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Fédération des médecins omnipraticiens du Québec FORMATION CONTINUE 2010-2011

JEUDI 15 SEPTEMBRE 2011 11h15

SÉANCE PLÉNIÈRE DE L'AVANT-MIDI

L'andropause : approche pratique pour l'omnipraticien

Docteur Gilles Bernard Bellavance Urologue Clinique médicale Legardeurois

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L’andropause Approche pratique pour l’omnipraticien

D Gilles Bellavance r

L andropause L’andropause

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Approche pp p pratique q p pour l’omnipraticien p

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n““ i ““ n““ŒšGiŒ““ˆˆ•ŠŒGœ™–“–ŽœŒ “

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joGsŒGnˆ™‹Œœ™

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joGqŒˆ•G{ˆ“–•

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kœ“Žˆ›–•  “ 

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j–•šœ“›ˆ•› Œ› —™ïšŒ•›ˆ›Œœ™ —–œ™ ›–œ›Œš “Œš j–•šœ“›ˆ•›GŒ›G—™ïšŒ•›ˆ›Œœ™G—–œ™G›–œ›ŒšG“ŒšG —™•Š—ˆ“ŒšGŠ–”—ˆŽ•ŒšG—ˆ™”ˆŠŒœ›˜œŒšG ™Œ“ïŒšGæG“˅œ™–“–ŽŒ Ž hœŠœ•Gˆœ›™ŒG“Œ•G•ˆ•ŠŒ™G–œGŠ–•›™ˆŠ›œŒ“U

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v‰‘  v‰‘ŒŠ›š yŒŠ–••ˆô›™ŒG“ŒšGšŽ•ŒšGŒ›G“ŒšGš ”—›ú”ŒšG ‹ŒG“˅ —–Ž–•ˆ‹š”ŒGˆŠ˜œšGb

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p•›Œ™—™ï›Œ™G“ŒšG™ïšœ“›ˆ›šG‹ŒšG›Œš›šG šˆ•Žœ•š —™ŒšŠ™›š ‹ˆ•š “˅“œˆ›–• šˆ•Žœ•šG—™ŒšŠ™›šG‹ˆ•šG“ “œˆ›–•G‹œG ‹œ —ˆ›Œ•›GŠŒ¡G˜œG–•Gš–œ—í–••ŒGœ•G ‹ˆŽ•–š›Š ‹˅ —–Ž–•ˆ‹š”Œ ‹ˆŽ•–š›ŠG‹  —–Ž–•ˆ‹š”ŒGbb

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{™ˆ›Œ™G“ŒG—ˆ›Œ•›Gš–œ™ˆ•›G ‹˅ —–Ž–•ˆ‹š”ŒGˆŠ˜œšb ˅

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hššœ™Œ™G“ŒGšœGŒ›G—™ïŒ•™G“ŒšG hššœ™Œ™ “Œ šœ Œ› —™ïŒ•™ “Œš Š–”—“Šˆ›–•šU

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L’andropause Approche pratique pour l’omnipraticien

Dr Gilles Bellavance

uŒˆœG‹ŒG›Œš›–š›ï™–•ŒGŒ›GˆœŽ”Œ•›ˆ›–•G uŒˆœ ‹Œ ›Œš›–š›ï™–•Œ Œ› ˆœŽ”Œ•›ˆ›–• ‹œG™š˜œŒG‹ŒG”–™›ˆ“›ï

Vous trouverez le tableau à cette adresse :

http://archinte.ama-assn.org/ cgi/reprint/166/15/1660

Fi Figure page 1663

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Taux de testostérone

Mortalité

95% IC

N Normal l

0 201 0,201

16 2 -24,1% 16,2 24 1%

Équivoque

0,246

19,2-30,0%

Bas

0,349

28,5-41,4%

h î “ h—™îšG“ŒšGˆ‘œš›Œ”Œ•›šG‹˅莌SG‹ŒG ‘ ‹˅ ‹ ”–™‰‹›ïG”Šˆ“ŒGŒ›G‹ŒšGˆœ›™ŒšG Š–ˆ™ˆ•›ŒšGŠ“•˜œŒšSG‹ŒšG›ˆœŸG‰ˆšG‹ŒG ›Œš›–š›ï™–•Œ –•› Š–•›•œï ‹˅𛙌 ›Œš›–š›ï™–•ŒG–•›GŠ–•›•œïG‹ 𛙌Gˆšš–ŠïšG ˆšš–Šïš æGœ•ŒGˆœŽ”Œ•›ˆ›–•G‹ŒG“ˆG”–™›ˆ“›ï yyGaGXS__ `\LGpjGaGXSZ[TYS]Z `\L pj X Z[ Y ]Z wGcGWSWWX

