ed for neonatal intensive care (a well-established system of proven benefit) to an experimental, unproven project . . .". All of us recognize the limitation of health care resources. If, however, this is going to become a reason to veto all clinical innovation, then medicine in Canada as a progressive science is certainly in trouble. Medical science has only progressed when imaginative individuals have been bold enough to try alternative approaches. Modem congenital heart surgery would not exist if resources had not been committed over the past three decades to "experimental, unproven projects". It is particularly troubling when such a statement comes from an organization like the Canadian Paediatric Society, with its commitment to the advancement of medical care. H.C. Rosenberg, MD, FRCPC Assistant professor Department of Paediatrics University of Western Ontario London, Ont.
Medical staffing in Ontario neonatal intensive care units D_ r. Bosco Paes and colleagues have highlighted the difficulty of attracting physicians to staff neonatal intensive care units (Can Med Assoc J 1989; 140: 1321-1326). One explanation for this might be found in the advertisement in the Apr. 15, 1990, issue of CMAJ for clinical assistants in a neonatal intensive care unit in Toronto (page 905). The stipends for these positions range from $60 000 for physicians with no pediatric experience to $72 000 for physicians with specialty certification in pediatrics. This so-called generous salary is for a 48-hour workweek. The nurses in Alberta are currently ratifying a contract that will pay a nurse who has graduated
from a 2-year college program a base rate of $17.47 per hour for 1921 hours per year. This amount does not include the medical and dental benefits provided for them or the weekend and shift differentials, which may be as much as $6 per hour for approximately 20% of a nurse's working time. The nurses will also be paid double time for overtime. If the nursing contract arrangements are applied to the 48-hour workweek it is clear that a newly graduated nurse would earn $56 351, not including her weekend and shift differential pay. A nurse at the most senior staff level would earn $69 092, not including differential pay. Perhaps the difficulty in recruitment for neonatology would be solved if physicians entering this field could expect to earn more than what is possible after completion of a 2-year program in a technical college. Richard Johnston, MD Allan Shustack, MD Department of Adult Intensive Care Royal Alexandra Hospital Edmonton, Alta.
document the failure rate of this method when used by a highly motivated couple adhering closely to the guidelines ranges between 2% and 11%. The more typical failure rate, when the method is used by couples with various degrees of motivation, is in the region of 20%. These rates correspond to effectiveness rates of 80% to 98%, "effectiveness" being the descriptive term used in the Ministry of Health pamphlet. The ministry has stated that it will correct the data when the pamphlet is next printed. In the meantime, physicians should be aware of this source of error when providing information to their patients. Qualified teachers in natural family planning are available in most major centres through Serena, a national organization providing information on this method of birth control (613-728-6536). Anthony T. Kerigan, MB, FRCPC McMaster Clinic Hamilton General Hospital Hamilton, Ont.
Reference 1. Hatcher RA, Guest F, Stewart F et al:
Effectiveness of natural family planning L ' ast year the Ministry of Health in Ontario circulated to all physicians in the province a series of pamphlets on various methods of birth control. In these pamphlets was a list of the comparative effectiveness rates of the various methods. The data were taken from the most recent edition of Contraceptive Technology.' Unfortunately the data on the effectiveness of natural family planning, in terms of the rate of accidental pregnancy in the first year of use, are incorrect and would be very misleading to those considering this method of birth control. According to the original
Contraceptive Technology, 1988-1989, 14th ed, Irvington, New York, 1988: 151
Cholestatic jaundice associated with lovastatin (Mevacor) therapy have recently treated a 72-year-old woman who had a clinical course similar to that described by Dr. Matthew J. McQueen (Can Med Assoc J 1990; 142: 841-842). During the 13 months that she had been taking lovastatin her serum cholesterol level had improved and her liver enzyme levels remained normal (e.g., the aspartate aminotransferase [AST] level had been 15 to 1 8 U/L). CAN MED ASSOC J 1990; 143 (1)
13
The patient presented with nausea, malaise, anorexia, pale stools and dark urine and was found to have elevated liver enzyme levels (AST 177 U/L, alkaline phosphatase 351 U/L) and a high serum bilirubin level (30 ,umol/L). The symptoms resolved and the liver enzyme levels reverted to normal within a month of discontinuing lovastatin therapy. She had received a course of amoxicillin about 2 months previously for a sinus infection, and cloxacillin had been prescribed by her dentist about 2 weeks before detection of the liver enzyme changes. McQueen's patient had been taking amoxicillin before his jaundice developed. Could there be an interaction between penicillins and lovastatin that potentiates cholestasis? John A. Geddes, MD, CCFP 779 Blackburn Mews, Bay 4 Kingston, Ont.
[Dr. McQueen responds.]
