Understanding Pain

Transcription

Understanding Pain

LE
SPÉCIALISTE
LE MAGAZINE DE LA FÉDÉRATION DES MÉDECINS SPÉCIALISTES DU QUÉBEC
Vol. 13 no. 2
June 2011
Offre
exclusive
aux nouveaux
membres
voir texte p. 41
Les dix principales
raisons de consultations
auprès des médecins
exerçant en cabinet
au Canada, 2010
Québec
Canada
Nombre de consultations 75 761 170
Nombre de consultations 323 515 440
Hypertension
4 402 770
1
Hypertension
20 562 420
Examen médical courant
2 657 160
2
Diabète
10 113 200
Diabète
2 477 340
3
Examen médical courant
9 779 600
Anxiété
1 528 820
4
Dépression
8 063 920
Dépression
1 509 210
5
Anxiété
6 382 130
Hyper-lipidémie
1 315 940
6
Infection aiguë des voies respiratoires
5 251 960
Infection aiguë des voies respiratoires
1 250 230
7
Suivi normal de grossesse
5 043 990
Trouble déficitaire de l’attention avec hyperactivité
1 055 610
8
Hyper-lipidémie
4 708 690
Hypothyroïdisme
1 047 470
9
Oesophagyte
3 621 120
880 870
10
Hypothyroïdisme
3 602 050
Infection de l’oreille (otite moyenne)
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Summary
7 WORD FROM THE PRESIDENT
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EDITORIAL COMMITTEE
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Why Make Things Easy When They Can Be Made Difficult?
8 MESSAGE FROM THE TREASURER
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9 INTERVIEW
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13 DID YOU KNOW...
18 LEGAL ISSUES
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DOSSIER
LE
SPÉCIALISTE
LE MAGAZINE DE LA FÉDÉRATION DES MÉDECINS SPÉCIALISTES DU QUÉBEC
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2nd quarter 2011
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11 IN THE NEWS
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4
6
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41
43
Vol. 13 no. 2
UNDERSTANDING
PAIN
• Complex Regional
Pain Syndrome
• Unhappiness
• Neuropathic Pain
• Neuromodulation
June 2011
21
24
26
29
Offre
exclusive
aux nouveaux
membres
voir texte p. 41
31 GREAT NAMES IN QUEBEC
MEDICINE
Dr. Christine Colin, Community Health Specialist
32 CONTINUING PROFESSIONAL
EDUCATION
36 IN THE WORLD OF MEDICINE
New Atrial Fibrillation Guidelines
38 FINANCIÈRE DES
PROFESSIONNELS
40 SOGEMEC ASSURANCES
42 LE MOT DU PRÉSIDENT
Pourquoi « faire simple » quand on peut « faire compliqué » ?
44 SERVICES AUX MEMBRES
Avantages commerciaux
LE SPÉCIALISTE
VOL. 13 NO. 2
JUNE 2011
5
WORD FROM THE PRESIDENT
Dr. Gaétan Barrette
Why Make Things Easy
When They Can Be Made Diﬃcult?
t press time, the FMSQ has just reached an agreement
with the Ministère de la Santé et des Services sociaux
(the MSSS) regarding the treatment of age-related
macular degeneration (ARMD). A good outcome, but to achieve
it we had to resort to an ultimatum. Some of the highlights of
this bad film follow.
A
February 8 brought a complete turnabout! The Minister issued
a press release announcing treatments would be free. He
“asked all health establishments in Quebec to ensure
treatments were free (….). In the course of the next few weeks,
once the measure has been introduced, patients will no longer
have to pay incidental fees.”
Fall 2010. The issue of incidental fees reappears; this time with
regard to ARMD. Since patients could not obtain Lucentis at
hospitals (at a time when science had not yet formally decided
on the added value of using Lucentis in ARMD), they had to go
to clinics for their injections. The RAMQ does not reimburse
ophthalmologists for the technical component of their
procedures, and patients were asked to pay the fees. As you
know, the 1970 Health Insurance Act has not kept up with the
evolution of medical practice. The result has been that a certain
artistic fog surrounds the definition of incidental fees and, in
particular, many of the activities carried out in clinics. I would
emphasize this point! The fog is affecting ophthalmology for
the moment, but it could apply to a number of other
medical specialties.
On February 9, again responding to a journalist from Le Soleil,
the Minister’s press attachée clarified the previous day’s
announcement, stating that action to introduce this new offer of
service was just beginning, and it would only be “in the coming
weeks or months” that patients would learn what to expect.
Let us go further back, to October 1, 2007. At the request of
ex-Minister Couillard, a task force submitted the Chicoine
report (named for the committee chairperson); it contained
specific recommendations on the matter of incidental fees
and the need to act without delay. In the summer of 2008,
Mr. Bolduc made his entrance as Minister. Since then, the
airwaves have been silent. The problem of incidental fees has
remained untouched – and pending.
On April 7, Le Devoir reported that the Minister had raised the
possibility of “paying reasonable fees for injections. (…)
Incidental fees could also be paid in clinics. (…) We should
know which option will be selected in a few days’ time.”
The first signs of a “new” crisis arrived with an article published
in Le Soleil on November 18, 2010: “The government will not
pay for Lucentis injections”. In making this statement, the
Minister’s press attachée cited the “present budget situation” as
justification for the ministère’s decision.
On November 24, the Minister indicated to the same journalist
that he was working on the matter with the RAMQ. The article
ended by pointing out that “the matter had been submitted to
Minister Bolduc for the first time in March 2009”.
On February 3, via his press attachée, the Minister let it be
known that he intended to continue his deliberations on
incidental fees. “Discussions must take place with the various
parties involved, such as the medical federations and the
Collège des médecins.” The Minister hoped to move “as fast as
possible” on this matter, reported Le Devoir.
April 2, and a dramatic turn of events! In an article in Le Devoir
headed “No Free Lucentis To Be Found. Patients caught in
government and establishment tussle”, the journalist reported
that, upon checking, even the MSSS did not know which
establishments were currently offering the service and which
ones were expected to do so. The MSSS spokesperson
added, “It is hoped that (a plan) will be finalized in a few weeks
and submitted for the Minister’s approval.”
On Thursday, May 19, 2011 a patient with ARMD applied to the
Courts for permission to launch a class action against the
RAMQ, the Minister of Health and an ophthalmology clinic in
Quebec City (others may be added).
That same day, infuriated, the Federation gave the Minister an
ultimatum: 48 working hours to settle this situation once and for
all. The hours passed by, and intense negotiations (over a long
weekend!) finally brought about an agreement.
For years now, the FMSQ has consistently repeated to the
Minister that he should, once and for all, clear away the fog
surrounding the whole subject of incidental fees. By deciding to
circumvent the problem, not only the delivery of care is
voluntarily rationed in hospitals, but the Minister is “saving” at
the expense of patients by delaying investment of the amounts
required to deliver care. During this time, physicians for their
part are trying to do everything possible to treat patients in
clinics, with all the attendant risks. But all this should “really”
end one day!
Yours in solidarity!
On February 6, Lucentis treatment of ARMD was “a priority” for
the Minister, as reported in the Journal de Québec.
LE SPÉCIALISTE
VOL. 13 NO. 2
JUNE 2011
7
MESSAGE FROM THE TREASURER
Dr. Maurice Boudreault, MD
Annual Report
PAST TREASURER
The following motions presented by the Chair of the Finance
Commission were approved at the Annual Delegates’
Assembly, held on March 24, 2011:
1. To approve the FMSQ’s financial statements as at
December 31, 2010 as audited by Raymond Chabot
Grant Thornton, Chartered Accountants;
2. To approve budget forecasts for the year 2011, as
submitted by the FMSQ;
3. To increase annual union dues from $1,235 to
$1,266.
With regard to the special contribution of $2,000 levied in
2006 to fund the negotiations taking place at that time, it had
been agreed that any unused portion would be returned to
members. Reducing dues by $20, $950 and $275 for the
years 2008, 2009, and 2010 respectively allowed us to return
62% of the special contribution to members, the balance
having been used for the negotiations concluded in 2007.
The financial statements again confirmed that the FMSQ is in
good health financially.
After having been a member of the Board of Directors of the
FMSQ for six years, the last four as Treasurer, and in
accordance with the bylaws, I bowed out of my duties on
March 24. I can assure you that working closely with the
dedicated and dynamic team that provides constant support
to the various branches of our organization, as well as with my
colleagues on the Board of Directors, has been one of my
most satisfying experiences. It also provided me with the
privilege of getting to know many of you. I feel honoured by
the confidence you have shown me over the years, and I
thank you most sincerely!
Upon his election on March 24, 2011,
Dr. Raynald Ferland replaced Dr. Boudreault
as Treasurer of the Federation for the period
2011-2013.
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LE SPÉCIALISTE
VOL. 13 NO. 2
JUNE 2011
INTERVIEW
By Patricia Kéroack
Outgoing Vice-President of the FMSQ
Dr. Josée Parent
On March 24, Dr. Josée Parent resigned from her position as Vice-President of the FMSQ at
the end of a third term on the Board of Directors. Le Spécialiste met with her to fill in a picture
of her time on the Federation’s Board.
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Dr. Parent, what inspired
you to get involved with the
Federation?
In the past, both as a medical
student and a resident, nothing
indicated that I would become
involved in the union movement. To be
honest, I never even gave it a thought.
Then, by chance, I got involved in my
medical association and found that
certain issues affected me deeply. I
discovered I could contribute my ideas
and actions to the advancement of our
profession. I was a member of the
Executive of the Association des
gastro-entérologues du Québec for
four years then, at the suggestion of
its President, I applied for a position at
the FMSQ, where one thing led to
another and I went from being a
Counsellor to Vice-President.
JP
Did you have any specific
objectives during your tenure?
government is not inclined to listen
to us, even though we have a
thorough knowledge of the realities,
the needs and issues for each
medical specialty.
Insofar as negotiations are concerned, I count myself fortunate to have
been a part of the major shift that
allowed us to reach the 2006-2007
Agreement. That was the one that
most likely had the greatest impact,
at least in my professional life. The
negotiations were ground-breaking:
we finally achieved recognition of
academic teaching and the work of
researchers, a great step forward for
medical specialists who give a great
deal of themselves to residents,
medical students and young
researchers. We managed to catch
up somewhat, thus making us more
competitive on the Canadian level.
These elements were a great help to
academic medicine in Quebec.
When I stood for the Board of Directors,
Dr. Josée Parent
I sent a letter to the delegates which,
by pure chance, I reread just recently.
At the time, I wanted to be the standard-bearer for groups that
I COUNT MYSELF FORTUNATE TO HAVE BEEN A
were smaller or not well- represented, like women, younger people,
etc. Then, federation issues came up and I dove in, always
PART OF THE MAJOR SHIFT THAT ALLOWED US
keeping my initial objective in mind. That is how I developed an
TO REACH THE 2006:2007 AGREEMENT. THAT
interest for, among other things, the issues of parental leave and
WAS THE ONE THAT MOST LIKELY HAD THE
membership fee waiver.
What major issues have you been responsible for since
you joined the Board in 2005?
My principal file was the one on medical staffing, although I
should also mention negotiations and conditions of practice.
These major topics required in-depth work and, towards the
end of my term of office, I could see they had evolved
substantially. The latest medical staffing plans (PEMs) are not a
panacea, but we can at least say they are an improvement over
to the past. Let us not forget that the FMSQ does not have that
much influence with the government regarding PEM matters.
The Federation’s role on this committee is only advisory and the
GREATEST IMPACT, AT LEAST IN MY
PROFESSIONAL LIFE.
What can you tell us about the conditions of practice file?
It is an important one, and it captivated me. First of all, the
Federation set up a committee (chaired by the Vice-President)
to take charge of the file. That committee is still very active
today and meets with members, associations, professional
orders and others to advance discussions. Although at times
short on resources, we do move forward and realize that we
share the same objectives as the professional orders. To
LE SPÉCIALISTE
VOL. 13 NO. 2
JUNE 2011
9
INTERVIEW @SUITEA
change things, you need more than willpower. Sometimes it’s a
question of financing and that is precisely the area in which we
have had problems with the government. But, let’s be positive:
several major files have progressed, including that of
psychiatrist-responders, telemedicine, chronic diseases, etc.
From your point of view, what were some of the high points
for the Federation?
The last agreement with the government was a great moment
for me and for the Federation. The emergency act, and the
Federation’s reaction to it, really changed the tone of
negotiations and gave the Federation and its members a certain
momentum. Our agreement was historic; everyone says so. For
me, signing that agreement was a very high point.
I SINCERELY BELIEVE THAT THE FEDERATION HAS A
GREAT FUTURE. OF COURSE, WORK WILL STILL BE
NEEDED TO ENSURE THAT THE REMUNERATION GAP
WITH OTHER PROVINCES DOES NOT WIDEN, BUT WE
SHOULDN’T REACH THE SAME LEVEL AS DURING OUR
BATTLE IN 2006.
How do you foresee the Federation’s future?
Although I don’t have a crystal ball or the power to see what is
coming, I sincerely believe that the Federation has a great
future. Of course, work will still be needed to ensure that the
remuneration gap with other provinces does not widen, but we
shouldn’t reach the same level as during our battle in 2006. We
also have to continue working on the structural issues in our
healthcare network. Then, there is the specialized medical
staffing challenge, which the Federation hopes to settle with the
next agreement. Finally, we’ll have to adapt to demographic
changes linked to age and gender...
What should we hope for to settle the problems in the
area of medical staffing?
If we could settle the issue of part-time physicians, it would be
an enormous step forward. The situation absolutely has to be
recognized, be it for physicians nearing the end of their careers,
researchers who spend half their time (or more!) on medical
research or medical specialists who want to balance work and
family life... Contrary to what people may think, it isn’t female
medical specialists who work part-time (or are more inclined to
do so): it is more the case with physicians nearing the end of
their careers.
What are the greatest stakes at present and in the future?
Demographics are changing within the specialized medical
community. There are more women among younger physicians,
and the Federation will have to take this into account. The
situation is not as desperate as with general practitioners, but
we need to be able to meet the needs of this group of
physicians and facilitate their involvement with the Federation.
10
LE SPÉCIALISTE
VOL. 13 NO. 2
JUNE 2011
How did it feel to resume full-time work?
Getting back to normal took one week! I took a few days off
to rest, and then started working full-time at the hospital.
Since then, I have often spoken with Dr. Barrette: he keeps
me up to date on matters. I had six wonderful years, and I’m
not ready to forget them. My youngest daughter has just
turned five; I was pregnant when I joined the Federation’s
Board of Directors. It just goes to show that time does fly by!
Can you see yourself as Minister of Health? What are
your plans?
The position of Minister of Health doesn’t interest me at all. I
don’t have any political ambitions. I know other people who
might certainly be interested, but not me! At present, I do not
have any new career plans, but I do intend to become an
active member of my medical association once again.
I have to admit that I regret that the parental leave agreement
was not signed before the end of my term. I believe however
that it is on the verge of being approved and signed. And,
believe me, I’ll be there to applaud when it is!
Still, you were the initiator of the Welcome
Baby Program…
Yes, and it was a very good start. The Welcome Baby
Program was launched in 2008 and offers a membership fee
reduction for our members who have or adopt a child. This is
not a waiver of fees, but it is a first step in the right direction.
Do you have a favourite story to share with us
concerning your time at the Federation?
Working with Dr. Barrette has been a great pleasure for me.
We call one another for all sorts of reasons, to ask for news
or to test ideas... That being said, I have to tell you of an
instance when we really argued fiercely. Yes, it did happen!
But it didn‘t concern a federation file, stakes in negotiations,
nothing like that. It was about the colour of the new chairs
we wanted to order for the boardroom! Dr. Barrette wanted
chairs covered in white leather and I, being pragmatic and
having a mother’s instinct, disagreed. White shows stains
and dirt too easily. We got into a verbal fight over it and it was
so funny! I argued the practical side and he was adamant
about the importance of the “look”. The whole situation was
topsy-turvy!
Finally, I took advantage of his absence to place the order.
The chairs are a deep navy blue and it’s really very attractive.
In fact, even though he was astounded when he saw them
arrive, he candidly agreed in front of everyone.... “Blue is
better. You were right!”
S
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IN THE NEWS
SMC Safety Standards
According to the Act respecting health services and social services (Loi sur les services de
santé et les services sociaux or LSSSS), the services provided by specialized medical
centres (SMC) must be accredited within three years of an operating permit being issued.
The accreditation must be obtained from an entity recognized by the Minister (section 333.4).
The MSSS has mandated the Conseil québécois d’agrément and Accreditation Canada to act
jointly in this matter, and SMCs will thus have to apply to them for accreditation.
As part of the consultation process undertaken by the accreditation bodies regarding standards for Independent
Medical/Surgical Facilities, the FMSQ set up a working group
to study and evaluate the proposals made. After the group
had completed its work, the FMSQ drew up a list of
comments and recommendations. It considered that
accreditation criteria must be adapted to the reality of SMC
practice, in particular its size. Accreditation standards
applicable to SMCs cannot be the same as those that apply
to hospital centres or polyclinics. A number of SMCs are small
clinics with few physicians and a minimum of support staff.
