Cannabinoids for Behavioral Symptoms in Dementia: An Overview.

Dementia, with loss of memory, cognitive abilities, and independent daily functioning, is increasing worldwide, related to an aging population. Currently, there is no curative treatment for dementia. Treatment of the frequently occurring behavioral and psychological symptoms of dementia (BPSD) is partially effective and associated with significant side effects. Cannabinoids are lipophilic molecules acting on the CB1 end CB2 receptors, essential for main biological processes such as sleep, appetite, memory, and pain. Cannabinoids might have a positive impact on amyloid formation in Alzheimer's disease, the main form of dementia, and on BPSD symptoms. Most knowledge currently concerns delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). In the context of dementia and BPSD, THC might be beneficial for associated spasticity and possible pain or lack of appetite and CBD probably works better on sleep, agitation, and anxiety. This overview of prospective clinical studies and randomized clinical trials, published between 2005 and April 2023, using cannabinoids for BPSD suggests that older studies using low-dose oral synthetic THC showed no positive results. Still, more recent studies using THC/CBD-based oral medication at higher doses show promising results and are feasible and safe in this elderly polymedicated population. Several RCTs are ongoing and planned worldwide, and we hope other trials will follow to establish clinical efficiency and optimal dosing, as well as other outcomes such as deprescribing other medications and facilitation of care. We suggest that researchers also address the more sociological aspects of prescribing cannabinoids for dementia and BPSD in their specific context.

[Requests for cannabinoids for therapeutic use : how to support patients ?] / Demandes de cannabinoïdes à usage thérapeutique : comment accompagner les patient-e-s ?

The cannabis plant is used to relieve incapacitating symptoms that are refractory to recommended treatments and to improve quality of life, often as a treatment of last resort. Despite growing patient demand and political will in Switzerland, access to cannabinoids for medical use remains complicated in practice, due to the limitation of robust medical indications, high cost (most often non-reimbursed) and doctor's lack of knowledge how to prescribe them. Given the low risks of cannabinoids for medical use, a pragmatic approach would be to respect "the right of patients" to access these treatments, enabling patients to evaluate their effect, reinvest in the therapeutic relationship and regain a central and active role in the management of their illness.

La plante de cannabis est utilisée pour soulager des symptômes invalidants, réfractaires aux traitements recommandés, et pour améliorer la qualité de vie, souvent comme traitement de dernier recours. Malgré une demande croissante des patient-e-s et une volonté politique en Suisse, l'accès aux cannabinoïdes à usage médical reste compliqué en raison de la limitation des indications médicales robustes, de leur coût élevé le plus souvent non remboursé et du manque de connaissances des médecins pour les prescrire. Compte tenu des faibles risques des cannabinoïdes à usage médical, une approche pragmatique serait de respecter le droit des patient-e-s à accéder à ces traitements en en devenant les juges, en leur permettant de réinvestir la relation thérapeutique et reprendre un rôle central dans la gestion de leur maladie.

[Assisted suicide: a need for clarification]. / Suicide assisté : un besoin de clarification.

In Switzerland, altruistic assisted suicide is permitted. We present here the federal regulations, the deontological rules, the provisions adopted by the cantons and other requirements applicable to assisted suicide. Given the complexity of these different rules and the legal questions that remain open, we recommend the preparation of brochures for patients, as well as better training and support for people faced with requests for assisted suicide.

En Suisse, l'assistance altruiste au suicide est admise. Nous présentons ici la règlementation fédérale, les règles déontologiques, les dispositions adoptées par les cantons et les éventuelles autres exigences applicables en matière de suicide assisté. Vu la complexité de ces différentes règles et les questions juridiques encore ouvertes, nous recommandons la rédaction de brochures à destination des patients, ainsi qu'une meilleure formation et encadrement des personnes confrontées à des demandes d'assistance au suicide.

[Integrative medicine: what's new in 2022]. / Médecine intégrative : ce qui a changé en 2022.

