Diabetes: Emergency Case!

Transcription

LE
SPÉCIALISTE
LE MAGAZINE DE LA FÉDÉRATION DES MÉDECINS SPÉCIALISTES DU QUÉBEC
Vol. 12 no. 1– March 2010
2010
NEGOTIATION
PART 2
P. 8-9
Une
nouvelle
ADRESSE
voir texte p. 35
36.
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SUMMARY
7
8
10
13
17
28
30
WORD FROM THE PRESIDENT
Stirring Things Up!
2010 NEGOTIATION PREVIEW - PART 2
The Medical Powerl
IN THE NEWS
Get People Talking!
31
DID YOU KNOW...
COVER STORY
DOSSIER
Diabetes: Emergency Case!
LE
SPÉCIALISTE
LE MAGAZINE DE LA FÉDÉRATION DES MÉDECINS SPÉCIALISTES DU QUÉBEC
Vol. 12 no. 1– March 2010
2010
NEGOCIATION
PART 2
P. 8-9
• Status of Diabetes . . . . . . . . . . 18
• Waiting in the Wings . . . . . . . 21
• Impacts in Cardiology . . . . . 23
• Education Centres . . . . . . . . . 26
Une
nouvelle
ADRESSE
voir texte p. 35
LE
SPÉCIALISTE
Le Spécialiste is published 4 times per year by the
Fédération des médecins spécialistes du Québec
EDITORIAL COMMITTEE
Dr. Bernard Bissonnette
Dr. Raynald Ferland
Dr. Diane Francœur
Maître Sylvain Bellavance
Nicole Pelletier, APR, director
Patricia Kéroack, communications
consultant
DELEGATED PUBLISHER
Nicole Pelletier, APR
RESPONSIBLE FOR PUBLICATIONS
Patricia Kéroack
REVISION
Angèle L’Heureux
PRODUCTION ASSISTANT
Geneviève Roberge
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Dominic Armand
TRANSLATION
Anne Trindall
Annette Grimaïla
32
33
34
38
CONTINUING PROFESSIONAL EDUCATION
MOREOB: Safety-Driven Delivery of Care
IN THE WORLD OF MEDICINE
The Remote Monitoring of Pacemakers in
21st-Century Cardiology
GREAT NAMES IN QUEBEC MEDICINE
Dr. Phil Gold and the Discovery that Revolutionized
Our Knowledge of Cancer
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MOT DU PRÉSIDENT
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ADVERTISERS:
• Pfizer.................................. 2 and 36
• Hydro Québec
LE SPÉCIALISTE · VOL. 12 no. 1 · March 2010
3
• La Personnelle .............................. 4
• Groupe Fonds
des professionnels
• Cardiologie
interventionnelle
....................
......................
6
10
• Club Voyages Berri .................. 12
• Congrès Santé Respiratoire .... 14
• Bayer .............................................. 16
• ASSS du Bas-Saint-Laurent .. 22
• Banque Royale
The Fédération des médecins spécialistes du Québec represents the following specialties:
Allergy and Clinical Immunology, Anesthesiology, Cardiac Surgery, Cardiology, Community
Health, Dermatology, Diagnostic Radiology, Emergency Medicine, Endocrinology,
Gastroenterology, General Surgery, Geriatrics, Hematology and Medical Oncology, Internal
Medicine, Medical Biochemistry, Medical Genetics, Medical Microbiology and Infectious
Diseases, Nephrology, Neurology, Neurology, Nuclear Medicine, Obstetrics and Gynecology,
Ophthalmology, Orthopedics, Otorhinolaryngology, Pathology, Pediatrics, Physiatry, Plastic
Surgery, Pneumology, Psychiatry, Radiation Oncology, Rheumatology and Urology.
..............................
..........................
• Sogemec Assurances
............
25
35
• Valeant Canada .......... 37 and 40
• Solutions Cliniques .................. 39
5
WORD FROM THE PRESIDENT
Dr. GAÉTAN BARRETTE
Stirring Things Up!
y now you must have seen our TV campaign
and perhaps even visited the Internet microsite
expertisehasaprice.com (lexpertiseaunprix.com) – a
different style of campaign, even somewhat daring,
and one designed to arouse public debate. Mission
accomplished! We obviously knew that not everyone
would agree with us – and that has been confirmed! But, as a
celebrated author once said, it’s not because things are difficult
that we don’t dare.
B
realized that, in Quebec, systematic, significant differences
exist versus the main indices used for comparison purposes as
far as those with professional expertise who are paid within the
public sector are concerned. We are not the ones saying that:
it’s the Institut de la statistique du Québec, among others.
This state of affairs applies just as much to nurses, teachers,
engineers, occupational therapists, legal aid lawyers, Crown
prosecutors ... and doctors.
It also came as no surprise that the road construction and generic
drug lobbies, as well as some others, pressured us to withdraw
our spots. But, like it or not, killing the messenger does not kill
the message! The suggestions we make are all documented and
a number have been presented by others long before us, but
have gone unheeded. We wonder why …
The day is fast approaching when we will file our demands with
the government in connection with the renewal of our Agreement.
The outcry can already be anticipated – particularly from (rightthinking) people who will not take the time to talk to us, to delve
into matters, to understand, since their national sport is to “chronicle”.
Good for them! However, it will always be up to you to defend
your interests by readying your forces.
It is easy enough to hold discussions on the economic depression we are suffering. It is also easy to criticize, judge and condemn
our campaign, just as it is simple to claim that the FMSQ is only
entitled to speak on health matters. But that’s the whole point!
Health accounts for 45% of the Quebec budget. An unavoidable
“expenditure”. And physicians, specialists though they may be,
are also taxpayers.
In addition, to help convince you that there is money in Quebec
and that the problem lies not in the lack of it but in our governments’ failure to make decisions, I suggest you read the second
document put out by the Advisory Committee on the Economy
and Public Finances (Comité consultatif sur l’économie et les
finances publiques) report, which is available on the Web and
which clearly demonstrates that money is definitely available!
We are continuing our action. The reasoning is simple: add the
voice of medical specialists to all those raised over previous weeks,
months, years, hoping that the Charest government might finally
make some decisions and act to improve the financial health of
Quebec. But not just any decisions, and not just anyhow! Quebec
is in the red: we know that. But there is money in Quebec, and
we are demonstrating that fact!
Lastly, we have to underline that we are in a highly pivotal period.
In addition to recovery from the current depression, here as elsewhere
there is the whole debate on controlling government expenses
and, in the health field, maintaining a strong but efficient public
system. We are involved in this debate, as is right and proper.
And the timing is good. In fact, while aiming for an appropriate
level of payment for our services we believe it is time for medical
specialists to be involved at all levels of the health network, including
its administration. We favour a model based on the principle of
joint management. Hence the need to provide for appropriate
remuneration in order to attract the best candidates. Then, there
is the digitization of clinical records, the organization of care, and
so forth. In other words, we have much to do.
WE POSTULATE THAT IF IT WERE TO ASSUME
THE NECESSARY LEADERSHIP ROLE, THE
GOVERNMENT COULD SOLVE ITS DEBT
PROBLEMS AND FACE THE FUTURE WITH A
CERTAIN DEGREE OF ECONOMIC SERENITY.
We postulate that if it were to assume the necessary leadership
role, the government could solve its debt problems and face the
future with a certain degree of economic serenity. Better still, it
would have ample funds to pay an equitable amount for professional expertise in the Public Service AND doctors. It has to be
You can rest assured that we are ready! We believe that you are,
too. Always remember that our situation is the result of small
cutbacks accumulated over the years. Starting a new round of
negotiations from behind the eight ball is out of the question –
particularly when everywhere else in Canada physicians are reaching
agreements similar to their previous ones!
Yours, in union!
S
L
7
Maître Sylvain Bellavance
2010 NEGOTIATION PREVIEW
DIRECTOR
LEGAL AFFAIRS
The Medical Power
ou will have noted that, since the beginning of
February, the media – newspapers, radio / television public affairs programs – have been taking an
active interest in medical specialists’ negotiating
demands. The negotiating process is therefore under
way, even though the Federation’s official demands
with regard to the renewal of our Master Agreement have still
not been filed with the Ministère de la Santé et des Services
sociaux (MSSS).
ONCE AGAIN, LET US MAKE IT QUITE CLEAR:
THE 2007 AGREEMENT REDUCES THE GAP
IN REMUNERATION FROM THE 2007 LEVEL
OF 50-55% TO AROUND 15% IN 2016.
Y
You will also have seen that, as usual, the ideas expressed by
the media reflect the various social tendencies. Some strongly
criticize medical specialists; others acknowledge the validity
of their claims while insisting that no level down should be
made in Quebec.
I would like to discuss three aspects of the debate that has
begun, and which will only grow more heated during the
coming months.
1. The Remuneration Gap
Some people have understood the nature of the negotiations that will soon be beginning for medical specialists,
whereas others are under the impression that physicians
have already had the increases they deserve and that nothing
should be heard from them for some time. Let’s clarify this
issue, once again.
The government has acknowledged that the gap in remuneration between doctors in Quebec and their colleagues in the
other provinces was 50-55% at April 1, 2007. The Agreement
provides for a reduction of this shortfall over a period of 8 years,
i.e., between April 1, 2008 and March 31, 2016. Adjustment
of the April 1, 2007 remuneration gap does not in any way call
into question the need to negotiate the increases which should
apply as of April 1, 2010. The MSSS clearly understood this
point in the last Agreement by signing a clause which explicitly
states that the adjustment has absolutely no effect on the other
items up for negotiation, including the renewal of the Master
Agreement in 2010 and following years.
Since 2008, medical specialists have received slightly more
than 10% of the adjustment negotiated. Consequently, the
gap in remuneration (50-55% at April 1, 2007) is still more than
40% at the present time. Other fee increases will come into
effect this year as per the 2007 Agreement, but they have no
bearing on the negotiations which are now starting and the
increases applicable under the renewed Agreement.
Once again, let us make it quite clear: The 2007 Agreement
reduces the gap in remuneration from the 2007 level of 50-55 %
to around 15% in 2016. However if, during the upcoming negotiations, medical specialists were not to obtain increases similar
to those granted in the other provinces, the effect of the 2007
Agreement would quite simply be nullified and the gap in remuneration would remain at its present level of more than 40%
or even revert to the previous 50-55%.
2. Medical Power
Some people have strongly criticized the fact that medical
specialists command substantial powers of negotiation, without
analyzing the validity of the demands made. Once again, I would
like to set the record straight.
Power represents the very essence of the negotiating
process. As certain authors in the field have written “le pouvoir
de négociation est l’essence de la négociation” (the negotiating power is the very essence of the negotiation process).
This reality has nothing negative in itself.
History shows that physicians have only rarely been able
to insist on and support some of their claims. Some say
it does not belong to doctors to do so. Reacting firmly to
government decisions has been stronger here in Quebec
compared to other provinces in the last few years. Would this
be a shudder in our Judeo-Christian values?
Over the years, I have often seen medical specialists hesitate
to mention their remuneration. They feel embarrassed about
defending demands for an increase, particularly since they
already receive a good income. Politicians and bureaucrats
have used this very same reasoning to impose certain working
conditions or remuneration on physicians, assuming that no
protest would be forthcoming. Physicians therefore have a
choice of two evils: they either agree to working conditions or
remuneration which is inferior to that of others, or appear to
be blackmailers. I believe, however, that there is another option:
they should present their demands and the latter’s validity should
be analyzed objectively.
1
8
Rojot, Jacques (1994). La Négociation. Paris, Librairie Vuibert.
Physicians are independent workers. I sincerely believe that
this particular fact, as well as their professional freedom, is
essential to a quality healthcare system. The same applies to
their “medical power”. It stands as a rampart against political
dictates. Medical power must apply at all times and at all levels,
as has been proven over the past few years.
This power should first come into play with regard to conditions of practice, and a refusal to accept government decisions
like those imposed in 1990 and following years which harmed
the health system. It should be exerted when departments,
services, hospitals, outpatients clinics are closed down,
operating time is reduced and quotas imposed, etc. Quebec
physicians should act more promptly in resisting such decisions;
using their power can only have beneficial results.
It is also vital that medical power is exerted during the negotiating process, particularly because the strength of the
respective parties is unequal, with the government having full
powers on its side as well as the ability to act as both stakeholder and decision-maker.
Medical specialists do not want to have to use their negotiating power.
Since passage of the Canada Health Act, recourse to
arbitration has formed part of negotiations between physicians
and governments. This process exists in several Canadian
provinces. I would really like to hear the opinion of our
detractors on the subject of setting up an independent arbitration process for Quebec physicians; a process that would
be binding on government should there be a failure to reach
an agreement through negotiation. Until then, doctors have
the right to negotiate.
Medical specialists are demanding remuneration that is
competitive with that of their colleagues in the other provinces.
This is totally legitimate. All workers in Quebec earn less than
those in other Canadian provinces, mainly because the cost
of living is lower in Quebec. Medical specialists also accept
this situation. However, their situation is unique and the gap
in their remuneration is larger than others. All they are seeking
is to restore the balance, and they cannot be blamed for doing
that. If medical specialists earn more than other workers (and
I insist here, this is normal for the work they do), it doesn’t
justify they should reject the equity principle.
3. The Current Publicity Campaign
At a time when society in general is discussing ways to improve
public finances, medical specialists are also adding to the debate
by suggesting various measures which deserve consideration.
They are doing this in reaction to the public debate which is
trying to place us before a fait accompli and to convince
Quebecers that they will have to make difficult choices.
Actually, nothing guarantees that the government should
continue financing the rising costs of health sector. This is
reminiscent of 1995 and following years. But medical specialists
will not agree to again live through the upheavals that affected
our health system during that period and that resulted in a
reduction of the public’s access to care.
If the Federation had been content to present its demands
and to ask that the rise in health system costs be maintained,
it would have been described as irresponsible given the present
economic situation. It is more than surprising that it is being
reproached for the part it is playing in the debate.
