ommends steroid treatment for all such children: "Nous recommandons un traitement aux steroides pour tout enfant admis a l'h6pital avec un diagnostic de laryngotracheite aigue grave." Which recommendation is correct? Kenneth Brown, MD Canadian Forces Base Borden Borden, Ont.

[A Canadian Paediatric Society official (and consultant to the committee) responds.] We thank Dr. Brown for bringing to our attention the discrepancy in our position statement. The official statement is the English text. We said "could" and not "should" because the metaanalysis did not show a statistically significant advantage to using steroids, although there seems to be some clinical benefit. Victor Marchessault, MD Executive vice-president Canadian Paediatric Society Ottawa, Ont.

Nasogastric tube placement A fter reading the case report

"Inadvertent intracranial placement of a nasogastric tube in a patient with severe head trauma," by Drs. Julian S. Adler, Douglas A. Graeb and Robert A. Nugent (Can Med Assoc J 1992; 147: 668-669), I would like to remind readers of a simple technique to clinically confirm the placement of these devices. Injecting 40 to 60 mL of air from a 60-mL catheter-tip (Toomey) syringe (Becton Dickinson and Co., Rutherford, NJ) while ascultating the stomach region quickly confirms that the tip of the nasogastric tube is within the stomach cavity. If air bubbles are not heard the tube should be 1756

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immediately withdrawn and a more cautious insertion attempted. Placing fingers in the posterior pharynx to guide the catheter tip downward is also sometimes helpful (lidocaine topical anesthesia may be required in alert patients).

that the procedure is cost-effective and the results are encouraging. It is difficult to accept as an independent, unbiased investigator someone who has invested $850 000 in the device and who charges $5000 for a 1-hour treatment. Allen R. Huang, MD, CM, FRCPC In the United States thermoDivision of Geriatrics is currently available only therapy Royal Victoria Hospital as an investigative procedure Montreal, Que. under Food and Drug Administration regulations. It seems unfortunate that in Canada devices can be introduced and used to treat patients without having underThermotherapy still gone similar evaluation, and it is investigational disturbing to find unproven techniques being offered in such entreW r ith the funding con- preneurial fashion by members of x straints of our health the medical profession. care system the introduction of new, effective treat- Ernest W. Ramsey, MB, FRCSC ments can be difficult, often in- Professor, Section of Urology of Manitoba volving a great deal of effort and University Winnipeg, Man. frustration. The article by Pam Harrison "Innovative approaches Reference proving attractive to growing number of entrepreneurial MDs" 1. Barry MJ: Epidemiology and natural history of benign prostatic hyperplasia. (Can Med Assoc J 1992; 147: 512Urol Clin North Am 1990; 17: 495-507 513, 516-517) describes how some physicians have dealt with this problem. However, new technology does not necessarily equate with medical care of high quality. Transurethral microwave Conflict of interest thermotherapy is a highly innova- among researchers tive treatment for the common r. Douglas Waugh recentproblem of benign prostatic hyly reported on a joint pleperplasia (BPH). However, as innary session of the Assodicated in the article, it is still investigational. There are various ciation of Canadian Medical Colnew treatments for BPH under leges and the Association of Canevaluation, and these have dem- adian Teaching Hospitals in "Poonstrated the very marked pla- tential for conflict of interest cebo effect in this disease. In ran- among researchers increasing, domized studies of drug therapy meeting told" (Can Med Assoc J 20% to 40% of patients given a 1992; 147: 940). Waugh provided a succinct placebo demonstrated improveof three presentations summary controlled ment.' Randomized of conflict of inon the problem and therefore are studies essential, such studies of thermotherapy for terest. One cannot argue with the BPH are ongoing. Until they show three preventive measures proit to be of value, thermotherapy posed: that clear guidelines be provided for researchers (e.g., the should remain investigational. The Windsor group profiled policy at Johns Hopkins Universiin the article is quoted as claiming ty of permitting no more than a LE 15

