures. “3D printing is no longer considered a thing of the fu-ture. It has become a reality,” says Marc Thurner, director of RegenHU operating out of Fribourg. His company develops 3D bioprinting solutions, working with the Swiss university hospitals in Geneva, Bern and Zurich.

The Lausanne University Hospital (CHUV) bought a ProJet 3500 SD 3D print-er in November 2013 for 70,000 Swiss francs. The machine is mainly used to pro-duce organs to prepare for surgery. These

high-precision, life-size polymer plastic re-productions are designed based on the pa-tient’s medical imaging. The prints help the surgeon visualise and plan the procedure, prepare the replacement part or practise. “The object can be handled, cut or perfo-rated,” says José Pahud, head of CHUV’s Printing and Reprography Centre. “This avoids subjecting the patient to a battery of X-rays. However, the prints are not biocom-patible and cannot be used as implants or cutting guides.”

Nearly 70 parts have been printed at CHUV over the past two years, and a num-ber of projects are under way. To print a model of an eye socket (the most frequent-ly requested part), it takes an hour and a half to create the file and 19 hours of print-ing and finishing. The whole process costs 550 Swiss francs. “Parts used to be ordered from external suppliers, which took longer and was more expensive,” says José Pahud. The machine is primarily used by ortho-paedic and maxillofacial surgeons, but the technology is attracting other specialities, including radiation oncology. The Printing and Reprography Centre has also repro-duced aortic roots for the service of cardi-ovascular surgery and is working on producing a model of the heart.

Slow changeThings are definitely moving towards

3D printing, but experts agree that Swit-zerland has been somewhat reticent. “The process of accepting this emerging technol-ogy has been relatively slow,” says Marc Thurner of RegenHU. “Spearheading this shift are mainly the university hospitals that can more easily find funding to test inno-vative tools. These new techniques require staff training and incur costs, which are only partly covered by insurance.” ⁄

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

ABOVE: JOSÉ PAHUD,

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

TEXTSOPHIE GAITZSCH

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CAROLE BOURQUIN HER TEAM HAS DISCOVERED A NEW TECHNIQUE

TO INDUCE THE IMMUNE SYSTEM TO FIGHT CANCER CELLS.

3 QUESTIONS FOR

Professor of Pharmacology at the Department of Medicine at the University of Fribourg and head of the Clinical

Pharmacology Unit at the Fribourg Hospital

WHAT PRECISELY WAS YOUR DISCOVERY?Over the past few years, a number of drugs

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

HOW EXACTLY DID YOU GO ABOUT THAT?My research team at the University of Fri-

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

WHAT POTENTIAL THERAPIES CAN PATIENTS EXPECT?

I hope that our discovery can be used to select patients that will benefit most from this type of treatment. Pa-tients with tumours containing large amounts of the protein chemokine and with lots of shield cells are likely to respond better to these drugs. This could be a further step towards personalised medicine. /

1

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21In millions of Swiss francs, the amount of money raised by the Lausanne-based company AB2 Bio,

which develops therapeutical

approaches to treat severe systemic inflammatory

diseases. With this new funding round,

the EPFL spin-off will complete the clinical trials of its

various treatments, namely adult onset

of Still’s disease, a rare form of arthritis.

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

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

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

DIABETES

Diabetes affects half a million people in

Switzerland. Potential new treatments are being developed to address

this metabolic disorder as are new ways to make

day-to-day life easier for patients.

specialised centreAt the end of 2015, the University of Geneva

(UNIGE) opened a centre to bring together the expertise of all Geneva-based experts

specialising in metabolic disorders. Many fields are

involved in caring for these issues, including genetics,

endocrinology, immunology and surgery.

artificial pancreas The Lausanne-based firm

Debiotech and the University of Bern have developed an artificial pancreas. Diabetics have a defective pancreas, which cannot produce the insulin needed to regulate

blood sugar levels properly (glycaemia). A synthetic pancreas is designed to

automatically and continuously measure blood sugar and

deliver the right dose of insulin. The two organisations have

teamed up to develop a software programme that

can estimate hormone requirements based on the patient’s personal variables

(food, exercise). A smart algorithm will connect via Wi-Fi

to an electromechanical micropump placed directly

on the skin, like a patch.

kids’ app The Geneva University Hospitals (HUG) have come out

with “Webdia HUG”, an application for smartphones and tablets that children can use to manage their diabetes. With Webdia HUG, kids can estimate amounts of food

using photos of what they’re eating and calculate insulin doses. A function stores their blood sugar levels on

a server, making them available anytime and anywhere for the child, his or her family and health care providers.

The app can be downloaded from the AppStore and Google Play.


Humans have an amazing propensity for dreaming, for generating ideas.

But how many of these ideas are transformed into innovations to

improve our day-to-day lives? Not enough! What can we do to change

that? A region’s entrepreneurship can be measured by the number of

opportunities it offers. But that alone is not enough. Those opportunities have to

be identified. Even if they’re identified, they have to be transformed. And that

requires passion and expertise. Two new initiatives in Switzerland go beyond the awards that recognise existing solutions.

The Inartis Challenges aim to identify and stimulate new ideas, while MassChallenge transforms them by providing that passion

and expertise.

Inartis ChallengesThe Challenges offer a way to pick up on

new solutions and unleash society’s creative potential by giving meaning to ideas. They

provide guidance for collective intelligence. Taking an interdisciplinary approach has

become both a necessity and a reality in today’s world. People need to engage in intellectual

cooperation fuelled by an extraordinary technical environment. This will help spark disruptive and

truly revolutionary ideas. These crucial factors will allow us to build our future together. It is in this mindset that Debiopharm Inartis Challenge

has decided to make a tangible difference in the lives of hospital patients. A 50,000 Swiss franc

award was created to promote “Quality of life for patients undergoing treatment”.

This initiative, with the support of the Inartis Foundation, is the first of three challenges jointly organised with industry leaders in French-speaking Switzerland. More than awards for a past contribution, the challenges focus on bringing about deep changes in current thinking to come up with tomorrow’s solutions.

MassChallengeComing up with new ideas is the process that experienced minds go through using their honed sense of observation. But the “transla-tion” phase from idea to innovation is hardly ever spontaneous and natural. MassChallenge is on its way to Switzerland this year. Its purpose is to set off the revolution to be launched by tomorrow’s start-ups by driving new projects and drawing on all existing energies. Aren’t innovators expected to be visionary and business-orientated, utopic and pragmatic, passionate and patient? MassChallenge, the leading international start-up accelerator – with the advantages of being completely independent and requiring no fees – offers four-month accelera-tor programmes for the most ambitious innovators.

Start-ups are shaping our future with the strengths available to them. You and your network have these skills and these energies. MassChallenge is the godsend we need to perform and turn these initiatives into a springboard for innovative projects in Europe. Onlookers, come take part in the revolution. Join us and join them at www.inartis.ch. ⁄

DR

BENOÎT DUBUISDirector of the Campus Biotech site and Chairman of BioAlps

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

FOR MORE INFORMATIONwww.bioalps.org the platform for life sciences in Western Switzerland

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FOCUS

CARE

STOPPING BACK PAIN

/It’s easier than we think

to put an end to this condition which affects 80% of the population and drives health care costs through the roof.