Accreditation criteria must not require a hospital-style
organizational structure, but must relate to the type of
procedures performed and their level of risk. The wide range
of procedures that can be performed in an SMC must be kept
in mind, and the criteria adjusted accordingly. For instance, an
SMC that provides cataract surgery under local anesthetic
should obviously be subject to different standards than those
applicable to an SMC that offers complex and high-risk
plastic surgery.
Accreditation Canada, the standards will guarantee uniformity,
thus helping healthcare providers in these establishments
deliver safe, high-quality services to their clients.
Non-hospital establishments that perform procedures
covered by the Act (LSSSS) or by the Regulation respecting
the specialized medical treatments provided in a specialized
medical centre will use these standards. As far as
Accreditation Canada is concerned, and given the diversity of
the surgeries that can be delivered in these establishments,
the standards take into account both the various levels of
sedation used and the types of surgery.
Most of the recommendations presented to Accreditation
Canada and to the Conseil québécois d’agrément were not
accepted. However, physicians’ offices must still abide by
them. This is therefore an issue that requires ongoing scrutiny.
To learn more about the standards, see the Accreditation
Canada site at www.accreditation.ca or the Conseil
québécois d’agrément’s site at www.agrement-quebecois.ca.
In a March 17 press release, Accreditation Canada published
the new accreditation standards applicable to SMCs. It states
that these standards were developed in response to quality
and overall safety concerns for non-hospital establishments in
Canada where surgery is performed. According to
S
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LE SPÉCIALISTE
VOL. 13 NO. 2
JUNE 2011
11
IN THE NEWS
Building the new UHCs
Since September, we have been reporting photographically on how construction work is advancing
on the new university hospital centres being built in Quebec. As a picture is worth a thousand words,
what better way to keep track of these projects!
The new McGill University Health Centre will open its doors in the fall of 2014, while the CHUM is
expected to open in 2018.
CHUM
Picture taken on May 13, 2011
MUHC
Picture taken on May 13, 2011
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LE SPÉCIALISTE
VOL. 13 NO. 2
JUNE 2011
DID YOU KNOW...
On the Political Scene
Bill 127
On December 9, 2010 the Minister of Health and
Social Services tabled Bill 127, An Act to improve
the management of the health and social services
network. This proposed legislation was the subject
of individual and public consultations from March 14
to March 18, 2011. The Health and Social Services
Commission was mandated to hear representations
from 27 organizations, associations and experts and
received briefs from 12 other organizations who did
not take part in the consultations. The FMSQ’s brief
can be accessed on its website (www.fmsq.org)
under Publications (Mémoires) – in French only.
Most stakeholders criticized the Bill, questioning its
relevance, orientation, objectives and ultimate
purpose. Some groups went so far as to request its
total withdrawal. The Minister indicated he would
present amendments to the text, in particular by
immediately withdrawing section 39, the most
contested and criticized portion. The Commission
submitted its report on March 22. It remains to be
seen whether the Bill will be adopted during the
current session that is expected to end on June 10.
Section 39 of Bill 127 reads as follows:
39. The Act is amended by inserting the
following division after section 182.0.1:
to improving the health and well-being of the
population;
“DIVISION II.0.1
(5) the results targeted over the period
covered by the plan; and
“ORGANIZATION OF SERVICES
“182.0.2. In accordance with province-wide
and regional orientations and recognized
standards of accessibility, integration,
quality, effectiveness and efficiency, and
taking into account available resources, the
institution is responsible for preparing a
multi-year strategic plan containing the
following elements:
(1) a description of the mission of the
institution;
(2) a statement of the social and health
needs of the clientele served or the local
population, based on an understanding of
the health and well-being of that clientele or
population;
(3) a description of the context in which the
institution acts and the main challenges it
faces;
(4) the directions and objectives to be
pursued with respect to, among other
things, the accessibility, continuity, quality
and safety of care and services with a view
(6) the performance indicators to be used in
measuring results. The strategic plan must
also take into account the priorities
established in the clinical and organizational
projects with which the institution is
associated.
“182.0.3. The strategic plan must be
approved by the agency and sent to the
Minister.
“182.0.4. The institution must present its
service organization plans and any other
substantive policy document to the agency
before submitting them to its board of
directors for approval.
“182.0.5. The president and executive
director of the agency, the executive director
of the institution and, when required, the
chairman of the board of directors must
determine how to monitor the results of
implementing the strategic plan and the
management and accountability agreement
entered into by the institution and the
agency.”
Bill 133
Watch Out for…
Piloted by Michelle Courchesne, Chair of the Conseil du Trésor,
Bill 133, An Act respecting the governance and management of
the information resources of public bodies and government
enterprises, was also the subject of individual and public
consultations on March 24 and 29 and April 5, 6 and 7. This
text was also criticized by some stakeholders, who consider
that it simply creates additional bureaucratic levels. The
Commission des finances publiques submitted its report on
April 12. We expect the bill to proceed normally, and to be
adopted during the current session.
A new piece of legislation will be required to allow “patient”
information to be shared between institutions. The Minister of
Health confirmed this on March 22 during an update on the
Electronic Health Record (EHR) project. At present, legislation
prohibits institutions from sharing this type of information (which
is considered to be confidential) with a third party. At the time of
writing, we have no specific indication as to when such a Bill will
be tabled in the National Assembly.
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l’accès au terrain de pratique, un droit de jeu au club de golf Le Mirage en
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LE SPÉCIALISTE
www.fmeq.qc.ca
VOL. 13 NO. 2
JUNE 2011
13
DID YOU KNOW... @SUITEA
Prizes and Awards
The AMEQ’s Endocrinologist Emeritus
AMMIQ Prize
Dr. Khalil Khoury, a pediatric endocrinologist
at the Centre hospitalier universitaire de
Sherbrooke, was named Endocrinologist
Emeritus for 2011. He received the prize
during the Annual Meeting of the Association
des médecins endocrinologues du Québec.
The Association des médecins microbiologistes infectiologues du Québec awards
the prestigious Louis Pasteur Prize every two
years to mark the high-quality contribution of
one of its members to the advancement and
development of this medical discipline in
Quebec. The prize was presented to Dr. Gilles
Del ag e, Vice-President, Medical Affairs in
Microbiology, Héma-Québec.
AMPQ Annual Prizes
To highlight the organization of the colloquium Démence et souffrance psychique,
une dyade souvent
oubliée, held in October 2010, the Professional Development
Prize was given to
Drs. Arthur Amyot and
Nathalie Shamlian.
Dr. Pierre Lalonde has received the Heinz
E. Lehmann Prize for Excellence in
Psychiatry. The prize, accompanied by a
cheque for $5,000, recognizes exceptional
contributions to the progress and advancement of the profession.
Dr. Arthur Amyot
Dr. Hans Lamarre is the winner of the
Jacques-Voyer Prize for Humanitarianism
to highlight his role in the development of
Québec-Haiti intergovernmental relations.
The prize was given to him for his role as
a facilitator in coordinating humanitarian
actions associated with visits to the area,
as well as promoting action by government
bodies and civil organizations in Haiti.
Dr. Nathalie Shamlian
Dr. Vincenzo Di Nicola has received the
Camille-Laurin Prize for the accomplishment of the year: publication of his book,
“Letters to a Young Therapist: Relational
Practices for the Coming Community.”
The SCFR Recognizes
Excellence
• Dr. Jacques Boisvert and Dr. Dominique Màrton jointly received the Albert-Jutras Prize in
recognition of their careers as pioneers.
Five Quebec radiologists were
honoured at the 48th Annual
Meeting of the Société canadienne-française de radiologie.
The prizes were awarded in
recognition of the exceptional
contributions of certain radiologists to the profession or to
a related area of activity.
• The Bernadette-Nogrady Prize was given to Dr. Marie-France Giroux to underline her
remarkable contribution to research and teaching, as well as for the quality of her patient care,
after less than 11 years of practice.
• The Dr. Jean-A.-Vézina Prize for Innovation and Excellence was given to Dr. Michel Lafortune
(jointly with Dr. Stephanie Wilson of the University of Alberta).
• Dr. Guy Breton received the 2011 SCFR Prize for Personality to highlight his being appointed
Rector of the Université de Montréal.
Dr. Jacques Boisvert Dr. Marie-France Giroux Dr. Dominique Màrton Dr. Michel Lafortune
14
LE SPÉCIALISTE
VOL. 13 NO. 2
JUNE 2011
Dr. Guy Breton
DID YOU KNOW... @SUITEA
APQ Prize
AMSMNQ Prizes
At its annual convention, the Association des
pathologistes au Québec gave the PierreMasson Prize to Dr. André Bonin. This prize
is awarded every two years to a pathologist
who has made a significant contribution to
the practice and development of his/her
specialty in Quebec, whether in the scientific,
educational or clinical spheres.
The Association des médecins spécialistes
en médecine nucléaire du Québec awarded
prizes for excellence at its annual convention
held in April. D r. Ra ymon de Ch artran d
received the Lantheus Homage Prize to
highlight her commitment to nuclear medicine.
CMQ Prize
Dr. Pierre J. Durand, a geriatrician and the
outgoing dean of the Faculty of Medicine at
Université Laval, received the Prize for
Excellence from the Collège des médecins
du Québec to highlight his exemplary contribution to the healthcare and education
systems in Quebec.
Dr. Gilles Julien, a pediatrician, received the
Prize for Humanism for developing a model
of social pediatrics and for his actions overall
in favour of children from underprivileged
backgrounds. Dr. Julien is the first recipient
of this prize created to recognize the values
of humanism extolled by the Collège among
its members.
QMA Awards
At its annual convention, the Québec Medical Association
recognized the exceptional contribution of two Quebec medical
specialists to the development of their profession.
Dr. P ie rre G agn é, a nuclear medicine
specialist at the Centre hospitalier régional
de Trois-Rivières (CHRTR) and the outgoing
vice-dean of the Université de Montréal
Campus (Trois-Rivières) received the
Teaching-Clinician Award. This award recognizes the exceptional contribution of a
physician with teaching responsibilities in a
faculty of medicine.
Dr. André J. Luyet, a psychiatrist at Hôpital
Louis-H. Lafontaine, has received the Prestige
Award, the highest distinction given to a
member of the QMA. This prize recognizes
excellence and contributions to the advancement of medicine and of society in the
humanitarian, ethical, scientific, socioeconomic
and educational or communications fields.
Did you know?
New program to reimburse living donors for
expenses incurred
Since the adoption of the Act to facilitate organ and tissue
donation, the MSSS has implemented a program to reimburse
living donors for expenses incurred. This program is
administered by Québec-Transplant, and is intended to
support the donor’s action by compensating him/her for a
portion of the expenses related to the donation process.
For additional information, visit www.quebec-transplant.qc.ca.
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LE SPÉCIALISTE
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15
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DID YOU KNOW...
Information and Power
There is an old saying that knowledge (or, to extrapolate, information) is power. But,
is that still true? Can a person or an organization (like a corporation or a government)
exploit the information they have and share, in order to increase their power? In the
final analysis, can information be controlled – and who would benefit?
As the Editor and person responsible for Le Spécialiste, I
always look closely and critically at the various
communications we receive for the magazine. I pay especial
attention to press invitations, particularly when they arrive at
strange hours or outside normal working hours. For
example, the media can be invited on a Sunday evening to
attend an important announcement being made the next
morning. It seems that, over time, this method has gained in
popularity among our political leaders. It happened for the
official launch of work on the CHUM last February 25. The
press invitation was issued on the news wire, early in the
evening of Thursday, February 24, for an official
announcement the next morning at 9:00 a.m. Furthermore,
the invitation was issued by the Premier’s Office, not the
CHUM, the MSSS or even the Conseil du Trésor. However,
after checking with a few guests at the venue the next
morning, we confirmed the official launch had been planned
and announced a long time ago to project stakeholders,
CHUM employees (closed circuit television sets were even
made available in the various buildings for those who could
not attend in person), partners and other VIPs. So, why wait
until the last minute to invite those who actually convey
information to the general public?
Now, let’s talk about the press conference
in question…
In an article published on Cyberpresse,i reporters Ariane
Lacoursière and Sara Champagne wrote: “Invited to a
technical briefing one hour before the official announcement,
reporters had their cellphones confiscated at the door. When
questions from the media became too searching, an attempt
was made to cut short the technical briefing. Then,
immediately prior to Mr. Charest’s speech, Health Department spokespersons refused to return the cellphones to
reporters, until one journalist threatened to call the police if it
was not immediately returned.”
I was present at this press conference and personally
experienced this strange behaviour towards reporters. My
personal cellphone (which I had carefully turned off) was
confiscated and was returned to me... turned back on! And
then there was the glacial welcome, or rather non-welcome,
we encountered: a few chairs reserved for the media
(deliberately placed at the back of a room already
overflowing with guests), some mumbled invectives and the
all-encompassing suspicious glares from the Premier’s
bodyguards.
This was not an isolated occurrence. If we restrict ourselves
to last-minute invitations alone, a quick search of press
invitations from the Government of Quebec provides further
similar instances. For example, on August 27 last year (a
Friday), an invitation was sent out at 5:49 p.m. for an
important announcement by Minister Normandeau, on
Sunday morning, on the subject of shale gas. Then the
CHUM once again made the hit parade with a press
invitation sent out on Sunday afternoon at 3:30 p.m.
(December 19, 2010) for a technical briefing at 9:15 a.m. on
Monday morning (December 20, 2010), followed by a press
conference with several Ministers at 10:00 a.m.
Is this a normal way of acting? A good communicator must
know the public he or she is addressing, as well as those
who transmit the information in question. Communicators
know that most media operate with different teams during
the week (Monday to Thursday) and at weekends (Friday to
Sunday), that deadlines affect the coverage of events, that
electronic media reporters are subject to technical
production details (and, particularly, the time of news
broadcasts), etc.
The FMSQ’s Public Affairs and Communications Department
makes every effort to know the people who convey its
information. For instance, it keeps an up-to-date database of
reporters with an interest in health and the other areas in
which the Federation is involved. In the best of all possible
worlds, our team carefully plans the timing of press
conferences and other media activities to accommodate the
multiple conditions under which reporters work. Finally, if an
invitation has to be issued with a short lead time, everything
is done to ensure that press invitations reach reporters
rapidly (cellphones, personal e-mails, calls to news desk
editors, etc.). After all, knowledge (like information) is power!
i
http://www.cyberpresse.ca/actualites/quebec-canada/sante/
201102/25/ 01-4373923-construction-du-chum-cest-parti.php
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LE SPÉCIALISTE
VOL. 13 NO. 2
JUNE 2011
17
LEGAL ISSUES
By Maître Majorie E. Talbot
COUNSEL (INTERIM), LEGAL AFFAIRS
Do you know your obligations?
An Act respecting the determination of the causes and circumstances of death
The Act respecting the determination of the causes and
circumstances of death1 (the “Act”) empowers the Coroner to
search for the causes of a death and its circumstances when
the probable medical cause of death is unknown or when the
circumstances are obscure or violent.
As part of his duties and during an investigation or inquest, the
Coroner can formulate “any recommendation directed
towards the better protection of human life.”2 In the last year,
several recommendations for improving the quality of our
healthcare have been issued by the Coroner’s Office.3
To carry out his mission, the Coroner must be informed of all
deaths requiring investigation. In particular, he must be
informed of all deaths occurring in certain places, regardless
of the cause or circumstances. In the healthcare network, the
locations currently covered by this requirement are
rehabilitation centres, family-type resources and foster homes.
The Coroner must also be immediately informed of the death
of a person under confinement in an institution. However, the
law does not require automatic notification to the Coroner
when death occurs in a residential and long-term care centre
(CHSLD), an intermediate resource (IR) or in a residence for
the elderly.
Until 1991, the Coroner nevertheless had to be notified of all
deaths occurring in nursing homes.4 The latter
accommodated users whose profiles were similar, if not
identical, to those of persons currently living in a CHSLD.5 The
requirement has been abolished since, in most cases (98% of
them, according to the Coroner’s Office) such notifications
concerned natural deaths, which are not within the purview of
the Coroner.6
The Commission des droits de la personne et des droits de
la jeunesse (the “Commission”) considers that the law does
not take into consideration the vulnerability and loss of
independence of the elderly in a CHSLD, IR or home for the
elderly.7 In a notice dated last December, it recommended
that the Act be amended to require that the Coroner should
be notified of all deaths in these institutions.8 The
Commission also advocated heightening physicians’
knowledge of the various current provisions of the Act.9
Some coroners suspect an “under-notification” of deaths in
relation to the current Act, one of the causes of which would
be an inadequate knowledge of their obligations on the part
of certain physicians.10
Notifying the Coroner when unable to
establish the probable cause of death
A physician who confirms a death must prepare an attestation
of death, giving the name and gender of the deceased, as well
as the place, date and time of death.11 It is important to
differentiate between the time and the confirmation of death.