In conclusion, keep your heads high and your powder dry. Not
only are your demands reasonable and fair, there are various
ways in which they can be achieved.
S
L
Paul G. Brunet of the Council for the Protection of Patients “Misquoted”
Following an article in the Journal de Québec on Thursday,
February 11, 2010, entitled Les patients seraient victimes d’intimidation (Patients reported to be victims of intimidation), together
with a further article on Friday, February 12, 2010 in the
Journal 24 heures, and in response to a formal notice received
from lawyers for the FMSQ, the Council for the Protection of Patients
(CPM) issued a public retraction to the Federation and its President,
Dr. Gaétan Barrette.
A few (translated) extracts follow:
“When Mr. Brunet, President of the Council for the Protection of
Patients, responded to a reporter's question on Wednesday,
February 10, 2010 concerning the class action suit filed by some
patients, it was reported that the Federation's lawyers were using
every legal means to discourage witnesses who might be called
in the case concerning the alleged strike of medical specialists
in 2002 and 2003.
(…)
If the Federation or Dr. Barrette were insulted by that report or by
facts which, while reported, were not stated by the Council or its
President, the Council for the Protection of Patients and its
President, Mr. Paul G. Brunet, deeply regret the situation and
sincerely apologize. They also formally demand that the media
which incorrectly reported these comments or which used
Dr Barrette's photograph for the report, without authorization –
specifically the Journal de Québec and the Journal 24 heures –
apologize and issue a retraction.”
9
IN THE NEWS
Text by Patricia Kéroack and Nicole Pelletier
Get People Talking!
ince last fall, the Charest government has carefully
started setting the stage by touching on the
difficulties caused by the economic crisis, the lack
of available resources, predictable budget cuts, etc.
It has also announced loud and clear that the
Province's coffers are empty. This message clearly
shows the government’s colours for the upcoming round of negotiations with the entire public sector, whose contracts all expire
at the end of March 2010. The government also set up numerous
meetings and consultations with experts to support or to obtain
support for its position. This was the case with the 2010 Economic
Summit… an event that melted away like snow in March, when
a few dozen carefully chosen partners (but not the FMSQ), met
for 5 or 6 hours to talk about Quebec's economic future.
S
Furthermore, anticipating that the government would not change
its position, the FMSQ decided to launch a major campaign to
inform the general public. One of the aims was to suggest possible
approaches to replenishing the Province's coffers. Since January
31, the FMSQ has been suggesting economic measures that
the government could take without directly increasing the tax
burden on ordinary Quebecers. It must be emphasized that
many of the ideas had already been suggested or mentioned
by other parties, including the Auditor General of Québec and
the Montreal Economic Institute: not just anybody. The estimated
value of these proposals, were they to be put into effect, would
not only fix the government's budgetary deficit, but would also
pay for the expertise of all the professionals working in the public
sector who find themselves paid below par for their professions.
Hence the title for our campaign: "Expertise has a price."
Please note that our entire strategy was developed internally
and is the result of the close collaboration between the President
and the Public Affairs and Communications team. Certain specialized tasks, including producing the media messages, placing
the ads and obtaining public relations support were outsourced
to carefully chosen agencies.
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The absent are not always wrong!
Deploring its exclusion from the Summit and to highlight the absence of representatives
from the health sector – which accounts for more than 45% of Quebec's budget – the
Federation found ways to ensure its point of view was known. Firstly, a full page ad (see
http://www.fmsq.org/f/centredepresse/communiques/coms/ 20100120.htm) was conceived
and placed in several major dailies in Quebec, on October 21. Then, a special edition of
the magazine Le Spécialiste was given out to participants at the event, a good number
of whom were government ministers. You can consult this issue on the FMSQ's site at
www.fmsq.org/publications.
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Opportunité d'éducation médicale à la fine pointe des développements cliniques
10
Dr Jean-François Tanguay - Dr Serge Doucet
The campaign
The FMSQ decided to demonstrate that there is in fact money
available, but that political decisions are needed when it comes
to making choices. Why did we decide to go down this path?
POINT NO. 1: The economy and Quebec's finances
The FMSQ maintains that it is possible to solve the problem of
public finances. Moreover, if Quebec wants to retain professionals working in the public sector (all university graduates –
dentists, architects, legal aid lawyers, nurses, teachers, etc.), it
must recognize their expertise and pay them accordingly. In
order to raise Quebecers’ awareness and encourage both discussion and involvement, the campaign denounces waste, unused
resources, laws and regulations that are not properly enforced,
new avenues for financing and so on.
The Expertise Has A Price campaign consists of a
series of 15-second TV teasers and 30-second commercials.
Since it is impossible to say everything in a short advertising
message, the audience is invited to visit the campaign's site
www.expertisehasaprice.co m, where more information is
available on the measures we suggest.
POINT NO. 2: Better understanding of the 35 medical
specialties
At the same time as the campaign on the economy is running,
a public relations campaign entitled Passionnés pour la vie
(“A Passion for Life”) has been created to introduce the various
medical specialties. The FMSQ has chosen a little-used television format – the short program – which lasts 60 seconds
and during which a medical specialist talks of his or her passion
for a particular specialty. Physicians (real ones) from each medical
specialty were recruited for the filming and agreed to give their
points of view.
These short programs are to be aired at a set time since they
are part of a channel's regular programming. The series
will be presented (in French) from Monday to Friday, at 10:12 p.m.
during Le Téléjournal (Radio-Canada), at 9:12 p.m. during Le
Téléjournal (RDI), at 12:10 p.m. during RDI en direct (RDI),
and around 7:36 a.m. during RDI Matin (RDI).
It will continue until next November, with a break in the summer.
S
L
As expected, the ads drew a great many comments as soon
as they were aired. Political analysts, broadcasters, columnists
and the public gave their views on the contents and their
relevance. Some groups targeted by our campaign came out
in support and themselves denounced instances of waste; some
asked for more information or disputed our arguments. Our
president, Dr. Barrette, gave a number of interviews and made
a very strong impact on February 7, as a guest on the television program “Tout le monde en parle.” In the final analysis,
you can say something good or say something bad. What
counts is that you say something.
Dr. Thérèse Côté-Boileau presenting pediatrics.
11
IN THE NEWS (SUITE)
A Barometer than Speaks for Itself!
Reacting to news of the earthquake that devastated Haiti
on January 12, the FMSQ reacted rapidly and made donations
totalling $30,000 to Doctors of the World - Canada and Doctors
Without Borders. Through its website, the Federation also
organized a fund-raising campaign among its members, FMSQ
employees and those in affiliated associations. To date, more
than $200,000 has been collected and given to Doctors Without
Borders, Doctors of the World - Canada and the Centre for
International Studies and Cooperation (CISC) to help meet
the urgent humanitarian and health needs of the Haitian people
at this time of great suffering.
The FMSQ Bags the Bag!
The famous oversize handbag belonging to the former
Minister of Finance of Quebec,
Madame Monique JérômeForget, is now in the hands
of the FMSQ. The handbag
was auctioned off during
the 2009 Grande guignolée
des médias (the media’s
major food drive). Dr. Gaétan
Barrette, the President of the FMSQ, bid $2,000. When
placing his bid, Dr. Barrette challenged all other union
organizations (and, more specifically, the FMOQ) to bid
more and win the prize.
On December 10, Dr. Barrette finally took possession of
the handbag during Radio-Canada’s morning radio show
“C'est bien meilleur le matin”, adding a further $6,500 to
bring the Federation's total contribution to $8,500 (or the
equivalent of one dollar per member) to the very worthy
cause of the Grande Guignolée. According to the ex-Minister,
the bag has several secret compartments. As we approach
the 2010 round of negotiations, maybe a few dollars might
have escaped the sharp eye of the person who also held
the position of President of the Treasury Board!? There
are bound to be more references to the handbag during
the coming period.
Do you or do you
not trust... ?
1 Firefighters
97%
2 Nurses
96%
3 Doctors
91%
4 Farmers
90%
5 Teachers
86%
6 Mail delivery employees
85%
7 Notaries
78%
8 Electricians
76%
9 Artists
73%
10 Police Officers
72%
11 Engineers
71%
12 Plumbers
66%
13 Judges
65%
14 Taxi drivers
63%
15 Pollsters
60%
16 Journalists
44%
17 Bankers
40%
18 Church Representatives
40%
19 Economists
37%
20 Lawyers
29%
21 Construction Contractors
29%
22 Business People
29%
23 Real Estate Agents
28%
24 New Car Salespeople
26%
25 Financial Consultants
26%
26 Senior Public Servants
22%
27 Unionists
22%
28 Publicists
19%
29 Politicians
8%
30 Used Car Salespeople
6%
Pollster Jean-Marc Léger
of Léger Marketing
recently updated his
barometer of professions
in Quebec.
This barometer shows today's
main trends on how professionals in Quebec are appreciated and trusted. According
to the author, “professions
that help people are all in the
upper third in our survey.
More liberal professions, like
notaries, judges, engineers,
bankers or economists, long
admired in Quebec, are in the
second third. And all the gripers
– politicians, union members,
sales people, business people
and lawyers – are battling it out
in the lower third.”
Doctors rank third, immediately
after firefighters and nurses.
Our politicians come in 29th
place, at the bottom of the
popularity ranking.
January 2010, 1,500 people polled, +/- 2.8%
Source: Léger Marketing - Journal de Montréal
Pour un service
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Consultez les CONSEILLERS-SPÉCIALISTES de votre
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départ du 16/05 au 23/05
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Grand Tour d’Autriche
Option jeux de la passion à
Oberammergau
Corse – Sardaigne
à partir de 4156$
Espagne – Portugal
à partir de 4256$
à partir de 4156$
Plusieurs autres départs disponibles. Informez-vous!
Départ de Montréal. Les prix sont par personne en occupation double et incluent toutes les taxes de vente, les taxes et les autres frais. Pour le détail des inclusions des programmes, veuillez consulter les brochures 2010. Les prix sont en
vigueur au moment de l’impression. Titulaire d’un permis du Québec. md/mc Marque déposée/de commerce d’AIR MILES International Trading B.V., employée en vertu d’une licence par LoyaltyOne, Inc. et Transat Distribution Canada Inc.
Prix excluant le 3,50$/1000$ du fonds d’indemnisation des clients des agents de voyages détaillants.
12
S
L
DID YOU KNOW...
Prizes and Awards
Grants from the Association québécoise de la
douleur chronique (AQDC)
The AQDC has awarded four $5,000 grants
for improvements in the clinical knowledge
of chronic pain, a phenomenon that still
needs to be clarified. Among the winners,
two medical specialists will be undertaking
additional practical training. Dr. Patrick
Benhaim, a physiatrist, will be going to
Australia to complete his training with
Dr. Michael Cousins, then will return to the
Pain Clinic at the Institut universitaire de
gériatrie de Montréal. Dr. Mélanie Laverdière,
an anesthesiologist, will further her
knowledge on implanting neurostimulators
and intrathecal pumps with the team at the
Cecil Clinic in Lausanne, Switzerland.
King Faisal International Prize for Medicine
Awarded to Two Quebec Specialists
Dr. Jean-Pierre Pelletier,
a rheumatologist, and
his wife, Johanne Martel
Pelletier, Director of the
Osteoarthritis Research
Centre, are the recipients
of the prestigious King
Faisal International Prize
for Medicine.
L’Association des médecins de langue française
du Canada Awards its Annual Prizes
Dr. Michel Bergeron becomes the first
recipient of the Prix de l’ambassadeur du
français en médecine Jacques-Boulay.
This prize is awarded to a French-language
physician who has demonstrated a special
commitment to promoting French in the
practice of his profession.
SCFR Honours its Peers
The Société canadienne-française de radiologie (SCFR)
awarded prizes to certain of its members during the 46th Annual
Congress highlighting the exceptional contribution they have
made to their profession or to parallel activities.
Dr. Guy Breton, received the Prix AlbertJutras, in recognition for his hospital,
university and union career.
The Prix médecin de cœur et d’action are awarded to physicians who have made exceptional contributions to society and
in their professional lives. The recipients were:
Dr. Chantal Lapierre
was awarded the
Bernadette-Nogrady
Prize in recognition for
her remarkable contribution to teaching,
research and the quality of patient care,
with less than 11 years of medical practice.
Dr. Marie-Ève Cotton
(Mental Health Care)
Dr. Caroline Reinhold received the Dr. JeanA. Vézina Prize for Innovation and Excellence
to recompense her remarquable contribution as well as for noteworthy innovation
and excellent results in radiology.
Finally, Dr. Robert
Ouellet was honoured
by the ARQ/SCFR Personality Prize. Dr.
Ouellet is the former president of the
Canadian Medical Association and is actually
the Canadian representative of the World
Medical Association.
Dr. Éric Notebaert
(Emergency Care
Physician)
Dr. Louise Samson
Dr. Michel White
(Specialist in the field of (Medical Specialist)
diagnostic investigation
and management)
Dr. Geneviève Piuze
(Mother-child Care)
Dr. Roger Morrissette
(Surgical Specialist)
13
DID YOU KNOW... (SUITE)
Grand prix Sirius Ceremony, Centre hospitalier
universitaire de Québec (CHUQ)
2010 GOLF
TOURNAMENT
For the fifth year in a row, the CHUQ has given out its Sirius Major
Awards in recognition of the excellence, passion and commitment of medical specialists practising at that hospital. Three medical
specialists were honoured at this gala:
• Dr. Pierre Déry, Prix grand bâtisseur, in recognition of his
contribution to CHUQ’s Mother-and-Child Centre.
• Dr. Guy Boivin, Prix recherche, to honour his overall work
in virology.
• Dr. Carole Ratté, Prix enseignement, in recognition of
the development of the eating problem action plan and
teaching tools.