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Shores M., et al. Arch Intern Med. 2006;166:1660-1665.

v‰‘  v‰‘ŒŠ›š yŒŠ–••ˆô›™Œ “ŒšGšŽ•Œš Œ›G“ŒšGš ”—›ú”Œš ‹ŒG“˅ —–Ž–•ˆ‹š”Œ ˆŠ˜œš b p•›Œ™—™ï›Œ™ “ŒšG™ïšœ“›ˆ›š ‹ŒšG›Œš›šG šˆ•Žœ•š —™ŒšŠ™›š ‹ˆ•š ““˅“œˆ›–• “œˆ›–• ‹œG ‹œ —ˆ›Œ•›GŠŒ¡G˜œG–•Gš–œ—í–••Œ œ•G ‹ˆŽ•–š›Š ‹˅ —–Ž–•ˆ‹š”Œ ‹ˆŽ•–š›ŠG‹  —–Ž–•ˆ‹š”Œ b

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{™ˆ›Œ™ “ŒG—ˆ›Œ•›Gš–œ™ˆ•› ‹˅ —–Ž–•ˆ‹š”Œ ˅ ˆŠ˜œšb

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hššœ™Œ™ “Œ šœ Œ›G—™ïŒ•™ hššœ™Œ™G“ŒGšœ Œ› —™ïŒ•™ “ŒšG “Œš Š–”—“Šˆ›–•šU

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h•‹™–—ˆœšŒ

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Oo —–Ž–•ˆ‹š”ŒGˆŠ˜œšP

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ϛˆ›GŠ“•˜œŒG‹ˆ•šG“Œ˜œŒ“Gœ•ŒG‹ïŠŒ•ŠŒG ˆ•‹™–Žï•˜œŒG‹–••ŒG‹ŒšGš ”—›ú”ŒšGˆ™ïšG ˜œGŠ–™™Œš—–•‹Œ•›GæGœ•Gš—ŒŠ›™ŒGŠ“•˜œŒG •‹œU •‹œ uŒœ™–ïŽï›ˆ›šSG —š Šˆ›™˜œŒšSG

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”œšŠœ“–Tš˜œŒ“Œ››˜œŒšSG “ “ ›› šŒŸœŒ“šSG

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Šˆ™‹–ˆšŠœ“ˆ™ŒšGŒ›G”‰–“˜œŒšU

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L’andropause Approche pratique pour l’omnipraticien

D Gilles Bellavance r

j–•‹›–•šG”Šˆ“ŒšGˆšš–ŠïŒšGæG j–•‹›–•š ”Šˆ“Œš ˆšš–ŠïŒš æ “˅ —–Ž–•ˆ‹š”Œ Medical Conditions

Odds Ratio (95% C.I.)

Obesity

2.33 (1.90, 2.85)

Diabetes

2.04 (1.67, 2.50)

Hypertension

1.80 (1.50, 2.14)

Osteoporosis

1.59 (0.77, 3.30)

Rheumatoid Arthritis

1.55 (0.91, 2.62)

Hyperlipidemia

1.49 (1.25, 1.78)

Asthma/COPD

1.42 ((1.07, 1.88))

Chronic Pain

1.20 (0.95, 1.50)

Prostate Disease

1.19 ((0.95,, 1.49))

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Adapté de l'étude HIM

j–•‹›–•šG”Šˆ“ŒšGˆšš–ŠïŒšGæG j–•‹›–•š ”Šˆ“Œš ˆšš–ŠïŒš æ “˅ —–Ž–•ˆ‹š”Œ Patients hypogonadiques (n = 836)*

Patients normaux (n = 1326)*

547 (65,4)