For example, if rigor mortis is present, the time at which the
body is discovered and death is confirmed will obviously differ
from the time of death (or in this case, the presumed time of
death). This distinction will be very pertinent, particularly with
regard to succession.12
As for the notice of death, various people are responsible for
completing it depending on the circumstances. However, the
physician has the initial responsibility for filling out the notice of
death (or form SP-313) for a person in an institution.14 When
death occurs outside a healthcare institution, “the last
physician having cared for the person” is responsible for
completing it.15 Should that physician not be available, another
physician, nurse or Coroner can complete the notice.16 When
the death forms the subject of a Coroner’s investigation or
inquest, it is up to the latter to complete the notice of death.17
The notice must specify, as accurately as possible, the cause
of death and the disease from which the deceased suffered.18
If the death was a violent one, the circumstances surrounding
the death must also be included.19
When it is impossible for the physician to decide on the
medical cause of the death, he/she must immediately notify a
Coroner.20 When seeking the probable cause of death, the
Coroner is therefore called upon to establish which “disease,
pathological condition, trauma or intoxication” could have
“caused, contributed, or resulted” in the death.21 The
physician can also notify a peace officer of the death.22 That
person must immediately notify the Coroner of such death.23
The Act also contains a provision that the Director of
Professional Services (DPS) in a hospital centre or “a person
under his authority” can take steps to ensure a physician
determines the probable cause of death.24,25 If the
circumstances of the death are obscure or violent, or if
deceased’s identity is unknown, the Coroner’s authorization
must first be obtained.26
The author wishes to thank Maître Claire Bernard (Commission des droits et libertés de la personne) and Maître Dana Deslauriers (Bureau du coroner) for
their collaboration in this article’s preparation.
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LEGAL ISSUES @SUITEA
Should the cause of death remain unknown, an autopsy may
be required to establish it.27 In such cases, the DPS must take
the measures necessary to proceed with due diligence.28
What happens, then, when death occurs in “obscure or
violent” circumstances?
Notifying the Coroner when a death occurs in
obscure or violent circumstances
The physician who confirms a death that seems to him/her to
have occurred in obscure or violent circumstances, even if the
probable cause of death is known, must immediately notify the
Coroner or a peace officer.29 Everyone has an obligation to
inform the Coroner or a peace officer of a death that appears
to have occurred in obscure or violent circumstances, or when
the identity of the deceased is unknown.30 This requirement
applies unless it is reasonable to assume a Coroner, peace
officer or physician has already been informed of the death.31
Unfortunately, the law does not define “obscure” or “violent”.
The dictionary defines “obscure” as referring to something that
is “… 3. Not well-known; 4. Not easily discovered; 5. Not
distinct, not clear; …”32 According to the Coroner’s Office, a
death occurs in “obscure” circumstances when there is a “lack
of trauma, intoxication or obvious adverse effects”, but clues
or information surrounding the death leave doubt as to the
possibility of “external causal or contributory elements”33.
A death where the cause of death is “not clear” or is “not wellknown” must therefore be notified to the Coroner. For
example, the sudden death of a baby would be considered a
death occurring in “obscure circumstances.” We have to
conclude that there is a certain overlap between deaths for
which probable cause cannot be established and those
occurring in obscure circumstances.
Insofar as “violent” is concerned, it is defined as “1. Acting or
done with, or characterized by the use of strong, rough,
harmful force; 2. Caused by strong, rough force; 3. Showing
or caused by very strong feeling, action, etc…”34 The
Coroner’s Office considers that a death occurs in “violent
circumstances” when it results from “an external agent
responsible for a trauma, intoxication or any other adverse
effect, whether of an intentional nature or not.”35
Restraint asphyxia, falls, medication overdoses, suicides,
homicides and any act denoting harmful treatment are
considered violent deaths that must be notified to the
Coroner.36 While some circumstances leave no room for
ambiguity, others are more difficult to interpret. In such
situations, the Coroner’s Office encourages physicians to
contact the Coroner in their region.
deceased was under confinement; correctional facilities;
penitentiaries; “security units within the meaning of the Youth
Protection Act”;37 police stations; daycare centres;38 foster
families and family-type resources.39,40
In all of the above places, the director41 must immediately
inform a Coroner or a peace officer when a death occurs. If the
director is absent, this responsibility devolves to “the person in
authority.”42 If this person is a physician, it will be his/her duty
to notify the Coroner or the peace officer of the death
in question.
Legislators wanted to ensure stricter control with regard to
deaths occurring in places where personal liberty is restricted,
or when dependent and vulnerable persons are in the charge
of the State.43 But, what about CHSLDs, IRs and residences
for the elderly where those residing there are vulnerable and
losing their autonomy? The Commission considers that
deaths occurring there should be automatically notified to the
Coroner, even though most are from natural causes.44 The
Coroner’s Office seems to want to rely on the current
provisions of the Act, which allow it to fulfill its mandate and
guarantee such individuals’ fundamental rights. While deaths
occurring in obscure or violent circumstances or where the
probable cause is unknown are the Coroner’s responsibility,
that is not so for deaths from natural causes. We await
legislators’ reactions impatiently.
Penalties and sanctions
We must remind you that failing to notify the Coroner (or a
peace officer) of a death when probable cause cannot be
established, which occurred in obscure or violent
circumstances, or which requires automatic notification of the
Coroner, is an offence and subject to a fine of $125 to
$6,075.45 The Coroner’s Office informs us, however, that these
provisions have never been applied.
In conclusion, it must be noted that the law prohibits the
Coroner from making any statement concerning a person’s
civil liability or criminal responsibility.46 Nor is it within the
coroner’s purview to act as a substitute for the Collège des
médecins du Québec or any other professional order, or to
judge the quality of professional acts. Thus, physicians must
notify the Coroner when so required by the Act, and thereby
contribute, once again, to reducing the number of
avoidable deaths.
References and Tools
Notifying the Coroner or a peace officer
based on the place where a death occurred
Certain deaths must be notified to the Coroner or a peace
officer regardless of the causes or circumstances involved.
Such places are as follows: rehabilitation centres; adapted
enterprises for handicapped persons; facilities where the
Complete references for this article are available in page 43.
For further information, please contact Maître Sylvain Bellavance,
Director of Legal Affairs.
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19
Dossier
One person in five lives with some form of
chronic pain. How can pain be properly qualified
and quantified? Which mechanisms are responsible for pain?
In this issue, Le Spécialiste presents a few texts
from the book ‘Working Together When Facing
Chronic Pain’ (Faire équipe face à la douleur
chronique), published in French and in English in
2010 under the direction of Louise O’DonnellJasmin. The book deals with all aspects of
chronic pain, from the medical and psychological points of view as well as that of the patient.
Three medical specialists who contributed to the
book have agreed to review their texts (as published) in order to adapt and present them to a
specialized medical audience.
This issue’s Special Report also contains a text
detailing the most recent diagnostic criteria published on the subject of the complex regional
pain syndrome, a pathology that is still unknown
to a great extent.
WORKING TOGETHER
WHEN FACING
CHRONIC PAIN
A BOOK DESIGNED FOR PATIENTS
AND WRITTEN BY THEIR HEALTH PROFESSIONALS
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Working Together When Facing Chronic Pain
(Faire équipe face à la douleur chronique),
Laval, Les Productions Odon, 2010.
www.productionsodon.com
LE SPÉCIALISTE
VOL. 13 NO. 2
JUNE 2011
By Nicole Beaudoin, MD, physiatrist*
Yves Bergeron, MD, physiatrist**
François Fugère, MD, anesthesiologist***
Complex Regional
Pain Syndrome
Complex regional pain syndrome (CRPS) is
probably one of the most disabling of the
known chronic pain syndromes. Adopted in
1993 by the International Association for the
Study of Pain (IASP)1, the term is more
general and descriptive than reflex
sympathetic dystrophy. CRPS is characterized by pain of disproportionate intensity
in relation to the initial lesion. It usually occurs after trauma
or immobilization and is associated with sensitivity
problems, vasomotor changes, or abnormal sudomotor
function. In almost all cases, motor functions are affected,
and may be related or not to trophic changes. Two forms of
CRPS are recognized, and are based on the absence (type
1) or presence (type II) of nervous lesions.
The pathophysiology of CRPS is not completely
understood. Several processes may be involved in its onset
and continuation, including neurogenic inflammation, 2
described by Birklein and Weber, and the phenomena of
central and peripheral neuromodulation.3,4 A hyperactive
sympathetic nervous system is no longer considered the
central element in the pathophysiology of CRPS.5
CRPS predisposing factors
Nearly 65% of CRPS cases occur following trauma.6,7
Impairment of the locomotor system predisposes patients
to CRPS without any real link to the severity of the injury.
Two to five percent of trauma or musculoskeletal injuries
and one to two percent of fractures result in CRPS.8
Incorrectly applied or prolonged immobilization, particularly
when treating complex fractures, can contribute as much
to the appearance of the syndrome as to its chronicity.
Lesion of a peripheral nerve, in particular the median nerve,
results in type II CRPS in essentially 2% to 5% of cases.
Central nervous system involvement is often accompanied
by this syndrome, which is found much more rarely with
regard to visceral pathologies or neoplasias. In 10% to 17%
of cases, there is no identifiable etiology.9
Signs and symptoms
Patients presenting with CRPS describe various symptoms,
usually located at the distal portion of a limb, regardless of
the type of initial trauma. The signs and symptoms are not
limited to a single dermatome; the idea that they are found
only in injured tissue has now been abandoned. They can
appear rapidly, even during the week following trauma.
The predominant symptom is pain10 which is usually
spontaneous, intense, continuous, at times excruciating
and, more often than not, prevents the functional use of the
limb involved. Characteristically, it is exacerbated by joint
movement, as well as by being in an inclined position, by
variations in temperature and by anxiety. In 69% of cases,
the presentation of hyperalgesia or allodynia is described at
the level of the affected limb.
Most patients describe episodes of periarticular swelling
and hyperhidrosis11 as the condition evolves, mainly with
regard to the limb in question. They also report skin
discoloration, often increased or caused by painful stimuli,
stress loading, changes in body or surrounding temperature, as well as by being inclined.12
Despite a significant improvement in symptoms, the patient
may complain of muscle fatigue and lack of coordination or
endurance when undertaking manual tasks or those
requiring fine dexterity. Severe disabilities can develop,
even resulting in non-use of the limb or avoidance
behaviour.
Upon clinical examination, signs of sensitivity continue to
suggest CRPS. Hyperesthesia, dysesthesia and
hyperpathia are frequently observed.13 Allodynia is present
in 30% to 74% of patients.14 Pain caused by lateral
pressure on the metacarpophalangeal joints and by pulling
on the fingers is highly indicative of the presence of CRPS.
The first autonomic signs to look for are hyperhidrosis and
edema.15 Fingers are often the first affected. Chronic
recurrent edema can suggest a case of Münchhausen
syndrome.16 The skin can become mottled, reddish or
bluish. Changes in skin coloration and temperature are
often caused by aggravating factors, and can vary in the
course of a single day. T hey have very l ittl e s peci fici ty. The
presence of bruising does not lead to a diagnosis of CRPS
and should make us look for other etiologies.
Motor function impairment is frequently observed, such as
weakness, loss of active movement, coordination problems
or dystonia. These problems tend to persist in the chronic
phase and are, to a large extent, responsible for the loss of
function. Loss of finger flexion or wrist extension appears
early. Articular limitations at the shoulder joint are often
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21
associated with the presence of CRPS at the distal
extremity. Amyotrophy is most often related to non-use.
Other trophic problems are seen in the chronic phase; nail
splitting and growth disorders, hair loss or thin, shiny skin
is seen in almost half the cases.
It is still difficult to clinically distinguish between the normal
course of an injury and CRPS in the first four weeks after
the initial event, since the specificity of clinical examinations
at this period is very low. Continuous pain, loss of active
finger movement (difficulty in making a fist), hyperhidrosis or
edema extending to the dorsal side of the hand or even to
the forearm lead us to consider CRPS.17
Diagnostic criteria
CRPS diagnostic criteria were first published in 1994 by the
IASP.18 They led to an improvement in identifying the
syndrome. Sensitivity was evaluated at 98%, but specificity
at only 36%. Grouping vasomotor and sudomotor signs
and symptoms within a single criterion could explain the
low specificity. The absence of trophic and motor signs in
the IASP criteria also prevented differentiating CRPS from
other pain syndromes.17 In 2004, an expert panel proposed
new diagnostic criteria that are now used by the majority of
pain specialists.
IN 2004, AN EXPERT PANEL PROPOSED
NEW DIAGNOSTIC CRITERIA THAT ARE
NOW USED BY THE MAJORITY OF PAIN
SPECIALISTS.
Diagnosis
Diagnosing CRPS is based mainly on case history and
physical examination. Clinical tests are used to rule out
other pathologies. There is no clear link between
radiological imaging and the clinical picture, regardless of
the stage of the disease. Osteoporosis may never be
present; it is not a diagnostic criterion. A bone scintiscan
showing hyperfixation involving several joints of the affected
limb during the third phase of the disorder – also known as
the late or bony phase – has long been used as a good
indicator of CRPS.19 However, very few prospective studies
have enabled its evaluation as a useful diagnostic tool.
Scintigraphy has a sensitivity of only 50% during the first six
months following diagnosis; this is further reduced as the
condition progresses.20 It is not a di agno stic criteri on.
Interdisciplinary approach to rehabilitation
and medication
The treatment of CRPS presents a serious challenge
because of our incomplete understanding of pain
mechanisms. It requires an interdisciplinary approach for
the purpose of preventing complications as well achieving
remission and an acceptable quality of life for the patient.21
Immobilization for CRPS must be avoided. The fear of
pain22 usually prevents patients from using the affected limb
in daily life. It thus contributes to the persistence of pain
and disability. Mobilizing the affected limb and integrating it
functionally helps prevent or reverse the process of pain
centralization which could lead to hemisensory neglect of
the affected limb. Progressive motor activation seems to
help reorganize the mental imagery of movement.23 The
treatment sequence must be flexible to achieve adaptation
to the clinical picture, the phase of the condition and the
patient’s pain level. No controlled randomized studies have
evaluated the impact of physiotherapy on the natural
CRPS Diagnostic Criteria
1. Continuous and disproportionate pain in relation
to the initial event
2. At least one symptom in three of the four following
categories:
a. Sensitivity: hyperesthesia
b. Vasomotor: asymmetric variation in skin temperature
or colour
c. Sudomotor/edema: edema, asymmetrical sweating
d. Motor/trophic: amplitude reduction and/or motor
dysfunction (weakness, tremors, dystonia) or trophic
changes (hair, nails, skin)
3. At the time of the exam, at least one sign in two of the
following four categories:
a. Sensitivity: hyperalgesia or allodynia
b. Vasomotor: asymmetric variation in skin temperature
or colour
c. Sudomotor/edema: edema, asymmetrical sweating
d. Motor/trophic: amplitude reduction or motor dysfunction
(weakness, tremor, dystonia) or trophic changes (hair,
nails, skin)
4. No other diagnosis that can better explain signs
and symptoms.
Source: Harden RN, Bruehl S, Stanton-Hicks M, Wilson PR (2007), Proposed new criteria for complex regional pain syndrome. Pain Med 8:326–31
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course of the disorder. However, it remains first-line
treatment,24 although it does not produce beneficial effects
in the chronic phase of CRPS.25
Controlling edema; desensitization techniques; active and
prudent joint mobilization, based on patient tolerance; the
intermittent use of a splint to rest the wrist and fingers; as
well as avoiding aggravating factors are the approaches
used.26 Passive or intensive exercises should be avoided
for patients presenting with severe chronic pain or
allodynia. Using the affected limb in the activities of daily life
and during recreation is encouraged. A weight-relieving
brace, with kneecap support, allows partial weight-bearing
for patients who cannot tolerate putting weight on the foot.
The use of a mirror to reprogram central motor function can
be useful for patients presenting a motor disorder.27
Behavioural techniques can be added when there is
movement phobia. 28 Patients can take part in a
cardiovascular conditioning program according to abilities
and interests.
As the disorder evolves, psychological intervention can
often prove essential for patients with CRPS.29 Depression
is very often a major obstacle to rehabilitation, as is chronic
anxiety disorder or post-traumatic stress syndrome.30
Pain control is key in the treatment of CRPS. Persistent
pain, or pain that is too intense, prevents integration of the
affected limb into functional activities. Relaxation or
visualization techniques can be used. Multiple drugs are
often necessary if, for example, anxious or depressed
patients have, a sleep disorder or daytime sleepiness.31
Various drugs have been proposed for the treatment of
CRPS; however only some of them have been evaluated in
double-blind, randomized trials, with control groups. The
efficacy of corticosteroids for CRPS is reported in the
literature32,33 as well as that of nasal calcitonin in the acute
phase.34,35 Bisphosphonates have proven to be effective in
reducing pain and increasing joint amplitude, also in the
acute phase, although optimal dosage regimens are still
unknown.36,37,38 Tricyclic antidepressants are frequently used
in the chronic phase. Anticonvulsants such as gabapentin39
and pregabalin40 have been shown to be effective in
reducing neuropathic pain. Topical analgesic agents
(aerosols, creams, gels or 5% lidocaine patches) have
proven effective for neuropathic pain, including CRPS.41
Clinical experience has shown that muscle relaxants such
as baclofen and tizanidine or intra-articular injections of
corticoids can reduce pain. Opioids, administered in the
acute phase for a short period, can facilitate functional
reactivation during physiotherapy or occupational therapy.
There is very little evidence to establish the best time,
number and need for regional anesthetic techniques
(sympathetic and parasympathetic nerve blocks) in the
diagnosis and treatment of CRPS. Few randomized
prospective studies have evaluated their effecticacy.