It’s time to think about good weather, and give into the call of green
fairways, little white balls and golf clubs. The FMSQ once again invites
you to take part in the 5th Medical Federations Golf Tournament in aid
of the Quebec Physicians Assistance Program (Programme d’aide aux
médecins du Québec – PAMQ). More than half a million dollars have
been collected since the Tournament began to allow the PAMQ to
continue its activities. The need is still rising though because,
unfortunately, the PAMQ has recorded a net growth in requests for
assistance from physicians, residents and medical students over
recent years.
The 5th Tournament will be held on July 26, 2010 at Le Mirage
Golf Club, Terrebonne. You can register right now by downloading the
registration form on our Internet site, www.fmsq.org. Since each
tournament has surpassed previous ones in popularity, we have one
suggestion: Don’t delay! Register today!
Please note that various sponsorship options are also available. Contact
Geneviève Roberge (514-350-5000, local 498) or e-mail her at
[email protected] for all details and prices.
Dr. Guy Boivin
Dr. Carole Ratté
29 avril – 1er mai 2010
Dr. Pierre Déry
C O N G R È S C A N A D I E N S U R L A S A N T É R E S P I R AT O I R E 2 0 1 0
The World Trade and Convention Centre • Halifax (Nouvelle-Écosse)
Présenté par
En collaboration avec
Pour tous les détails du programme et pour s’inscrire, visitez le site
14
www.poumon.ca/crc
New Publications
Vivre avec un proche cardiaque
Distress Felt by Caregivers
Dr. Serge Doucet, a cardiologist at the
Montreal Heart Institute, full professor at the
Faculty of Medicine, Université de Montréal,
and holder of the Groseillers-Bérard Chair
in interventional cardiology, has recently
written Vivre avec un proche cardiaque
(Living with a Heart Patient). Among the
subjects covered are the heart and its
function, risk factors, warning signs of a heart
attack or infarction, heart arrhythmia, the origin
of cardiac valvular disorder, rehabilitation and resumption of
activities, as well as the services available.
As a result of the October 2008 symposium
on the Suffering of Caregivers: Express or
Repress? (La souffrance des soignants :
exprimer ou réprimer ?) organized by the
Université du Québec à Chicoutimi (UQAC),
this work reflects the presentations made
at that time and is intended to shed new
light on a very real situation experienced
by health and social services caregivers
(physicians, nurses, social workers, etc.).
Caregivers feel guilt over the fact that it is impossible for them
to achieve the therapeutic ideal with regard to all the actions
and practices intended to cure, heal and relieve. Conscious
of their inability, caregivers may resign and become ill themselves. Now unable to give care, such individuals must change
their role and, in their turn, become care receivers.
Practical Guide to Internal Medicine
Professor Luc Lanthier of the Faculty of
Medicine and Health Sciences, University of
Sherbrooke, has launched “Practical Guide
to Internal Medicine”, the first English edition
of Guide pratique de médecine interne of
which there are five editions in French.
The book is intended for medical students,
residents and general practitioners in Quebec
and has had phenomenal success with more
than 12,500 copies being sold. Professor Lanthier worked on
the book from the time of his residency in internal medicine
until he published it in 1999 at the start of his medical career.
It is a condensed compilation of the most common problems
found in the practice of this specialty, and he reviews vast
amounts of knowledge and data. Designed to be practical,
the Guide easily slips into a doctor coat pocket.
Stress, estime de soi, santé, travail
Fifty years after Dr. Hans Selye was responsible for the word “stress” being added to
dictionaries, we are barely beginning to fully
grasp and comprehend his influence on both
public and private health. Dr. André Arsenault
(nuclear medicine) and his colleague, psychologist Simon L. Dolan, have published a
book (Presses de l’Université du Québec) to
demonstrate that reduced stress at work can
be profitable for employers. The authors state
that professional stress is tied to three factors: perception of the
job requirements, individual differences, and social support. The
book puts forward suggestions to reduce and even avoid stress.
S
L
Petition seeks your support
The Coalition Priorité Cancer au Québec asks all residents of
Quebec to support their effort to create a Quebec agency to
fight against cancer and also centralize the coordination to conquer
this disease. According to the Coalition, Quebec already has
everything necessary to further the fight against cancer; all that
is needed is to orchestrate individual efforts into a whole. From
now until April 26, you can sign the petition (in French), which
can be found on the Internet site of the Quebec National Assembly
(http://www.assnat.qc.ca/petition/SignerFr.aspx?idPetition=97).
Conseil québécois de développement
professionnel continu des médecins
Explorons, innovons et partageons !
Prix de la recherche,
Prix de l’innovation pédagogique
et Bourses de recherche en développement
professionnel continu 2010
Date limite : 1er mai 2010
Pour participer, consultez le site Internet au www.cqdpcm.ca
À votre agenda
Vendredi 19 novembre 2010
Détails à venir
15
Vivre avec le diabète
n’est pas toujours simple.
L’indicateur de vos
patients, lui, devrait l’être.
L’indicateur CONTOUR® de Bayer
Simple. Précis. Personnalisé.
Aucune interférence
des sucres pouvant
causer des résultats
faussement élevés avec
certains indicateurs*
Deux modes de
fonctions pour
des analyses
personnalisées.
L’indicateur le plus vendu
au Canada**
Contribue à assurer
la précision des résultats
en éliminant les erreurs
qui pourraient découler
de l’étalonnage manuel.
–Alana Burns
ailier fort, diabète de type 1
simplesvictoires bayerdiabetes.ca
MC
© 2010, Bayer Inc. ®/MC Marques de commerce de Bayer HealthCare LLC utilisées sous licence par Bayer Inc. Bayer et la croix Bayer sont des marques déposées de Bayer AG
utilisées sous licence par Bayer Inc. * Avec les bandelettes d’analyse CONTOUR®, aucune interférence n’a été observée avec des concentrations de maltose et de galactose de
jusqu’à 6,54 mmol/L et 12,43 mmol/L, respectivement. Gestion du diabète de Bayer, données internes. ** Bayer Inc., données internes, décembre 2008 à décembre 2009.
DOSSIER
The growth of diabetes has reached alarming proportions.
The World Health Organization (WHO) even refers to a
true epidemic. According to the experts, if the trend is
maintained, the incidence of diabetes will have doubled
by 2025 in both Quebec and the rest of the world. Are all
types of diabetes alike? No: 90% of diabetic patients are
classed as Type 2 and today's lifestyle is pointed to as
the probable reason for the condition: a sedentary
lifestyle, diet, age, etc. Over the past few years, we have
witnessed the appearance of double diabetes: individuals
with Type 1 diabetes who develop Type 2 after age 40.
Diabetes alone can cause a veritable cascade of medical
problems: cardiovascular disease (two to three times the
rate in non-diabetics), blindness (the leading cause in
adults under 65), amputation (50% of non-traumatic
amputations), kidney failure (the leading cause of dialysis)
and other complications. One-fifth of hospital beds are
occupied by people with diabetes.
Diabetes is expensive for society and our health system.
Health service costs are up to five times higher for
diabetics. Direct and indirect costs are estimated today at
more than $3 billion, plus the additional socio-economic
costs created by depression, job loss, personal and
family problems, divorce, etc.
Even though research has now successfully identified
thirty or so genes that predispose a person to diabetes
and the mechanism of action of insulin is starting to be
known, we are still light-years away from a miracle cure
capable of eradicating the ravages of this scourge.
Diabetes is a major world-wide health problem. We are
facing an emergency.
17
This text is an adaptation of the expert committee report on the status of diabetes
in Quebec. We wish to thank Diabète Québec for allowing us to use it in our
Special Report. The complete report is available (in French) at www.diabete.qc.ca.
Expert Committee Report
Status of Diabetes in Quebec
S
ince the increase in the number of cases has clearly
become alarming, Diabète Québec asked a group
of experts to review the overall status of diabetes
in Quebec and to recommend action that will make
the fight against this scourge more efficient and
more effective, as well as provide better service and
treatment to people who already have diabetes.
Diabetes is a chronic disease caused by the insufficient
production of insulin. There are two main types of diabetes:
Type 1, which mainly affects younger people, and Type 2, in
which symptoms generally occur in people over 40 years of
age. Gestational diabetes can be added to these two groups
and, very recently, double diabetes has appeared, i.e. cases
where Type 1 diabetics develop Type 2 diabetes at a mature
age. This latest group is growing consistently. It is crucial that
we upgrade our action in Quebec at all levels, both with regard
to the prevention of diabetes and the care and treatment of
individuals affected by this disease.
It is imperative that we reduce the prevalence, incidence and
impact of diabetes. To succeed, the experts recommend the
adoption and adequate financing of a strategy to fight diabetes,
giving priority to a continuum of action at all levels, from prevention to tertiary services.
The number of prediabetic and diabetic persons in Quebec is
estimated at more than 930,000, or some 15% of the population. At present, 35,000 new cases are diagnosed each year.
• The prevalence of diabetes (known cases) is 7% in
people aged 20 and over.
• One person in eight will become diabetic.
There are two main reasons for this phenomenon: aging of the
population, which affects the prevalence of the disease, and
lifestyle changes, with a surge in excess weight and obesity.
Type 2 diabetes is appearing earlier than ever before. The disease
used to occur as people reached their sixties; nowadays, it is
being found around age forty. Since 2003, Canadian guidelines have recommended that people be tested for the disease
starting at age 40. But, despite this, 30% to 40% of Type 2
diabetics remain undiagnosed. It is often when the first complication happens that the disease is identified. It is therefore not
uncommon to detect diabetes following an initial cardiovas-
cular or other event. These people will have been living with
high blood sugar levels for several years, with all their attendant
consequences.
Two other relatively recent phenomena have been added to
this picture. There has been a large increase in cases of gestational diabetes in hospitals serving patient populations made
up of Aboriginals, African Americans, Asians or Latin Americans.
Up to 50% of these women will become Type 2 diabetics.
We are also seeing cases of Type 2 diabetes in children and
adolescents. In some pediatric clinics serving at-risk populations, the number of young people with Type 2 diabetes is
alarming. People with diabetes use more medical services and
are more likely to develop complications such as cardiovascular, renal, ophthalmic and neurological problems if their illness
is not well controlled.
On the economic side, it is estimated that diabetes costs the
Quebec health system more than $2 billion per year. A further
billion dollars in indirect costs can be added to this figure.
The situation with Type 1 diabetes is just as disturbing, since
reports indicate an increase in incidence of 3% per year. Experts
therefore consider that the time has come to undertake an
exhaustive epidemiological study, covering prevalence, incidence,
diabetic complications and hospitalizations, along the lines of
what is being done in Ontario and Great Britain.
Diabetes Prevention And Control Strategy
The group of experts believes that Quebec urgently needs an
overall diabetes strategy. Unfortunately, it is difficult to convince
all stakeholders to take action, very likely because of the lack
of a strategy to fight and control diabetes and the dispersal of
efforts across other health issues.
For example, since 2008, Ontario has chosen to invest
$741 million over four years in the fight against diabetes. This
investment has specific targets: 40% to increase care by interdisciplinary teams, 30% to improve services for kidney patients
(nephropathy), 20% to create a diabetes registry, etc. If Quebec
were to choose this path, the investment needed would be
approximately $100 million per year for 4 years.
* Members of the Diabète Québec Expert Group: Dr. André Bélanger, endocrinologist, Agence de la santé et des services sociaux de Montréal; Dr. JeanMarie Ékoé, endocrinologist, CHUM – Hôtel-Dieu; Dr. Simon Kouz, cardiologist, Centre de santé et de services sociaux Nord-de-Lanaudière (CHRDL Joliette); Dr. David Morris, endocrinologist, MUHC – Royal Victoria Hospital; Dr. Jean-François Yale, endocrinologist, MUHC – Royal Victoria Hospital.
Other committee members: Serge Langlois, President and General Manager, Diabète Québec, and Marc Aras, its Director of Communications.
18
In England, diabetes budgets are also protected. For example,
a national retinopathy follow-up program has been in place
for three years. People with diabetes have an annual
retina check-up. In Quebec, a single report from the Agence
d’évaluation des technologies et des modes d’intervention en
santé (AETMIS) proposes the systematic follow-up of diabetic
patients to reduce the consequences of retinopathy.
The Strategy: A Continuum Of Action
And Services
Reduce the prevalence and incidence of diabetes
1. Priorit y preven tion / children, adol escents and you ng adults
Poor eating habits and a sedentary lifestyle are clearly the
primary cause of the increase in Type 2 diabetes in Western
society. Foods rich in sugars, fats and calories cause obesity.
Combined with a sedentary lifestyle, this can lead to glucose
intolerance, a frequent precursor of Type 2 diabetes. We therefore
need to concentrate on modifying lifestyles. Promoting healthier
behaviour, especially with regard to young people, their parents
and schools, is the foundation for our effort to reduce the prevalence of diabetes. Unfortunately, this is a very difficult task;
results are gradual and visible only over a long period of time.
2. Pri mary preventi on / pati ents at ris k
Too often, the diagnosis is made once complications have set
in. On average, a patient has diabetes for a period of seven
years before being diagnosed. It is therefore all the more important
to reduce the incidence of the disease through the early detection
of prediabetes and diabetes, targeting those who are at risk.
According to the most recent screening and treatment guidelines, everyone aged 40 and over should have a blood glucose
test every three years.
To curtail the time during which the person with diabetes is
unaware of his condition, we should also focus on persons
who are prediabetic (abnormally high fasting blood sugar [5.6
to 6.9 mmol/L], or glucose intolerance [blood sugar 7.8 to
11.1 mmol/L after ingesting 75 g carbohydrates], or both at
the same time), or who present with metabolic syndrome or
a cardiometabolic risk (abdominal obesity, abnormal lipids, hypertension, insulin resistance, etc.).
Convincing individuals who are at risk of diabetes to change
their habits and supporting their efforts to take charge of
their lifestyle remains the focal point of efforts to reduce
the incidence of diabetes.
Priorities
• Create a single source per CSSS territory to guarantee
access to first-line medical services and other
interdisciplinary resources and install a safety net
for all prediabetics and diabetics.
• Provide greater access to information on diabetes in
order to increase diabetics’ motivation and awareness of
their responsibility for their health (e.g. education centres).