To illustrate the news of 2022, we present first a scientific article on mindfulness: a meta-analysis shows both preventive and therapeutic effects for the pediatric population. A second scientific article is summarized: it investigated acupuncture in an obstetrical context, demonstrating its effectiveness on post-caesarean pain and on functional capacity, by improving early mobilization. Hence, these approaches have an increasing level of scientific evidence in these given fields, calling for a clinical implementation. Finally, we offer a practical summary concerning the prescription of cannabis, especially useful following the abolishment of the obligatory FOPH authorization as of August 1, 2022. Nevertheless, we underline that the evidence for cannabinoids being effective remains weak in most indications.

En termes de nouveautés 2022, nous présentons en premier lieu un article scientifique traitant de la pleine conscience : une méta-analyse montre des effets tant préventifs que thérapeutiques pour la population pédiatrique. Le deuxième article scientifique présenté traite de l'acupuncture dans un contexte obstétrical, démontrant son efficacité sur la douleur postcésarienne et sur la capacité fonctionnelle, en améliorant la mobilisation précoce. Ces deux approches bénéficient donc d'un niveau de preuve scientifique croissant appelant à une implantation clinique. Finalement, nous offrons un résumé pratique concernant la prescription de cannabis, tout particulièrement utile suite à la levée de l'obligation d'autorisation de l'OFSP dès le 1er août 2022. Néanmoins, nous soulignons que les preuves restent faibles concernant l'efficacité des cannabinoïdes dans la plupart des indications.

[Drugs: minors and harm reduction?] / Drogues : mineur-e-s et réduction des risques ?

The use of controlled substances (narcotics and psychotropic substances) poses increased risks for minors. However, minors are generally excluded from existing harm reduction services (e.g. drug consumption rooms, drug checking, exchange of consumption material). Based on public health considerations, the authors recommend the establishment of harm reduction services for minors.

La consommation de substances soumises à contrôle (stupéfiants et substances psychotropes) présente des risques accrus pour les mineur-e-s. Pourtant, ces derniers sont généralement exclus des offres existantes de réduction des risques et des méfaits (par exemple, locaux de consommation, drug checking, échange de matériel de consommation). Sur la base de considérations de santé publique, les auteurs recommandent la création de services de réduction des risques dédiés aux mineur-e-s.

[Addiction: what's new in 2022]. / Addictions : ce qui a changé en 2022.

Addictions appear everywhere, mutate, transform with new products and behaviors, playing on our painstaking efforts to try to control them. Drawn into this current, the impression that dominates invites more to understand and to coax rather than to fight. Addictions are our condition, let's deal with it, rather than fight against them. It is therefore a question of knowing the products, that everyone can identify their level of risk, and of giving as many tools as possible, at any age, whatever the behavior or the product. This article shows us that there is a lot to do, from school benches to liver transplantation. There is also a lot to discover, in the recognition of the therapeutic virtues, of cannabinoids for example or even in their prescription, of pharmaceutical heroin for example, sometimes by far the best option.

Les addictions émergent de partout, mutent, se transforment avec des nouveaux produits et comportements, se jouant de nos efforts laborieux pour tenter de les contrôler. Entraînés dans ce courant, l'impression qui domine invite davantage à comprendre et à amadouer plutôt qu'à lutter. Les addictions sont notre condition, faisons avec, plutôt que contre. Il s'agit donc de connaître les produits, que chacun puisse identifier son niveau de risque, et de donner autant d'outils que possible, à tout âge, quel que soit le comportement ou le produit. Cet article nous montre qu'il y a beaucoup à faire, des bancs de l'école à la transplantation hépatique. Il y a aussi beaucoup à découvrir, dans la reconnaissance des vertus thérapeutiques, des cannabinoïdes par exemple, ou encore dans leur prescription, de l'héroïne pharmaceutique, parfois de loin la meilleure option.

[Physician selfcare or the cobblers of Montaigne]. / Selfcare des médecins ou les cordonniers de Montaigne.