678 (51,1)

< 0,001 < 0,001

Hypertension

P

Hyperlipidémie

506 (60,5)

670 (50,5)

Diabète

258 (30,9)

237 (17,9)

< 0,001

Obésité

270 (32,3)

225 (17,0)

< 0,001

Maladie ou troubles prostatiques

165 (19,7) (19 7)

226 (17,0) (17 0)

0 121 0,121

Douleur chronique

155 (18,5)

211 (16,0)

0,113

Insomnie ou trouble du sommeil

129 (15,4)

185 (14,0)

0,342

Asthme ou BPCO

102 (12,2)

118 (8,9)

0,013

* Valeurs exprimées en n (%)

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Adapté de l'étude HIM

mˆŠ›Œœ™šG‹ŒG™š˜œŒG‹ mˆŠ›Œœ™š ‹Œ ™š˜œŒ ‹˅œ•Œ œ•ŒG ‹ïŠŒ•ŠŒGŒ•G›Œš›–š›ï™–•Œ }Œ““ššŒ”Œ•›GGGGGGGGGG

tˆ“ˆ‹ŒšGŠ™–•˜œŒš

kˆ‰î›Œ

p•šœšˆ•ŠŒG™ï•ˆ“ŒGŠ™–•˜œŒ

p•ŒŠ›–•G—ˆ™G“ŒG}po

w–“ ˆ™›™›ŒG™œ”ˆ›–õ‹Œ

j jˆ•ŠŒ™

twvj

vš›ï–—–™–šŒ

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w™šŒ ‹Œ ”Šˆ”Œ•›š O— Œ w™šŒG‹ŒG”Šˆ”Œ•›šGO—UGŒŸUSGŠ–™›Š–š›ï™–õ‹ŒšGŽï•ï™ˆœŸSGš›ï™–õ‹ŒšG Š–™›Š–š›ï™–õ‹Œš Žï•ï™ˆœ š›ï™–õ‹Œš ˆ•ˆ‰–“šˆ•›šSG–—ˆŠïšP v‰ïš›ïGGGGGGGGGGGGGGGGGGGGGGG

tˆ“•œ›™›–•

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h“Š––“š”ŒGŠ™–•˜œŒG–œGŠ–•š–””ˆ›–•G‹ŒG‹™–ŽœŒ z›™ŒššG— š˜œŒG•›Œ•šŒGOŠˆ”—G‹˅Œ•›™ˆô•Œ”Œ•›SG‰™ā“œ™ŒšP

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p•šœšˆ•ŠŒGŠˆ™‹ˆ˜œŒGŒ›GŠ–™–•ˆ™Œ••Œ

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L’andropause Approche pratique pour l’omnipraticien

 “  w™ïšŒ•›ˆ›–•GŠ“•˜œŒ zŽ•ŒšGˆš–”–›Œœ™š i–œïŒš ‹Œ Šˆ“Œœ™S ‹ˆ—–™îšŒS •Œ™–š›ï Œ› i–œïŒšG‹ŒGŠˆ“Œœ™SG‹ˆ—–™îšŒSG•Œ™–š›ïGŒ›G ˆŽ›ˆ›–•

{™–œ‰“ŒšG‹ŒG“ ˅œ”Œœ™ {™š›ŒššŒSGˆ›ˆ“š”ŒSG± Ž™•ŠŒœŸ ÁSGˆ—ˆ›ŒSG •‹ïŠš–•SG‹ï—™Œšš–•U

{™–œ‰“ŒšG‹ŒG“ˆG™“šˆ›–• m–™ŠŒG”œšŠœ“ˆ™ŒSG” ˆ“ŽŒSG–‰ïš›ïSG—“–š›ïU

Dr Gilles Bellavance

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{™–œ‰“ŒšGšŒŸœŒ“š s‰‹ ‹  s‰‹–SG‹ š–•Š›–•GŠ›“ŒSGŠœ“è›SG–™Šˆ“ŽŒSG › ï ›“ ï‘ “è›  “  ˜œˆ“›ïG‹ŒG“ ˅–™Žˆš”ŒU

zŒŸG‹Œ™Œ•ŠŒšG–GŒ•‹–ŽŒ•–œšGšŒŸG –™”–•ŒšGˆ•‹G™š’G–G› —ŒGYG‹ˆ‰Œ›ŒšaGˆG š š›Œ”ˆ›ŠG™ŒŒžGˆ•‹G”Œ›ˆTˆ•ˆ“ šš This systematic review indicates that endogenous sex hormones may differentially modulate glycemic status and risk of type 2 diabetes in men and women. High testosterone levels are associated with higher risk of type 2 diabetes in women but with lower risk in men; the inverse association of SHBG with risk was stronger in women than in men.