Other recommendations
• Increase continuing medical education (screening,
prevention and teaching).
• Create structured intervention programs aimed at
modifying lifestyles, with the evaluation of relevant
indicators (waistline, A1C, etc.); promote and improve
existing programs offered in health centres supported
by interdisciplinary teams, etc.
• Increase access to screening for persons at risk in order
to improve diabetes control and supervision.
Reduce the consequences of diabetes
3. Secondary prevent ion / diabet ic individuals
The committee believes the risk of complications due to diabetes
must be reduced, in particular through early screening (identification, control and action to change lifestyles). In 2008, the
Canadian Diabetes Association published new clinical data for
which the experts were able to develop specific treatment targets.
It is not enough, however, to approach desired targets: they
must be achieved and, ideally, surpassed, if real short and
long-term health and welfare benefits are to be attained.
Unfortunately, most diabetic patients in Quebec do not reach
their treatment goals.
The DICE (Diabetes In Canada Evaluation) Study has shown
that diabetes control gradually deteriorates the longer the disease
lasts. While 70% of people diagnosed less than 5 years ago
manage to control their blood sugar well, this percentage falls
to 40% after 10 years. The frequency of micro- and macrovascular complications will have tripled over the same period.
Diabetes is mainly asymptomatic and evolves stealthily. People
with the condition often tend to relax their efforts over time.
Many patients have a poor understanding of their illness, and
ignore their physician's recommendations. Diabetes education
centres have limited resources. In large urban centres and
outlying regions, it is difficult to meet demand. Teaching is still
the key to getting the individual to accept responsibility, particularly with regard to Type 2 diabetes. Only one person in ten
takes advantage of it, most of the time as a result of complications, not for purposes of prevention. To obtain significant
results, it is imperative that access to medical and interdisciplinary resources be improved.
19
Medication is an additional problem in controlling diabetes.
While the choice is sometimes limited, access is often
inadequate because of associated costs. Certain new products
appear on the exception drug list, but are not available through
private insurance.
According to the committee experts, a lack of understanding
about the type and quality of therapy needed by diabetics still
persists, and yet such people will have to live with the disease
for many years. New drugs meet specific needs and bring an
innovative approach to situations that often cannot be controlled
by classic medication. Inadequate access to all drug treatments is a serious impediment to reaching treatment objectives.
Restrictions on use are applied to almost 100% of the new
treatments available.
According to the Canadian Diabetes Association's treatment
guidelines, new treatments, such as second-generation
sulfonylureas, thiazolidinediones and incretins which are
subject to restrictions, should be instituted earlier. The fact
that no diabetes medication was launched on the market during
the first years of the Quebec Public Drug Insurance Plan, when
the acceptance of new drugs was more generalized, no doubt
explains this situation. Instead of comparing new drugs to
those that appeared in the 1990s, price is strictly compared
with that of treatments launched between 1950 and 1970.
This historical difference in no way justifies the discrimination
that has been applied to diabetes medication since then.
Treatment compliance
Treatment compliance remains a major issue, as diabetic patients
must often take more than seven drugs a day. Forgetting to
take one or more doses deliberately or otherwise, not taking
medication at the right time or not having a prescription for a
new drug filled, for example, can have serious consequences
on blood glucose control and the associated risk factors. Health
professionals must seek to prevent, identify and correct
problems of adherence to treatment, while patients need to
tell their health professionals about any difficulties they are
experiencing. As always, good education and follow-up by an
interdisciplinary team can improve the situation.
Action Priorities
• Set up routine (automatic) screening, targeting diabetesrelated complications, without compromising the
availability of third-line resources.
• Refer to the Canadian Diabetes Association's guidelines
regarding the availability of resources, compliance and
lifestyle measures.
• Set up a national diabetes registry.
• Increase continuing medical education (screening,
prevention and teaching).
• Create simple programs targeting lifestyles; support and
improve existing programs: CSSS, family medicine
groups, interdisciplinary teams, etc.
• Improve access to exception medication by the
codification of all diabetes drugs.
• Set up a systematic, computerized follow-up of
diabetic patients.
• Adopt and promote an aggressive strategy to detect
diabetes-related complications.
• Evaluate the various diabetes action programs
(indicators) periodically.
• Maintain access to and the optimal quality of
patient services.
4. Terti ary services / people wi th diabetes
There is an urgent need to slow the evolution of complications
and reduce the appearance of new cases. Controlling diabetes
is necessary to decrease or even prevent complications. Several
key elements have to be combined to facilitate the management and control of Type 2 diabetes: teaching diabetic patients
about micro- and macrovascular complications; equal access
to health care and health professionals; optimal use of and
access to medications; regular follow-up of patients. It is essential
that medical staff ensure that blood sugar remains at optimal
levels during hospitalization, as many studies have shown a
higher degree of success with tighter control.
Action priorities
• Equip physicians: continuing medical training, expert
support to family medicine groups and medical clinics,
patient education centres, etc.
• Create safety nets: support by interdisciplinary teams,
referral to specialized education centres.
• Tie third-line and first-line treatment together
(complementarity and patient follow-up).
• Encourage the training of endocrinologists by promoting
the choice of this profession.
• Rely on physicians’ motivation.
• Integrate performance indicators.
We have the knowledge. Now we need an organized system
and an overall strategy to fight diabetes more efficiently and
to control it as part of a continuum of care. The expert group
fervently hopes that the government of Quebec will proceed
accordingly, without further delay.
S
L
20
François Gilbert, MD
Endocrinologist
Diabetes: Waiting in the Wings
The metabolic syndrome can be a clinical warning sign for Type 2 diabetes. It is known that the
principal physiological abnormality at the root of this health problem is insulin resistance, a
genetically-acquired phenomenon that usually becomes clinically apparent after age 40. In an
article published in the December 2007 issue of Le Spécialiste, Dr. Élaine Letendre gave a
detailed description of this syndrome.
he ultimate consequence of this hereditary defect is
Type 2 diabetes, which may require several years before
becoming a clinical entity. Since insulin plays a normal
role in several metabolic processes, a variety of clinical
factors can provide health professionals with an early
warning of the potential for diabetes. Following is a
list of the main factors:
T
Diabetes-Related Medical Conditions
Obesity
Dyslipidemia
Hypertension
Hyperuricemia and gout
Fatty liver
Chronic kidney failure
Microalbuminuria
Erectile dysfunction
Polycystic ovary syndrome
Sleep apnea
When a patient presents with a waistline of more than 94 cm,
a body mass index above 27, blood glucose levels higher than
5.5. mmol/L or, alternatively, dyslipidemia, hyperuricemia, fatty
liver or hypertension, clinicians should order a 2-hour glucose
tolerance test (75 g solution) or, at the very least, screen for the
presence of Type 2 diabetes by checking fasting blood glucose
once a year.
Some populations are at higher risk of developing Type 2
diabetes because they carry genes that predispose them to
insulin resistance. Particular attention should therefore be paid
to members of aboriginal nations, South-East Asians, Pacific
Islanders, people from the Caribbean, Latin America and African
Americans. Patients with a family history of diabetes, dyslipidemia or hypertension or who have had previous cardiovascular
disease require close supervision, as do women with a history
of polycystic ovary syndrome or gestational diabetes.
The early diagnosis of diabetes is important because these conditions predispose patients to the premature onset of cardiovascular
disease. For example, we frequently see outpatient clinics diabetics
who have had a myocardial infarction 20 years earlier than generally
seen in the general population. Diabetes is also the main reason
for the non-traumatic amputation of the lower limbs. This type
of diabetic complication, even if not fatal, often results in disability
that prevents the victim from working and enjoying life, to say
nothing of the serious drain on the human and financial resources
of the health system.
To prevent the occurrence of such cardiovascular and microvascular complications, experts in international diabetes
organizations have issued recommendations encouraging clinicians who treat diabetes to have their patients adhere to strict
metabolic targets. Fasting blood glucose should be maintained
below 7 mmol/L and levels 2 hours after a meal should not exceed
10 mmol/L. Glycosylated hemoglobin levels should be under 7%.
Plasma LDL-cholesterol should remain below 2 mmol/L, or
less than 50% of levels prior to lipid-lowering therapy if that
measurement was under 4 mmol/L. The total cholesterol to HDLcholesterol ratio should be below 4. Finally, blood pressure should
be maintained under 130/80 mm Hg. These recommendations
are set out in the following table:
Diabetes Management: Metabolic Targets
Fasting blood glucose
< 7 mmol/L
Blood glucose 2 hours after meals
< 10 mmol/L
A1C hemoglobin
< 7%
LDL-cholesterol
< 2 mmol/L or
< 50% of level prior to
treatment if < 4 mmol/L
Total cholesterol/HDL-cholesterol ratio
<4
Blood pressure
< 130/80 mm Hg
21
Some cardiovascular experts even recommend a similar
preventive approach for glucose-intolerant individuals, i.e. those
with fasting blood glucose levels over 5.5 mmol/L, especially
if they also present with metabolic syndrome. Epidemiological
studies have shown that the cardiovascular risk in this group
is as high as that for people with diabetes.
All clinicians who adopt these recommendations quickly realize
that they must prescribe a number of medications to achieve
these metabolic targets. This is in addition to convincing the
patient to adopt a healthy lifestyle, with a balanced diet and
at least 30 minutes of physical activity per day. It is common
for diabetic patients to take two to three different types of
diabetic drugs, three or four hypertensive agents and maybe
two types of lipid-lowering drugs. In addition, these medications must often be taken every day for several years. In the
circumstances, it is easy to understand why convincing
patients to comply with their treatment represents a major
challenge for medical teams, particularly when there are
no symptoms, as is often the case in individuals with
metabolic problems.
To sum up, practitioners should adopt a clinical approach to
diabetes that incorporates a heightened awareness of its possible
presence, early diagnosis, aggressive treatment immediately
22
following diagnosis and a capacity for the imaginative persuasion of the patient being treated.
Bibliography
Selvin E, Marinopoulos S, Berkenblit G et al. Meta-analysis: glycosylated hemoglobin and cardiovascular disease in diabetes mellitus. Ann
Intern Med 2004;141:421.
Selvin E, Coresh J, Golden SH et al. Glycemic control and coronary
heart disease risk in persons with and without diabetes: the atherosclerosis risk in communities study. Arc Intern Med 2005;165:1910.
Coutinho M, Gerstein HC, Wang Y, Yusuf S. The relationship between
glucose and incident cardiovascular events. A metaregression analysis
of published data from 20 studies of 95,783 individuals followed for
12.4 years. Diabetes Care 1999;22:233.
Qiao Q, Pyorala K, Pyorala M et al. Two-hour glucose is a better risk
predictor for incident coronary heart disease and cardiovascular
mortality than fasting glucose. Eur Heart J 2002;23:1267.
Sasso FC, Carbonara O, Nasti R et al. Glucose metabolism and
coronary heart disease in patients with normal glucose tolerance.
JAMA 2004;291:1857.
Khaw KT, Wareham N, Bingham S et al. Association of hemoglobin A1c
with cardiovascular disease and mortality in adults: the European
prospective investigation into cancer in Norfolk. Ann Intern Med
2004;141:413.
Paul Poirier, M.D.*
The Impact of Diabetes in Cardiology
Despite an improvement in the management of diabetes and the treatments available,
this disorder continues to be a major public health issue because of the worrisome
increase in its prevalence.1
ccording to the World Health Organization (WHO),
the number of people with diabetes worldwide
rose from 30 to 171 million between 1985 and
2000 and is expected to reach 366 million by the
year 2030.2 Preliminary data from the new Quebec
Diabetes Surveillance System (QDSS) indicates
that, in 2006-2007, the prevalence of diabetes (standardized
using the age of the Quebec population in 2001) reached 7.1%
in those aged 20 or older, a 31% increase since 1999-2000
(prevalence then estimated at 4.9%).
A
The seriousness of diabetes is essentially related to the complications it engenders. Without proper treatment, diabetes can
entail serious macro- and microvascular complications which
themselves cause morbidity and premature death, resulting in
enormous economic and social costs. The problems related
to these complications will occur more and more frequently
because of the dramatic rise in the number of younger patients
diagnosed with Type 2 diabetes. Life expectancy can be
shortened by 15 years in people with Type 1 diabetes, and by
5 to 10 years in those with Type 2 disease.3 Eighty percent
of deaths in diabetics can be attributed to cardiovascular disease,
with 13% directly related to diabetes (ketoacidosis, coma and
hypoglycemia) and 10% to stroke.4
THE SERIOUSNESS OF DIABETES IS
ESSENTIALLY RELATED TO THE
COMPLICATIONS IT ENGENDERS.
Coronary atherosclerosis is more frequent, more extensive and
more serious in diabetics than in non-diabetics.5 Angiography
studies show more severe and more diffuse coronary lesions
in diabetics.6 According to the data, Type 2 diabetics are two
to four times more likely to suffer an acute myocardial infarction than non-diabetics.7 Coronary disease thus remains the
main cause of death in people with diabetes, reducing their
life expectancy by close to 15 years.8 Over 80% of Type 2
diabetics die from cardiovascular complications and approximately 30% of all patients admitted to cardiac intensive care
have diabetes.
Diabetic cardiomyopathy also plays an important role in the
prevalence of coronary morbidity and mortality in diabetic patients.
Very early preclinical identification is possible because of the
presence of functional alterations to the left ventricle, when
multiple diabetes-related factors such as obesity or hypertension9 are already present. At the clinical stage, it takes the
form of congestive heart failure in the normotensive diabetic
patient with no clinical signs of coronary problems.10 Diabetic
cardiomyopathy is associated with certain metabolic factors,
including long-standing hyperglycemia and changes in insulin
action, which can lead to structural and functional alteration
of the myocardium. Cellular overload by fatty acids and calcium
also plays a crucial role by inducing insulin resistance, affecting
myocardial contractility and, in certain cases, causing cardiomyocyte death.11 Autonomic cardiac neuropathy, an early
complication of diabetes that is often present when the
disorder is diagnosed, can also alter the prognosis because
of its negative effect on diabetic patients’ heart function. In
fact, autonomic cardiac neuropathy is widely associated with
cardiovascular risk factors, including a higher prevalence of
hypertension, elevated triglycerides and LDL-cholesterol, and
decreased HDL-cholesterol.12 Autonomic cardiac neuropathy
is primarily related to impairment of the parasympathetic system.