Because the interaction of drugs and their metabolites can be very complex it is difficult to be dogmatic about the possibility of an interaction between penicillins and lovastatin that may potentiate cholestasis. Such an interaction was considered for the patient I described. However, neither the literature nor discussions with colleagues revealed any possible mechanism. Approximately half of each oral dose of amoxicillin is excreted in an active form in the urine, although some does appear in the bile, undergoes enterohepatic circulation and is excreted in appreciable quantities in the feces. At present more than 1 million patients in North America are receiving lovastatin (Dr. Jonathan A. Tobert, Research Laboratories, Merck Sharp & Dohme, Rahway, NJ: personal communication, 1990). Many must have received concurrent prescriptions 14
CAN MED ASSOC J 1990; 143 (1)
for penicillins, yet cholestatic jaundice has been very rare. I think that any interaction between the penicillins and lovastatin is unlikely. However, I appreciate Dr. Geddes' letter, which may prompt others to share their experience. Matthew J. McQueen, MB, ChB, PhD, FRCPC Lipid Research Clinic Hamilton General Hospital Hamilton, Ont.
sending me printed promotional material. Very likely the amount of money that the companies will not spend on sending me material which I don't read over the next year will equal or exceed the $76 which you suggest as a fair price for a copy of the CPS, which I do read. Thank you kindly for your attention. Robert Shepherd, MD 37 Beechmont Cres. Gloucester, Ont.
Junk mail
Structured abstracts
n association publisher has A inadvertently prompted me to come up with another possible way to reduce the volume of "junk mail" plaguing the letter boxes and landfill sites that physicians use. I recently received in the mail a request from Leroy Fevang, publisher of the Canadian Phar-
In a recent Editor's Page Dr. Bruce P. Squires asked for readers' comments on standardized structured abstracts for biomedical articles (Can Med Assoc J 1990; 142: 703). I agree with the recommendations that Squires outlines. Too often abstracts look like stretched titles and have no utility at all. Such abstracts were probably prepared in the vain hope that the reader would feel obliged to read the article to learn more about the authors' research. However, they only tend to make me skip the article. And if specific headings remind authors of this ideal format they should be mandatory.
maceutical Association's Compendium of Pharmaceuticals and Specialties (CPS) for a voluntary contribution to help defray the costs of publishing the CPS. In response I sent the following letter to Fevang. Dear Mr. Fevang:
I noted with interest your request for a contribution to the current edition Guilbault, MD of the CPS, a reference text which I Paul Box 37 PO certainly refer to frequently. My first Grand'MWre, PQ inclination was to send in a contribution. I then realized that over the last several months I have spent several hours (and many dollars on postage) writing letters to various pharmaceu-
tical companies, requesting that the companies stop sending me advertising material. Most of the companies that I have written to have been good enough to comply with my request. In place of a direct monetary contribution from me, please request a contribution from your member companies for an amount equal to the money that they would have spent on planning, printing and posting bulk advertising material to me. Demand that your member companies stop
Medical procedures prohibited outside hospital in Nova Scotia rT he letter from Dr. Henry Morgentaler begs a response, for Morgentaler pleads his case to be allowed to practise good medicine by being able to peform abortions on demand in Nova Scotia. Since when is it good medicine to treat a socioeconomic
Medical staffing in Ontario neonatal intensive care units D_ r. Bosco Paes and colleagues have highlighted the difficulty of attracting physicians to staff neonatal intensive care units (Can Med Assoc J 1989; 140: 1321-1326). One explanation for this might be found in the advertisement in the Apr. 15, 1990, issue of CMAJ for clinical assistants in a neonatal intensive care unit in Toronto (page 905). The stipends for these positions range from $60 000 for physicians with no pediatric experience to $72 000 for physicians with specialty certification in pediatrics. This so-called generous salary is for a 48-hour workweek. The nurses in Alberta are currently ratifying a contract that will pay a nurse who has graduated
from a 2-year college program a base rate of $17.47 per hour for 1921 hours per year. This amount does not include the medical and dental benefits provided for them or the weekend and shift differentials, which may be as much as $6 per hour for approximately 20% of a nurse's working time. The nurses will also be paid double time for overtime. If the nursing contract arrangements are applied to the 48-hour workweek it is clear that a newly graduated nurse would earn $56 351, not including her weekend and shift differential pay. A nurse at the most senior staff level would earn $69 092, not including differential pay. Perhaps the difficulty in recruitment for neonatology would be solved if physicians entering this field could expect to earn more than what is possible after completion of a 2-year program in a technical college. Richard Johnston, MD Allan Shustack, MD Department of Adult Intensive Care Royal Alexandra Hospital Edmonton, Alta.
document the failure rate of this method when used by a highly motivated couple adhering closely to the guidelines ranges between 2% and 11%. The more typical failure rate, when the method is used by couples with various degrees of motivation, is in the region of 20%. These rates correspond to effectiveness rates of 80% to 98%, "effectiveness" being the descriptive term used in the Ministry of Health pamphlet. The ministry has stated that it will correct the data when the pamphlet is next printed. In the meantime, physicians should be aware of this source of error when providing information to their patients. Qualified teachers in natural family planning are available in most major centres through Serena, a national organization providing information on this method of birth control (613-728-6536). Anthony T. Kerigan, MB, FRCPC McMaster Clinic Hamilton General Hospital Hamilton, Ont.