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h“Œššˆ•‹™– t–™ŒšŠ h“Œššˆ•‹™–Gt–™ŒšŠ OX_\_TX`YYP

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tˆô›™ŒG‹œGŠ–Œœ™G‹ŒG“ˆG jˆ—Œ““Œ zŸ›•Œ jˆ—Œ““ŒGzŸ›•Œ

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zœ™•–””ïG± “˅h•ŽŒG‹ŒG y–”Œ Á

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hGŒ•™ŒŽš›™ïGšœ™G h Œ•™ŒŽš›™ï šœ™ Ž™ˆ”–—–•ŒGŒ•GX`WYG Œ›GŒ•GX`W[U

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w™ïšŒ•›ˆ›–•GŠ“•˜œŒ  “ 

L’andropause Approche pratique pour l’omnipraticien

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vš›ï–—–™–šŒG”ˆšŠœ“•Œ

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h•ï”ŒG•ŒŸ—“˜œïŒ kŒšš–•G—Œ™šš›ˆ•›Œ

_____________________________________

zhz

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v‰‘  v‰‘ŒŠ›š

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yŒŠ–••ˆô›™Œ “ŒšGšŽ•Œš Œ›G“ŒšGš ”—›ú”Œš ‹ŒG“˅ —–Ž–•ˆ‹š”Œ ˆŠ˜œš b p•›Œ™—™ï›Œ™ “ŒšG™ïšœ“›ˆ›š ‹ŒšG›Œš›šG šˆ•Žœ•š —™ŒšŠ™›š ‹ˆ•š ““˅“œˆ›–• “œˆ›–• ‹œG ‹œ —ˆ›Œ•›GŠŒ¡G˜œG–•Gš–œ—í–••Œ œ•G ‹ˆŽ•–š›Š ‹˅ —–Ž–•ˆ‹š”Œ ‹ˆŽ•–š›ŠG‹  —–Ž–•ˆ‹š”Œ b

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{™ˆ›Œ™ “ŒG—ˆ›Œ•›Gš–œ™ˆ•› ‹˅ —–Ž–•ˆ‹š”Œ ˅ ˆŠ˜œšb

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hššœ™Œ™G“ŒGšœ hššœ™Œ™ “Œ šœ Œ›G—™ïŒ•™ Œ› —™ïŒ•™ “ŒšG “Œš Š–”—“Šˆ›–•šU

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Ï “  ‰   ϝˆ“œˆ›–•G‰–Š”˜œŒ i“ˆ• ‹Œ ‰ˆšŒ Omzj –•š Š™ïˆ›••Œ i“ˆ•G‹ŒG‰ˆšŒGOmzjSG–•šSGŠ™ïˆ›••ŒSG Ž“ Šï”ŒP {zo

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i“ˆ•G“—‹˜œŒ

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i“ˆ•Gï—ˆ›˜œŒ

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{Œš›–š›ï™–•ŒGO‰–G‹š—–•‰“ŒGšG — —–šš‰“ŒP šš P

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soT so TmzoGw™–“ˆŠ›•Œ

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L’andropause Approche pratique pour l’omnipraticien

Dr Gilles Bellavance

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È YU\LG—ˆ™Gˆ••ïŒ

zoin zoinaG

Ç XTZLG—ˆ™Gˆ••ïŒ X Z

kolhzaG

È \UYLG—ˆ™Gˆ••ïŒ

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È XU[GLG—ˆ™Gˆ••ïŒ

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Ç šŒŠ–•‹ˆ™ŒGæG“˅Ç ‹ŒG“˅ˆ™–”ˆ›šˆ›–•