This deficit can be responsible for permanent sinus tachycardia, the inability for the heart rate to adjust to stress and,
far less frequently, the risk of syncope or sudden death.
Other organs are also involved. Nephropathy is 10 to 13 times
more common in diabetics than in non-diabetics and is found
in 14% to 30% of diabetic patients.13 Although kidney problems
are more frequent in Type 1 diabetic patients, those with Type 2
are more numerous and thus account for the majority of cases.
Diabetic retinopathy is present in 40% of Type 2 diabetic patients
aged 40 and over.14 It is a predictor of coronary morbidity and
mortality in both Type 1 and Type 2 diabetics.15 In patients with
advanced diabetic retinopathy, cardiovascular disease was
the main cause of death in 55% of subjects.16
23
Cardiovascular risk factors identified in the general population
also apply to diabetic patients, especially Type 2 diabetic patients.
Hypertension is approximately twice as frequent in diabetics
as in non-diabetics and often precedes onset of the condition.17
Most Type 2 diabetes patients present with dyslipidemia several
years before diabetes is diagnosed. This is characterized by
increased levels of lipoproteins rich in triglycerides (VLDL and
LDL), increased plasma apolipoprotein B (an atherogenic lipoprotein concentration marker) and decreased HDL-cholesterol
levels. It is associated with an increased risk of cardiovascular
disease, even in the absence of other risk factors such as
hypertension and smoking.
In 2008, the Canadian Diabetes Association published guidelines on screening for coronary disease in diabetic patients.18
In practice, in addition to evaluating coronary risk in this type
of patient, a resting ECG should be administered to all diabetics
who 1) are 40 years of age or older, 2) have had diabetes for
more than 15 years, regardless of their age, or 3) present with
hypertension, proteinuria, decreased pulse intensity on physical
examination or a vascular murmur.
It should be understood that, together, these risk factors have
a cumulative effect and their reduction has a synergetic effect
on patients.19 Strict monitoring helps prevent the onset of
diabetes and cardiovascular disease and reduces mortality by
46% when compared with regular care.20
In conclusion, diabetes involves many systems and has a definite
effect on the daily practice of physicians in many medical and
surgical specialties. It goes without saying that prevention is
the key when dealing with this disabling, fatal pathology.
S
L
* The author is a cardiologist with the Institut universitaire de
cardiologie et de pneumologie de Québec and Associate
professor at the Faculty of Pharmacology, Université Laval.
References
Complete references for this article are available in page 41.
Does Diabetes Differ from Region to Region? Country to Country?
It would seem so. In Quebec, the prevalence of diabetes differs
from one administrative region to another. According to the data
issued by the Quebec Diabetes Surveillance Program (Programme
québécois de surveillance du diabète) for 2006-2007, the adjusted
average prevalence is 7.1% for people aged 20 and over. Four
regions are higher: Côte-Nord (8.7%), Gaspésie-Îles-de-laMadeleine (8.0%), Île de Montréal (7.5%) and Lanaudière (7.6%).
Prevalence of diabetes in people age 20-79, 2010
Four other regions have a similar prevalence: Abitibi-Témiscamingue (7.2%), Laurentides (7.0%), Laval (7.3%) and Montérégie
(7.2%). Six regions were below the average: Estrie (6.2%),
Mauricie et Centre-du-Québec (6.8%), Capitale-Nationale (6.4%),
Chaudière-Appalaches (6.5%), Saguenay Lac-Saint-Jean (6.4%)
and Bas-Saint-Laurent (5.9%). The adjusted prevalence of
diabetes for the population of Eeyou Istchee aged 20 and over
was 23.9% in 2006.
Elsewhere in the world, diabetes varies a great
deal in prevalence from one country to another.
According to regional data published by the
International Diabetes Federation, the rate is
highest in North America and the Caribbean
(10.2%), followed by the Middle East (9.3%). In
fact, six countries in the Middle East rank among
the Top Ten countries with the highest prevalence
of diabetes in the world: Bahrein, Egypt, Kuwait,
United Arab Emirates, Oman and Saudi Arabia.
Changes in lifestyle appear to be responsible for
this situation. The region with the lowest prevalence of diabetes is Africa (3.8%), despite a
significant rise in cases over the past decade.
All sources – diabetes surveillance, information
and research – agree that diabetes will increase
or even explode worldwide over the next 20 years.
24
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Nahla Aris-Jilwan, M.D.
Endocrinologist
Education and Diabetes Centres
Approximately 7% of the population of Canada has diabetes, or some 2 million people
(3 million, if we include those not yet diagnosed). The Canadian Diabetes Association
estimates this number will reach 3.7 million by 2020. At present, 90% of cases are Type 2
diabetes and the majority of these patients are obese. After age 60, one person in five will
become diabetic. We are thus dealing with a major health issue.
D
iabetes is a chronic illness. If it is poorly controlled,
it affects the quality of life of those with the
condition and increases the risk of microvascular
complications, retinopathy, nephropathy and
cardiovascular disease. Eighty percent will die
because of it.
Fortunately, studies have highlighted the importance of effective
preventive control, pointing to a 25% to 30% reduction in the
risk of microvascular complications for each 1% decrease in
glycosylated hemoglobin (A1C) and a 16% decrease in cardiovascular problems. Early control also helps prevention. A follow-up
of patients 10 years after the end of the United Kingdom
Prospective Diabetes Study (UKPDS),1 showed a reduction of
complications in the originally better controlled group versus
controls, in spite of a leveling of A1C hemoglobin.
The treatment of diabetes is complex. It involves a change in
dietary habits, regular physical activity, medication, monitoring
capillary blood glucose and visits to the doctor, in addition to
ophthalmology and possibly nephrology examinations. In addition,
the overall management of lipid levels and high blood pressure
is recommended to avoid cardiovascular complications.
It is therefore understandable that a diagnosis of diabetes often
disrupts patients’ lives and that they find it hard to make the
required changes. People with known diabetes can also find
themselves at a loss if they have not been fully informed.
In 1989, in the St. Vincent Declaration on diabetes mellitus,
diabetic patients’ right to education was recognized by the
International Diabetes Federation. Education about treatment
and training sessions are also recommended by various
diabetes associations. This approach focuses on patients’
treatment and makes them recognize that they are ultimately
responsible for managing their condition. Instead of taking control
of therapy as it would do in acute conditions, the medical team
guides patients so that they can make informed decisions
regarding their treatment.
From a historical perspective, Joslin published the first manual
on diabetes for patients and physicians in 1919. In the 1960s
and ‘70s, sporadic experiments demonstrated a link between
the onset of coma and the length of hospitalization. However,
26
in the following decades, a serious lack of knowledge and
abilities was still to be observed in 50% to 80% of diabetic
patients, with suboptimal control in most instances.
With such poor results, teaching methods needed to evolve.
Lectures gradually gave way to patient-oriented training
designed to encourage their active participation and empowerment. The emphasis was placed on mastering behaviour,
even if the training content had to be reduced. Learning methods
were based on concrete situations, problem-solving, role-playing,
games and questionnaires encouraging introspection and
participation. Allowing patients to express themselves was also
recommended, enabling them to construct and clarify their
thinking, as well as assimilate the training received.2
Exploring the emotional aspect of the disease and its treatment
can help find solutions and better motivate behavioural change.
According to Lacroix and Assal,2 analyzing behaviour in light
of emotions can serve as the basis for the modification goals
chosen by the patient. Taking into account the stages of
adjustment to chronic illness3 can help target the intervention
better, since patients’ listening skills can vary according to
where they are in the process. Another study, Prochaska's
transtheoretical approach,4 defines the five stages of change
and calls for specific interventions to facilitate action.
In 1987, in Quebec, the Ministère de la Santé allocated resources
to open up dedicated diabetes education centres. At that
time, the Royal Victoria Hospital was already providing training
and the Cité de la Santé in Laval had opened a diabetes
centre in 1984.
Today, Montreal's Agence de la santé et des services sociaux
organizes the management of chronically ill diabetics, integrating
various care lines so as to empower patients. There are diabetes
centres in hospitals, CLSCs, some clinics and pharmacies.
Various formats are used. Most centres provide training that
is individualized or for groups of four to ten persons, while
others combine group and individual training. Sessions are
held on consecutive days or spread out over time. Some centres
limit themselves to training while others, particularly in hospitals,
combine it with treatment. A few even offer follow-up after
the sessions.
The group formula has the advantage of being more economical
and reaches more people. However, it is more rigid when it
comes to scheduling and making it suitable for all participants;
there is also a lesser degree of confidentiality. The individual
format can be personalized more easily and adjusted to the
needs of people who have difficulty expressing themselves in
a group or who have scheduling conflicts with the group format.
It is also more suitable for more urgent cases.
Group training is estimated at 12 to 20 hours, while individual
training requires 8 to 12 hours. In his meta-analysis covering
Type 2 diabetic patients, Norris5 calculated a decrease of 0.04%
in A1C hemoglobin for Type 2 patients for each additional hour
of contact with the medical team. He extrapolated that
23.6 hours were required to lower A1C by 1%.
A team with at least one physician, one nurse and one nutritionist is responsible for therapeutic education. Other team
members could be a pharmacist, psychologist, social worker,
physical therapist, foot care specialist, etc. The team receives
training beforehand in behavioural psychology, group dynamics
and motivational techniques. Its members complement each
other, retaining their own expertise while keeping informed
about the other fields, and sharing information on each patient
and their goals. The team must also be able to provide psychosocial support to diabetic patients, their families, etc.
The coordinator is responsible for planning, implementing and
evaluating the program. A physician supervises the training
and is responsible for the treatment delivered. Relations are
established with the various medical specialties involved in
identifying and treating complications (ophthalmology, dermatology, cardiology, nephrology, neurology, etc.). Referrals are
mainly received from endocrinologists and general practitioners,
but other health specialists can also be involved.
All new diabetic patients should be referred to a diabetes centre.
Those already diagnosed are often referred for various reasons
such as additional training, especially with regard to diet, poorly
controlled diabetes (A1C > 7), hypoglycemia, a review of medication, the start of insulin therapy, poor adjustment to diabetes,
anxiety and lifestyle modifications.
Some centres separate Type 1 and Type 2 diabetics while
others welcome both. The advantages and disadvantages of
both practices have not really been studied. People with diabetes
are often encouraged to attend meetings accompanied by
someone close to them, as this type of support is known to
help with treatment compliance.
To be effective, teaching must be systematic, with course plans
covering all aspects of the illness and its management: what
diabetes is, prevention, complications, medication and adjustments, diet, exercise, hypo- and hyperglycemia, foot care,
special occasions (e.g. parties, restaurant meals, etc.),
psychosocial aspects and pregnancy. It must be adapted to
the individual patient, and measurable behavioural objectives
established jointly with the patient, based on their needs,
knowledge and possible problems.
TO BE EFFECTIVE, TEACHING MUST
BE SYSTEMATIC, WITH COURSE PLANS
COVERING ALL ASPECTS OF THE ILLNESS
AND ITS MANAGEMENT.
Assessing success in reaching objectives is recommended,
as well as repeated evaluations of the program itself to ensure
its quality. These must cover the biological, behavioural and
psychological changes in those taking part in the sessions.
Techniques for capillary blood glucose tests and insulin injections are taught on an individual basis through demonstration
and practice. A report is sent to the referring physician at the
end of the session and follow-up must be organized. In most
cases, patients are returned to the referring physician.
What is the impact of this education? It is difficult to draw
precise conclusions at this point, as the studies available are
often subject to methodology problems. It seems that a trained
group is four times less likely to present complications than
an untrained one. Only behavioural modification strategies
improve hemoglobin A1C levels. Education is more effective
when combined with medication adjustments by a physician.
Improvement is also seen in acute complications, hospitalization,
amputation, eating habits, and the frequency of capillary blood
glucose tests. Few studies have looked at the quality of life
for people with diabetes.
In conclusion, all diabetics are entitled to interactive treatment
education designed to change behaviour, adjusted to their
needs and delivered by a trained team, with regular follow-up
whenever possible and the appropriate medical intervention.
S
L
The urgency of the referral depends on the severity of the
symptoms, level of control and knowledge, survival skills and
the patient's psychological profile.
References
27
CONTINUING PROFESSIONAL
EDUCATION
SPECIAL COLLABORATION
MOREOB:
Safety-Driven Delivery of Care
Guy-Paul Gagné, M.D.
Obstetrician-Gynecologist
n December 2007, the Ministère de la Santé et des Services
sociaux (MSSS) approved the introduction of the MOREOB
Managing Obstetrical Risk Efficiently) Program in all
(M
obstetrical units in hospitals and birthing centres in
Quebec. The first training cycle of this three-year program
will end in 2013. It covers all health professionals working
in obstetrics: obstetricians-gynecologists, family physicians,
midwives and nurses.
I
Why the interest in MOREOB?
Experience gained over the last seven years in other Canadian
provinces has led us to conclude that the MOREOB program
allows hospital obstetric departments to reduce the number of
accidents, save more lives and reduce time and money spent,
while improving participating professionals’ quality of life!
The program makes use of the most recent andragogical and
risk management techniques. It goes beyond traditional training
by modifying attitudes and clinical practices. It is rooted in a
multidisciplinary core team that assumes leadership in risk
management. It is fully interdisciplinary: it breaks down the
barriers between professions and creates a new culture based
on community of practice, where safety is everyone's priority.