A recent survey conducted in the French-speaking part of Switzerland ("Romandie") showed that only about half of the primary care physicians (PCP) in Romandie had a personal doctor. Moreover, 37 % of the PCP declared they had foregone consulting a doctor for a health problem or a check-up during the past year. Finally, 29 % of them had chosen to continue working despite being ill. The literature describes multiple origins for these behaviors, both systemic (especially workload) and individual (denial, fear of social and peer judgment, culture of invincibility…). There is room for improvement for this still too often overlooked problem, in order to enhance the PCP's health (or well-being), and consequently the quality of care.

Une récente enquête menée en Suisse romande a montré qu'environ la moitié seulement des médecins de premier recours (MPR) romands avaient un médecin traitant. De plus, 37 % des MPR ont déclaré avoir renoncé à consulter un médecin pour un problème de santé durant l'année écoulée. Enfin, ils étaient aussi 29 % à avoir choisi de continuer à travailler tout en étant malades. La littérature évoque divers facteurs pouvant expliquer ou du moins contribuer à ces comportements, qu'il s'agisse de facteurs systémiques (principalement la charge de travail) ou individuels (déni, peur du jugement de la société et des pairs ou culture de la toute-puissance). Des voies d'amélioration, pour traiter cette problématique souvent méconnue, sont non seulement possibles, mais certainement nécessaires pour le bien de nos médecins et la qualité des soins délivrés aux patients.

[Driving under the influence ]. / Conduite sous l'emprise de .

Prescribing medicines containing controlled substances (SSC : narcotics and psychotropic substances) can have legal consequences as per the Road Traffic Act. We set forth the physician's duties as well as the risks incurred by the patient. We recommend that rules regarding SSC, which can influence the capacity or the ability to drive, be clarified.

Prescrire des médicaments contenant des substances soumises à contrôle (SSC : stupéfiants et substances psychotropes) peut avoir des conséquences en matière de circulation routière. Nous présentons ici les devoirs du médecin et les risques encourus par la personne en traitement, avant de plaider pour une clarification s'agissant de médicaments pouvant influer sur la capacité ou l'aptitude à la conduite.

[COVID-19 pandemics and medical training : supporting and trusting students]. / Pandémie Covid-19 et études médicales : soutenir les étudiant·e·s et leur faire confiance.

The COVID-19 pandemics has deeply impacted academic teaching and forced a complete shift to distance learning formats during the first and second waves. Medical education, among other professional training programs, relies also on practical and clinical immersion, while some of these clinical activities had to be postponed. This article analyzes how one medical school was able to maintain its teaching while ensuring clinical training and taking into account the psychological impact imputed to the lockdown. It also highlights the learning opportunities and unprecedented life experiences contributing to the training of tomorrow's physicians.

La pandémie Covid-19 a imposé à l'enseignement, notamment universitaire, le passage complet à des formats à distance durant les première et deuxième vagues. La formation médicale, entre autres, se caractérise par une forte composante pratique et une immersion clinique. Cet article analyse comment une faculté de médecine a pu maintenir son enseignement en assurant au mieux une formation clinique, en tenant compte autant que possible des conséquences psychologiques objectivées par des enquêtes facultaires. Il valorise également les opportunités d'apprentissage et les expériences inédites amenées par la pandémie et leur intégration dans la formation des médecins de demain.

An international consultation on case reports in addiction medicine.

Background: A Case Report (CR) is a scientific documentation of a single clinical observation which serves to inform but also to educate the reader. Case reports help to compliment clinical critical thinking in Addiction Medicine (AM) when there is limited evidence base. Aim: This study aims to analyze how international clinical and research leaders in Addiction Medicine view Case Reports and their relevance to bridge the gap between evidence and practice. Methods: A semi-structured, audio-recorded interviews were conducted with 12 international Addiction Medicine scholars. Thematic content analysis was used to code the transcribed interview data. Results: Interviewees showed a positive view toward publishing Case Reports in Addiction Medicine. They found that medical students and clinicians working in the field of Addiction Medicine should be encouraged to share and record cases of clinical interaction. To aid this process (1) formal supervised training in case reporting within an academic environment must be facilitated. And (2) journals should also offer a place to publish Case Reports. Conclusion: The international scholars agree that Case Reports are important for the development of Addiction Medicine and that they can contribute to a better understanding of patients with substance use disorder.