Report.

BY MELINDA MARCHESE

/

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THE BACK

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O f all the punishments the heroes of Greek mythology were given, the giant Atlas was certainly handed down one of the most bur-

densome sentences. To get back at Atlas for going into battle against him, Zeus forced the god to carry the Earth on his back for eternity. Perhaps a dubious consolation for the poor Titan, but his story inspired the fathers of anatomy, who named the first cervical vertebra after him. The atlas ver-tebra carries the weight of the head and provides its mobility.

This small bone sits at the top of a pile of 24 joint-linked verte-brae which together form the vertebral column. This extremely sophisticated structure makes up the core of the skeleton, like a central mast for the human body. All the back muscles are attached to it, allowing the torso to move about and the entire body to re-main upright.

“Today, we understand how the vertebral column and the struc-tures surrounding it work,” says Viktor Bartanusz, head of the new Unit of Spinal Surgery at the Lausanne University Hospital (CHUV). “But we still don’t fully grasp the pain it causes. Certain spinal problems cause sharp pain in some people but no symptoms in others,” he says. “And even more puzzling is that some pa-tients complain of back pain for years but have no organic cause. Does it come from the bones? Muscles? Discs? Ligaments? A wide range of theo-ries is now being studied on the reasons for this

‘non-specific’ pain and how to relieve it, such as ge-netic predisposition or the exposure to vibrations at the workplace.”

Eighty per cent of the population in industrialised countries consults a doctor at least once in their life for pain in their lower back (lumbago), the middle of their back (dorsalgia) or their neck (cervicalgia).

And the Swiss League Against Rheumatism says that 85% of that pain is not caused by a spe-cific injury or disease.

The costs generated by back pain reflect how bad the situation is. In Switzerland, the Swiss Federal Statistical Office estimates that low back pain alone incurs costs representing between 1.6% and 2 . 3 % o f S w i s s G D P, w h i c h equalled about 10 billion Swiss francs in 2005. That amount in-cludes both direct costs for treat-ment and indirect costs due to work disruption. “Those are the most recent official figures,” says Iohn Norberg, from the Service of Rheumatology at CHUV. “But the percentage remains the same to-day, at about 14 billion.” Many measures have been taken to re-duce these numbers. “We need to come up with solutions for eco-nomic reasons of course, but also to help people to regain an active social and professional life,” the ex-pert says. “But to do that, patients must take care of their back (see point 1 below), and health profes-

sionals need to adapt by only providing care that is truly useful and beneficial in the long term.”

MOVING HEALSTHE IMPORTANCE OF STAYING ACTIVE

n the past few years, a major change has revolutionised care for people suffering from chronic back pain not due to injury. No more forced bed rest. Physical activ-ity is now highly recommended. “Anyone

who doesn’t show signs of obvious trauma, such as a fracture or tumour, needs to stay active and use their

back,” says Iohn Norberg. “For acute pain, inactivity is not recommended for more than three weeks.”

Doctors long recommended not doing exercise or carrying any weight, but the result of inactivity is that the muscles weaken and get to be out of shape. “Many studies have shown how effective physical

FIGURES

80%The percentage of the Swiss population that suffers from

back pain between once a year and several times a week.

/

1.4 In millions, the number of Swiss people unable to work for several

days or weeks a year due to low back pain.

/

10 In millions, the number of days

per year Swiss people take leave, unfit to work due to back pain.

Source: Report, Le dos en Suisse 2011 (The Back in Switzerland), by the Swiss

League Against Rheumatism.

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

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

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

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

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

iv So it’s “all in their heads”?lb No, the pain is very real. The treatment should not simply be restricted to the organic cause that we’re address-ing with drugs or surgery. Today, we recommend taking a “biopsychosocial” approach, meaning that we also con-sider psychological aspects and the social environment in which the patient lives. A person who’s been in pain for years is very often depressed, doesn’t sleep well, etc. Their

health worsens, and that can lead to both social and professional isolation. Before even prescribing an X-ray, the patient should be asked about their family and social life. That’s why we need multidisciplinary care to get the best results when treating such complex pain. ⁄

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

TINTERVIEW BY

MELINDA MARCHESE

“THERE ARE A LOT OF MISCONCEPTIONS”

Liliana Belgrand insists on the importance of taking a biopsychosocial approach.

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“I came to terms with my back!”

Chloé Buchmann Sanroma decided to start exercising again. She was diagnosed with scoliosis as a teenager. For 25 years, she only allowed herself to do a bit of dance, thinking she was protecting her back.

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

That’s how the young woman lived for more than twenty years, giving her back pain an important place in her everyday life. “I took it as a fate that I had to live with. Not one day went by that I didn’t repeat to myself that my back hurt. Like a routine that I had ingrained in my mind.”

Chloé Buchmann Sanroma tried several methods to relieve her chronic low back pain. “I took the advice of several schools on back pain, did a lot of physiotherapy, practised the right postures in ergotherapy and saw my osteopath a lot. I never stopped going to my orthopaedic doctor, who prescribed anti-inflammatory drugs every year. Nothing really changed.”

Until 2013. “I was sick of it! I couldn’t see myself living with that pain all my life! I told my new doctor that I wanted surgery. That’s when I heard an all-new viewpoint for the first time, which questioned

what I’d thought was true and lived with for years. I needed to reactivate my muscles, stop protecting my back and put an end to my fear of pain.”

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

INTERVIEW BY MELINDA MARCHESE

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activity can be,” the rheumatologist says. “Strength-ening the back muscles provides better support for the vertebral column.”

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

The back’s enemiesStarting in the teen years, the structures of the vertebral

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

A study by the Occupational Health and Safety Research

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

Time

Stress

THE FEAR OF MOVEMENTIt’s not just about muscles. Guillaume Finti, a physio-therapist registered with the Unit of Spinal Rehabili-tation at CHUV, sees patients every day who have “kinesiophobia”, the fear of movement. “Some people stop moving for too long after experiencing acute pain and they end up afraid to move,” he says. “Unfortu-nately, that’s how acute pain can become chronic. What we do is help these people get over their fear.” The physiotherapist works with a team of ergothera-pists, psychologists and rheumatologists to help peo-ple with kinesiophobia overcome their anxiety. “We offer a three-week treatment programme,” Finti says. “Patients spend 35 hours a week doing physical exer-cises as a group and individually, receiving care and advice. In most cases, we manage to rebuild their con-fidence in their abilities, which gradually leads them to start moving again, experience their pain differently and resume professional activity.”