Clinical evolution and prognosis
With time, slightly more than 10% of CRPS patients
experience a relapse, half of them without any new related
event.42 Initially, the signs and symptoms are located at the
site of the trauma. They can become more diffuse, migrate
proximally or, far more rarely, to another limb.43,44 They can
reappear more than two years after the initial symptoms.
CRPS can last from a few weeks to several years.
All patients do not progress towards an amyotrophic,
dystonic picture or major functional crippling. Sixty-four
percent of patients evolve relatively well over the years, but
barely half of them have no symptoms. Only 15% recover
grip strength that is more than 50% of their former
strength.45 In more than 60% of cases, patients are
restricted in their daily or domestic activities.46 Mood and
sleep disturbances are frequent and quality of life is
diminished.47
The pathophysiology of CRPS is still unknown to a large
extent. Diagnostic criteria are still essentially clinical. A
better understanding of this syndrome will prevent
mistaken or missed diagnoses of CRPS.
References
S
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* Dr. Beaudoin is physiatrist at the Institut de réadaptation Gingras-Lindsay de Montréal and associate professor at the Université de Montréal
** Dr. Bergeron is physiatrist at the CHUM (Hôpital Notre-Dame) and assistant clinical professor at the Université de Montréal
*** Dr. Fugère is anaesthesiologist at Hôpital Maisonneuve-Rosemont
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By Guylène Cloutier, MD*
PSYCHIATRIST
When Pain is Synonymous with Unhappiness...
Mood Disorders and Chronic Pain
The Role of the Psychiatrist in a Pain Clinic
The psychiatrist plays an important role within the
interdisciplinary team treating chronic pain. His or her sole
mission is to confirm the existence of a psychiatric pathology
with an impact on the clinical presentation and treatment of
the chronic pain condition. Major depression and pain make
up a complex clinical presentation and the exact
interrelationships between these conditions have not yet
been clearly established even though several hypotheses
have been suggested.
The treatment of chronic pain must involve the treatment of
major depression, when it is present; a medical team that
neglects one or the other of these facets risks giving rise to
a chronic condition or, through the persistence of residual
symptoms from one or the other, place the patient at risk of
suffering a relapse.
Psychiatrists are also sleep experts. Sleep disorders in
patients with chronic pain are also associated with a more
unfavourable prognosis. Insomnia can aggravate
psychological and somatic symptoms.
Chronic Pain and Depression: the Chicken
or the Egg?
Pain, especially when it is acute, is a sensation that plays a
role in survival. When this sensation extends over a long
period of time, regardless of whether the cause can be
identified and treated, it becomes chronic pain, which is a
predisposing factor for depression. Approximately 40% to
60% of individuals with chronic pain will suffer from major
depression. Depression itself also brings on pain, pain that is
not only emotional but physical.
For several years now, although pain as a symptom is not a
diagnostic criterion for major depression, researchers have
agreed that pain symptoms (headaches, back pain,
musculoskeletal pain, muscular tension, heartburn, etc.) can
be part of a mood disorder in about 60% to 85% of cases.
Some people have criticized the diagnostic criteria of the
Diagnostic and Statistical Manual of Mental Disorders (DSMIV-TR) for giving psychological criteria priority over somatic
criteria. Not only are these types of pain part of the clinical
presentation, but the treatment of this disease can
occasionally lead to the complete resolution, or at least the
alleviation of this category of symptoms.
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Depression and pain have a complex and reciprocal
relationship. Each of these conditions aggravates the
severity of the other. Pain is an obstacle to the achievement
of remission in the patient who suffers from a depressive
episode. Depression accentuates an individual’s pain. The
overlapping of pain and depression demonstrates the need
for combined and simultaneous treatment of both medical
conditions.
Is Depression a Weakness of Character?
Depression is a disease that is still too often tainted with
shame. In Canada, in 2002, 4.8% of the population suffered
from a major depressive disorder. One person out of five will
suffer from depression during the course of their lifetime.
Depression does not strike randomly: clearly identified risk
factors can predispose us to the development of this
medical condition.
The presence of chronic pain increases the risk of
developing major depression. Although major depression
can be qualified as mild, it will still require pharmacological
treatment or psychotherapy. Left untreated, it modifies the
neurobiological structure of the brain and causes emotional,
physical and/or cognitive symptoms that can be irreversible
if they persist for several years.
Fortunately, major depression, when it is treated early and
effectively, can also at times be completely healed. This is
one of the reasons why we must continue to demand better
access to first-, second-, and third-line care. People
suffering from depression and those around them tend to
find a multitude of reasons to account for the presence of
depressive symptoms: “You have to understand, she’s just
lost her job. Her daughter is very ill. He’s suffering so much;
I’d be depressed too if I were in his shoes. He just has to
push a little. She likes to wallow in her sadness.”
It is essential to treat depression as early as possible if we
want to avoid it progressing to a chronic state.
Sleep Disorders
Sleep disorders are closely associated with psychiatric
problems and chronic pain conditions. The three conditions
make up an infernal triangle for the patient. The presence of
insomnia is associated with greater morbidity in the primary
condition.
Text adapted by the author especially for Le Spécialiste.
The original text was published in Working together When Facing Chronic Pain.
Les Productions Odon, Laval (2010), www.productionsodon.com
Several epidemiological studies have shown that patients with
insomnia tend to present with more serious psychic distress as
well a reduced capacity to manage stressors.
Chronic pain is associated with a greater prevalence of sleep
disorders. Pain aggravates sleep disorders and sleep disorders
negatively alter the perception of pain.
Sleep disorders can include difficulty falling asleep, difficulty
staying asleep or sleep that is not perceived as having been
restful by the patient. This last category has been studied
especially in fibromyalgia patients.
Treatments studied up to now include cognitive-behavioural
interventions, teaching the patient good sleep hygiene, as well
as a regimen of physical activities. Pharmacological treatments
that have been the subject of studies include the
benzodiazepines (triazolam), tricyclic antidepressants
(amitriptyline) as well as zolpidem and zopiclone. These
molecules have not however been successful in reversing EEG
anomalies encountered in insomniac patients.
The close availability of a psychiatrist is then of great assistance.
Along the same lines, psychotherapy plays an essential role as
well. It must focus on change, not only on providing reasons for
an individual’s difficulties. Cognitive and behavioural
interventions are those that have been studied the most.
Conclusion
Some people have wanted to believe that major depression
results from a lack of courage, that it is a failure, a reflection of
a patient’s inability to adapt to a chronic pain condition. This is
not so. Depression is not synonymous with weakness,
regardless of the cause. It is a disease that can have lasting
effects, and that can recur if it is not treated in time. Depression
is contagious: the spouses and children of those who suffer
from depression are more at risk of becoming depressed
themselves. Depression can result in death (15% risk of
successful suicide). Depression must be treated, whatever
its cause.
Treating Major Depression
Several chronic pain conditions are being treated with
increasing effectiveness. Certain types of chronic pain,
combined with a mood disorder or a functional somatic
syndrome, have not yet been characterized and are
occasionally attributed, at least in part, to faking or
exaggeration on the part of the patient. If the treatment is to
succeed, health professionals and patients must share the
same understanding of the clinical picture and the treatment
plan.
A therapeutic partnership is essential and is built upon the
quality of the dialogue between the care-giver and the patient.
Several therapeutic means can be chosen to treat mild or
moderate depression. Commonsense is always appropriate
and good personal health practices may lead to a prompt
recovery. It is often necessary and essential to add other
therapeutic means, such as a pharmacological treatment or
psychotherapy, or a combination of these.
Medication includes various classes of antidepressants, several
of which are also used to treat pain conditions that are not
necessarily associated with depression. As mentioned earlier,
these various conditions probably share common
psychopathological mechanisms. When antidepressants are
used by non psychiatrists, it is important to take into
consideration the possible existence of depression associated
with a bipolar disorder that can sometimes clinically resemble
major depression, but that is associated with a response that
can be catastrophic (euphoric, depressive, or mixed episodes).
References
CME Institute. Academic highlights, depression and pain. J Clin
Psychiatry 2008 ;69:1970-8.
Fava M. Somatic symptoms, depression, and antidepressant treatment.
J Clin Psychiatry 2002 ; 63:305-7.
Gameroff MJ, Olfson M. Major depressive disorder, somatic pain, and
health care costs in an urban primary care practice. J Clin Psychiatry
2006;67:1232-9.
Graziono O, Bernabei R. Association between pain and depression among
older adults in Europe: Results from the aged in home care (AdHOC)
project: a cross-sectional study. J Clin Psychiatry 2005 ;66:982-8.
Lee P, Dossenbach M. Frequency of painful physical symptoms with major
depressive disorder in Asia: Relationship with disease severity and quality
of life. J Clin Psychiatry 2009 ;70:83-91.
Ohayon MM. Specific characteristics of the pain/depression association in
the general population. J Clin Psychiatry 2004 ;65(suppl 12):5-9.
Stahl SM. Stahls’ essential psychopharmacology, Neuroscientific basis
and practical applications. Cambridge: Cambridge University Press, 2008.
Workman EA, Hubbard JR, Felker BL. Comorbid psychiatric disorders and
predictors of pain management success in patients with chronic pain.
Primary Care Companion. J Clin Psychiatry 2002 ;4:137-40.
Zimmerman M, McGlischey JB, Posternack MA, Friedman M, Boerescu D,
Attiullah M. Differences between minimally depressed patients who do and
do not consider themselves to be in remission. J Clin Psychiatry
2005;66:1134-8.
Benca RM, Ancoli-Israel S, Modolfsky H. Special consideration in
insomnia diagnosis and management: depressed, elderly and chronic pain
populations. J Clin Psychiatry 2004 ;65(suppl 8):26-35.
* The author is psychiatrist at the Clinique États d’Esprit.
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By René Truchon, MD*
ANESTHESIOLOGIST
Neuropathic Pain
Of the three principal types of chronic pain, neuropathic pain
is the one that has seen enormous progress with respect to
understanding its underlying mechanisms and developing
new pharmacological agents.
Chronic pain affects approximately 20% of the adult Canadian
population, ranking it ahead of diabetes and asthma. Recent
Canadian surveys reveal that 5.7% of the pediatric population
also suffers from chronic pain. Moreover, neuropathic pain
affects 2% to 3% of the Canadian population which
represents close to one million Canadians.
Physiopathology can be used to classify chronic pain into
three broad categories (excluding visceral pain): nociceptive,
idiopathic (psychological) and neuropathic. The underlying
mechanisms are complex and involve a multitude of receptors
and biochemical substances. When the pain process
becomes chronic, various types most often overlap resulting
in what is called mixed neuropathic pain. Pure neuropathic
pain, as a result, is clinically rarer. In this article, we will only
discuss the neuropathic component of chronic pain.
Neuropathic pain results from a dysfunction of the nervous
system at several levels (brain, spinal cord and peripheral
nerves). It is important to understand that once pain has
become chronic, it is independent of the initial trauma or
lesion and is maintained by the patient’s own nervous system.
The syndrome then evolves according to the dysfunction of
the nervous system, not necessarily as the consequence of an
anatomical pathology.
Pathophysiology
Unlike nociceptive pain which we feel as a result of tissue
trauma when we burn or prick ourselves, neuropathic pain
results from a dysfunction of the nervous system at various
sites throughout the human body. It is maintained by the
nervous system itself, even when the initial trauma or painful
lesion is healed. Notable changes in the nervous system
(brain, spinal cord, nerves) involved in the appearance of
neuropathic pain include:
• Spontaneous discharge of painful impulses from peripheral
nerves and the spinal cord, which causes the patient to
experience electrical discharges;
• At the level of nerves and the spinal cord, increased
transmission and amplification of normal nerve impulses; for
example, where touch is concerned, the signals can be
perceived as a burning sensation rather than a light stroke
of the skin (allodynia);
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• The appearance of spontaneous impulses from the pain
coordination center (the thalamus may present phenomena
similar to the ones observed in the nerves and spinal cord);
these spontaneous discharges can themselves be painful
or exaggerate pain messages from other regions of the
body. In addition, at the level of the spinal cord, the
mechanisms in a healthy subject that partially block the
conduction of pain signals to the brain, have become very
weak or inexistent in the affected patient, thus increasing
the sensation of pain. Numerous protective hormones,
such as endorphin, serotonin, noradrenaline and various
neurotransmitters, become much less effective at reducing
or blocking neuropathic pain.
Thus, in order to relieve neuropathic pain, the physician will
use specific classes of medication that will act on the different
portions of the nervous system:
• On the cutaneous or mucous levels, by blocking the
spontaneous triggering of pain and the conduction of
painful impulses: this is the mode of action of local topical
anaesthetics, such as lidocaine;
• On the medullar and cerebral levels, by blocking the
transmission of pain signals with anticonvulsants (pregabalin
and gabapentin) or antidepressants (amitriptyline, venlafaxine,
duloxetine) that modify the action of serotonin and
noradrenaline that our body produces.
• When pain is intense or disabling, treatment on both
peripheral and central levels will be sought through the use
of medication with analgesia as the principal effect: opioids
(morphine, hydromorphone, methadone), tramadol, and
acetaminophen.
Symptoms
Chronic pain with a neuropathic component is accompanied
by numerous physical signs and symptoms (see table). The
specific characteristics of neuropathic pain include the
perception of a cutaneous burning sensation, spontaneous
and continuous spasms often associated with tingling
sensations or electrical shocks in a given region. Other
symptoms are allodynia, hyperalgesia or hyperpathia. The
physician will systematically look for pain located more distally,
but still linked to the injured area (for example, pain in the right
hand after a lesion to the right shoulder).
When nerve tissue has suffered a direct lesion, the healing
process attempts to repair the injury in the following weeks or
months. Thus, a nerve that has been cut or crushed tries to
regenerate by forming a bud or neuroma. The latter can
automatically trigger activity in the damaged nerve, which the
patient experiences as an electrical discharge or muscular
contraction. Moreover, neuromas cause exaggerated responses
to touch. The patient describes extreme sensitivity to touch
and spontaneous tingling sensations.
At times, the sympathetic component of the nerve may be
affected by the same nerve dysfunction that provokes
neuropathic pain. The syndrome is then called complex
regional pain syndrome (CRPS).
Autonomic signs and symptoms develop superfluous
components that are characterized by a sensation of burning
heat or cold in a painful or injured part of the body. A complete
limb may be affected and develop edema and present
sudomotor anomalies or abnormal hair growth that may
increase or totally disappear. Very frequently, sudden
variations in colour in the painful region can manifest
themselves; for example, the affected hand becomes deep
red or pasty white.
Without specific treatment, such as a sympathetic nerve block
combined with intensive physiotherapy, a limb affected by
complex regional pain syndrome may become totally
disabled, with severe atrophy of the muscles, complete
ankylosis of the joints, swelling of the fingers, and continuous
pain. At the severe dystrophy stage, the affected hand can
also become twisted into the shape of claw if it is not
submitted to intensive treatment rapidly. Pain treatment
centres undertake the evaluation of this condition and provide
urgent treatment.
Characteristics of Neuropathic Pain
• Sensation of cutaneous burn
• Spontaneous and continuous spasms
• Spontaneous or provoked tingling or electrical discharges
• Allodynia: pain caused by a stimulus that is not intrinsically painful
• Hyperalgesia: intense pain perceived when the triggering stimulus
is only slightly painful
• Hyperpathia: long-term, intense pain after repetitive pain is
provoked
Multi-Dimensional Evaluation
During the patient’s initial evaluation, the physician makes an indepth examination of the events that led to the problem; he will
be looking for clinical signs of neuropathic pain through the use
of specific and multi-dimensional evaluation tools such as the
following questionnaires: EVA, McGill, BECK, MPI, BPI, MMPI2, SIP, etc. These questionnaires are used to measure the
functional, psychological and social effects on the individual.
Neuropathic Evaluation
Various specialized questionnaires enable us to measure the
impact of neuropathic pain (Neuropathic Pain Scale, DN4 and
Pain Detect). These have been validated scientifically and are
used as well to track the progress of treatments, both physical
and psychosocial.
Treatment
The treatment of neuropathic pain has three objectives:
1. to minimize the pain or make it tolerable;
Most common sources of neuropathic pain
CENTRAL
•
•
•
•
•
•
•
Hemicorpus pain following a CVA
AIDS-related myelopathy
Spinal cord injury
Multiple sclerosis
Phantom limb pain
Parkinson’s disease
Spinal cord lesion
PERIPHERAL
•
•
•
•
•
•
•
•
•
•
•
Trigeminal neuralgia
Complex regional pain syndrome
Nerve compression in a limb
Nerve damage caused by HIV
Diabetic neuropathies
Postherpetic neuralgia
Post-thoracotomy and post-thoracoscopy neuralgia
Radicular disc herniation
Neuropathy following anti-cancer chemotherapy
Nerve amputation (as part of a limb amputation)
Post-mastectomy pain
2. to improve the functioning of the body and the individual;
3. to improve the patient’s quality of life.
These objectives have to be reached with a minimum of side
effects from treatments and medication. All therapeutic means
must be integrated into the patient’s treatment schedules and
plans, while relying on his or her active involvement in the
therapy.
Non-Pharmacological Treatments
Non-pharmacological
categories:
treatments
include
the
following
• Physical treatment (physiotherapy, occupational therapy,
kinesiology);
• Rehabilitation and psycho-social treatments (psychiatric and
psychological evaluations and treatments, individual and
group therapies);
• Evaluation of the patient’s social and professional
circumstances along with current and future effects resulting
from the neuropathic pain syndrome diagnosis.