_____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________

s–•ŽŠ–—ŒGhŽ•ŽGtˆ“ŒšSGmŒ™GYWWY

TESTOSTÉRONE

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(DOSAGE ET IMPRÉCISION)

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F O R M AT I O N C O N T I N U E F MO Q — 2 0 11- 2012 La thérapeutique — 15 et 16 septembre 2011

L’andropause Approche pratique pour l’omnipraticien

D Gilles Bellavance r

y—›Œœ™šGˆœŸG y—›Œœ™š ˆœŸ ˆ•‹™–Žî•Œš Ž sŒGŠ–™—šGœ”ˆ•G—–ššî‹ŒG—“œšŒœ™šGš›ŒšG sŒ Š–™—š œ”ˆ• —–ššî‹Œ —“œšŒœ™š š›Œš —–ššï‹ˆ•›G‹ŒšG™ïŠŒ—›Œœ™šGˆœŸG Ž ˆ•‹™–Žî•ŒšU s˅ŒŸ—™Œšš›ïG‹ŒGŠŒšG™ïŠŒ—›Œœ™šGŒš›G ˆ™ˆ‰“Œ Œ› ”–‹œ“ˆ‰“Œ —ˆ™ ‹Œ ”œ“›—“Œš ˆ™ˆ‰“ŒGŒ›G”–‹œ“ˆ‰“ŒG—ˆ™G‹ŒG”œ“›—“ŒšG ˆŠ›Œœ™šU s sŒG—–“ ”–™—š”ŒG‹ŒšGŽî•ŒšG”—“˜œïšG “  ‹  “ Œš›G›™îšG”—–™›ˆ•›U

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v‰‘  v‰‘ŒŠ›š

_____________________________________ yŒŠ–••ˆô›™ŒG“ŒšGšŽ•ŒšGŒ›G“ŒšGš ”—›ú”ŒšG ‹ŒG“˅ —–Ž–•ˆ‹š”ŒGˆŠ˜œšGb p•›Œ™—™ï›Œ™G“ŒšG™ïšœ“›ˆ›šG‹ŒšG›Œš›šG šˆ•Žœ•š —™ŒšŠ™›š ‹ˆ•š “˅“œˆ›–• šˆ•Žœ•šG—™ŒšŠ™›šG‹ˆ•šG“ “œˆ›–•G‹œG ‹œ —ˆ›Œ•›GŠŒ¡G˜œG–•Gš–œ—í–••ŒGœ•G ‹ˆŽ•–š›Š ‹˅ —–Ž–•ˆ‹š”Œ ‹ˆŽ•–š›ŠG‹  —–Ž–•ˆ‹š”ŒGbb

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{™ˆ›Œ™G“ŒG—ˆ›Œ•›Gš–œ™ˆ•›G ‹˅ —–Ž–•ˆ‹š”ŒGˆŠ˜œšb ˅

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hššœ™Œ™G“ŒGšœGŒ›G—™ïŒ•™G“ŒšG hššœ™Œ™ “Œ šœ Œ› —™ïŒ•™ “Œš Š–”—“Šˆ›–•šU

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xœˆ•‹G›™ˆ›Œ™Gf x ‹  f

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h‰šŒ•ŠŒG‹ŒGŠ–•›™Œ h‰šŒ•ŠŒG‹ŒG Š–•›™ŒT T•‹Šˆ›–•U

• Il doit y avoir des symptômes significatifs pour le patient. patient {Œš›–š›ï™–•Œ ‰–G ‰–G‹š—–•‰“Œ ‹š—–•‰“Œ Oˆ™ˆ‰“ŒGRRRP

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t–•š ‹ŒG\WGˆ•š ‹ŒG\WGˆ•š

\UW

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w“œšG‹ŒG\WGˆ•š w“œšG‹ŒG\WG ˆ•š

[U\

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{Œš›–š›ï™–•Œ ›–›ˆ“Œ

XY

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L’andropause Approche pratique pour l’omnipraticien