Iohn Norberg points out that this type of programme has been available for several years. “This type of care should be offered on a wider scale, and all doc-tors, both with public and private institutions, should encourage patients to move more in their daily lives. That’s certainly less profitable than reg-ular cortisone injections or other repetitive treat-ments, but physical activity remains without a doubt the best long-term remedy.”

PROGRESS OF SURGERY

LESS, BUT BETTER

new mindset is also emerging about back surgery. Patients should only have surgery if the anatomical cause of the pain has been specifically identified and can be treated with a surgical pro-cedure. In its Smarter Medicine cam-

paign launched in 2014 to limit unnecessary procedures, the Swiss Society of Internal Medicine also advises against X-rays for patients experiencing low back pain for less than six weeks if they show no other alarming signs (read our report on the “Less is more” movement on www.invivomagazine.com). “Any image of such a complex structure can show a small, harmless abnormality,” says Iohn Norberg. “Is that the cause of the pain? Often, we have no idea! The patient might end up focusing on it, whereas with a

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bit of patience and physical activity, the pain would disappear on its own.”

“People are in so much pain that they ask us to operate, even if they have no serious pathology,” says the neu-rosurgeon Viktor Bartanusz. “As specialists, we must study the test results and decide whether the operation would be useful. If surgery won’t help or risks making the pain worse, we have to be able to say no. Only 10% of people with back pain really need an operation.”

This less-is-more approach is not yet systematically applied by professionals or taken into adequate con-sideration by researchers. Viktor Bartanusz takes an example from the study conducted by the Department of Neurosurgery at the University of Texas reported in the scientific publication The Spine Journal in 2013.

“It shows that between 1993 and 2012 the number of trials per-formed to compare the choice of surgical instruments far exceeded the number of trials to determine the effectiveness of surgery,” the ex-pert laments.

MORE PRECISION, MORE RELIABILITY

When dealing with certain organic causes of back pain, such as a tu-mour or fracture, surgery is in fact likely to improve the patient’s health. “Tremendous technical ad-vances have been made in recent years,” says Viktor Bartanusz. “With smaller instruments and ever more accurate imaging, surgery is being optimised and becoming more pre-cise. Statistically speaking, it is now safer to have herniated disc surgery than to drive on the motorway!”

Viktor Bartanusz predicts another change over the next ten years. “Orthopaedic surgeons will work jointly with neurosurgeons on spi-nal disorders. These two speciali-ties will eventually become one and further improve the quality of our surgical procedures.”

GROWING USE OF ROBOTICSIn the future, back surgeons will increasingly benefit from the assis-tance of robots. In December 2015

TRUE OR FALSE?“You should sleep on a firm

mattress to prevent or relieve back pain.”

FALSE A mattress that is too firm can cause stress for the

vertebrae. But a mattress that is too soft fails to support the body adequately. If the shoulders and hips dip into the mattress, the

spine is arched. The best option is a mattress that is neither too

firm nor too soft and can support and relax the back.

“Back pain definitely means a serious illness.”

FALSE 85% of pain is “non-specific”, meaning it is not

due to any particular organic cause such as a fracture, tumour

or inflammation. If it’s not related to an injury or disease,

this is good news.

“Drugs are used for quick relief.”

TRUE/FALSE Taking anti- inflammatory drugs for acute pain can offer relief within a

few hours. However, medication should not be the only treatment. It is merely a temporary remedy.

For people who are inactive for long periods of time or do

not do enough physical exercise, the discomfort is likely to come

back. As soon as the pain subsides, people should take care of their backs by staying

as active as possible.

Several studies have shown that excess weight

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

All research into the causes of back pain point

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

Sedentary lifestyle

Being overweight

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FOCUS THE BACK

ERAX

ION

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

Intervertebral discsCartilaginous and fibrous structures located between the vertebrae that act as shock absorbers.

Curvature of the spineA healthy adult vertebral column features four curves when viewed from the profile, two lordotic, or inward, curves – the cervical and the lumbar – and two kyphotic, or outward, curves in the thorax and the sacrum. This sinuous shape gives the skeleton stability and helps it absorb shocks.

CoccyxThis bone is located at the bottom of the vertebral column. Also referred to as the tailbone, the coccyx is believed to be a vestigial leftover of the tail that ancestors of human beings eventually lost through evolution.

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

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

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FOCUS THE BACK

BUILDING MUSCLEThere are a number of

strength training exercises to build muscle in the back.

Strengthening the core targets deep muscles and, when practised properly and regularly, guarantees

results. The classic version involves facing the floor with your body weight

distributed between the tips of your toes and

your forearms bent at a 90-degree angle to the

shoulders. The longer you hold the position, the more

muscle you build.

WARMING UPBefore beginning any

activity that will put strain on your back – be it

gardening, ironing or of course muscle building – you should warm up your back muscles. Kneeling on all fours with your hands

resting on the floor, switch from a rounded back to an

arched back about 30 times. Keep your head aligned with your spine so it can

follow the movement.

at the Amiens-Picardie University Hospital in France, a robotic surgery system developed by the French com-pany Medtech was used to operate on a herniated disc for the first time. The Rosa Spine machine features an articulated arm guided by the surgeon for greater safety and dexterity in movement.

The Lausanne-based company KB Medical is also pre-paring for the commercialisation of its spine surgery robot AQrate. “We are currently in talks with large dis-tributors in Germany and the United States,” says the CEO Jean-Marc Wismer. “Minimally-invasive, robot- assisted surgery is used to make smaller, more precise incisions. That means that the patient recovers more quickly. And in general, the risks that can occur during surgery are reduced.”

HIGH-TECH INNOVATIONS

SMART T-SHIRTS AND BACK PACEMAKERS

he “back pain market”, with its many potential customers, has sparked innova-tion from start-ups to develop ways of relieving pain. The Paris-based Percko attracted a lot of attention with its sen-sor-embedded T-shirt that corrects poor

posture. This lightweight garment fits like a second skin and alerts its wearers when they start to slouch, encouraging them to adjust their posture with its string of tensors fastened into the fabric along the spine, shoulders and thorax. “We hope to sell 10,000 shirts in 2016 to bring in about €1 million in reve-nue,” say Quentin Perraudeau and Alexis Ucko, the two young engineers who launched the project.

The target seems feasible as the Percko T-shirt, sold at €129 apiece online and at selected points of sale, garnered immediate interest. By the end of 2015, the start-up had raised more than €385,000 pledged by 3,325 backers on the crowdfunding website Kick-starter. Backers include ten or so companies that view the product as a useful tool to improve their employ-ees’ well-being.

The posture of employees, sitting physically inactive for long hours in front of their screen, is often called out as one of the main causes of back pain. “In a seat-ed position, tension increases in the deep muscles of

RELAXINGThe back muscles must be relaxed regularly. For

example, to relax the lumbar region, lie down on

your back with your legs elevated and bent onto a structure, such as a stool.

The arms should lie alongside the body with the palms down. This position

is beneficial because it takes all pressure off the back.

The tilt of the pelvis stretches the lumbar muscles and removes

any tension.