The new program was therefore aimed squarely at patient
safety, and it was expected that all other goals would be achieved
based on this core. The gamble was great, but experience
and program results tend to show in a hospital environment
what other industries, such as aviation, concluded a long time
ago: an organization that adopts safety as a guiding principle
will simultaneously develop excellence in its management and
in its cl inical results, two areas often thought of as bei ng in
conflict. The results were conclusive, to the point where the
methods and tools used in MOREOB can now be used in other
hospital specialties.
Based on the principles of high reliability organizations (HRO),
MOREOB resembles programs implemented in complex, interactive technical environments, where participants from all spheres
work together. These organizations carry out demanding
tasks, day after day, with catastrophic errors in their systems
occurring very rarely. The public therefore has very high expectations regarding their reliability.
A hospital unit has many of the features that characterize HROs,
except perhaps their high, consistent reliability. MOREOB
seeks to imprint the following HRO principles on the culture
of obstetrics units:
Context: patient safety
• Safety is the priority; everyone is responsible for it.
The program came into being because of the Society of
Obstetricians and Gynaecologists of Canada (SOGC) wanted
to examine the increase in the risk of professional liability lawsuits
and also the expected critical lack of human obstetrical
resources. The practice of obstetrics was considered increasingly stressful and became less popular among the health
professionals concerned. An innovative program was therefore
needed to improve quality of care, reduce the risk of adverse
events and improve quality of life at work, as well as the retention
and recruitment of personnel.
• Communication is of the utmost importance.
MOREOB was developed as a response to the Institute of Medicine
report,1 whose conclusions were confirmed in the Baker
Norton report,2 i.e. that adverse events in the context of health
care continue to be a serious problem having a considerable
negative effect on patients, health care providers, governments
and society.
28
• Activities are a team effort.
• Emergencies are rehearsed.
• The chain of command disappears when there is an emergency.
• Current practices and events are submitted to multidisciplinary analysis.
The culture of blame that reigns at present when analyzing
events affecting patients is recognized as one of the main
obstacles to improving safety. MOREOB places the emphasis
on identifying the fundamental cause rather than attribute blame.
Proven results
In Quebec, 41 hospitals and 7 birthing centres are now taking
part in the program. Training in all 65 hospitals is expected to
have begun by the end of 2010. At the Canadian level, MOREOB
has produced the following statistically significant, results:4
Health Insurance Reciprocal of Canada
Costs
incurred
from
2000
!toto2008
Costs
incurred
from
2000
2008
39 hospitals participating in the program since 2002
$35,000,000
• Fewer admissions to intensive care; fewer babies on
ventilators; fewer cases of serious disability (including respiratory distress, septicemia, traumatic or non-traumatic
intracranial hemorrhage); fewer lacerations and shorter
maternal stays. A greater proportion of high-risk deliveries
transferred to an appropriate centre.
$30,000,000
• A reduction in the overall cost of benefit expenses and the
average cost per hospital insurance claim (figures 1 and 2)
in 39 hospitals which began the program in 2002.
$5,000,000
• Improvement and maintenance of obstetrical knowledge
of participants from all disciplines, as well as of the culture
of safety in care units.5
A survey6 also indicates that 86% of participants would
recommend the program to others; 82% agree that it
increases their professional satisfaction, and 68% say that
work-related stress has been reduced.
––––– Obstetric
––––– !"#$%&'&%$()*%&
Others
' services
$25,000,000
$20,000,000
$15,000,000
$10,000,000
$Year of loss
Fig. 1
Source: Health Insurance Reciprocal of Canada (HIROC)
Health Insurance Reciprocal of Canada
Average
costper
perclaim
claim:
2000
to 2008
Average
cost
from
2000
to 2008
39 hospitals participating in the program since 2002
$350,000
$300,000
MOREOB creates a new care model by dismantling traditional
structures and practices, emphasizing teamwork and the
creation of communities of practice. Results show that clinic
governance centered on safety is both profitable and effective
in improving clinical results. MOREOB leads not only to a
reduction in the incidence of adverse events but also to a
more rational use of resources. This model’s popularity with
professionals and managers augurs well for the future, and
also its transposition to other areas of hospital activity.
+,&#-#$)."%
–––––
Obstetric
!"#$%&'&%$()*%&
–––––
Others services
$250,000
$200,000
P = 0.01
$150,000
$100,000
$50,000
$-
Fig. 2
Year of loss
Source: Health Insurance Reciprocal of Canada (HIROC)
The process is based on studying the systems in question, understanding how events originated, sharing results and formulating
recommendations to the appropriate levels of the organization.
Program structure
A multidisciplinary core team is chosen by the members of
each hospital's unit to direct and support the implementation
and maintenance of the program, as needed. Specific on-site
training is given at the beginning of each of the three modules
by a team of certified interprofessional facilitators. A consultant
is then given the responsibility of providing ongoing support
to the team during implementation of the program.
Module 1 Learning together emphasizes group learning and
the creation of a common evidence-based pool of knowledge.
Practical exercises on basic skills are organized. The objective
is to improve confidence, respect and interprofessional communication. Module 2 Working together carries on from module 1
and includes tools for communication, teamwork, practice review
and emergency exercises. Module 3 Modifying the culture deals
with the creation and maintenance of a culture of patient safety.
Events are analyzed in an interdisciplinary manner, with standard
tools. The accent is on establishing communities of practice.3
S
L
References
29
IN THE WORLD OF MEDICINE
SPECIAL COLLABORATION
21st-Century Cardiology
The Remote Monitoring of Pacemakers
Bernard Thibault, M.D.*
n October 22, 2009, for the very first time in Canada,
a team of electrophysiologists at the Montreal Heart
Institute installed a new type of pacemaker that,
with the help of an external terminal, has wireless
communication capability. We have just crossed a
barrier, and the results could be very positive for
patients. It is now possible to get information from the pacemaker
while the patient remains at home. This technology has so far
been available only for defibrillators. It will now be possible to
provide it to the much larger number of patients who need
a pacemaker.
O
The advantages of this new technology are undeniable when
we remember that these devices are implanted in elderly or
disabled patients. In the 21st century, it is obviously preferable
to move information rather than patients. Over the years, pacemakers have become ultrasophisticated and capable of detecting
significant conditions that might have serious or even fatal consequences, such as the imminent failure of one of the components
of the stimulation system, or the presence of asymptomatic
cardiac fibrillation. Manufacturers of these devices generally
recommend patient follow-up every three months. However,
overcrowded clinics often make it impossible to abide by such
recommendations, and appointments are very often scheduled
every six or twelve months.
With this new type of pacemaker, patients are equipped with a
communications terminal (a modem) that they install in their
bedrooms. The terminal queries the pacemaker on a regular
basis (daily, weekly or monthly programming) and sends the
information to a dedicated, secure Internet site. If there are no
problems, the information is then sent on (also programmed)
to the clinic in charge. Alarm situations can also be programmed,
in which case the information is transmitted on an immediate
and urgent basis. The advantages for patients are obvious: they
no longer have to travel and then wait for a routine check-up
and, from the point of view of safety, the initial signs of impending
problems can be identified. For example, the gradual failure of
a lead can be determined through variations in its resistance to
electrical current before it becomes total. Another advantage is
when the pacemaker battery nears the end of its useful life.
When the voltage begins to decline, the battery often has another
9 to 18 months before it runs out completely. Visits are routinely
increased to every two or three months during this period.
30
It is easy to understand the advantages of this wireless technology for elderly patients or those with reduced mobility. But this
approach does carry a certain risk: missing or postponing an
appointment could be harmful, particularly for patients who are
completely dependent on their pacemaker. The safest attitude
is to change the device more frequently, which generates a
certain degree of wastage. With remote monitoring, battery voltage
can be checked daily, making it possible to maximize the useful
life of the pacemaker without risking the health of patients or
further overloading our clinics.
Every technological advance has its limits and drawbacks. Wireless
communication systems are efficient and information is dealt
with confidentially and securely, but there will undoubtedly be
some unforeseen “bugs”. While the effort required on the part
of patients is minimal, the situation will probably be quite different
in the specialized clinics that will have to handle a heavier workload.
In fact, the advantage of seeing fewer patients in person is counterbalanced by the mass of information to be analyzed (we follow
more than 5,000 patients each year!). Procedures to deal with
all this “new” information and allow communication with patients
still need to be developed. At present, the resources allocated
are inadequate. The lower costs realized because of the
reduction in the number of visits and maximization of the useful
life of pacemakers must therefore offset the cost of processing
the information generated. Finally, as with all new technologies,
purchase costs are higher (for the pacemaker and the transmission terminal). Once again, we will need to develop specific
strategies, set priorities and, at least at the beginning, establish
criteria for selecting patients who could benefit from this technology, when and for how long. Even without a crystal ball, it is
easy to foresee that access to this technology is the way of the
future, especially in the context of Quebec: the vast territory to
be covered, the limited number of specialized clinics, and a
climate known for its unpredictability. Since telemedicine is a
priority for our decision-makers, this advance could not have
come at a better time.
S
L
* The author is a cardiologist and electrophysiologist at the Montreal
Heart Institute and a professor at Université de Montréal.
GREAT NAMES IN QUEBEC MEDICINE
Patricia Kéroack
COMMUNICATION CONSULTANT
Dr. Phil Gold and the Discovery that
Revolutionized Our Knowledge of Cancer
ith his velvety voice and consummate charm,
Doctor Gold starts off the interview with
some light banter, playing with words. I am
completely captivated as I get to know this
Titan who literally revolutionized our knowledge
of cancer. But he will try to convince me that
his contribution is one infinitesimal drop in the ocean of science
today. In 1965, Dr. Gold, together with Dr. Samuel O. Freedman,
discovered a human tumor marker in blood tests, the carcinoembryonic antigen (CEA), that is still commonly used today to
diagnose the onset or recurrence of cancer.
W
In April, Dr. Gold will be inducted into the Canadian Medical Hall
of Fame, taking his place alongside famous physicians like Doctors
Banting, Best, Bethune, Penfield and Selye. Is he pleased with
this nomination? Absolutely. “Everything happened so fast. I didn't
even know I had been nominated. Then, one day the phone
rang and that's how I found out. It's unbelievable. I am very
flattered my colleagues thought of me and showed their appreciation in this fashion”.
Who would have thought that the doctoral student in physiology would turn to medicine? His mentor, Sir Arnold SV Burgen
invited him to round off his training on the more “human” side
of science. But the change was short-lived. After graduating,
he left his residency and, within two years, had received a doctorate
for his thesis on the role of CEA in digestion. His mentor did not
think he would continue working in oncology; in his view, the
young Gold had a much brighter future elsewhere. But, Dr. Gold
persisted and continued both the work he had undertaken and
his interrupted medical training. By chance, a colleague and
friend, Dr. Freedman, had a laboratory. Since Dr. Gold had an
idea and wanted to pursue his research, they would work together
on expanding their knowledge of a glycoprotein.
Why the interest in CEA? Two specialized speeches marked
Dr. Gold and awoke his desire to further his knowledge on the
subject. The first speaker said that, up to that point, researchers
couldn’t see any difference between healthy and cancerous
cells. And yet, cancerous cells were inevitably fatal for the individual affected. Dr. Gold remained skeptical; according to him,
there had to be a difference somewhere. He then attended the
second conference, which discussed a surprising concept:
immunological tolerance. According to this concept, long before
our birth, we already have an identity map which enables our
body to rapidly identify an attack or an external addition (a graft,
for example). Dr. Gold found this interesting, but an important
factor seemed to be missing. According to this
concept, our body eventually develops a tolerance
for its own immunity, without which we would
all become intolerant to our “self” and develop
autoimmune diseases... even going as far as auto- Dr. Phil Gold
rejection. The tolerance acquired by our cells was
the premise that led to the discovery of CEA. Using immunology
technologies, Dr. Gold continued to check the identity map at
various stages during life, from conception to death.
Today, the CEA test is widely used for diagnosing and following
up cancer patients. “Our research, which was spread over a
long period of time, was first published 45 years ago in the
Journal of Experimental Medicine. Had we had access to today's
technologies and knowledge, we could have reached the same
point in a fraction of the time. But, what we did, we did with
indescribable joy.”
Dr. Gold is a tireless worker but, above all else, he loves his
work. According to him, a real passion for work starts with attitude.
If your head or your heart isn’t in it, you’re wasting your time.
Dr. Gold could have worked in medical oncology. “Although my
work dealt with oncology, my clinical career focused on allergies
and clinical immunology... as I think I know a couple of things
about immunology!” His clinical career was punctuated by research,
as well as teaching and management. His alma mater, McGill
University, which he only left for two short years to complete
his training at the New York Public Health Research Institute,
created the McGill Cancer Centre in 1978. This was the very
first oncology teaching department in North America and
Dr. Gold was its first director. Afterwards, he filled other management positions, in particular at the Montreal General Hospital,
where he was Physician-in-Chief, then Director of the Department
of Medicine at McGill University. Today, he is Executive Director
of the Clinical Research Centre of the McGill University Health
Centre's Research Institute.
The recipient of numerous awards, distinctions and honorary
diplomas, Dr. Gold is also a Companion of the Order of Canada
and an Officer of the Ordre national du Québec. Invited to speak
and teach in numerous universities, Dr. Gold is still carrying on
his professional activities at age 73 and is in love with his work
as much as ever.
S
L
31
PUBLICITÉ
SECTION
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professionnels
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À l’@ffût
Bulletin électronique
Vous voulez rejoindre
les médecins
spécialistes
du Québec ?