DECEMBRE 1992

half day per week for outside commitments), that a fair arbitration mechanism for resolving differences be provided (e.g., the committee of faculty members at Harvard University) and that disclosure be routine, both to one's employer and to one's peers (the latter by means of a disclosure statement accompanying research presentations and publications). Although one of the speakers (Dr. Frederick Lowy) acknowledged that potential conflicts of interest are ubiquitous and not inherently unethical the phrase "conflict of interest" conjures up an image of something distasteful, to be avoided by properly motivated and upwardly mobile academicians. Such an image fails to capture the simultaneous, congruent and entirely ethical benefits to the university, the public and the faculty member: the provision of patient care, the dissemination of advice to industry or the transferring to the marketplace of useful technology developed in the laboratory. When a researcher can create such a "harmony of interests," as is so very often possible, such an accomplishment is worthy of celebration, not censure. R. Lee Kirby, MD, FRCPC Professor and head Division of Physical Medicine and Rehabilitation Department of Medicine Dalhousie University Halifax, NS

Kaiser Permanente system I was fascinated by Dr. Timothy Brox's article "Goodbye Ontario, hello California: Leaving medicare for the Kaiser Permanente system" (Can Med Assoc J 1992; 147: 490, 492-493), but I would appreciate confirmation of some of Brox's figures. Brox reports that Kaiser Permanente (KP) provides care to 6.4 million US subscribers, a number equivalent to the combined population of British Columbia, Alberta and Saskatchewan. Although KP uses 9000 physicians Canada's three western provinces have 12 543 active civilian physicians, excluding interns and residents. Therefore, western Canada has about 3500 physicians more than needed. In addition, Brox reports that 2.5 million subscribers in northern California were covered by $2.9 billion (US) in medical insurance in 1991. Alberta, with the same population, spent about $3.4 billion (Can.) in 1991. Apparently KP can provide equivalent coverage, plus drug coverage, in a better system, with fewer physicians, at about the same total cost. In addition, physicians have a better lifestyle and earn more! In view of the potential policy implications of the article I would appreciate verification of the figures.

[Dr. Waugh responds.] Dr. Kirby is quite right to point out the pejorative overtones of the expression "conflict of interest." However, in my role as reporter my job was simply to report what was said and not editorialize on the titles of the session and the papers presented. It is quite appropriate for Kirby to do so, as he does with eloquent impact. Douglas Waugh, MD Ottawa, Ont. DECEMBER 15, 1992

G. Howard Platt, MB, ChB Provincial medical consultant Alberta Department of Health Edmonton, Alta.

[Dr. Brox responds.]

The number of physicians working for KP must be viewed with caution. The system uses health care providers not directly employed by the Permanente Medical Group for contracted tertiary and specialized medical and surgical services when internal services

would be cost-ineffective; examples are radiation therapy and renal dialysis. In preparing my article I was tempted to compare KP costs and Canadian provincial health expenditures. However, a direct comparison was not possible from the available data and would be complicated by the different accounting practices. In addition, there are important differences in benefits. The purpose of my article was to describe an alternative arrangement for health care delivery, emphasizing that physicians can be responsible and effective in the delivery of health care and the management of health care systems. A direct comparison of costs will have to be left to the health care economists. Timothy Brox, MD Chief of orthopedics Fresno Medical Center Kaiser Permanente Medical Group Fresno, Calif.

Hospital mergers recommended for London, England I was interested in Charlotte Gray's article on the closure of St. Bartholomew's Hospital, London, England (Can Med Assoc J 1992; 147: 1366), and thought that the many London teaching hospitals' graduates now living in Canada would be interested in knowing the fate of their almae mater. The Tomlinson Enquiry into Medicine in London, a government-commissioned report that was released on Oct. 23, 1992, recommends the following: merge St. Bart's with the Royal London Hospital and close the Bart's site; merge St. Thomas's and Guy's hospitals on one site; close the Middlesex Hospital and merge it with University College Hospital; CAN MED ASSOC J 1992; 147 (12)

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Conflict of interest among researchers.

ommends steroid treatment for all such children: "Nous recommandons un traitement aux steroides pour tout enfant admis a l'h6pital avec un diagnostic...
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