SITTING PROPERLYRemaining seated for

many hours in front of a screen can cause muscle contractions. Your heels

should be placed under your knees (legs should not be crossed) with the lumbar

region resting firmly against the back of the chair and the weight of the body on

the ischia bones that make up the lower pelvic region. The middle of the back is naturally slightly forward. The shoulders are relaxed and the elbows free. It is

also highly recommended to get up and move around regularly.

Taking care of your back

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FOCUS THE BACK

Nearly two hours and 30 minutes per day.

That’s the average amount of time that people spend on

their smartphones, according to the American market research company Millward Brown. During that time, as users enjoy writing text messages or browsing through their favourite blog, the neck suffers in silence. A study recently published in the scientific journal “Surgical Technology International” reports that when people tilt their head forward – the typical position for looking at their smart-phone – the stress on the cervical spine increases. The author of the study, the American spine surgeon Kenneth Hansraj, describes how the further forward the head is tilted, the greater the weight exerted on the neck.

He writes that the adult head weighs 4.5 to 5.5 kg. In a neutral position, this weight is naturally distributed and supported by the spine. But by tilting the head forward 15 degrees, “the forces on the neck surge” to more than 12 kg. At 30 degrees, the head weighs 18 kg, at 45 degrees 22 kg and at 60 degrees nearly 30 kg.

Due to that excess weight, many smartphone addicts complain of neck pain. This rapidly growing phenomenon has been coined “text neck syndrome”. Doctors clearly advise people to avoid tilting their head for several minutes in a row and to make sure their ears are aligned with their shoulders when using their smartphone. ⁄

The syndrome

of SMS addicts

15°

12 k

g

0°5

kg

30°

18 kg

45°

22 kg

60°

30 kg

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

The Irish company Mainstay Medical developed a system, ReActiv8, to relieve chronic low back pain. The implant works like a pacemaker, with two elec-trodes placed on either side of the vertebral column. The electrodes are connected to a device that sends out small electric impulses to stimulate the nerves responsible for contracting the key muscles that sta-bilise the lower back. Mainstay Medical announced positive results to its clinical trials and plans to initi-ate the commercialisation phase shortly.

“That’s great if these innovations relieve pain,” says the rheumatologist Iohn Norberg. “But we shouldn’t rely on these devices and forget the most natural and most effective way to prevent and treat back pain. Moving!” ⁄

20

Nearly 30 coronaviruses, a tiny fraction of those out there, have

been discovered since 2003. PATRICK WOO

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MENS SANA INTERVIEW

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

Patrick Woo, a professor with the Department of Microbiol-ogy at the University of Hong Kong, has set out to uncover new viruses that can spread from animals to humans. Pro-fessor Woo was a member of the team that discovered the virus that caused the severe acute respiratory syndrome (SARS) epidemic in 2003. He tells us about his quest, at a time when the deadly new bird flu virus H5N6 has killed its first victims in China.

IV How do you go about finding new viruses? PATRICK

WOO I travel through Hong Kong, China and other countries looking for animal and human samples that I can analyse at a lab. I specialise in coronaviruses [a large family of viruses that can cause a wide variety of diseases in humans], which has led me to focus on species that carry these viruses such as bats. I also study animals that have the most contact with humans and mammals, because the chances are greater that viruses infecting these species will spread to humans. Hospitals sometimes inform me when they have a patient with pneumonia and they haven’t been able to identify the viral cause in the laboratory because it doesn’t re-semble any known virus. So we take a sample from the patient and analyse it.

IV How are these samples analysed? PW There are two ways of studying them. The

first involves using traditional molecular tech-nology. We use highly conserved DNA se-

quences to amplify certain fragments of the virus genome. Then we can sequence these

snippets of DNA. The second method, metagen-omics, is a more recent technique which is used to sequence all the genetic material in the sample

that interests us. In both cases, we feed these DNA sequences into a computer to analyse whether it’s a

new virus.

IV How does it detect a new virus? PW The comput-er compares the DNA in our samples with the ge-

nomes of all known viruses. They’re then listed in GenBank, an American open access database for re-searchers reporting a new DNA sequence. This analysis

produces a list of viruses whose genome is similar to our samples, indicating the percentage of similarity. We then

decide if that percentage is low enough to confirm that we’re dealing with a new virus.

IV Can you give us an example of a recent discovery? PW Following the outbreak of the coronavirus that caused

“I hunt viruses around the world”

INTERVIEW: JULIE ZAUGG

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MENS SANA INTERVIEW

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

IV You contributed to the discovery of the SARS virus. Tell us how you did that. PW When the epidemic broke out 12 years ago, we didn’t know what caused it. We start-ed working on samples taken from several patients suffer-ing from the disease, including a man who came to Hong Kong after contracting it in China. We cultured the virus from his sample by maintaining a cell line. That helped us establish that it was a new coronavirus and determine its genetic structure.

IV What were the consequences of this advance? PW At the time of the SARS outbreak, not many re-searchers were looking for new viruses. The only tech-nique available was to breed the pathogen in a lab setting. But it was slow and ineffective. Some viruses are very difficult to culture us-ing a cell line because they need an organism to reproduce. When the epidemic subsided, scientists realised that there were still many viruses that we didn’t know existed. More efficient molecular and metagenetic tools were then developed to identify them. The number of new viruses exploded at the time. Before 2003, we only knew about two hu-man coronaviruses discovered in the 1960s. But in 2004 and 2005 alone, we found two others, including one that was discovered by the University of Hong Kong.

IV Where is our knowledge lacking the most? PW In coronaviruses. Before SARS, we had only sequenced the genome of about ten of these pathogens. Since 2003, we’ve discovered 20 or 30 more. But we still only know about a small portion of

them. Many animals have never been screened for coronaviruses.

IV Do we know how viruses spread from ani-mals to humans? PW Yes. The genetic material of a virus changes all the time, either by muta-tion or by recombination. The function of the virus proteins can be altered. They develop the ability to latch on to human cell receptors, and that’s when the virus can be transmitted from an-imals to people. This jump from species to species sometimes goes unnoticed. We think we’re dealing with a new virus, while in fact it spread to humans ages ago. That’s what happened with the two new human coronaviruses discovered in 2004 or 2005.

IV How can we overlook something so important? PW We’re far from knowing everything that goes on in hospitals and even less in the general population. The vi-rus that causes pneumonia is identified less than half the time. In the rest of the cases, we don’t know what triggered the disease. But as patients generally recover, we don’t investigate any further. Most of these mys-terious cases of pneumonia are probably caused by viruses that haven’t yet been re-ported. The same goes for other types of in-fections, like diarrhoea.