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www.sogemec.qc.ca
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SERVICES IMMOBILIERS RÉSIDENTIELS (VENTE OU LOCATION)
514 816-6447
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Un simple coup de fil : 514 350-5274
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La Personnelle
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Demandez notre carte
des tarifs dès maintenant :
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COURTIER AUTOMOBILES ET CAMIONS
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ABONNEMENTS
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Park’n Fly
Service de stationnement
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Pour tout savoir sur les avantages commerciaux
réservés aux membres de la FMSQ,
visitez le www.fmsq.org/services
GROUPE FONDS DES PROFESSIONNELS
France Leclerc
TAX SPECIALIST AND FINANCIAL PLANNER
A Tax Medley
ll taxpayers want to reduce their tax burden. Whether
you are younger or older, tax will always be an
important subject. This article gives an overview
of our tax system, and credits that allow you to
reduce the amount you pay. In Quebec, personal
tax rates are incremental: in other words, the more
you earn, the more tax you pay. You can see this from the
following table:
A
Tax Bracket
Income Tax
Capital
Gains
Fixed
Dividend1
Ordinary
Dividend2
$10,382 - $38,570
28,53%
14,26%
5,90%
11,74%
$38,570 - $40,970
32,53%
16,26%
11,66%
16,74%
$40,970 - $77,140
38,37%
19,19%
16,47%
24,05%
$77,140 - $81,941
42,37%
21,19%
22,23%
29,05%
$81,941 - $127,021
45,71%
22,86%
27,04%
33,22%
$127,021 and over
48,22%
24,11%
30,65%
36,35%
2. RRSP (Registered Retirement Savings Plan)
Paying into your RRSP or that of your spouse can reduce your
tax bill for the contribution year and defer it until your
retirement. If your tax bracket is lower at that point, you will
save on the tax. The maximum annual contribution to an RRSP
is equal to 18% of the income earned the previous year (to a
maximum of $22,000 in 2010), in addition to any unused
RRSP room.
3. TFSA (Tax-Free Savings Account)
If you contribute to this new account, you can accumulate
amounts without generating tax. The maximum annual contribution is $5,000 for 2010, regardless of earned income.
4. Life insurance
Some life-insurance policies allow you to accumulate money
that is sheltered from tax.
5. Student loan
1
Dividends paid by public corporations, by CCPCs from income
(other than investment income) that is not eligible for the small business
deduction (SBD), and by the other corporations resident in Canada with
income taxable at the general corporate rate.
2
Dividends paid by Canadian-controlled private corporations (CCPC)
from income eligible for the SBD or investment income (other than fixed
dividends paid by public corporations).
Following are a few ways to help you reduce your tax bill.
You should note that this list is not exhaustive and certain
strategies may not be compatible with your situation.
Remember that our Members’ Consultants can analyze your
financial status and suggest specific strategies to meet your
own particular needs.
1. Segregating funds
This strategy consists in converting non-tax-deductible loan
interest into deductible interest.
Interest on this type of loan can generate a tax credit. It is
therefore preferable for you to pay back other loans before
your student loan. In addition, at the federal level, interest paid
can be deferred for up to five years, while in Quebec it can be
deferred indefinitely. If you pay little or no tax in a given year,
it would be better to declare interest payments for that year
in a later year when your tax will be higher.
6. Child care costs
Based on certain criteria, it is possible to reduce your tax if
you have paid child care costs with respect to your children.
7. Buying a first home
The federal government now allows a non-refundable tax credit
(15% of $5,000) on the purchase of a first home.
8. Incorporation
Incorporation as a professional can be beneficial from a tax
point of view, in certain situations.
Some of the above strategies can be relatively complicated.
We therefore recommend you consult specialists in this field.
Members’ Consultants at Groupe Fonds des professionnels
know your situation and your concerns. They also have access
to a specialized financial planning team, which includes a
tax expert.
33
Chantal Aubin
SOGEMEC ASSURANCES
DIRECTRICE
ADMINISTRATION DES RÉGIMES
Are You Planning on Driving Outside the Province?
Make Sure You’re Fully Protected
very year, many Quebecers use their summer
vacations to travel to another Canadian province or
to the United States. Are you one of them? Before
setting off, make sure that you have the proper
coverage because the laws outside Quebec are
different to ours, particularly with respect to car
insurance and civil liability coverage.
E
In the United States and also most other Canadian provinces,
bodily injury caused to someone else as a result of a highway
accident is not covered by a government agency (as is the
case in Quebec with the SAAQ). In addition, if an accident
occurs outside Quebec, the victims have the right to take legal
action against you.
So, if you are held responsible for an accident and have damaged
someone else’s property or caused bodily injury to a third party,
you could be facing a costly lawsuit. But, take heart! Your civil
liability insurance would protect you in such a situation!
The best way to make sure you are fully
covered
Contact your insurers before you drive to the United States or
another Canadian province. They will point you towards the
coverage that best meets your needs so that you are completely
protected while away from home.
Some automobile insurance companies, including The Personal,
give you an opportunity to increase your coverage up to $5 million.
A simple telephone call to your agent or broker will enable you
to select the appropriate amount and save yourself a lot of
worry if there is an accident!
What does your car civil liability cover
in Quebec?
If an accident occurs in Quebec, your civil liability insurance
covers you for damage you may cause to someone else’s
property, such as a fence, house, hydro pole, etc.
If your car insurance is with Sogemec/The Personal Insurance
Co., contact an agent at 1-866-350-8282, Monday to Friday,
8 a.m. to 8 p.m. and, on Saturdays, from 8 a.m. to 4 p.m.
Do you plan on renting a car while you
are away?
The Quebec Automobile Insurance Act requires that anyone
owing a vehicle must hold civil liability insurance of at least
$50,000. However, most insurers give a higher amount. This
is the case with Sogemec Assurance’s automobile/home/
business group insurance company, The Personal Insurance
Co., which covers you for $2 million, providing you with good
protection should an accident occur.
Make sure that your automobile insurance includes Rider #27
which covers damage caused to a vehicle rented in Canada
or the United States.
Is your civil liability coverage effective
outside Quebec?
Have a great vacation!
The civil liability insurance you have with your private insurer
in Quebec covers you elsewhere in Canada or in the United
States for a period of up to 180 days per year. However, it is
important to make sure that you have sufficient coverage.
34
If you plan on renting a car elsewhere in the world, get information from one of our agents about our “umbrella” protection which
will provide you with worldwide automobile insurance coverage.
Sogemec Assurances has chosen The Personal Insurance
Company to provide top-quality automobile/home/ business
insurance. For a quotation, please contact an agent at
1-866-350-8282 or visit sogemec.lapersonnelle.com.
SOGEMEC ASSURANCES
Maurice Giroux
GENERAL DIRECTOR
A New Address – The Same Preference Service
S
ince January 18, the Sogemec Assurances team
has taken pleasure in welcoming you to its new
contemporary offices, located on the 20th Floor of
the East Tower at Complexe Desjardins. Only our
address has changed: our telephone and fax
numbers remain the same.
Preference Service
At Sogemec Assurances, PREFERENCE SERVICE is a commitment to excellence by our team of consultants and Customer
Service Department.
• Outstanding personalized service.
• No computer call system or voice mail, without your
agreement.
• Your questions answered within 24 hours.
• Individual step-by-step processing of your claims.
• Consultants who keep abreast of the very latest
developments.
POUR TOUS VOS
BESOINS D’ASSURANCES
Sogemec Assurances, a
subsidiary of the Fédération
des médecins spécialistes
du Québec, was created
by and for physicians. Your
insurance needs change
along with your lifestyle
and needs. We remain
available throughout your
career to make sure that you enjoy the most recent products
to suit your requirements. For instance, we provide a unique
disability insurance plan that includes: the protection of your
own profession” should you become disabled, benefits l asting
“o
5 ye ars longer than those offered by the competition, a UNIQUE
pre sumed total d isa bility clause for surgic al spec ialtie s if you
suffer t he pe rmane nt loss of one hand.
Our consultants are available to answer all your insurance
questions in our new offices or at your home.
Grâce au
SERVICE PRÉFÉRENCE
SOGEMEC ASSURANCES
ÉVOLUE AVEC VOUS
Avec le SERVICE PRÉFÉRENCE de
Sogemec Assurances, toutes vos
assurances sont pensées en fonction
de votre style de vie et de vos besoins.
POUR EN SAVOIR PLUS :
1 800 361-5303 / 514 350-5070 / 418 658-4244
Par courriel ou Internet :
[email protected] / www.sogemec.qc.ca
SOGEMEC ASSURANCES
filiale de la
35
RÉSUMÉ DES RENSEIGNEMENTS POSOLOGIQUES
CRITÈRES DE SÉLECTION DES PATIENTS
CLASSE THÉRAPEUTIQUE : Régulateur du métabolisme des lipides
INDICATIONS ET USAGE CLINIQUE
Hypercholestérolémie
LIPITOR MD (atorvastatine calcique) est indiqué comme adjuvant aux changements du mode de vie, y
compris l’adoption d’une diète, pour réduire les taux trop élevés de CT, de C-LDL, de triglycérides
et d’apolipoprotéine B (apo B) dans les cas d’hyperlipidémie et de dyslipidémie, lorsque la réponse
au régime alimentaire et à d’autres interventions non médicamenteuses n’est pas satisfaisante. En
présence d’hypercholestérolémie familiale homozygote, LIPITOR devrait être utilisé comme adjuvant à
des traitements tels que l’aphérèse des LDL, ou en monothérapie si on ne peut avoir recours à ce type de
traitement; comme adjuvant à une diète, afin de réduire les taux de CT, de C-LDL et d’apolipoprotéine B
chez les garçons et les filles (après l’apparition des premières règles) de 10 à 17 ans atteints
d’hypercholestérolémie familiale hétérozygote si, après l’essai d’une diète, le taux de C-LDL demeure :
a. ≥ 4,9 mmol/L (190 mg/dL); ou
b. ≥ 4,1 mmol/L (160 mg/dL) en présence de l’un ou l’autre des éléments suivants :
sANTÏCÏDENTSFAMILIAUXDEMALADIECARDIOVASCULAIREPRÏCOCE
sAUMOINSDEUXAUTRESFACTEURSDERISQUECARDIOVASCULAIRECHEZLENFANT
LIPITOR fait aussi augmenter le taux de cholestérol HDL et, ce faisant, diminue les rapports C-LDL/C-HDL
et CT/C-HDL chez les patients atteints d’hypercholestérolémie primitive ou d’hyperlipidémie combinée
(mixte). Selon les données compilées à partir de 24 essais cliniques comparatifs, LIPITOR a fait augmenter
le taux de C-HDL de 5 à 7 % chez des patients atteints d’hypercholestérolémie primitive et de 10 à 15 %
chez des patients atteints de dyslipidémie combinée.
Prévention de la maladie cardiovasculaire
s,)0)4/2ESTINDIQUÏPOURRÏDUIRELERISQUEDINFARCTUSDUMYOCARDECHEZLADULTEHYPERTENDUNACCUSANT
aucun signe clinique de maladie coronarienne, mais présentant au moins 3 autres facteurs de risque
coronarien, notamment : âge égal ou supérieur à 55 ans, sexe masculin, tabagisme, diabète de type 2,
hypertrophie ventriculaire gauche, certaines anomalies de l’ECG, microalbuminurie ou protéinurie,
rapport CT/C-HDL égal ou supérieur à 6 et antécédents familiaux de maladie coronarienne précoce.
s,)0)4/2 EST AUSSI INDIQUÏ POUR RÏDUIRE LE RISQUE DINFARCTUS DU MYOCARDE ET DACCIDENT VASCULAIRE
cérébral (AVC) chez l’adulte atteint de diabète de type 2 et d’hypertension n’accusant aucun signe
clinique de maladie coronarienne, mais présentant d’autres facteurs de risque, notamment : âge égal
ou supérieur à 55 ans, rétinopathie, albuminurie ou tabagisme.
s,)0)4/2ESTINDIQUÏPOURRÏDUIRELERISQUEDINFARCTUSDUMYOCARDECHEZLESPATIENTSPRÏSENTANTDES
signes cliniques de maladie coronarienne.
CONTRE-INDICATIONS
Hypersensibilité à un des composants du produit (pour connaître la liste complète des ingrédients, voir
la monographie). Hépatopathie évolutive ou élévations persistantes inexpliquées du taux sérique de
transaminases dépassant 3 fois la limite supérieure de la normale.
L’utilisation de LIPITOR au cours de la grossesse n’a pas été documentée. LIPITOR ne devrait être
administré aux femmes en âge de procréer que si les probabilités de conception sont extrêmement
faibles et après qu’on ait informé ces femmes des risques du traitement. Si une patiente tombe enceinte
pendant le traitement par LIPITOR, il faut cesser l’administration du médicament et avertir la patiente des
risques auxquels le fœtus est exposé.
Chez la rate, les concentrations d’atorvastatine dans le lait sont comparables à celles du produit dans
le plasma. On ignore si le produit est excrété dans le lait chez la femme. Étant donné le risque d’effets
indésirables chez le nouveau-né, les femmes qui prennent LIPITOR ne doivent pas allaiter.
RENSEIGNEMENTS RELATIFS À L’INNOCUITÉ
MISES EN GARDE
Effets musculaires : De très rares cas de rhabdomyolyse associée à une insuffisance rénale aiguë
consécutive à une myoglobinurie ont été signalés en rapport avec LIPITOR et d’autres inhibiteurs
de l’HMG-CoA réductase.
Effets hépatiques : Si l’augmentation des taux d’alanine aminotransférase (ALAT) ou d’aspartate
aminotransférase (ASAT) montre des signes de progression, notamment en cas d’augmentation
persistante à plus de 3 fois la limite supérieure de la normale, il faut réduire la dose de médicament
ou cesser le traitement. À l’instar d’autres inhibiteurs de l’HMG-CoA réductase, LIPITOR doit être
utilisé avec précaution chez les patients qui consomment de l’alcool en quantités substantielles
et/ou qui ont des antécédents de maladie du foie. La fonction hépatique doit être évaluée avant
l’amorce du traitement et à intervalles réguliers par la suite.
PRÉCAUTIONS
Avant d’instaurer un traitement par LIPITOR, il faut essayer de maîtriser l’hyperlipoprotéinémie à l’aide
d’un régime alimentaire approprié, d’exercice physique et d’une réduction pondérale chez les patients qui
ont un excès de poids, et de traiter, s’il y a lieu, les autres troubles médicaux sous-jacents.