Dr Gilles Bellavance

_____________________________________ j–•›™ŒT•‹Šˆ›–•šGˆœG ›™ˆ›Œ”Œ•› Absolues jˆ•ŠŒ™G‹ŒG“ˆGw™–š›ˆ›ŒGŒ›G‹œGšŒ• w–“ Š ›Œ”Œ {™–œ‰“Œš ‹œ Š–”—–™›Œ”Œ•› O—ï‹–—“ŒSG {™–œ‰“ŒšG‹œGŠ–”—–™›Œ”Œ•› O—ï‹–—“Œ –“Œ•ŠŒP w™–š›ˆ›š”Œ šïî™Œ •–•G›™ˆ›ïU

Relatives o{h ”ˆ“ Š–•›™ú“ïŒ o{hG”ˆ“GŠ–•›™ú“ïŒ h—•ïŒ ‹œGš–””Œ“ •–•G›™ˆ›ïŒ p•šœšˆ•ŠŒ Šˆ™‹ˆ˜œŒ

 {™ˆ›Œ”Œ•›G hˆ•›G›–œ›G™ïˆššœ™ˆ•ŠŒU j–™™ŒŠ›–• ‹Œš ˆ•–”ˆ“Œš ‰–Š”˜œŒš j–™™ŒŠ›–•G‹ŒšGˆ•–”ˆ“ŒšG‰–Š”˜œŒšG Œ›Gˆ‰›œ‹ŒšG‹ŒGŒU z zœ——“•›ˆ›–•Gˆ•‹™–Žï•˜œŒG—–œ™G “  ‹  ˆ››Œ•‹™ŒGœ•G‹–šˆŽŒG— š–“–Ž˜œŒ ˆ››Œ•‹™ŒGœ•G‹–šˆŽŒG — š–“–Ž˜œŒ ”ˆšG —ˆšG—“œšU — — kŒ“ˆ›Œš›™ “GGO^WWT kŒ“ˆ›Œš›™ “GGO^WW TYWWGptG˜GYGšŒ”ˆ•ŒšP h•‹™–“G_WT h•‹™–“G_W T_WG”ŽG–œGXYWT _WG”ŽG–œGXYWT_WGˆœŸG™Œ—ˆš h•‹™–‹Œ™”GYU\T h•‹™–‹Œ™”GYU\ T\G›”‰™ŒšG“ŒGš–™U

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h•‹™–ŽŒ“G–œG{Œš›”G\GæG^U\GŽG“ŒG”ˆ›•U

v‰‘  v‰‘ŒŠ›š

69-8

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yŒŠ–••ˆô›™Œ “ŒšGšŽ•Œš Œ›G“ŒšGš ”—›ú”Œš ‹ “˅ ‹ŒG“˅ —–Ž–•ˆ‹š”Œ ‹ ˆŠ˜œš  b

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p•›Œ™—™ï›Œ™ “ŒšG™ïšœ“›ˆ›š ‹ŒšG›Œš›šGšˆ•Žœ•š —™ŒšŠ™›š  ‹ˆ•š ‹ “˅ï “  ‹œG—ˆ›Œ•›GŠŒ¡G “˅“œˆ›–• ‹   ˜œG–•Gš–œ—í–••Œ œ•G‹ˆŽ•–š›ŠG  — Ž b ‹˅ —–Ž–•ˆ‹š”Œ

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{™ˆ›Œ™ “ŒG—ˆ›Œ•›Gš–œ™ˆ•›  — Ž ˆŠ˜œšb ˜ ‹˅ —–Ž–•ˆ‹š”Œ

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hššœ™Œ™G“ŒGšœ Œ›G—™ïŒ•™ “ŒšG Š–”—“Šˆ›–•šU Š–”—“Šˆ›–•š

_____________________________________

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F O R M AT I O N C O N T I N U E F MO Q — 2 0 11- 2012 La thérapeutique — 15 et 16 septembre 2011

L’andropause Approche pratique pour l’omnipraticien

D Gilles Bellavance r

zœ OZŒ

”–šSG]Œ

”–šG—œšGˆ••œŒ“P

yï“œˆ›–•G‹ŒšGš ”—›ú”Œš yï“œˆ›–• ‹Œš š ”—›ú”Œš {Œ•š–•Gˆ™›ï™Œ““Œ

_____________________________________ _____________________________________ _____________________________________ _____________________________________