IV And once the new virus is discovered, what can we do? PW That depends on the virus. If it only infects animals, most likely nothing. However, if it’s a highly pathogenic virus for humans, we’ll study it to understand how it spreads, how it causes the disease and what symptoms it induces. Eventually, we

BIOGRAPHYPatrick Woo joined the Department of Microbiology at the University of Hong Kong in 1997. Eight years later, the scientist traced the source of the SARS epidemic to the rhinolophus, a species of bat pre-sent in China, and discovered HKU1, a human corona-virus that causes pneumonia. Professor Woo also conducts research in other countries. In 2013, he went to Dubai to take samples from camels, which is how he identified five new viruses. He reported another type of coronavirus in dolphins in 2014.

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

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MENS SANA INTERVIEW

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

IV Do you have an example? PW Ten years ago, we discovered a new human coronavirus at the University of Hong Kong called HKU1, which was very close to the hepatitis virus in mice. Researchers in other countries began to look for it in their population pools. We found it in Connecticut in the United States, Australia and France. Due to this broad geographical dis-tribution, we began researching a treatment and diagnosis for the virus.

IV How can we prevent a new virus from spreading? PW

When there’s no vaccine or form of prevention, the only way to protect people is to limit their exposure to the vec-tors that spread the disease. For example, if we know that a virus is transmitted by mosquitoes, we’ll encourage people to protect themselves. In the same way, the authorities launched a public campaign during the SARS epidemic to convince people not to eat certain wild animals, such as civ-ets, the source of numerous infections. And with the H5N1 outbreak in 1997, the government of Hong Kong had all the chickens in the city slaughtered.

IV What do we know about the new H5N6 flu virus? PW We know very little about it because we’re just now seeing the first cases emerge. It’s still too early to determine how and how fast the disease spreads in humans. We don’t even know what its animal reservoir is. We’re in the same situation as Saudi Arabia three years ago, when the first cases of MERS were reported.

IV How did this new flu virus develop? PW The genome of the flu virus is segmented, meaning that it is divided into eight different pieces of DNA, while the genome of coro-naviruses is in a single piece. Two strains of flu virus often exchange genetic material when they infect the same cell. For example, if the H1N1 virus meets the H2N3 virus, they could exchange DNA and form a H1N3 virus. And that would be a whole new virus. This genetic recombi-nation frequently occurs in birds, which are the natural reservoir for influenza. And the new virus that results from these exchanges can sometimes be transmitted to humans, such as H5N6.

IV H5N6, SARS and H5N1 all came out of southern China. Is there a reason for that? PW We can’t be sure. All we have are hypotheses. One of them is relat-ed to people’s eating habits in southern China. They eat lots of meat and prefer fresh food. That means that the food markets in this region of the world are full of live animals, increasing the chances of contact between humans and animals and therefore the species-to-species transmission of viruses.

IV How did you get interested in discovering new viruses? PW When I joined the Department of Microbiology at the University of Hong Kong 20 years ago, I specialised in studying infections in patients who had undergone a bone marrow transplant. One day, I came across a bacterium that we couldn’t identify. I decided to use a mo-lecular method to list it. That made me want to go out looking for other new bacteria. I started out using various samples kept at the hospital that had been collected from patients infected with an unknown pathogen. These “archives” led me to discover 10 or 20 new bacteria. And when the SARS epidemic hit in 2003, I traded in bacteria for viruses. ⁄

“THE ONLY WAY TO PRO-TECT PEOPLE IS TO LIMIT THEIR EXPO-SURE TO THE VECTORS THAT SPREAD THE DISEASE.”

24

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

more intelligently.

Super-bacteria are gaining ground

MENS SANA DECODING

ve seen patients die of an infection, espe-cially in the service that treats severe burn victims, because no antibiotic would work on them,” says Yok-Ai Que, head of Edu-cation and Research at the Department of Fundamental Microbiology at the University of Lausanne. “Sometimes we have to put pa-tients on an IV just to treat cystitis (inflam-mation of the bladder).” What causes these tragedies? The growing number of antibiot-ic-resistant bacteria in Swiss hospitals.

E. coli, a common intestinal bacterium that can cause gastroenteritis and urinary infec-tions, no longer reacts to fluoroquinolone, the antibiotic usually used to kill it off, in

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

“When you attack bacteria with antibiotics, they will almost invariably develop resistance to it. It’s a survival mechanism,” says Didier Pittet, head of the Service of Infectious Diseases at the Geneva University Hospi-tals (HUG). “Resistance to penicillin first emerged just nine months after the drug was discovered in 1947”, and resistance has only become worse with the overuse of antibiot-ics. At Swiss hospitals, the number of daily doses administered jumped 36% between 2004 and 2013. “They’re often mistakenly used for diseases caused by viruses instead of bacteria, like colds,” he says.

Outside Switzerland, the situation is no more reassuring. Turkey, Greece, France and the United States are the champions of antibiot-

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ics consumption, according to the European Centre for Disease Prevention and Control. “In countries where poor hygiene is wide-spread, like India, or common in hospitals, like in Italy and Greece, patients are often given antibiotics as a preventive measure”, says Patrice Nordmann, a professor from the Microbiology Unit at the University of Fribourg.

The use of antibiotics on chicken, pig and fish farms – to prevent the spread of infec-tions when animals are kept in cramped living conditions – also builds resistance, as have globalisation and the growth in medical tourism. Patients are increasingly transferred between countries, and that spreads germs. “We think that the first ex-tended-spectrum beta-lactamases [enzymes that cause resistance to antibiotics] first came to French-speaking Switzerland when the victims of the 2002 Bali bombings were brought to the Lausanne University Hospital (CHUV),” says Didier Pittet.

“Travellers who go to countries like India often bring back resistant germs in their gut flora,” says Thierry Calandra, head of the Infectious Diseases Service at CHUV. These healthy carriers have no symptoms, but they can pass these bacteria on to other people with weakened immune systems.

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MENS SANA DECODING

THE MOST DANGEROUS BACTERIA

ESBL Extended-spectrum beta-lacta-

mases are enzymes produced by certain gut bacteria such as E. coli and K. pneumoniae. Discovered for the first time in France and

Germany in the mid-1980s, ESBL provide resistance to beta-lactam

antibiotics, which are the most commonly used. These enzymes appeared in Switzerland in the early 2000s. In 2010, 4.8% of

patients admitted to the Geneva University Hospitals and 5.8% of those coming to the Zurich

Hospital were carriers.

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

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MENS SANA DECODING

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

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

But that won’t be enough to stop the spread of these super-bacteria. “To do that, we have to identify the presence of resistant germs in hospitals as quickly as possible. One way to do that is by systematically screening all pa-tients who’ve been abroad and then isolating carriers,” says Thierry Calandra.

That is what has driven Patrice Nordmann and his colleague Laurent Poirel to develop a diag-nostic test that can detect resistant strains of the Acinetobacter baumannii

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

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

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

In 2015, the Swiss Confederation announced its new National Research Programme on Antimicrobial Resistance backed with total funding of 20 million Swiss francs. “This programme aims to develop new ways of treating resistant bacteria”, says Karin Wäfler. The FOPH said that it would

provide further details between now and mid-2016 while keeping the public regularly informed of its progress. The fight against super-bacteria has begun. Now all we have to do is win it. ⁄

CARBAPENEMASES Carbapenemases is another

enzyme produced by intestinal microflora that deactivates car-

bapenems, the latest generation of antibiotics. Patients infected

with this superbug are left with only one option, colistin. Discovered in 1949, this drug is used as a last-resort antibiotic due to its toxicity. For the time being, all cases of carbapene-mases reported in Switzerland

have been imported from either Mediterranean countries or the Indian sub-continent. But the number of strains present in Switzerland has exploded

from less than 15 in 2009 to more than 400 today.