La prudence est de mise chez les patients atteints d’hypercholestérolémie grave qui présentent
aussi une insuffisance rénale grave, qui sont âgés ou qui suivent un traitement concomitant par
la digoxine ou des inhibiteurs de la CYP 3A4.
Utilisation chez la femme enceinte : LIPITOR est contre-indiqué au cours de la grossesse.
Pour obtenir de l’information additionnelle sur les mises en garde et les précautions, consulter la
rubrique Renseignements supplémentaires sur le produit.
EFFETS INDÉSIRABLES
LIPITOR est généralement bien toléré. Les effets indésirables ont habituellement été légers et transitoires.
Au cours des études cliniques comparatives (avec placebo et avec d’autres hypolipidémiants) menées
auprès de 2 502 patients, le traitement a dû être interrompu chez moins de 2 % des patients en raison
d’effets indésirables attribuables à LIPITOR. Sur ces 2 502 patients, 1 721 ont été traités pendant au
moins 6 mois, et 1 253, pendant 1 an ou plus.
Les effets indésirables qui sont survenus à une fréquence supérieure ou égale à 1 % chez les participants
aux études cliniques sur LIPITOR comparatives avec placebo et dont le lien avec le traitement était
possible, probable ou certain sont les suivants : constipation, diarrhée, dyspepsie, flatulence, nausée,
céphalées, douleurs, myalgie et asthénie.
Pour déclarer un effet indésirable, composer le 1-866-234-2345.
ADMINISTRATION
POSOLOGIE ET ADMINISTRATION
Hypercholestérolémie primitive et dyslipidémie combinée (mixte), y compris l’hyperlipidémie
familiale combinée : La dose initiale recommandée de LIPITOR est de 10 ou de 20 mg, 1 fois par jour,
selon la réduction du taux de C-LDL que l’on souhaite obtenir. Chez les patients ayant besoin d’une forte
réduction du taux de C-LDL (supérieure à 45 %), le traitement peut être amorcé à la dose de 40 mg, 1 fois
par jour. La dose maximale est de 80 mg par jour.
Dyslipidémies graves : Il peut être nécessaire d’administrer LIPITOR à des doses plus élevées (jusqu’à
80 mg/jour).
Hypercholestérolémie familiale hétérozygote chez les enfants (de 10 à 17 ans) : La posologie
initiale recommandée de LIPITOR est de 10 mg par jour, et la posologie maximale recommandée est de
20 mg par jour.
Prévention de la maladie cardiovasculaire : Pour la prévention secondaire de l’infarctus du myocarde,
la posologie optimale va de 10 à 80 mg d’atorvastatine, 1 f.p.j.
RÉFÉRENCE DE L’ÉTUDE
1. Friedewald WT et al. Clin Chem 1972;18(6):489-502.
RENSEIGNEMENTS SUPPLÉMENTAIRES SUR LE PRODUIT
MISES EN GARDE ET PRÉCAUTIONS
Veuillez consulter la monographie de LIPITOR pour connaître les mises en garde relatives aux aspects suivants : interactions
pharmacocinétiques; effets musculaires (particulièrement myalgie, myopathie et, dans de très rares cas, rhabdomyolyse);
augmentation des taux sériques de transaminases; augmentation des taux de Lp(a); augmentation de la concentration
plasmatique d’atorvastatine chez les patients hypercholestérolémiques traités aux doses élevées; dysfonctionnement
endocrinien; effets hépatiques (y compris l’administration aux patients dont la fonction hépatique peut être compromise);
administration aux patients ayant des antécédents d’insuffisance rénale; syndrome d’hypersensibilité.
POPULATIONS PARTICULIÈRES
Utilisation chez l’enfant : On a évalué l’innocuité et l’efficacité de LIPITOR chez des patients de 10 à 17 ans (n = 140)
atteints d’hypercholestérolémie familiale hétérozygote dans le cadre d’un essai comparatif de 6 mois mené auprès
de garçons adolescents et de filles ayant déjà eu leurs premières règles. Dans l’ensemble, les marges d’innocuité et
de tolérabilité observées étaient semblables dans le groupe traité par LIPITOR et dans le groupe placebo. Les doses
supérieures à 20 mg n’ont pas été étudiées chez cette population de patients.
LIPITOR n’a eu aucun effet sur la croissance et la maturation sexuelle des garçons ou des filles. Les effets du médicament
sur le cycle menstruel n’ont pas été évalués.
Il importe de recommander une méthode contraceptive efficace aux adolescentes qui prennent LIPITOR.
On a évalué pendant 1 an le traitement par LIPITOR, à une posologie allant jusqu’à 80 mg/jour, auprès de 8 enfants atteints
d’hypercholestérolémie familiale homozygote.
L’innocuité et l’efficacité de LIPITOR chez l’enfant n’ont pas été déterminées en contexte de prévention de l’infarctus du
myocarde.
Utilisation chez la personne âgée : D’après les données cliniques accumulées auprès d’adultes âgés de 70 ans ou
plus (n = 221) avec des doses de LIPITOR pouvant atteindre 80 mg par jour, l’innocuité et l’efficacité de l’atorvastatine
chez cette population seraient comparables à celles observées chez les patients âgés de moins de 70 ans. L’évaluation
pharmacocinétique de l’atorvastatine chez les patients de plus de 65 ans indique une augmentation de l’ASC. Par mesure
de précaution, il faut administrer au départ la dose la plus faible.
Les patients âgés peuvent être plus prédisposés à la myopathie.
Insuffisance rénale : Les concentrations plasmatiques de LIPITOR et l’efficacité de ce médicament dans la réduction du
taux de C-LDL chez les patients atteints d’insuffisance rénale modérée sont comparables à celles qui ont été observées
chez les patients dont la fonction rénale est normale. Cependant, comme plusieurs cas de rhabdomyolyse ont été rapportés
chez des patients ayant des antécédents d’insuffisance rénale de gravité inconnue, il faut administrer la dose la plus faible
de LIPITOR (10 mg par jour) à ces patients, par mesure de précaution et jusqu’à ce que de plus amples essais soient
effectués en présence de maladie rénale. Il est recommandé d’administrer avec prudence la dose la plus faible chez les
patients atteints d’insuffisance rénale grave (clairance de la créatinine < 30 mL/min [< 0,5 mL/s]).
INTERACTIONS MÉDICAMENTEUSES
L’atorvastatine est métabolisée par l’isoenzyme 3A4 du cytochrome P450. L’administration concomitante d’inhibiteurs
de la CYP 3A4, comme certains antibiotiques macrolides (y compris l’érythromycine et la clarithromycine), les
immunosuppresseurs (cyclosporine), les antifongiques azolés (c.-à-d. itraconazole, kétoconazole), les inhibiteurs de
la protéase ou l’antidépresseur néfazodone, risque d’augmenter les concentrations plasmatiques des inhibiteurs de
l’HMG-CoA réductase, y compris LIPITOR. La prudence est de mise lors de l’administration concomitante de ces agents.
L’administration concomitante d’atorvastatine et d’un inducteur de l’isoenzyme 3A4 du cytochrome P450 (p. ex., l’éfavirenz
ou la rifampine) peut entraîner des baisses variables des concentrations plasmatiques d’atorvastatine. Pour obtenir les
renseignements complets sur les interactions médicamenteuses établies ou possibles et sur les interactions
médicament-aliment, consulter la monographie.
Selon les rapports de pharmacovigilance, le gemfibrozil, le fénofibrate, d’autres fibrates ainsi que la niacine (acide
nicotinique) administrée à des doses hypolipidémiantes peuvent accroître le risque de myopathie lorsqu’ils sont administrés
en concomitance avec des inhibiteurs de l’HMG-CoA réductase, probablement parce qu’ils peuvent provoquer une
myopathie en monothérapie. Par conséquent, ce genre de traitement d’association doit être entrepris avec prudence.
L’administration concomitante de jus de pamplemousse risque d’augmenter les concentrations plasmatiques des inhibiteurs
de l’HMG-CoA réductase, y compris LIPITOR. Une consommation équivalant à 1,2 litre par jour a donné lieu à une ASC de
l’atorvastatine 2,5 fois plus élevée.
SURDOSAGE
Il n’existe pas de traitement spécifique pour le surdosage par l’atorvastatine. En cas de surdosage, administrer un traitement
symptomatique et les mesures de soutien nécessaires. Étant donné la forte capacité de liaison de l’atorvastatine aux
protéines plasmatiques, l’hémodialyse ne devrait pas augmenter sa clairance de manière significative.
FORMES POSOLOGIQUES
LIPITOR (atorvastatine calcique) est offert en comprimés dosés à 10, 20, 40 et 80 mg.
Pour obtenir la monographie de LIPITOR, composez le 1-800-463-6001 ou rendez-vous sur le site www.pfizer.ca
MOT DU PRÉSIDENT
DR GAÉTAN BARRETTE
Une campagne qui dérange
ous avez certainement vu notre campagne télé,
et peut-être même visité le microsite Internet
lexpertiseaunprix.com (expertisehasaprice.com). Une
campagne différente, audacieuse même, dont
l’objectif était de susciter le débat public. C’est mission
accomplie ! Nous savions bien que tout le monde ne
serait pas d’accord avec nous. C’est confirmé ! Mais, comme l’a
dit un auteur célèbre, ce n’est pas parce que les choses sont
difficiles qu’on ne les fait pas.
V
docteurs. Il faut savoir qu’au Québec, quand on détient une expertise
professionnelle et que l’on est rémunéré à l’intérieur du secteur
public, les écarts sont systématiquement significatifs par rapport
aux principaux indices de comparaison. Ce n’est pas nous qui
le disons, c’est l’Institut de la statistique du Québec, entre autres.
Cela s’applique tout autant aux infirmières, aux professeurs, aux
ingénieurs, aux ergothérapeutes, aux physiothérapeutes, aux
avocats de l’aide juridique et aux procureurs de la Couronne…
qu’aux médecins.
Il était également prévisible que les lobbys du monde de la construction des routes, de celui des médicaments génériques et quelques
autres fassent pression sur nous pour que nous retirions nos
publicités. Mais, ne leur en déplaise, tuer le messager ne fait pas
en sorte de tuer le message ! Les propositions que nous faisons
sont toutes documentées et plusieurs ont été présentées par
d’autres bien avant nous, mais sont restées lettre morte. Allez
savoir pourquoi…
Viendra le jour prochain où nous déposerons nos demandes au
gouvernement dans le contexte du renouvellement de notre Entente.
Anticipons déjà un tollé ! Surtout de la part de personnes (bien
pensantes) qui ne prendront pas la peine de nous parler, d’aller
au fond des choses, de comprendre et dont le sport national est
de « chroniquer ». Libre à elles ! Néanmoins, il demeurera toujours
à vous de défendre vos intérêts, et ce, par votre mobilisation.
Il est facile d’entretenir un discours portant sur le marasme
économique qui nous afflige. Facile aussi de critiquer, juger et
condamner notre campagne. Facile de prétendre que la FMSQ
n’a droit au chapitre que sur les sujets qui concernent la santé.
Justement ! La santé, c’est 45 % du budget du Québec. Une
« dépense » incontournable. Et les médecins, tout spécialistes
soient-ils, sont aussi des contribuables…
Quoi qu'il en soit, nous poursuivons notre démarche. Et elle est
simple : ajouter la voix des médecins spécialistes à toutes celles
qui se sont élevées depuis des semaines, des mois, des années,
en espérant que le gouvernement Charest allait enfin prendre
des décisions et agir pour améliorer la santé financière du Québec.
Mais pas n’importe quelles décisions et pas n’importe comment !!!
Le Québec est dans le rouge, nous le savons. Or, il y a de l’argent
au Québec, et nous le démontrons !
EN ASSUMANT LE LEADERSHIP NÉCESSAIRE,
LE GOUVERNEMENT POURRAIT RÉGLER
SES PROBLÈMES D’ENDETTEMENT ET
FAIRE FACE À L’AVENIR AVEC UNE
CERTAINE SÉRÉNITÉ ÉCONOMIQUE.
Nous postulons qu’en assumant le leadership nécessaire, le
gouvernement pourrait régler ses problèmes d’endettement et
faire face à l’avenir avec une certaine sérénité économique. Mieux,
il aurait les fonds amplement suffisants pour payer équitablement
l’expertise professionnelle de la fonction publique ET celle des
38
Par ailleurs, pour vous convaincre qu’il y a de l’argent au Québec
et que ce n’est pas le manque d’argent le problème, mais bien
l’incurie décisionnelle de nos gouvernements, je vous suggère
de lire le deuxième fascicule du Comité consultatif sur l’économie
et les finances publiques, disponible sur le Web, où il est clairement démontré que de l’argent, il y en a !
Finalement, il faut souligner le fait que nous sommes dans une
période ultra-charnière. Au-delà de l’actuelle récession, de
laquelle nous sortons, il y a, ici comme ailleurs, tout le débat du
contrôle des dépenses publiques et, en santé, celui de maintenir
un système public fort, mais efficace. Nous sommes partie prenante
de ce débat, et c’est très bien ainsi. Et le « timing » est bon. En
fait, tout en visant une rémunération adéquate pour nos services,
nous croyons qu’il est temps que les médecins spécialistes soient
impliqués à tous les étages du réseau de la santé et ceci inclut
celui de la direction. Nous favoriserons un modèle où la cogestion
sera le principe de base. D’où la nécessité de prévoir une rémunération adéquate pour susciter les meilleures candidatures. Puis, il
y a la numérisation du dossier clinique, l’organisation des soins,
etc. Bref, nous avons amplement de pain sur la planche.
Soyez-en assuré, nous sommes prêts ! Et nous croyons que vous
l’êtes aussi. N’oubliez jamais que notre situation est le résultat
d’une somme de petits reculs accumulés au fil des ans. Pas
question de recommencer un nouveau cycle à la baisse avec
cette négociation. Surtout que, quand partout au Canada, les
médecins concluent des ententes semblables aux précédentes !
Syndicalement vôtre !
S
L
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41
37

Diabetes: Emergency Case!

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