Reference 1. Hatcher RA, Guest F, Stewart F et al:
Effectiveness of natural family planning L ' ast year the Ministry of Health in Ontario circulated to all physicians in the province a series of pamphlets on various methods of birth control. In these pamphlets was a list of the comparative effectiveness rates of the various methods. The data were taken from the most recent edition of Contraceptive Technology.' Unfortunately the data on the effectiveness of natural family planning, in terms of the rate of accidental pregnancy in the first year of use, are incorrect and would be very misleading to those considering this method of birth control. According to the original
Contraceptive Technology, 1988-1989, 14th ed, Irvington, New York, 1988: 151
Cholestatic jaundice associated with lovastatin (Mevacor) therapy have recently treated a 72-year-old woman who had a clinical course similar to that described by Dr. Matthew J. McQueen (Can Med Assoc J 1990; 142: 841-842). During the 13 months that she had been taking lovastatin her serum cholesterol level had improved and her liver enzyme levels remained normal (e.g., the aspartate aminotransferase [AST] level had been 15 to 1 8 U/L). CAN MED ASSOC J 1990; 143 (1)
13
The patient presented with nausea, malaise, anorexia, pale stools and dark urine and was found to have elevated liver enzyme levels (AST 177 U/L, alkaline phosphatase 351 U/L) and a high serum bilirubin level (30 ,umol/L). The symptoms resolved and the liver enzyme levels reverted to normal within a month of discontinuing lovastatin therapy. She had received a course of amoxicillin about 2 months previously for a sinus infection, and cloxacillin had been prescribed by her dentist about 2 weeks before detection of the liver enzyme changes. McQueen's patient had been taking amoxicillin before his jaundice developed. Could there be an interaction between penicillins and lovastatin that potentiates cholestasis? John A. Geddes, MD, CCFP 779 Blackburn Mews, Bay 4 Kingston, Ont.
[Dr. McQueen responds.]
Because the interaction of drugs and their metabolites can be very complex it is difficult to be dogmatic about the possibility of an interaction between penicillins and lovastatin that may potentiate cholestasis. Such an interaction was considered for the patient I described. However, neither the literature nor discussions with colleagues revealed any possible mechanism. Approximately half of each oral dose of amoxicillin is excreted in an active form in the urine, although some does appear in the bile, undergoes enterohepatic circulation and is excreted in appreciable quantities in the feces. At present more than 1 million patients in North America are receiving lovastatin (Dr. Jonathan A. Tobert, Research Laboratories, Merck Sharp & Dohme, Rahway, NJ: personal communication, 1990). Many must have received concurrent prescriptions 14
CAN MED ASSOC J 1990; 143 (1)
for penicillins, yet cholestatic jaundice has been very rare. I think that any interaction between the penicillins and lovastatin is unlikely. However, I appreciate Dr. Geddes' letter, which may prompt others to share their experience. Matthew J. McQueen, MB, ChB, PhD, FRCPC Lipid Research Clinic Hamilton General Hospital Hamilton, Ont.
sending me printed promotional material. Very likely the amount of money that the companies will not spend on sending me material which I don't read over the next year will equal or exceed the $76 which you suggest as a fair price for a copy of the CPS, which I do read. Thank you kindly for your attention. Robert Shepherd, MD 37 Beechmont Cres. Gloucester, Ont.
Junk mail
Structured abstracts
n association publisher has A inadvertently prompted me to come up with another possible way to reduce the volume of "junk mail" plaguing the letter boxes and landfill sites that physicians use. I recently received in the mail a request from Leroy Fevang, publisher of the Canadian Phar-
In a recent Editor's Page Dr. Bruce P. Squires asked for readers' comments on standardized structured abstracts for biomedical articles (Can Med Assoc J 1990; 142: 703). I agree with the recommendations that Squires outlines. Too often abstracts look like stretched titles and have no utility at all. Such abstracts were probably prepared in the vain hope that the reader would feel obliged to read the article to learn more about the authors' research. However, they only tend to make me skip the article. And if specific headings remind authors of this ideal format they should be mandatory.
maceutical Association's Compendium of Pharmaceuticals and Specialties (CPS) for a voluntary contribution to help defray the costs of publishing the CPS. In response I sent the following letter to Fevang. Dear Mr. Fevang:
I noted with interest your request for a contribution to the current edition Guilbault, MD of the CPS, a reference text which I Paul Box 37 PO certainly refer to frequently. My first Grand'MWre, PQ inclination was to send in a contribution. I then realized that over the last several months I have spent several hours (and many dollars on postage) writing letters to various pharmaceu-
tical companies, requesting that the companies stop sending me advertising material. Most of the companies that I have written to have been good enough to comply with my request. In place of a direct monetary contribution from me, please request a contribution from your member companies for an amount equal to the money that they would have spent on planning, printing and posting bulk advertising material to me. Demand that your member companies stop
Medical procedures prohibited outside hospital in Nova Scotia rT he letter from Dr. Henry Morgentaler begs a response, for Morgentaler pleads his case to be allowed to practise good medicine by being able to peform abortions on demand in Nova Scotia. Since when is it good medicine to treat a socioeconomic