GOLDEN STAPH Staphylococcus aureus is a

bacterium found in the skin of 30% of the human population.

It can cause infections in the bloodstream, soft tissue and

joints. The bug has developed resistance to the first-line anti-biotic meticillin, making it one of the most common causes of hospital-acquired infections. Its incidence has begun to subside over the past ten years, however, with the prevalence of resistant strains dropping from 12.7%

in 2004 to 5% in 2013.

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MENS SANA INNOVATION

Serious games are increasingly used by patients and health care

professionals. More serious games are being developed in Switzerland,

with the support of the country’s hospitals and leading schools.

BASED ON A TRUE STORY, THE GAME “THAT DRAGON, CANCER” EXPLORES THE DAY-TO-DAY LIFE OF THE GREEN FAMILY,

WHOSE YOUNG SON JOEL WAS DIAGNOSED WITH CANCER.

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In a fictitious town, Alex London is conducting an investigation. He has to find the kidnapped scientist Professor Birman. Clues keep coming, while the hero, a diabetic, has to monitor his blood sugar throughout his adventure. This video game, called The Birman Af-fair, available from the online plat-form Gluciweb, is an educational tool designed to support patients in managing their insulin therapy. Players have an insulin pen, a glucose meter, a sugar reserve and different snacks. Diabetic patients learn about their own treatment by managing their character’s blood sugar through the story.

The Birman Affair is what is called a “serious game”, a programme that uses the context of a game to reach a serious objective, such as educating or informing players. “Serious games have been around for many years, especially in management, but they’ve only recently been applied to medicine,” says Dominique Jaccard, director of the research team at AlbaSim, a laboratory at the School of Business and Engineering Vaud (HEIG-VD) that develops a variety of serious games. “It took a while for the appeal of using entertain-ment to gain ground in health care due to preconceived notions. Many people have trouble associating games with a serious purpose.”

THE MOTIVATION FACTORVideo games are garnering sup-port in medical training. “We’re trying to combine traditional teaching with serious games,” says Dominique Truchot-Cardot, a

1ADVERGAMINGobjective: Prevent

and educate.example: “Ce soir il

conclut”, designed for young adults aged 18

to 25, presents the risks of excessive alcohol

consumption. www.cesoirilconclut.com

2EXERGAMINGobjective: Train

and rehabilitate.example: “Voracy fish”, a fun rehabilitation

programme for stroke victims. The main charac-ter is a little fish guided

by the player’s arm. www.voracy.com

3IMMERSIVE GAMING

objective: Immerse the player in a virtual environment to deal with a situation from

the real world. example: “Ludomedic”

immerses the patient in a hospital environment.

www.ludomedic.com

4HEALTH CARE

GAMINGobjective: Educate

and train.example: “Théo et les

psorianautes” is designed to help children deal

with psoriasis. www.theoetlespsoria-

nautes.fr

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EVERY GAME HAS ITS “SERIOUS” PURPOSE

Different types of serious games are used in health care:

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physician and full professor at the Institut et Haute École de la Santé La Source in Lausanne. “Our students are digital natives. They love these types of programmes, which they find stimulating and motivating.” The software is used to confront students with real-life situations of their profession through virtual representations. Pulse!!, the leading American game, was one of the first serious games for health care profession-als in which future doctors have to make the right decisions to save a virtual patient’s life.

The La Source school currently uses a serious game on clinical car-diac evaluation developed jointly with the AlbaSim laboratory. A virtual simulation forces the player to deal with a patient who comes to the Accident and Emergency department with chest pain. “The programme aims to develop the ability to care for the patient holis-tically,” says Dominique Jaccard, the laboratory director. “The player can ask the patient questions and run tests, and then determine what action to take.”

The use of entertainment has also proved beneficial for patients. They get more involved in their treatment and more serious about taking it. “We’re currently seeing a change in paradigm,” says Dominique Truchot-Cardot. “Patients want to take an active role in their health and be independent with their care. Health care professionals need to adapt to that demand and integrate it into their practices.”

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

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

ankle injuries. “The Wii Fit Board features several games that are effective in rehabilitation,” she says. “It can be used to vary exercises and better motivate some patients. But it’s only a tool. Recovery re-quires medical treatment and the Wii Fit Board can’t substitute that.”

Most serious games available have been developed abroad. This can sometimes be a problem, espe-cially when patient care rules and procedures differ from one coun-try to another. Some games can’t be used in Switzerland. But more Swiss games are being developed. “Technology is advancing, and development costs are falling. Costs are now one-fifth of what they used to be ten years ago,” says Dominique Jaccard. “The development of serious games will grow.” The games available today are expensive and under licence, “but they’re moving into the mainstream,” says Dominique Truchot-Cardot. Switzerland’s hospitals and specialised schools are beginning to develop their own serious games to improve medical training, treatment and patient care.” ⁄

UNDERSTANDING THE FIGHT AGAINST CANCER

“That Dragon, Cancer” is a game developed by Ryan Green based on his young son Joel’s

fight against cancer. This serious game explores Joel’s day-to-day experience in dealing with the disease and the hardships his family faced with

him. The player has to react in a series of scenes, interacting with doctors, nurses and members

of Joel’s family to help him during his treatment. The project was developed based on a text by

Amy Green, Joel’s mother, written to explain her son’s disease to her four young boys. The Green family wanted to help patients and their loved ones going through the same turmoil to better

understand and live with the disease.SEE MORE ON WWW.INVIVOMAGAZINE.COM

MENS SANA COMMENTARY

Spice of life or kiss of death. The title of the first major report on work-related

stress published by the European Commission in 1999 presented the

problem well. Stress has been studied scientifically for more than 80 years. It is

the natural response triggered when we are faced with a challenging, frightening or threatening situation. This reaction is

complex, combining changes in our hormone levels and our bodies, aggravat-ing our emotions and our behaviour. The

sole purpose of stress is to help us adjust to the situation, to face it effectively. But beyond a certain threshold, when this

response becomes too intense or chronic, stress loses its primary function and

endangers our health.

Between 20% and 25% of employees currently suffer from work-related stress. The condition affects all sectors and all categories of people:

workers, office employees, managers and executives. “Hyperstress” is responsible for

causing a number of disorders that can be either psychological (depression, burnout, suicide) or

physical (cardiovascular diseases).