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Pharmacological Treatment
Pharmacological treatment of neuropathic pain follows
treatment algorithms developed by experts. These were
based on the evaluation of treatment protocols, randomized
and controlled studies and a systematic review of the
therapeutic effectiveness of various pharmacological agents.
When neuropathic pain is diagnosed, the first objective is to
relieve the pain by following the recommendations contained
in the Québec treatment algorithm for neuropathic pain.
Treatment starts with the use of a single agent (in Class 1).
Following this, a second pharmacological agent may be
combined with the first or may be substituted for it. When
certain symptoms are present, specific therapies, such as
the use of a topical anaesthetic (lidocaine) or a ketaminebased cream may be proposed, as is done in the case of
postherpetic pain.
Depending on circumstances, an antidepressant can be
prescribed to provide pain relief (nortriptyline, amitriptyline,
desipramine and venlafaxine). Medication can also be
prescribed to prevent painful impulses from being conducted
through the spinal cord. Other drugs can also be used at the
start of the treatment, such as anticonvulsants that block
pain through their effect on the alpha-2-delta nerve receptor.
For patients with severe, debilitating pain, analgesic
medication can be administered concomitantly, namely a
morphine derivative or tramadol.
The purpose of adjusting the medication is to obtain pain
relief with an EVA evaluation of less than 4/10 or tolerable for
the patient. Pharmacological treatment that effectively
inhibits pain will frequently involve a combination of several
medications from the four classes in the treatment algorithm.
These medications will be adjusted to obtain the fewest side
effects possible with effective relief.
Specialized Treatments at a Pain Treatment
Center
Pain treatment centres are located in large urban centres.
The advantage of these centres lies in the multidisciplinary
and interdisciplinary treatment team who have superspecialized invasive techniques available. These services are
offered to all the patients who have not responded
adequately to the treatment algorithm’s Class I and Class 2
medications, even though they have been receiving physical
and psychological therapies.
In the case of CRPS, specific treatments include sympathetic and parasympathetic nerve blocks, chemical or
thermal neurolysis, epidural cortisone injections or cortisone
* The author is medical director of the RUIS Université Laval Chronic
Pain Centre.
injections near a nerve root, and the destruction of small
sensitive fibres or neuromas by radiofrequency techniques.
Neuromodulation may also be proposed.
Major pain treatment centres can also call upon specific
programs to combine interventions by several practitioners
(physical medicine, rehabilitation, psychology, psychiatry,
anaesthesiology, etc.) so as to improve the physical,
psychological and social aspects of the patient’s life.
Treatment Options for Chronic Neuropathic Pain
PHYSICAL
• Normal physical activities
• Swimming, physiotherapy, passive and active occupational
therapy
• Stretching
• Physical training
• Weight loss
• Massage and acupuncture
• TENS
• Physical rehabilitation
• Physical retraining
PSYCHOLOGICAL
• Psychotherapy
• Stress management and reduction
• Behavioural therapy
• Cognitive therapies
• Mirror imaging
• Reprogramming
• Individual and group therapies
• Family therapy
INVASIVE PROCEDURES
• Steroids
• Infiltration anesthesia
• Sympathetic block
• Peripheral and central nervous blocks
• Therapeutic epidurals
• Specific rhizotomy by radiofrequency treatment or by
cryotherapy
• Implanting central and peripheral spinal stimulation
• Spinal injection of opiates with co-analgesics in a closed
circuit
• Nerve decompression surgery
• Central cerebral stimulation
PHARMACOLOGICAL
• Canadian and Québec pharmacological protocol for the
treatment of neuropathic pain
The goals of the ‘best’ therapy
•
•
•
•
•
Greatest evidence of effectiveness;
Most readily available;
Least costly;
Fewest secondary or harmful effects;
Least painful.
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By Christian Cloutier, MD*
NEUROSURGEON
Neuromodulation
There are many approaches to dealing with pain: drug therapy,
physical therapy, psychological therapy, etc. Occasionally, these
approaches do not successfully relieve painful conditions,
particularly those of a neuropathic nature and it then becomes
necessary to refer the patient to a physician for an invasive
treatment. Occasionally, curative surgery is indicated (for a
herniated disk, a nerve compressed by a pulsating artery, etc.), or
the implanting of a neuromodulation device for certain types of
refractory pain (in pre-selected and well-prepared patients).
These treatments may appear risky, yet, since they are known to
be effective, they may be less dangerous than the over-use of
conventional approaches. Above all, they can be very beneficial
for the individual who is dealing with severe, incapacitating pain
that is destroying his or her life.
When so-called conservative medical treatment fails, it is
occasionally possible and necessary to have recourse to what
are known as invasive techniques (surgical). As mentioned
previously, any treatment for chronic pain must be multimodal.
Health Canada had already put out the following warning in
1990: “… no specialty or therapeutic intervention can remedy this
problem on its own. We can only overcome it by calling upon the
skills of specialists in several disciplines.”
In certain cases of severe, rebellious and refractory pain, the
patient must be referred to an interventionist surgeon. Most
often, this will be a neurosurgeon.
Surgical Approaches
Curative surgical approaches
Occasionally, there is a clear indication for surgery to correct the
cause of the pain, as in the case of a herniated disc, lumbar
spinal stenosis, a tumorous mass, a vascular loop compressing
the trigeminal nerve (causing facial pain like an electrical
discharge), etc. There is a possibility these surgical treatments will
remedy the anomaly and often eliminate the pain completely.
However, certain types of interventions that create lesions
(destructive) are very useful in certain situations, such as
irradiating the Gasserian ganglion of the sensitive facial nerve
(trigeminal nerve), with a Gamma Knife. This device creates a
partial lesion through ionized radiation with concentrated gamma
rays on the ganglion. In order to relieve facet pain (one of the
causes of neck pain and non-specific lower back pain), we can
perform a thermolesion on the posteromedial branch of the nerve
of the zygoapophyseal joint (the posterior joint of the vertebra,
called the facet). Such a procedure is indicated for patients who
experienced adequate but temporary relief (lasting only a few
weeks) following an infiltration (xylocaine and cortisone).
Thermolesion provides an extended, but highly variable effect (a
few months to a few years).
Augmentative surgical approaches
Finally, there are the augmentative surgical approaches, so called
because they involve the addition of specialized equipment, such
as neurostimulators or intrathecal pumps. If no beneficial
analgesic effect is obtained, the equipment is removed and there
is usually no consequence for the patient nor, more importantly,
any damage to the central nervous system.
Neuromodulation
The term ‘neuromodulation’ refers to a specialized medical
treatment, used to modulate the functioning (and not alter the
anatomy) of the nervous system and to alleviate pain. This is
done by surgically implanting a device that either electrically
stimulates or chemically inhibits the transmission of the signal or
neuron activity, in order to produce a therapeutic effect. Two very
different systems are used:
• The first, known as neurostimulation, consists of electrically
stimulating certain parts of the nervous system (the spinal cord
or the brain);
• The second involves injecting substances into the cerebrospinal
fluid in the spinal column through an intrathecal pump.
Destructive surgical approaches
For a long time, it was believed that cutting off the painful nerve
impulse was the only effective solution. For example, the nerve or
nerve bundle was sectioned in the spinal cord at the level
corresponding to the zone of pain. Nowadays, we know that the
central nervous system reacts very poorly to such an insult, that
the pain returns within 6 to 12 months, often intensified, and that
the consequences of a loss of function can be devastating.
These approaches are rarely used, except in the case of palliative
care provided to terminal phase patients, with a life expectancy
of less than three to six months.
Compared to destructive techniques, neuromodulation systems
are clearly better in clinical terms.
Before an internal neuromodulation system is installed, care must
be taken to accurately identify the medical pathology, as well as
ensure the patient is a good candidate for this invasive surgical
approach (indication and risks), that he or she is psychologically
prepared to undergo this type of surgery (profile, expectations)
and that he or she has a clear understanding of the
consequences of the surgery.
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The exact mechanisms involved in neuromodulation through the
stimulation of the posterior cords of the spinal cord remain
unknown: electrical effect on the neurotransmitters of the
posterior horn or activation of the long ascending or descending
nerve bundles of the spinal cord.
These interventions are called invasive because there is a risk of
complications. The one most feared is an epidural hematoma
(rare: 1 case out of 700) along with paraparesis, or even
paraplegia, a paralysis of the lower limbs with urinary
incontinence. Most often, it can be reversed through the exeresis
(removal) of accumulated blood, but there is a very low possibility
of irreversible damage.
Does the effect occur at the spinal level, where the electrode is
placed, or at the supraspinal level; or at the cerebral level from a
distance? Articles in the past related evidence that stimulation
was only effective 50% of the time over the long-term.1 In 2007,
a group of researchers at the European Federation of
Neurological Societies (EFNS) published a complete review of the
literature, encompassing the most recent articles based on
evidence.2 This review attributes B-level effectiveness, i.e.
probably effective, to neurostimulation in cases of refractory
lumbar sciatica (or Failed Back Surgery Syndrome, for patients
with at least one but especially several lower back operations);
and cases of Type 1 complex regional pain syndrome (CRPS), i.e.
the type with no neurological lesions.
In the most refractory situations, it is possible to place the
electrode in the cortical motor epidural region of the brain when
dealing with neuropathic pain, or to insert the electrode in the
thalamus for nociceptive pain. Motor cortex stimulation or MCS,
the type most commonly used at present, produces good
results4 for neuropathic pain of the face and arms, and for pain
secondary to a cerebral vascular accident (CVA), formerly
referred to as thalamic syndrome. Neuropathic pain in the lower
limbs is excluded, since there is a problem with accessibility and
the procedure for inserting the electrode on the median line (of
the brain), the falx cerebri.
Neurostimulation, spinal cord and brain
The review attributed D-level effectiveness, or the one based on
descriptive, non-comparative studies, for the relief of pain caused
by Type 2 CRPS (with nerve damage); a traumatic, diabetic or
postherpetic neuropathy; a plexopathy; an amputation (phantom
limb) or a partial spinal injury.
To summarize, effectiveness is recognized for neuropathic
lesions, particularly those that are peripheral and result in
neuropathic pain, clearly identified by means of the DN43
questionnaire, and which must be accompanied by a sensory
deficit, a state of deafferentation. On the other hand, purely
nociceptive pain (somatic and visceral, not neurological) does not
respond to this technique, unless the cause is vascular, as in the
case of chronic ischemia of the lower limbs, and serious
refractory angina. Once again, the mechanism is not understood,
although probably managed by interaction via the autonomic
sympathetic system, since neurostimulation serves to improve
vascularization. Results for these patients are excellent in the
context of a progressive disease. The condition improves initially,
then deteriorates in the long term, but with a lot less pain.
It is difficult to conduct comparative placebo-controlled studies
on surgical treatments with equipment installation; such
randomized studies are rather rare. Yet, the lack of evidence does
not necessarily mean the absence of effectiveness. The relief rate
is 70% to 85% for well-selected cases. In a review of 101
patients, conducted by the author, the effectiveness rate was
85% (article in preparation). It should not be forgotten that we are
at the top of the ladder in terms of pain treatment. The cases
selected were difficult-to-treat refractory ones.
Intrathecal pump
The intrathecal pump is exceptionally effective in the case of
spasticity (using baclofen), and significantly effective in the case
of refractory pain, particularly neuropathic pain (using an
anaesthetic substance, an opiate or clonidine). It is possible to
insert a catheter in the spinal column and the pump under the
skin of the abdomen without too great a risk. The principal
inconvenience for the patient is the need to return to the outpatient clinic every three months to fill the pump, except for
baclofen, where this can be done every six months if the amount
to be injected does exceed the capacity of the pump‘s reservoir.
This localized and targeted pharmacotherapy5 allows a gradient
of 100:1, on average, for the dosage the patient is to receive. As
a result, systemic secondary effects can be reduced
considerably, except in the case of opiates that deregulate the
hypothalomo-hypophyseal axis. This could create a series of
endocrinal problems, for example, this could result in
amenorrhea for women and hypogonadism in men.
Conclusion
As in any other surgical intervention, these invasive techniques
can result in complications which are for the most part perioperatory, yet rarely significant and permanent. For this reason,
these invasive approaches are reserved for well selected clinical
conditions. In a therapeutic context, at times both difficult and
burdensome, this approach serves not only to reduce the pain but
also to increase the physical activities of daily life and reduce the
quantity of drugs that in turn have their own load of complications.
References
* The author is clinical Professor, Department of Surgery, Centre
hospitalier universitaire de Sherbrooke (CHUS); President of the
Quebec Pain Society; Medical Officer, Pain Expertise Centre,
Sherbrooke RUIS.
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GREAT NAMES IN QUEBEC MEDICINE
Where There’s a Will, There’s a Way
“Why is my best friend poor, and why does she live in such
difficult conditions?” These were Christine Colin’s first great
observations as a youngster living in Nancy and discovering
the extent of social inequities. The painful observation
created the desire to find an explanation and a solution, in
order to compensate for the negative effects linked to
social differences.
Extremely gifted in science, one day she received the book
Great Men of Medicine by Ruth Fox Hume as a school prize;
she found it fascinating. She realized that medicine was the
path she could follow some day to help people, and it was the
clinical side that attracted her. However, during the course of
her studies and meeting professors who had an influence on
her, she realized that fixing a broken arm was easy; but if we
could avoid breaking the bone, the situation would be better,
both for the person and for society. That was what made
her opt for a career in public health, bringing together
the prevention aspect and the battle against inequalities
in healthcare.
She received her medical degree in France, where her thesis
dealt with the epidemiology of newborns from disadvantaged
areas. An in-depth study of patient medical files caused her to
observe that the incidence of certain problems, such as
premature birth rates, delayed development and the low birth
weight of the newborns was directly related to living
conditions, as well as health problems suffered by the
mothers. Her thesis gave her a desire to follow through on the
question. Then, she received a proposal to continue her
training in Quebec. She fell in love with Quebec and... with a
Quebecker, with whom she has two children.
Since 1985, Dr. Colin has worked as a medical specialist in the
field of community health, department head and director of the
community health department, while at the same time being a
professor (at the clinical level, as a full professor, then as a
tenured professor). She became the first dean of the Faculty
of Nursing Sciences at the Université de Montréal who did not
hold the professional title of nurse. She published and
produced numerous prevention programs, including Naître
égaux – Grandir en santé and Le défi de l’intervention
prénatale en milieu défavorisé.
Dr. Colin says she has never had a career plan. “I knew I
wanted to work on identifying the healthcare needs of the
underprivileged and set up prevention programs to respond to
them.” She did everything possible to advance the fight
against social inequity: developing strategic plans, taking
stands and presenting reports to parliamentary committees.
She took advantage of every opportunity to defend her ideas
and her convictions. Recognized for her expertise, she was
selected to fill the position of Assistant Deputy Minister for
Public Health and General Manager of Public Health (MSSS) in
1993; a position, however, that would force her to live away
from her family. She was convinced that the position would
help her advance public health issues. But the political
environment at the time was difficult, with Quebec going
through a period of severe budgetary cutbacks and
major reforms.
Dr. Christine Colin
Community Health Specialist
With respect to her time at the MSSS, Dr. Colin has good
memories of the major projects to which she contributed a
great deal. She is especially proud of the production of the first
Quebec public health priorities (1997-2002), upon agreement
between the various parties. She is also glad she helped
create the Institut national de santé publique du Québec, and
was in at the beginning of the redistribution of regional
financial resources.
Back in Montreal, Dr. Colin became Director of the
International Adoption Secretariat, an ideal position for
someone who has for years represented Quebec on missions
abroad. Since 2010, she has directed the Health Promotion
Centre of Sainte-Justine University Hospital Centre, an
innovative project that draws together all those who care
about children. Dr. Colin is currently on a sabbatical from the
university: a period to recharge her professional batteries, but
definitely not a rest, as she maintains her hospital obligations
and her international schedule. And these already keep her
busy full-time!
If we had to summarize Dr. Colin’s career, we could certainly
say she is a physician who is totally committed to her
professional practice, someone with vision who knows how to
bring together all areas of public health, whether at the level of
management, planning and practical aspects, as well as field
organization. It is therefore not surprising that she has received
numerous prizes and awards for an exceptional career. In
June 2010, Dr. Christine Colin became a Chevalière de l’Ordre
national, the highest distinction awarded by the government
of Quebec.
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CONTINUING PROFESSIONAL EDUCATION
By Gilles Hudon, MD
DIRECTOR, HEALTH POLICIES AND PROFESSIONAL DEVELOPMENT OFFICE
3rd Cycle Changes
RCPSC Maintenance of Certification Program
Officially launched in 2001, after a one-year pilot project, the first and second
five-year cycles of the Maintenance of Certification (MOC) Program ended in
2005 and 2010 respectively.
The program’s third cycle starts in 2011 and changes are
being made at 3 levels: the educational activity framework is
reduced from 6 to 3 sections; the number of credits granted
for each hour of learning is unchanged for certain activities,
reduced or increased for others; finally, the requirement for
400 credits over 5 years or, at a minimum, 40 credits per
year remains unchanged, although no more than 75% of
credits will be applicable to a single section within a cycle
from now on.