{–œŠŒ™G™ŒŠ›ˆ“G wzh

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o‰ o‰T To›

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hs{

‹ f wˆšG‹ŒG™ï—–•šŒGf y•šŒG—™ïšŒ•›ŒG”ˆšG•–•G™ïˆ“šïŒG —ˆ™G“ŒG—ˆ›Œ•›GOŠ›–•GHHHP yšŒ™G“ŒG‹ˆŽ•–š›Š

_____________________________________

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h››Œ•›ŒšG›™–—GïŒš     w“œ“ŒšGˆœG™Ž‹ˆ™Œ

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j–”—“ˆ•ŠŒ ‹œ —ˆ›Œ•› j–”—“ˆ•ŠŒG‹œG—ˆ›Œ•›

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h‰š–™—›–•G•ˆ‹ï˜œˆ›Œ

_____________________________________

tˆ“ˆ‹ŒGŠ–•Š–”›ˆ•›ŒU

h h™™ð›G‹œG›™ˆ›Œ”Œ•› ‹  hœŽ”Œ•›ˆ›–• ‹Œ “ˆ wzh hœŽ”Œ•›ˆ›–•G‹ŒG“ˆGwzh WU^\G—™Œ”î™ŒGˆ••ïŒG hœŽ”Œ•›ˆ›–•G‹ŒGXU\GˆœG›–›ˆ“U w“œš ˜œŒ [ W ˆœ ›–›ˆ“ w“œšG˜œŒG[UWGˆœG›–›ˆ“

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kï›ï™–™ˆ›–•G‹ŒšGš ”—›ú”Œš kï›ï™–™ˆ›–• ‹Œš š ”—›ú”Œš

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kï›ï™–™ˆ›–•G‹ŒG“˅oiw

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h h™™ð›G‹œG›™ˆ›Œ”Œ•› ‹ 

Dr Gilles Bellavance

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wˆš ‹Œ ™ï—–•šŒ šˆ•š ŠˆœšŒ ‹Œ•›Œ wˆšG‹ŒG™ï—–•šŒGšˆ•šGŠˆœšŒG‹Œ•›Œ w–“ Ž“–‰œ“ŒG j–”—“Šˆ›–•GŠˆ™‹–ˆšŠœ“ˆ™ŒU

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{™–œ‰“ŒšG‹œGŠ–”—–™›Œ”Œ•›U

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lŒ›š šŒŠ–•‹ˆ™Œš lŒ›šGšŒŠ–•‹ˆ™ŒšG

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”ˆš›ˆ“ŽŒGŒ›GŠï—ˆ“ïŒU

j j–•Š“œš–•G “ 

_____________________________________

_____________________________________ _____________________________________

u–œšGˆ–•šG‹ŒšG—™ŒœŒšGŠ–•Š“œˆ•›ŒšG ‹Œ ‹ŒG““˅ŒŸš›Œ•ŠŒ ŒŸš›Œ•ŠŒG‹ŒG“ ‹Œ “˅ˆ•‹™–—ˆœšŒ ˆ•‹™–—ˆœšŒ |•ŒGˆ”–™ˆ›–•GŠ“•˜œŒGŒš›G—–šš‰“ŒG Œ›G”ð”ŒG˜œˆšT Œ›G”ð”ŒG˜œˆš TŠŒ™›ˆ•ŒGˆŒŠGœ•ŒG ‰ ‰–••ŒGšï“ŒŠ›–•G‹ŒšG—ˆ›Œ•›šU ï“  ‹  p“G•ŒGˆœ›G—ˆšG›™ˆ›Œ™Gš˅“G•˅ GˆG—ˆšG‹ŒšG š ”—›ú”Œš et œ•G‹–šˆŽŒG‹”•œïG‹ŒG œ• ‹–šˆŽŒ ‹”•œï ‹Œ š ”—›ú”ŒšGet š ”—›ú”ŒšG ›Œš›–š›ï™–•ŒU |• šœ ˆ››Œ•› Œš› —™”–™‹ˆ“ —–œ™ |•GšœGˆ››Œ•›GŒš›G—™”–™‹ˆ“G—–œ™G ›Œ™G“ŒšGŠ–”—“Šˆ›–•šU

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