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

Our professional lives are increasingly complex, uncertain and often challenging. Meanwhile, we have much higher aspirations of well-being but tolerate adversity significantly less. Is it a sign of weakness on the part of our contemporaries? That’s a tough question to answer. Do these demands reflect the progress of our civilisation? Whatever the answers to these questions, the companies with the greatest chances of success will be those that help people deal with stress and organise the work environment in line with human aptitudes and aspirations. ⁄

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

Companies must act to reduce work-related stress.

PROFILEPsychiatrist at Sainte-Anne

University Hospital in Paris, Patrick Légeron founded the

consulting firm Stimulus which helps businesses

develop well-being in the workplace. He has authored

several books, including La peur des autres,

Le stress au travail and La gestion du stress.

READ“Le stress au travail: un enjeu de santé”,

Odile Jacob, 2015.

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

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

thanks to the work of interven-tionist doctors, heart attack survival rates are high. That’s great news, but the downside is that the number of patients suffering from heart failure is increasing.

TRANSPLANTS AND ARTIFICIAL HEARTS Drugs can slow the deteriora-tion of the cardiac function, but the only real way to treat severe heart failure is a transplant. That’s not really a solution though, because patient waiting lists are long and the number of available organs is small. Artificial hearts offer a more viable option.

Recent innovations promise to improve the fate of patients with a severely slow heart rate. For example, CHUV has recently implanted a new

FIXING A DAMAGED HEART

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TEXT: RACHEL PERRET

SCIENTISTS AND DOCTORS HAVE LONG DREAMT OF BEING ABLE TO REGENERATE CARDIAC CELLS.

NOW, SWITZERLAND IS THE SETTING FOR CUTTING-EDGE RESEARCH TO MAKE THAT DREAM REALITY.

CORPORE SANO PROSPECTING

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

PROGRAMMING STEM CELLS

IN VITRO

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

Similar experiments have been carried out with embryonic stem cells. But this method is more complex as there is a risk of rejection, which is not the case when the patient’s own stem cells are used. Other trials work with blood stem cells to promote the revascularisation of blood vessels.

These methods have met with mixed results. And not one has succeeded in recolonising dead

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

BUILDING

A BIOLOGICAL BANDAGE

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

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

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

REPROGRAMMING CARDIAC CELLS

IN SITU

Thierry Pedrazzini, director of the Experimental Cardiology Unit at CHUV, has been exploring a very different solution. He aims to control the reprogramming and differentiation of cardiac cells directly in the heart. His approach is based on a fundamental discovery involving long non-coding RNAs, i.e. the RNA molecules produced by 98% of the cell genome. As yet, their functions mostly remain a mystery. “We’ve been able to show that the long non-coding RNAs control how cardiac cells respond to stress,” says Thierry Pedrazzini. “These molecules function like switches that activate specific physiological responses in cells and trigger programmes for their adapta-tion to environmental factors. For example, the haemodynam-ic response of cardiac cells after a heart attack.”

His team identified 1,500 non- coding genes that control the response to heart attack in mice. “These genes have counterparts in humans. We can try to protect the heart following a heart attack by improving its resist-ance. We can also give it the

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

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

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

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CORPORE SANO PROSPECTING

This mouse heart underwent artificial

cardiac arrest for research purposes. Part of the tissue

is dead (in red) due to the interruption in blood flow. Researchers are now looking into different ways

of restoring life to dead cells to improve the quality

of life of heart attack survivors who suffer from heart failure.

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TFacial recognition can be used to reduce the risks involved in general anaesthesia. And this technology could prove promising

for other medical applications.

SAY CHEESE, YOU’RE ABOUT

TO BE INTUBATED!

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

which analyses 177 precise points on the face. “The machine prepares a facial composite that predicts if intubation will be easy, medium or difficult while they are under general anaesthesia,” says Patrick Schoettker, an anaesthe-tist at the Lausanne University Hospital (CHUV).

Intubation remains a delicate procedure. A tube is inserted into the trachea to maintain artificial ventilation during surgery. Obesity, mobility of the head and a receding chin are some of the physical risk factors. “Patients are examined based on these criteria at the pre-operative anaesthetic assessment,” says Patrick Schoettker. “But that isn’t enough. The doctor can still end up faced with unexpected difficulty in intubation and only four minutes to deal with it, because the patient isn’t breathing.”

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

TEXT:PAULE GOUMAZ

CORPORE SANO INNOVATION

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CORPORE SANO INNOVATION

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

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

A patent was filed for the commercial launch of the photo

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

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

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

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TRANSPLANT IN MICROMETRES

Innovation A new corneal transplant technique guarantees better results and fewer postoperative complications. Report from the operating room.

TEXT: MELINDA MARCHESEIMAGES: PHILIPPE GÉTAZ

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

CORPORE SANO IN THE LENS

Corneas for transplant are kept at the Eye Bank at the Jules Gonin Eye

Hospital. “Our job is to remove, store, assess tissue quality and distribute

grafts,” says Michaël Nicholas, a biologist and head scientist at the

laboratory. “We perform about 120 transplants every year thanks to

donations. But unfortunately not even those are enough. We have some

140 people on the waiting list.” Most organs must be transplanted within hours after removal from the donor.

However, corneas can be stored for 30 days if maintained in the

proper environment.

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2/ ENDOTHELIUM REMOVAL

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

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Three two-millimetre incisions are enough to remove the diseased

endothelium from the patient, under general anaesthesia, and to

transplant the healthy corneal tissue. The procedure takes nearly one hour, during which the surgeon, assisted by

a technician, will delicately position the endothelium. “To finish, we inject

air to help the transplanted tissue adhere tightly to the stroma, another

layer of the cornea. Over the next few days, the new cornea will become

transparent again, and the patient will regain very good eyesight.”

TRANSPLANT/3

CORPORE SANO COMMENTARY

Put your back into it, turn your back on someone, have your back

to the wall. So many negative expressions based on this part of our

anatomy! Our back – much more than a simple column of

twenty-four vertebrae – is a noble organ. From our early childhood, we

load our national rucksack on it and set off to explore the land carrying

everything we need. We use our backs constantly to make journeys

long and short every day.

But as with all of our organs, we only really pay attention to it when something is wrong or when we’re in pain. And that’s

what ends up happening to many of us. Musculoskeletal disorders were the most

common cause of hospitalisation in our country in 2014, and 25% of those cases

were back-related problems.

What we all need to do is keep our backs healthy. That means correct posture, exercise, good eating habits, i.e. conscious prevention. By “conscious”, I mean using our knowledge. “I know what position I should be in to carry this load, I know what position I should be in to work at my desk, I know what position I should be in to get out of bed, etc.” And as with all knowledge, it’s most beneficial when we learn it as children. But is our society really doing enough to teach that? Have we decided to invest in that knowledge that leads us to adopt preventive behaviour? Or do we take a more curative approach?