In 2010 in Quebec, 6,077 medical specialists were Fellows
and close to 90% of them participated in the MOC program.
In addition, some 325 Quebec medical specialists not
certified by the Royal College also took part in the Royal
College of Physicians and Surgeons of Canada’s (RCPSC)
continuing professional development program (CPD).
Framework of activities
During its first 10 years, the MOC offered Fellows a
framework of educational activities divided into 6 sections.
This framework was widely criticized by Fellows because,
after 10 years, they claimed they still could not memorize it.
The lack of logic in the presentation seemed to annoy many.
From now on, the new framework will contain three sections
in an easily-remembered order: group learning activities
(certified or not), self-learning activities and assessment
activities (knowledge assessment and performance
assessment).
New credit system
The first 2 cycles have kept the same initial system of credits
or learning units, whereby only non-certified activities in
section 2 have a limit of 20 credits per year, for a total of 100
credits per 5-year cycle. The program’s designers had
assumed that over the years Fellows would use the more
personal type of activities, such as the certified selfassessment programs (section 3), structured educational
projects (section 4) or practice assessment (section 5). That
was their aim, but the reality turned out to be different.
Credited group activities, basically conferences and hospital
meetings, was the section used most often to claim credits:
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a Fellow could meet the requirements of the Maintenance of
Certification Program by just passively attending accredited
group activities.
Almost everywhere around the world, CPD is increasingly
being defined as an endeavour to improve the quality of care
and not simply the acquisition of new knowledge. In the
United States, a new association, the National Institute for
Quality Improvement and Education (NIQIE), wants to
abolish continuing medical education in classrooms and
move it to the workplace, calling for it to be coupled with
Continuing Quality Improvement (CQI) Departments in U.S.
hospital centres. In France, the new HPST (Hôpital Patient
Santé Territoire) law defines CPD as being a combination of
continuing medical education (CME) and the assessment of
professional practice (APP). Thus, the current direction taken
by the RCPSC is not a Canadian invention, but follows the
CPD trend taken in all Western countries.
The proposed new credit system encourages Fellows to
devote more time to reflection and self-assessment of their
practice. An assessment activity would thus allow a Fellow to
claim three learning units per hour of participation. On the
other hand, group learning activities would continue to
receive one credit per hour of participation, while noncertified activities would be reduced to one-half credit per
hour of participation. Self-learning activities will no longer be
evaluated based solely on the number of hours of
participation, but also in terms of accomplishment. Credits
for personal learning projects will be increased to two per
hour, and reading specialized journals would receive one
credit per activity. Developing guidelines or taking part in a
patient safety committee would receive 20 or 15 credits per
year, respectively.
Useful links towards the MOC Section
www.collegeroyal.ca/mdc
www.collegeroyal.ca/mainport
CONTINUING PROFESSIONAL EDUCATION @SUITEA
Concerns
The members of the RCPSC Board are aware that altering
the MOC some medical specialists’ concerns as to their
ability to carry out knowledge or performance assessment
activities. Such concerns are legitimate, but they should
resolve as the appropriate tools are made available to
medical specialists. Other specialists wonder how they
should evaluate their own practice and foresee a gigantic
and insurmountable review of files, etc. Some authors1 have
already started on the task and have found that reviewing 10
clinical charts is enough to gain a valid assessment of a
particular aspect of a medical specialist’s practice. This is a
reassuring finding. This personal assessment, which is
simple to undertake in one’s own setting, also meets the
concerns of other physicians who have found it especially
taxing, both in time and money, to have to travel to medical
conferences that do not necessarily prove of benefit to them.
Various measures will be taken to assist medical specialists.
At the RCPSC level, the Director of Professional Affairs has
set up a team of CPD educators to help their colleagues with
their own CPD. Two Quebec medical specialists have
accepted the invitation: Dr. Sam Daniel, an ENT specialist at
the Montreal Children’s Hospital, and Dr. Nina Verreault, an
allergist at CHUL Quebec City.
The FMSQ Office of Professional Development (OPD) will
develop the necessary tools to facilitate access to sections 2
and 3 of the new program. It will also continue to be available
to assist Continuing Professional Development units of the
affiliated associations. Finally, the OPD remains available to
any medical specialists seeking help or answers in managing
their own continuing professional development.
Additional information is available on the Royal College’s website
at http://rcpsc.medical.org/opa/moc-program/ index.php or by
contacting your CPD leader (Dr. Sam Daniel in Montreal or
Dr. Nina Verreault in Quebec City) via e-mail at ens-dpc4@
collegeroyal.ca (same e-mail address for both educators).
1
À votre agenda
Vendredi
11 novembre 2011
Palais des congrès de Montréal
ASSOCIATIONS PARTICIPANTES :
Association des médecins psychiatres du Québec
Association des obstétriciens gynécologues du Québec
Association des médecins rhumatologues du Québec
Association des médecins microbiologistes
infectiologues du Québec
Association des pneumologues de la province de Québec
Association des médecins spécialistes
en santé communautaire du Québec
Association Québécoise de chirurgie
Association des radiologistes du Québec
Association des médecins hématologues
et oncologues du Québec
Association d'oto-rhino-laryngologie et de
chirurgie cervico-faciale du Québec
Association des médecins radio-oncologues du Québec
Wooster DL. A structured audit tool of vascular ultrasound interpretation reports: a quality initiative. J Vascular Ultrasound
2007;31(4):207-10.
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CONTINUING PROFESSIONAL EDUCATION
By Réjean Laprise, Ph. D.
CONSULTANT, OFFICE OF PROFESSIONAL DEVELOPMENT
A reading club in your own living-room!
Almost everyone has heard of “webinars”, interactive conferences that allow
you to take part regardless of where they may be given in the world and ask
questions directly from any computer, as long as it is connected to the
Internet. But what about virtual reading clubs? Do you know of any?
Despite the prodigious volume of biomedical research
published each year, it is estimated that only four to eight
studies have a significant impact on the practice of a given
specialty. In theory, therefore, a specialist would only need to
read four to eight texts per year to keep abreast of
developments in his/her specialty. But, it’s not that simple.
Even if some extensively sponsored studies generate a lot of
noise, they are not necessarily all valid statistically. The
methodology used can also limit the extrapolation of a
study’s conclusions beyond the population studied.
Recommendations are sometimes difficult to apply in the
context of our healthcare system. These are the issues
studied in reading clubs and the reason they are so useful to
the profession. In a university setting, methodology experts
can often assist clinical experts to ascertain the underlying
aspects of a study. They then have all the information they
require to decide collegially if the factual data presented
justify changing practice conduct. Unfortunately, such
resources are not always available in all areas.
The FMSQ’s Office of Professional Development, in
cooperation with the Association des pneumologues de la
province de Québec and the Vice-Dean’s Office for
Education and Continuing Professional Development at the
Faculty of Medicine, Université Laval, has developed and
validated a new educational concept that allows all Quebec
medical specialists to host and take part in a high-grade
reading club via Internet. This is sure to be of interest to
those who practise with a limited number of colleagues in
their own specialty, those who have difficulty accessing
experts in the various areas of their specialty, or those who
simply wish to update their knowledge while balancing their
work and family life.
In addition to the pneumologists, the Association des
spécialistes en médecine interne du Québec and the
Association des médecins gériatres du Québec joined in the
pilot project to develop and validate the concept. The
associations organized five on-line reading clubs, each
lasting 60 minutes, between January 2010 and March 2011.
Activities took place in the evening (from 7:30 to 9:00 p.m.)
and everyone could take part while at home. Participants
had the benefit of a critical analysis by a methodology expert
and by a clinical expert, and were able to interact with other
participants and also with the experts. Emphasis was placed
on the validity of the study, comparing it with previous
studies, evaluating the applicability of the results and seeking
to establish a consensus as to its impact on medical
practice. Eighty-seven participants, who were representative
of medical specialists in Quebec (regions, age, gender, type
of practice), signed up for the pilot on-line reading clubs
offered by their respective associations. The content and
technological environment used were both highly
appreciated. Among aspects needing improvement, several
participants suggested that their associations should offer
this type of activity on a regular basis... That says it all!
As a result of the pilot project’s great success, the FMSQ
and the Vice-Dean’s Office at Université Laval have formed a
partnership that enables the Federation and interested
affiliated professional associations to use the technological
infrastructure of the Université Laval at a low cost to hold
real-time reading clubs and other continuing development
activities for their members. Université Laval will also offer
personalized technical support and accredit activities. The
content and conduct of on-line educational activities will still
depend on associations, who are solely responsible for
training their members.
The pilot project defined the concept, established
procedures and developed an organization guide and
standard templates (e.g., on-line evaluation forms) that
should make it much easier for each association to organize
this kind of activity. A participant’s guide is also available on
line from the FMSQ website, so that medical specialists can
check their computer equipment’s compatibility, update it if
necessary, and become familiar with the technological
environment used (www.fmsq.org/f/medecins/dpc/activites
enligne.html). Everything is now set up for you to take part in
a reading club and in high level conferences right in the
comfort of your own home!
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VOL. 13 NO. 2
JUNE 2011
35
IN THE WORLD OF MEDICINE
By Christian Constance, MD*
New Atrial Fibrillation Guidelines
CARDIOLOGIST
Why were new atrial fibrillation (AF) guidelines issued in 2010?
Essentially, because new studies now allow us to confidently
make suggestions based on clinical evidence.
Major advances have been made since the Canadian
Cardiovascular Society’s (CCS) last recommendations for AF
in 2005, including clinical trials that have led to drug therapy
for the management of AF, antithrombosis treatments, the
continuing development of catheter ablation, etc.
dation, weak quality evidence). The aim is to evaluate the
symptomatic disorder caused by AF, develop a treatment
strategy to relieve symptoms, evaluate and manage the risk
of thromboembolism, establish a prognosis and, when
possible, identify the underlying cause of AF.
For the first time, recommendations were developed using
the GRADE 1 system (Grading of Recommendations
Assessment, Development and Evaluation) to weigh the
value of studies (table 1), i.e. evaluate the quality of the
evidence provided in the literature (very weak, weak, medium
or high quality). This system replaces the scale of evidence
levels previously used by the American Heart Association.
Based on the CCS example, other specialties could eventually
use the GRADE system for their recommendations, should
they find it interesting and worthwhile.
This latter aim (identifying the underlying cause) is particularly
important as it may allow AF risk factors to be identified and,
once these have been treated, could reduce or eliminate a
subsequent recurrence of AF, improve the patient’s general
health, or help establish the optimal AF treatment strategy in
the patient’s case. Hypertension constitutes one of the major
risk factors associated with AF. Recommendations in this
regard stipulate that risk factors need to be identified and
treated (strong recommendation, high quality evidence).
Recommendations for the emergency room
treatment of AF
Table 1. GRADE Evaluation System
Quality of
evidence
High
Comments
Future research is not expected to modify current
knowledge; for example, numerous well-designed and
carefully-conducted clinical trials.
Medium
Future research will probably have an important impact
on current knowledge and could modify it; for example,
limited clinical trials, inconsistent results or study
limitations.
Weak
Future research is likely to have an important impact on
current knowledge and will probably modify it; for
example, a small number of clinical or cohort studies.
Very weak
Data are very uncertain; for example, case studies,
consensus opinions.
Extract from Gillis AM et al. Can J Cardiol 2011;27:27-30
Very weak quality studies are excluded, as a matter of
course. This grading of information quality is one of the main
factors in determining the strength of recommendations
(strong, or conditional – in other words, weak). For example,
when initially evaluating AF,2 the guidelines recommend
establishing a familial, social and medication history, carrying
out a complete physical examination, electrocardiogram,
echocardiogram and laboratory tests (strong recommen-
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Atrial fibrillation is the type of arrhythmia most often seen by
emergency physicians and represents approximately onethird of all hospitalizations for cardiac rhythm problems. Two
treatment strategies are used: controlling ventricular rate by
the administration of oral anticoagulants, or controlling and
maintaining sinus rhythm (cardioversion) via a pharmacological or electrical approach. The decision as to which of
these two strategies should be used in the initial treatment of
emergency AF depends upon multiple factors such as the
type and duration of AF, severity of symptoms, medical
condition and AF-related cardiovascular illnesses, as well as
physician and patient3 preferences. In such situations, the
guidelines recommend either strategy when treating a stable
patient with AF or recent-onset atrial flutter (strong
recommendation, high quality evidence).
Once the ventricular rate is controlled, AF treatment comes
down to slowing the pulse rate and administering
anticoagulants. While we previously insisted on maintaining
the pulse rate at 60 beats/minute, new studies indicate that
slowing it to less than 100 beats/minute at rest (< 110 during
moderate exercise such as walking) is quite sufficient.
Intravenous medication, such as metoprolol (a beta-blocker),
verapamil or diltiazem (both calcium channel blockers) is the
IN THE WORLD OF MEDICINE @SUITEA
first-line treatment. If the patient continues to present
symptoms and has been on anticoagulants for more than
four to six weeks, electrical or chemical cardioversion can be
used to restore sinus rhythm in certain cases (mentioned in
the previous paragraph).
More complex alternatives
With the sinus rhythm control strategy, antiarrhythmia drugs
are the first line of treatment. However, their efficacy in
controlling sinus rhythm over time is relatively modest.
Adverse effects also limit their usefulness over the long term,
especially in young patients. Catheter ablation is an
alternative if drugs prove ineffective or poorly tolerated.8
This surgery isolates the arrhythmia- initiating foci by
THE CCS GUIDELINES ARE THE ONLY ONES THAT cauterization at the junction of the pulmonary veins and
RECOMMEND DABIGATRAN TO PREVENT STROKE IN the left atrium.
HIGH:RISK PATIENTS AND SUGGEST THIS MEDICATION
IS PREFERABLE TO WARFARIN IN MOST CASES.
With regard to anticoagulation, a new treatment option is
now available: dabigatran etexilate is a new reversible
anticoagulant that inhibits thrombins and can be
administered at fixed doses by mouth without having to
monitor coagulation on a regular basis. The results of the
RE-LY4 study have shown the advantages of this drug versus
warfarin: no further need for blood tests, anticoagulation
stability and reduced incidence of hemorrhage (intracranial,
in particular). The most recent data from two sub-group
analyses in the RE-LY5-6 study, presented at the 2011 Annual
Scientific Session of the American College of Cardiology,
show that 150 mg BID of dabigatran is consistently superior
to warfarin in the prevention of AF-related stroke, regardless
of the level of the risk of stroke or the type of AF. Dabigatran
is contraindicated in patients with a creatinine clearance rate
lower than 30 cc/min. In addition, there is no antidote (such
as vitamin K for Coumadin) for dabigatran. If the patient
presents with serious bleeding, PTT can be used to establish
the intensity of the agent’s anticoagulation effect. Several
strategies are available depending on the severity of the
bleeding: local compression, volemic repletion, blood
transfusions, cryoprecipitates and fresh frozen plasma (this
agent is dialyzable in cases of serious bleeding and, if there
is an acute intoxication, activated charcoal must be tried).
The CCS guidelines are the only ones that recommend
dabigatran to prevent stroke in high-risk patients and
suggest this medication is preferable to warfarin in most
cases. That being said, the European Society of Cardiology
(ESC) guidelines and those of the American College of
Cardiology Foundation/American Heart Association/Heart
Rhythm Society (ACCF/AHA/HRS) contain similar
recommendations without, however, specifically identifying
dabigatran for the moment.7
Techniques and technology have evolved since surgical
AF ablation was first described more than 10 years ago,
giving high success rates, particularly in patients
suffering from paroxysmal AF. In such patients, the
success rate in maintaining sinus rhythm without using
anti-arrhythmia drugs, is 60% to 75% after a first procedure
and 75% to 90% following two procedures. However, the
rate of major complications is 2% to 3%. It is therefore
recommended this approach only be considered for patients
with symptomatic AF who do not respond to pharmacological treatment.
Should both anti-arrhythmia drugs and catheter ablation
fail, there remains the possibility of AF surgery,9 which is
an effective treatment to restore and maintain sinus
rhythm. Although it is possible to use such surgery as a
single primary intervention, it is mainly provided to
patients who need other types of cardiac surgery (for
example, coronary bypass, aortic valve surgery, mitral
valve repair or replacement).
Atrial fibrillation and other concomitant
illnesses
In conclusion, it may be useful to recall that AF is often
present in patients with atherosclerosis, hypertension or
diabetes. The international registry known as REACH10 (The
REduction of Atherothrombosis for Continued Health), which
is designed to study all of the clinical aspects of
atherothrombosis, confirms that, in AF patients, morbidity
and mortality rates are twice as high for each of these
pathologies. As a result, the new guidelines are not
addressed solely to cardiologists, electrophysiologists or
cardiac surgeons; they also concern general practitioners,
those who work in emergency rooms and all other
specialists, such as neurologists for example, who may be
confronted with stroke patients with atrial fibrillation.
References
* The author is assistant clinical professor at the Université de Montréal
Department of Medicine and chief of the Coronary and Haemodialysis
Unit at Hôpital Maisonneuve-Rosemont)
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VOL. 13 NO. 2
JUNE 2011
37
FINANCIÈRE DES PROFESSIONNELS
By Alain Doucet, a.s.a., acs, Financial Planner
Impact of new quebec pension
plan rules
SENIOR MANAGER, FINANCIAL PLANNING
The last provincial budget amended rules for the Quebec Pension Plan. What
impact will these new provisions have on your decision to request a pension
before or after age 65?