Medical students' perceptions and coping strategies during the first wave of the COVID-19 pandemic: studies, clinical implication, and professional identity.

BACKGROUND: The unfolding of the COVID-19 pandemic during spring 2020 has disrupted medical education worldwide. The University of Geneva decided to shift on-site classwork to online learning; many exams were transformed from summative to formative evaluations and most clinical activities were suspended. We aimed to investigate the perceived impact of those adaptations by the students at the Faculty of Medicine. METHODS: We sent an online self-administered survey to medical students from years 2 to 6 of the University of Geneva, three months after the beginning of the pandemic. The survey explored students' main activities during the first three months of the pandemic, the impact of the crisis on their personal life, on their training and on their professional identity, the level of stress they experienced and which coping strategies they developed. The survey consisted of open-ended and closed questions and was administered in French. RESULTS: A total of 58.8% of students responded (n = 467) and were homogeneously distributed across gender. At the time of the survey, two thirds of the participants were involved in COVID-19-related activities; 72.5% voluntarily participated, mainly fueled by a desire to help and feel useful. Many participants (58.8%) reported a feeling of isolation encountered since the start of the pandemic. Main coping strategies reported were physical activity and increased telecommunications with their loved ones. Most students described a negative impact of the imposed restrictions on their training, reporting decreased motivation and concentration in an unusual or distraction-prone study environment at home and missing interactions with peers and teachers. Students recruited to help at the hospital in the context of increasing staff needs reported a positive impact due to the enriched clinical exposure. Perceived stress levels were manageable across the surveyed population. If changed, the crisis had a largely positive impact on students' professional identity; most highlighted the importance of the health care profession for society and confirmed their career choice. CONCLUSION: Through this comprehensive picture, our study describes the perceived impact of the pandemic on University of Geneva medical students, their training and their professional identity three months after the start of the pandemic. These results allowed us to gain valuable insight that reinforced the relevance of assessing the evolution of the situation in the long run and the importance of developing institutional support tools for medical students throughout their studies.

[Benzodiazepines, addiction and cantonal authorization : legal framework and clinical implications.] / Benzodiazépines, addiction et autorisation cantonale : cadre juridique et implications cliniques.

Use of benzodiazepine and Z-drug is common in Switzerland, also for prolonged periods of time. Physical dependence, psychological dependence and a syndrome of dependence may ensue. Related to a lack of well-established medical guidelines, current clinical practices are subject to debate. Also controversial is the need to request an authorization from the cantonal health authorities before starting treatment with these controlled substances. The present article describes the limited circumstances in which such prior authorization is required.

La prescription de benzodiazépines et de Z-drugs (zolpidem, zopiclone, zaléplone) est fréquente en Suisse, y compris en traitement de longue durée. Il peut s'ensuivre une dépendance physique ou psychologique, et plus rarement un syndrome de dépendance. En l'absence de directives reposant sur des évidences scientifiques consolidées, les pratiques effectives des professionnels de la santé sont sujettes à débat. L'est également l'obligation d'obtenir une autorisation cantonale préalable à la mise en place d'un traitement contenant ces substances soumises à contrôle. Le présent article décrit les conditions dans lesquelles une telle autorisation est requise ou non.

[Integrative and complementary primary care medicine: new evidence in 2020]. / Médecine complémentaire intégrative : nouveautés utiles en médecine de premier recours.

Integrative medicine proposes a coordinated approach to conventional medicine and complementary treatments. This approach is of particular interest in the field of prevention and in comprehensive primary care. This article presents some key studies published in 2020, which highlight the potential benefits of an integrative approach in primary care medicine.

La médecine intégrative permet de coordonner médecine conventionnelle et traitements complémentaires. Cette approche est particulièrement intéressante dans le domaine de la prévention et dans la prise en charge globale en médecine de premier recours. Cet article présente quelques études clés, publiées en 2020, qui mettent en lumière les bénéfices potentiels d'une approche intégrative en médecine de premier recours.