And that is where awareness in our profes-sional lives becomes both a public health and a productivity issue. This is evidenced in the development of robots to substitute humans for certain activities requiring physical strength, especially robotic exoskeletons that assist and relieve humans in performing certain physical activities. The technology was initially developed for construction and civil engineer-ing, but robot assistance is now being applied to patient care and patient mobilisation. Over the next few years, we’ll see how machines and humans can work together to perform numerous tasks, even in hospitals, so that we can watch our backs. ⁄

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DANIEL JOYEHead of Nursing, Department of Musculoskeletal Health and Department of Clinical Neurosciences

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

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CURSUS COMMENTARY

million Swiss francs. That’s how much fuel the Federal Council will be injecting into the Swiss education engine to increase the number of medical graduates from 800 to 1,300 per year. The Council confirmed that decision on 3 February 2016. In our previous article published in In Vivo’s December issue, we discussed how a financial boon of this size would send schools scrambling for a piece of the pie. But Bern’s resounding and stumbling response to the shortage of doctors should not be a way of avoiding the tough questions.

This sum of 100 million Swiss francs should instead be sending out an electro-shock, the opportunity to finally take a serious look at our health care system. And examine the time factor. Between the first year of medical school and graduation from the Swiss Institute of Medical Education, these young men and women embark on a long pilgrimage as young students, young doctors, and young heads of clinics. Young, but not so young when they hit the job market. It’s a long, arduous journey for both

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future doctors and the establishments that educate them. This time scale should be considered in light of the temporary support from

Bern between 2017 and 2020.The 100 million Swiss francs also

reveals the importance of education in the sometimes converging and sometimes diverging strategies and interests of universities, Swiss Federal Institutes of Technology, hospitals and federal and cantonal governments. Having so many partners can be an advantage, driving cooperation and synergies, but can also become a burden due to the energy required to lift projects off the ground. Increasing the number of doctors is a simple enough objective but is easier said than done. This never-ending whirlwind, this organised chaos we’re all swept up in, can be difficult to understand. Let’s take this opportunity to unravel the mystery and think hard about medical training.

However, let’s do it without losing sight of the fundamentals. At the crossroads of economic liberalism (controlled by insurers) and enlightened intervention (controlled by governments), the role of medicine should be to serve patients, the sick in our society, without creating new needs and without producing modern-day quacks. Despite the objectives set by politicians, our objective as doctors remains to heal and ease suffering. We need to take care of our sick, but this care should not be limited or affected by our financial resources. ⁄

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Isabelle DécosterdAssistant Dean of Teaching

and Education

Jean-Daniel TissotDean of the Faculty

of Biology and Medicine at the University of Lausanne

100Money and questions

For the past five years, medical

students have been doing a one-day observation pro-gramme at community health centres throughout the Canton of Vaud. Jean-Bernard Daeppen, chief of the Alcohol Treatment Centre and of the community medicine teaching programme, tells us more.

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

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

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

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

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Community immersion

Restoring all brain functions

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

Treating strokes

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“Anorexics need inter-

vention as quickly as possible,” says Laurent Holzer, chief physician of the Child Psychiatry Section of the Vaud Centre for anorexia and bulimia (abC) at CHUV. “Fami-lies need to be closely involved in order to take part in the care process and take charge of the patient’s weight gain. To maximise the chances of recovery, they need to put weight back on as of the first month.” The abC is a treatment centre for adults and teenagers with eating disorders. Laurent Holzer and Yves Dorogi, a clinical nurse from the Liaison Psychiatry Service and head of patient care at the abC, work closely together overseeing the doctors, psychologists and health care assistants who work at the centre. This type of facility is multidisciplinary by nature and requires long-term patient care. Teamwork is indispensa-ble, and the two experts meet regularly to discuss matters at hand. “We try to identify what is specific to adults or teenagers and where any crossover might be,” says Laurent Holzer. “For example, mixing patients can encourage younger women not to follow the same path as the older ones.” Unsur-prisingly, nine out of ten patients suffering from eating disorders are women.

This frequent dialogue also helps develop standard responses and ties with partner struc-tures, while monitor-ing the health care staff. These profes-sionals are on the front lines, and caring for these

patients can be gruelling. “Our role is to find the best way to manage the various transition issues,” says Yves Dorogi. “That means offering support for patients between their teen years and adulthood to help them become independ-ent,” he explains. “We also have to handle the transitions between the different levels of care, especially from the hospital to the outpatient day centre.”

Each member of the health care staff – nurses, social workers, physiotherapists, dieticians, physicians, psychologists and nutritionists – has to bring their work into line to make sure the patients are being monitored consistently. “Only after patients start regaining weight can we start working on the causes of the problem at a deeper level, especially their relationship with their body, their body image and their inflexible obsessions about thinness and food,” says Laurent Holzer. That is why steering current practices towards more flexible and creative care could be an effective option. “And that’s where the point of view of our health care staff is especially useful,” says Yves Dorogi. ⁄

Physician Laurent Holzer and nurse Yves Dorogi form a close-knit team at the Vaud Centre for anorexia and bulimia. Their goal is to help patients suffering from eating disorders.TEXT: WILLIAM TÜRLER, PHOTOS: GILLES WEBER

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CURSUS CAREER AT THE CHUV

CURSUS NOMINATIONS

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CHUV’s Depart-ment of Psychiatry

took home the 2015 Salling Award. This honour comes in recognition of the work by Stéphane Kolly and Ueli Kramer in psychotherapy for personality disorders. The two researchers and clinicians have developed a unique method combining brief psychiatric treatments, emotion-focused group therapy and long-term psychotherapy. SG

CHUV wins the Salling AwardORGANISATION

LAST NAME VOGT FIRST NAME PIERRE POSITION Chief of the “Cardiovas-cular” Department

To develop its cardiovascular expertise, CHUV is bringing its cardiology, cardiac surgery, vascular surgery, angiology and experimental cardiology units together into a single service, the newly created “Cardiovascular” Department. Pierre Vogt, full professor at the Faculty of Biology and Medicine at the Uni-versity of Lausanne, has been ap-pointed to get the new department up and running by 1 January 2017. He will work with a team compris-ing a project manager, a chief of staff and the heads of the different services.

LAST NAME GRABHERR FIRST NAME SILKE POSITION Chief of the University Center of Legal Medicine

Silke Grabherr and her team are the leading experts in post-mortem angiography with their modified heart-lung machine used to exam-ine blood circulation. She has also created a virtual database to better identify bones and highly decom-posed cadavers and developed an application to detect substances such as cocaine in fluids. Read the interview with her predecessor, Patrice Mangin, at www.invivomagazine.com

LAST NAME PACCAUDFIRST NAME FRED POSITION Chief of the Uni-versity Department of Com-munity Medicine and Health

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

NOMINATIONS

Biobanks getting organised

A nationwide platform was launched

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

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

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

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

Jan Harry Cabungcal came to Lausanne to do research on schizophrenia.

LAST NAME Cabungcal

FIRST NAME Jan Harry

AT CHUV SINCE 2007

TITLE Researcher at the Unitfor Research in Schizophrenia, Department of Psychiatry

GIL

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