To start with, to be eligible for a pension before age 65 (the
earliest age is 60), you have to meet one of the following
conditions: you have to have stopped working, cut back
your working hours by at least 20% (this is more difficult to
demonstrate for the self-employed) or confirmed that your
work income does not exceed 25% of the maximum
pensionable earnings (MPE), i.e. 25% of $48,300 in 2011
($12,075). If you do not fulfill any of these conditions, at
present your pension will be reduced by 0.5% for each
month you retire before age 65
– i.e., 6% per year or 30% at
age 60.
The new budget has increased
the reduction applicable prior
to age 65. For those retiring in
2014, their pension will be
reduced by 6.36% per year, or
31.8% at age 60. For those
retiring in 2015, their pension
will be reduced by 6.72% per
year, or 33.6%, and for those
taking retirement in 2016, the
reduction will be 7.2% per year
for a total reduction of 36%.
Please note that if your career
average employment income is
less than the MPE, the
reduction percentage will be
slightly less. However, since
this is unlikely to be the case
for most medical specialists,
we will not be dealing with it in
this article.
If a pension starts to be paid
after age 65, current rules
stipulate that the pension
amount is increased by 0.5%
per month after age 65 (or 6%
per year) up to a maximum
total of 30% at age 70. As a
result of the latest budget, the
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VOL. 13 NO. 2
JUNE 2011
pension will be increased by 0.7% per month (or 8.4% per
year) starting in January 2013, for a maximum increase of
42% at age 70.
How can you evaluate these changes? Several factors have
to be taken into account to determine whether an eligible
person should start drawing down a pension before 65, at
65 or, alternatively defer it to age 70, in order to receive the
maximum amount.
Comparison - 60 to 65 years
Without returns
At age 60
Age
Annual
pension
At age 65
Cumulative
Before taxes
After taxes
Cumulative
Annual
pension
Before taxes
After taxes
60
$7,373
$7,373
$3,834
61
$7,520
$14,893
$7,745
62
$7,671
$22,564
$11,733
63
$7,824
$30,389
$15,802
64
$7,981
$38,369
$19,952
65
$8,140
$46,510
$24,185
$12,719
$12,719
$6,614
66
$8,303
$54,813
$28,503
$12,973
$25,692
$13,360
71
$9,167
$98,887
$51,421
$14,324
$94,557
$49,170
72
$9,351
$108,238
$56,284
$14,610
$109,167
$56,767
73
$9,538
$117,776
$61,243
$14,902
$124,069
$64,516
With returns
At age 60
Âge
Annual
pension
At age 65
Cumulative
Before taxes
After taxes
Cumulative
Annual
pension
Before taxes
After taxes
60
$7,373
$7,373
$3,834
61
$7,520
$15,262
$7,844
62
$7,671
$23,696
$12,037
63
$7,824
$32,705
$16,419
64
$7,981
$42,321
$20,996
65
$8,140
$52,578
$25,774
$12,719
$12,719
$6,614
66
$8,303
$63,510
$30,762
$12,973
$26,328
$13,532
73
$9,538
$162,317
$72,153
$14,902
$151,032
$71,407
74
$9,729
$180,162
$79,088
$15,200
$173,784
$81,168
75
$9,923
$199,093
$86,304
$15,504
$197,978
$91,340
FINANCIÈRE DES PROFESSIONNELS (SUITE)
1) In fl ation: Generally speaking, the MPE increases faster
than inflation and thus encourages putting off benefits. When
the pension amount is established, it is calculated on the
basis of an average of MPEs; pensions paid are increased
each year based on inflation.
2) Taxat ion Rate: If the retired physician is taxed at the
maximum marginal rate, there is little advantage in delaying
his/her retirement benefit claim.
3) H eal th: If the physician’s state of health is not the best, it
is definitely preferable to apply for a pension as soon
as possible.
70, $16,358 (+42%). The tables without returns will be useful
for those applying their entire pension to expenses, while
those with returns will be useful for those not using their
pension to meet expenses.
The tables show that, under the new rules, waiting until age
65 before drawing down a pension lowers the break-even
point by about 3 years, from age 75 to age 72, without
returns, and from age 77 to age 74, respectively.
For rules after the age of 65, if you live longer than age 80
(without returns), it would be better to delay applying for a
pension until age 70. But who can predict the age at which
you will die?
4) Break-Even Point: When do pension payments received
from age 65 on equal those received starting at age 60
(given certain assumptions)? The same question applies in
the case of a pension received starting at age 70 compared
with one received starting at age 65. The following
assumptions are used in the tables below: inflation rate, 2%;
rate of return, 5%; tax rate, 48%; annual pension (AP) at age
60, $7,373 (-36%), AP at age 65, $11,520, and AP at age
5) Contributory Period: To be eligible for a full pension,
physicians must have contributed during 85% of the
contributory period, starting on January 1, 1966, or from the
age of 18 for physicians who turned 18 after that date. The
contributory period ends the month preceding the one for
which the pension is paid. Other criteria can also come into
play, but they are not discussed here. Thus, if a physician
retires at age 60 (or before) and
waits until age 65 to apply, five
additional years of zero contriComparison - 60 to 65 years
butions (from age 60 to 65) will
Without returns
be taken into account when
At age 65
At age 70
calculating the pension and
Cumulative
Cumulative
Annual
could reduce the amount paid at
pension
Before taxes
After taxes
Before taxes
After taxes
age 65. The impact of this choice
$11,520
$5,990
would extend the break-even
$23,270
$12,101
point to age 76, without returns,
$35,256
$18,333
and age 79, with returns.
Age
Annual
pension
65
$11,520
66
$11,750
67
$11,985
68
$12,225
$47,481
$24,690
69
$12,470
$59,951
$31,174
70
$12,719
$72,670
$37,788
$18,061
$18,061
$9,392
71
$12,973
$85,643
$44,534
$18,422
$36,483
$18,971
.
.
.
.
.
.
79
$15,200
$199,220
$103,594
$21,585
$197,763
$102,837
80
$15,504
$214,725
$111,657
$22,016
$219,779
$114,285
81
$15,814
$230,539
$119,880
$22,457
$242,236
$125,963
.
With returns
At age 65
At age 70
Cumulative
Age
Annual
pension
Before taxes
65
$11,520
$11,520
$5,990
66
$11,750
$23,846
$12,256
67
$11,985
$37,024
$18,807
68
$12,225
$51,100
$25,653
69
$12,470
$66,125
$32,805
70
$12,719
$82,150
71
$12,973
$99,231
.
Cumulative
Annual
pension
Before taxes
$40,271
$18,061
$18,061
$9,392
$48,065
$18,422
$37,386
$19,215
After taxes
After taxes
.
.
.
.
.
.
81
$15,814
$342,442
$146,576
$22,457
$317,641
$144,753
82
$16,131
$375,695
$158,775
$22,906
$356,429
$160,427
83
$16,453
$410,933
$171,459
$23,364
$397,615
$176,748
6) Other Income: There may be a
reason to postpone or advance
drawing down your pension if
other income (e.g. Old Age
Security) might be subject to
a decrease.
In conclusion, it used to be
generally held that a retirement
pension from the Quebec
Pension Plan should be drawn
down as early as possible.
Greater caution is now required,
and you should take all the
factors listed above into
account. Do not hesitate to talk
to one of our Financial Solutions
Advisors: they will guide you
through the process!
LE SPÉCIALISTE
VOL. 13 NO. 2
JUNE 2011
39
SOGEMEC ASSURANCES
By Chantal Aubin
Insuring Pleasure with The Personal
DIRECTOR, PLAN ADMINISTRATION MANAGER
Motorcycle Insurance: Freedom
and Simplicity
Motorcycle fans can obtain complete protection from The
Personal for a wide range of brands and models, at very
competitive prices. Regardless of whether you are shopping
for a new motorbike or renewing your insurance, asking for a
quote online makes your life easier. You can obtain a quote
rapidly, 24 hours a day, so that you can compare offers and
make an informed choice.
Recreational Vehicle Insurance: Worry-Free
Adventure
Whether you enjoy ATVs, or want to cross Canada or the
United States in your truck camper, The Personal offers you
the protection to meet your needs. The Personal insurance
covers most RVs: all-terrain vehicles, trailers, campers, boats,
personal watercraft, etc. The Personal’s consultants will be
happy to help you choose the protection that suits you.
In preparation for the summer season, we wish to remind you
that Sogemec Assurances, a subsidiary of the Fédération des
médecins spécialistes du Québec, has negotiated a selection
of insurance products from The Personal Insurance Company
and that these products are not limited to automobile and
home insurance. We are proud to announce we have
negotiated a range of quality insurance products to meet all
your needs.
If you own a motorcycle, a boat or an RV, The Personal has
the product for you. Pleasure vehicle enthusiasts are often
passionate about their mode of transport. Even if they
sometimes use them for practical purposes, like a motorcycle
to get to work, their vehicle is first and foremost synonymous
with pleasure and escape.
Marine Insurance: Upcoming New Features
With its new reduced rates and expanded eligibility criteria for
certain types of boats, The Personal’s marine insurance is
better than ever. Reduced rates apply, in particular, to craft
valued at $30,000 or less. This reduction, combined with the
exclusive group discounts available to members of the
Fédération des médecins spécialistes du Québec, makes
rates highly competitive. Marine insurance is reserved
for clients who already have their homes insured with
The Personal. This is another advantage offered by your
group insurer.
Thinking of Staying Outsi de Quebec?
Specialists from The Personal, the automobile, home and
commercial group insurer chosen by Sogemec A ssurances,
know this full well. They are used to responding to the needs
of their clients eager to hit the road or set sail while confident
that they are well protected.
Whether you are thinking of exploring the east coast of the
United States on a motorcycle, visiting national parks with
your camper or even sailing on Lake Champlain... it is
important to start by checking into your protection with
your insurer.
Basically, The Personal offers you the same privileges as with
its automobile and home insurance, i.e. preferential group
rates, sound advice from a team of certified agents and firstclass service. Then you add in the various specifics for each
insurance product.
Some limits may apply on your automobile, motorcycle or
marine insurance. Checking will take five minutes of your time
and will prevent any unpleasant surprises, as your agent will
be able to offer you the appropriate protection. For example,
an umbrella policy will allow you to increase your public liability
insurance, which might be important should you find yourself
liable for third-party injuries while you are out of the country.
For more details on the various RV insurance policies or to ask
for pricing, please contact one of our agents at 1-866-350-8282
or visit our website at www.sogemec.lapersonnelle.com.
40
LE SPÉCIALISTE
VOL. 13 NO. 2
JUNE 2011
SOGEMEC ASSURANCES
By Yves Martel
WEALTH MANAGEMENT CONSULTANT
Join an insurance plan with
no medical proof required
New FMSQ members
You have just completed your
residency! Congratulati ons! As
you know, the insurance plans
covered by the Agreement
between the Fédération des
médecins résidents du Québec
(FMRQ) and the Ministère de la
Santé et des Services sociaux du
Québec (MSSS), expire on July 1.
Coverage with no medical proof*
Under age 35
$3,000
Disability insurance
$3,000
Office overhead
insurance
$100,000
Life insurance
* If you are 35 or over, please get in touch with our
consultants for details on the amounts for which
you are eligible without proof.
Coverage tailored to your
profession
Since 33 years, the Fédération des
médecins spécialistes du Québec has been
working closely with Sogemec Assurances,
to offer you the best insurance products
available, as well as coverage tailored to
your profession.
The only broker
Just for you
As a new medical specialist, the FMSQ, by the means of its
subsidiary, Sogemec Assurances, offers you to subscribe to its
life, disability and office overhead insurance programs to you,
without requiring medical proof. However, you must join within
90 days of the end of your residency.
POUR TOUS VOS
BESOINS D’ASSURANCES
Sogemec Assurances is the only broker offering the FMSQ’s
insurance programs, which also include prescription drug,
disability, automobile and home coverage, as well as individual
products from other insurance companies. Contact the
consultants at Sogemec Assurances without delay. We
understand your needs!
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 / 418 990-3946
Par courriel ou Internet :
[email protected] / www.sogemec.qc.ca
SOGEMEC ASSURANCES
filiale de la
LE SPÉCIALISTE
VOL. 13 NO. 2
JUNE 2011
41
LE MOT DU PRÉSIDENT
Dr Gaétan Barrette
Pourquoi « faire simple » quand
on peut « faire compliqué » ?
u moment d’aller sous presse, la FMSQ vient de conclure
une entente avec le ministère de la Santé et des Services
sociaux (MSSS) quant au traitement de la dégénérescence
maculaire liée à l’âge (DMLA). Une finale heureuse. Mais pour y
arriver, il nous aura fallu imposer un ultimatum. Un mauvais film dont
voici quelques faits saillants.
A
Le 8 février : volte-face ! Par voie de communiqué de presse, le
ministre annonce « la gratuité des traitements ». Il a « demandé à
l’ensemble des établissements de santé du Québec d’assurer la
gratuité des traitements (…). Au cours des prochaines semaines,
une fois la mesure mise en œuvre, les patients n’auront plus à
assumer les frais accessoires ».
Automne 2010. Le dossier des frais accessoires refait surface. Cette
fois, dans le cas de la DMLA. Faute d’avoir accès au Lucentis à
l’hôpital (à une période où la science n’a pas encore déterminé
formellement la valeur ajoutée de l’utilisation du Lucentis pour la
DMLA), les patients doivent se tourner vers les cliniques pour
recevoir leur injection. Parce que la RAMQ ne rembourse pas les
ophtalmologistes pour la composante technique, des frais sont
exigés aux patients. Rappelons que la Loi sur l’assurance maladie
date de 1970 et n’a pas suivi l’évolution de la pratique médicale.
Résultat : un flou artistique entoure la définition des frais
accessoires, flou qui touche une grande partie des activités
dispensées en clinique. J’insiste ! Ce flou frappe pour l’instant
l’ophtalmologie, mais pourrait s’appliquer à plusieurs autres
spécialités médicales.
Le 9 février, toujours en réponse à une journaliste du Soleil,
l’attachée de presse du ministre précise l’annonce de la veille en
indiquant que les travaux pour mettre en place cette nouvelle offre
de services ne font que commencer, et ce n’est que « dans les
prochaines semaines ou les prochains mois » que les patients
sauront à quoi s’en tenir.
Avançons en arrière : le 1er octobre 2007. À la demande de
l’ex-ministre Couillard, un comité de travail dépose un rapport (le
rapport Chicoine - du nom du président du comité) dans lequel
se trouvent des recommandations précises sur la question des
frais accessoires et sur la nécessité d’agir rapidement. Été 2008 :
entrée en scène du ministre Bolduc. Depuis, silence radio. La
problématique des frais accessoires demeure entière et en suspens.
Le premier signe d’une « nouvelle » crise arrive avec un article publié
dans Le Soleil du 18 novembre 2010 : L’État ne paiera pas l’injection
de Lucentis. C’est ce qu’affirme l’attachée de presse du ministre,
qui évoque « le contexte budgétaire actuel » pour justifier la décision
du ministère.
Le 24 novembre, le ministre indique à la même journaliste qu’il
travaille ce dossier avec la RAMQ. L’article se termine en rappelant
que « le dossier a été soumis au ministre Bolduc pour la première
fois en mars 2009 ».
Le 3 février 2011, par la voie de son attachée de presse, le ministre
fait savoir qu’il entend poursuivre sa réflexion sur les frais
accessoires. « Des discussions doivent avoir lieu avec les
intervenants concernés, tels que les fédérations de médecins et le
Collège des médecins. » Le ministre souhaite par ailleurs bouger « le
plus rapidement possible » rapporte Le Devoir.
Le 6 février, le dossier du traitement de la DMLA avec le Lucentis est
« un dossier prioritaire » pour le ministre, comme le rapporte le
Journal de Québec.
42
LE SPÉCIALISTE
VOL. 13 NO. 2
JUNE 2011
Le 2 avril : coup de théâtre ! Dans un article du Devoir intitulé : Le
Lucentis gratuit reste introuvable. Les patients font les frais d’un
bras de fer entre le ministère et les établissements, la journaliste
rapporte que, vérification faite, même le MSSS ignore quels sont
les quelques établissements qui offrent présentement le service et
lesquels sont pressentis pour le faire. La porte-parole du MSSS,
ajoute : « On peut espérer qu’[un plan] sera arrêté d’ici quelques
semaines et soumis pour approbation au ministre ».
Le 7 avril, Le Devoir rapporte que le ministre soulève la possibilité
de « payer des frais raisonnables par rapport à l’injection. (…) Des
frais accessoires pourraient aussi être payés en clinique. (…) Nous
devrions savoir d’ici quelques jours quel scénario sera retenu ».
Le jeudi 19 mai dernier, un patient atteint de DMLA demande à la
cour la permission d’intenter un recours collectif contre la RAMQ,
le ministre de la Santé et une clinique d’ophtalmologie de Québec
(d’autres pourraient s’ajouter).
La même journée, excédée, la Fédération lance au ministre un
ultimatum de 48 heures ouvrables, et ce, pour régler la situation
une fois pour toutes dans ce dossier. Les heures s’égrènent et
d’intenses négociations (pendant un long weekend !) déboucheront
sur une entente.