[Preventive care in adults with disabilities]. / Comment aborder la médecinepréventive chez les personnesen situation de handicap ?

The health check-up is an opportunity for the general practitioner to carry out preventive measures and screening. Like any other patient, adults with intellectual and developmental disabilities must have access to it without discrimination. The preventive recommendations for people with disabilities follow those of the general population with some specificities, in particular the prevention of sensory disability, attention to the underestimated health problems in this population and those associated with the handicap. Here several types of barriers to the implementation of preventive measures such as patient's participatory and emotional barriers, the caregiver's barriers and the environmental barriers will be discussed. Finally, practical advice for the management of these patients will be presented.

Le bilan de santé est l'occasion pour le médecin interniste généraliste d'effectuer des mesures préventives et de dépistage. Comme tout autre patient, la personne en situation de handicap doit y avoir accès sans discrimination. Les recommandations de prévention pour les personnes atteintes de handicap suivent celles de la population générale avec quelques spécificités, notamment la prévention du surhandicap sensoriel, l'attention aux problèmes de santé sous-estimés dans cette population, ainsi que les problèmes spécifiques en lien avec l'étiologie du handicap. Dans cet article, plusieurs obstacles à la mise en pratique des mesures préventives comme les barrières participative et émotionnelle du soigné, du soignant et environnementales seront abordés. Finalement, des conseils pratiques pour la prise en charge de cette patientèle seront proposés.

[Addictions]. / Addictions.

This article describes a new form of administration of inhaled prescribed heroin currently under investigation. It underlines the particularity of opioid agonist prescription in jail and presents new perspectives in using psilocybin in addiction medicine treatment. A brief literature review about vaping confirms its interest in quitting cigarette, with a cost of addiction to vaping and recent worrisome reports of chemical pneumonia. Finally, the withdrawal of WHO guidelines on opiates use in pain management, in the context of a suspicion of conflict of interest, underlines the sensible balance between over- and under- prescription of opiates in analgesic treatment.

Cet article montre l'intérêt d'une nouvelle forme d'administration inhalée d'héroïne pharmaceutique actuellement à l'étude. Il sensibilise aux conditions particulières de la prescription d'agonistes opioïdes en milieu carcéral et ressuscite des souvenirs des seventies en reprenant l'exploration scientifique des vertus thérapeutiques de la psilocybine. Même si le vapotage semble être un bon moyen de lâcher la cigarette, les anciens fumeurs ont tendance à s'y accrocher et un risque de pneumonie chimique parfois mortelle vient d'être mis en évidence. Finalement, le retrait de l'OMS de deux directives relatives à l'usage d'opioïdes dans le traitement de la douleur, sur fond de suspicion de conflit d'intérêts, montre l'équilibre délicat entre sur- et sous-prescription des antalgiques opioïdes.

[Knowing how to deliver healthcare is now as important as having medical knowledge]. / Savoir délivrer les soins est -désormais aussi important que d'avoir -les -connaissances médicales.

Traditionally, the doctor has focused his efforts on mastering medical knowledge. Given the challenges facing him, the medical institutions and the society, it becomes clear that his concern must also be about how this medical knowledge hits the patients and the general population. Knowing how to deliver our care is now as important as having the medical knowledge ! In this article, we present new models of healthcare delivery that we implemented or plan to implement in Geneva, Switzerland.

Traditionnellement, le médecin a concentré ses efforts sur la maîtrise de la connaissance médicale. Face aux enjeux qui se présentent à lui, aux institutions et à la société, il devient évident que sa préoccupation doit également se porter sur la façon dont cette connaissance médicale atteint les patients et la population en général. Savoir délivrer nos soins est désormais aussi important que d'avoir les connaissances médicales ! Dans cet article, nous présentons des nouveaux modèles de soins de santé que nous avons mis en œuvre ou prévoyons de mettre en œuvre à Genève, en Suisse.