Depuis des années, la FMSQ n’a cessé de répéter au ministre qu’il
doit mettre un frein au flou et régler, une fois pour toutes, l’ensemble
du dossier des frais accessoires. En décidant de ne pas s’attaquer
à cette problématique, non seulement la desserte des soins est
volontairement rationnée en centre hospitalier, mais le ministre
« économise » sur le dos des patients en tardant à investir les
sommes nécessaires à la dispensation des soins. Pendant ce
temps, les médecins, eux, font tout en leur pouvoir pour traiter les
patients en clinique avec les risques que cela encourt. Mais cela
devra « vraiment » finir un jour !
Syndicalement vôtre !
S
L
REFERENCES
References (page 18)
23
1
24
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
19
20
21
22
Act respecting the determination of the causes and
circumstances of death, R.S.Q., Chapter R-0.2.
Ibid, Section 3.
Some recommendations aim at improving the organization of
care, others at encouraging better communications between
facilities. For more information see: Coroner's Office, Rapport
des activités des coroners en 2010, Government of Quebec,
2011 (in French only).
Ibid, article 37 paragraphe 3.
This requirement represents Section 37 of the Act respecting
the determination of the causes and circumstances of death,
R.S.Q., Chapter R-0.2, until its amendment on October 31,
1991.
Nursing homes are no longer included in the category of
"centres" provided for in the Act respecting health services
and social services, R.S.Q., Chapter S-4.2, with respect to
where institutions deliver care and services. They are however
included in the Act respecting health services and social
services for Cree Native persons, R.S.Q., Chapter S-5.
Opinion on the application of the Act respecting the
determination of the causes and circumstances of death in
institutions, resources and homes for the elderly: Me Claire
Bernard, December 2010, p. 19. This opinion (in French only)
is available on line at: http://www2.cdpdj.qc.ca.
Me Claire Bernard, Opinion on the application of the Act
respecting the determination of the causes and circumstances
of death in institutions, resources and homes for the elderly,
December 2010.
Ibid, p.26. The Commission also recommends that the
Coroner be granted discretionary powers allowing him to
decide whether there are grounds or not to proceed with an
investigation into the deaths reported to him. This procedure
would avoid needless investigations while protecting users'
fundamental rights. It must be understood that the Act
respecting the determination of the causes and circumstances
of death, (Section 45) specifies that an investigation "must
take place every time notice (as provided for in the Act) is
given to the coroner."
Ibid, page 22.
Ibid, pages 19 to 21.
Ibid, pages 19 to 21.
Civil Code of Québec, C-1991, Sections 122 and 124.
Leclerc (Estate of) c.Turmel, J.E. 2005-805 (S.C.): In this
decision, the Court was called upon to establish the time at
which a mother and son died, following a highway accident, in
order to reach a conclusion as to the rights of their heirs.
Regulation respecting the application of the Act respecting
medical laboratories, organ and tissue conservation and the
disposal of human bodies, Chapter L-0.2, r.1, Section 18.
Public Health Act, R.S.Q., Chapter S-2.2, Section 46, Par. 1.
Public Health Act, R.S.Q., Chapter S-2.2, Section 46, Par. 2.
Ibid.
Ibid, Section 46, Par. 3.
Regulation respecting the application of the Act respecting
medical laboratories, organ and tissue conservation and the
disposal of human bodies, c. L-0.2, r.1, Section 19.
Ibid, Section 19.
circumstances of death, R.S.Q., Chapter R-0.2, Section 34 and
Section 2, Par. 3 and 4.
Ibid, article 19.
Loi sur la recherche des causes et des circonstances de
décès, L.R.Q., chapitre R-0.2, article 34 et article 2
paragraphes 3 et 4.
25
26
27
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
Ibid, article 2 paragraphe 3.
Ibid, Section 34.
Ibid, Section 44.
Ibid, Section 35.
The Act refers to the PSD of an "an institution operating a
hospital centre" and therefore to the PSDs of institutions that
carry on the mission of a hospital centre – e.g., health and
social services centres, hospital centres and universityaffiliated hospital centres.
Québec Coroner, L’investigation, Gouvernement du Québec,
March 2001, p 39 to 40 (in French only): The authors of this
manual provide for a three-stage process to help institutions
establish probable cause of death.
circumstances of death, R.S.Q., Chapter R-0.2, Section 35,
Par. 2 and Section 36.
Ibid, Section 73.
Ibid, Section 76, Par. 1.
circumstances of death, R.S.Q., Chapter R-0.2, Section 34.
Ibid, Section 36.
Ibid, Section 36.
Gage Canadian Dictionary, Toronto; Gage Educational
Publishing Company, a Division of Canada Publishing
Corporation, 1997, page 1021.
March 2001, page 37 (in French only).
Gage Canadian Dictionary, Toronto; Gage Educational
Publishing Company, a Division of Canada Publishing
Corporation, 1997, page 1640.
March 2001, page 37 (in French only).
Nolet, Louise; Perron, Paul-André; Le Médecin du Québec,
Les morts violentes et inattendues en milieu hospitalier,
2005:40(10); 105-9.
mars 2001, p.36.
This term no longer exists in the Youth Protection Act, R.S.Q.,
Section P-34 ("YPA"). The YPA now refers to "an intensive
supervision unit maintained by an institution operating a
rehabilitation centre" (Section 11.1.1 YPA).
circumstances of death, R.S.Q., Chapter R-0.2, Section 39:
This section refers in particular to the death of children while
they are in the custody of the holder of a permit issued by the
Minister of Families, Seniors and the Status of Women.
circumstances of death, R.S.Q., Chapter R-0.2, Sections 37 to
40.
43
Ibid.
44
Avis sur l’application de la Loi sur la recherche des causes et
des circonstances de décès dans les établissements,
ressources et résidences pour personnes âgées, Me Claire
Bernard,, Décembre 2010, p.7-8.
45
Ibid.
46
décès, L.R.Q., chapitre R-0.2, articles 170-171.
47
Ibid, article 4.
48
décès, L.R.Q., chapitre R-0.2, article 96.
49
À ce sujet, voir entre autres : Robert c. Hôpital de Chicoutimi
inc, AZ-91011590 (Cour d’appel du Québec).
LE SPÉCIALISTE
VOL. 13 NO. 2
JUNE 2011
43
SUMMARY
Do you know your obligations?
(page 18)
Physicians must notify the Coroner or a peace officer in the
following situations:
• Upon confirming a death for which no probable medical cause
can be established
• Upon confirming a death that seems to have occurred in
obscure circumstances
• Upon confirming a death that seems to have occurred in violent
circumstances
Should the director be absent and the physician is the person in
authority in one of the following places, he/she must immediately
notify the Coroner or a peace officer of any death occurring in:
• A rehabilitation centre
• An adapted enterprise for handicapped persons
• A facility where the deceased person was under confinement
• A correctional facility
• A penitentiary
• A security unit within the meaning of the Youth Protection Act
• A police station
• A daycare centre
• A foster family
• A family-type resource
Source: Sections 34 to 40 of the Act respecting the determination
of the causes and circumstances of death, R.S.Q., chapter R-0.2
44
LE SPÉCIALISTE
VOL. 13 NO. 2
JUNE 2011
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3
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Bengston K. Physical modalities of complex regional pain
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Huygen FJ, De Bruijn AG, De Bruin MT, et al. Evidence for local
inflammation in complex regional pain syndrome type 1. Mediators
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McCabe CS, Haigh RC, Ring EFG, et al. A controlled pilot study of
the utility of mirror visual feedback in the treatment of complex
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25
Crombez G, Vlaeyen JWS, Heuts PH, Lysens R. Pain-related fear is
more disabling than pain itself: evidence on the role of pain-related
fear in chronic pain disability. Pain 1999 ;80:329-39.
26
Bruehl SP. Psychological interventions. CRPS: current diagnostic
and therapy, progress in pain research and management, IASP
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Schürmann M, Gradl G, Zaspel J, et al. Peripheral sympathetic
function as a predictor of complex regional pain syndrome type 1
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4
Allen G, Galer BS, Schwart L. Epidemiology of regional pain
syndrome: a retrospective chart review of 134 patients. Pain 1999 ;
80:539-44.
27
Monti DA, Herring CL, Schwartzman RJ, Marchese M. Personality
assessment of patients with complex regional pain syndrome type 1.
Clin J Pain 1998 ;14:295-302.
5
Sandroni P, Benrud-Larson LM, McClelland RL, et al. Complex
regional pain syndrome type 1: incidence and prevalence in Olmsted
county, a population-based study. Pain. 2003 ;103:199-207.
28
Harden RN. Pharmacotherapy of complex regional pain syndrome.
Am J Phys Med Rehabil 2005 ;84:S17-28.
29
6
Birklein F, Riedl B, Sieweke N, et al. Neurological finding in complex
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2000 ;101:262-9.
Geurts AC, Visscheas BA, van Limbeek J, et al. Systematic review of
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7
Veldman PH, Reynen HM, Arntz IE, Goris RJ. Signs and symptoms
of reflex sympathetic dystrophy: prospective study of 829 patients.
Lancet 1993 ;342:1012-6.
Kozin F, Ryan LM,Carerra GF, Soin JS. The reflex sympathetic
dystrophy syndrome (RSDS). III. Scintigraphic studies, further
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and proposed diagnostic criteria. Am J Med 1981 ;70:23-30.
8
Galer BS, Henderson J, Perander J, Jensen MP. Course of
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syndrome: a pilot survey. J Pain Symptom Manage. 2000 ;20:286-92.
31
Bickerstaff DR, Kanis JA. The use of nasal calcitonine in the
treatment of post-traumatic algodystrophy. Br J Rheumatol 1991
;30:291-4.
9
Birklein F, Sittl R, Spitzer A, et al. Sudomotor function in sympathetic
reflex dystrophy. Pain 1997 ;69:49-54.
32
Gobelet C, Meier JL, Schaffner W, et al. Calcitonine and reflex
sympathetic dystrophy syndrome. Clin Rheum 1986 ;5(3):382-8.
10
Wasner G, Backonja MM, Baron R. Traumatic neuralgias,complex
regional pain syndromes (reflex sympathetic dystrophy and
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and therapy. Neuro Clin. 1998 ;16:851-68.
33
Adami S, Fossaluzza V, Gatti D, Fracassi E, Braga V. Biphosphonate
therapy of reflex sympathetic dystrophy syndrome. Ann Rheum Dis
1997 ;56:201-4.
34
11
Birklein F, Handworker HO. Complex regional pain syndrome: how to
resolve the complexity ? Pain. 2001 ;94:1-6.
Maillefert JF, Cortet B, Aho S. Pooled results from two trials biphosphonates in reflex sympathetic dystrophy. J Rheumatol 1999
;26(8):1856-7.
12
Bruehl S, Harden RN, Galer BS, et al. Complex regional pain
syndrome: are there distinct subtypes and sequential stages of the
syndrome ? Pain 2002 ;95:119-24.
35
Kubalek I, Fain O, Paries J, et al. Treatment of reflex sympathetic
dystrophy with pamidronate: 29 cases. Rheumatology 2001
;40:1394-7.
13
Van der Laan L, Veldman PH, Goris RJ. Severe complications of
reflex sympathetic dystrop y: infection, ulcers, chronic edema
dystonia, and myoclonus. Arch Phys Med Rehabil 1998 ;79 ;424-9.
36
McQuay H, Carroll D, Jadad AR, et al. Anticonvulsivant drugs for
management of pain ; systematic review. BMJ 1995 ;311:1047-52.
37
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Verdugo RJ, Ochoa JL. « Sympathetically maintained pain. » 1.
Phentolamine block questions the concept. Neurology 1994
;44:1003-10.
Rosenstock J, Tuchman M, LaMoreaux L, Sharma U. Prégabaline for
the treatment of paintful diabetic peripheral neuropathy: a doubleblind, placebo-controlled trial. Pain 2004 ;110 ;628-38.
38
15
Birklein F, Künzel F, Sieweke N. Despite clinical similarities, there are
significant differences between acute limb trauma and complex
regional pain syndrome 1 (CRPS 1). Pain 2001 ;93:165-71.
Devers A, Galer BS. Topical lidocaine patch relieves a variety of
neuropathic pain conditions: an open-label study. Clin J Pain 2000
;16(3):205-8.
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16
Holder LE, Mackinnon SE. Reflex sympathetic dystrophy in the
hands: clinical and scintigraphic criteria. Radiology 1984 ;152:51722.
Veldman P, Goris R. Multiple reflex sympathetic dystrophy: which
patients are at risk for developping a recurrence of reflex sympathetic dystrophy in the same or another limb. Pain.1996 ;64:463-6.
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17
Lee GW, Weeks PM. The role of bone scintigraphy in diagnosis
reflex sympathetic dystrophy. J Hand Surg Am 1995 ;20:458-63.
Masson C, Audran M, Pascaretti C, et al. Different patterns of
extension and recurrence in algodystrophy. Acta Orthop Belg. 1998
;64:71-6.
18
Stanton-Hicks MD, Burton AW, Bruehl SP, Carr DB, et al. An updated
interdisciplinary clinical pathway for CRPD: report of an expert
panel. 2002 World Institute of Pain, Pain practice 2002:2(1):1-16.
41
Maleki J, Lebel AA, Bennet GJ, Schwartzman RJ. Patterns of spread
in complex regional pain syndrome, type 1 (reflex sympathetic
dystrophy). Pain. 2000 ;88:259-66.
19
Crombez G, Vlaeyen JWS, Heuts PH, Lysens R Pain-related fear is
more disabling than pain itself: evidence on the role of pain-related
fear in chronic pain disability. Pain 1999 ;80:329-39.
42
Zyluk A. The sequelae of reflex sympathetic dystrophy. J Hand Surg.
2001 ;26:151-154.
43
20
Janig W, Baron R. Experimental approach to CRPS. Pain 2004 ;108
;3-7.
21
Perez RSGM, Kwakkel G, Zuurmond WWA, de Lange JJ. Treatment
of reflex sympathetic dystrophy (CRPS Type 1): a research synthesis
of 21 randomnized clinical trials. J Pain Manage 2001 ;21(6):511-25.
Geertzen JH, Dijkstra PU, van Sonderen EL, Groothoff JW, ten jDuis
HJ, Eisma WH. Relationship between impairements, disability and
handicap in reflex sympathetic dystrophy patients: a long-term
follow-up study. Clin Rehab. 1998 ;12:405-12.
44
Galer BS, Henderson J, Perander J, Jenson MP. Course of
symptoms and quality of life measurement in complex regional pain
syndrome: A pilot survey. J Pain Symptom Manage. 2000 ;20:286-92.
22
Kemler MA, Rijks CP, de Vet HC. Which patients with chronic reflex
sympathetic dystrophy are most likely to benefit from physical
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VOL. 13 NO. 2
JUNE 2011
45
REFERENCES
1. Day M. Neuromodulation: spinal cord and peripheral nerve stimulation.
Current Review of Pain 2000 ;4(5):374-82.
1.
Gillis AM et al. Canadian Cardiovascular Society atrial fibrillation
guidelines 2010: implementing GRADE and achieving consensus.
Can J Cardiol 2011 ;27:27-30.
2. Bouhassira D et al. Comparison of pain syndromes associated with
nervous or somatic lesions and development of a new neuropathic pain
diagnostic questionnaire (DN4). Pain 2005 ;114:29-36.
2.
Healey JF et al. Canadian Cardiovascular Society atrial fibrillation
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3.
Stiell IG et al. Canadian Cardiovascular Society atrial fibrillation
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4.
Connolly S et al. Dabigatran versus Warfarin in patients with atrial
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5.
Flaker GC et al. 60th Annual Scientific Session of the American
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6.
Oldgren J et al. 60th Annual Scientific Session of the American College
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7.
Gillis AM, Skanes AC. Comparing the 2010 North American and
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8.
Verma A et al. Canadian Cardiovascular Society atrial fibrillation
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Can J Cardiol 2011 ;27:60-6.
9.
Pagé P et al. Canadian Cardiovascular Society atrial fibrillation
guidelines 2010: surgical therapy. Can J Cardiol 2011 ;27:67-73.
3. Cruccu G, Aziz TZ, Garcia-Larrea L, Hansson P, Jensen TS, Lefaucheur
JP et al. EFNS guidelines on neurostimulation therapy for neuropathic
pain. Eur J Neurol 2007 ; 4(9):952-70.
4. Richard K, Osenbach MD. Motor cortex stimulation for intractable pain,
neurosurgical focus, Published: 2007-02-05.
5. Deer MD et al. Polyanalgesic Consensus Conference 2007.
Recommendations for the management of pain by intrathecal
(intraspinal) drug delivery: report of an interdisciplinary expert panel.
Neuromodulation 2007 ;10(4):300-28.
10. Goto S et al. Prevalence, clinical profile, and cardiovascular outcomes
of atrial fibrillation patients with atherothrombosis. Am Heart J
2008 ;156(5):855-63.
46
LE SPÉCIALISTE
VOL. 13 NO. 2
JUNE 2011
Parce que
votre temps est trop
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L’administration de la facturation est souvent complexe, exigeant
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Pour information :
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ou 514 350-5274

Understanding Pain

Transcription

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