Letter to the Editor Regarding: Evolving Business Models in Orthotics by Schneider, N.

The purpose of this letter is to continue the dialogue regarding the paper "Evolving business models in Orthotics" in the Canadian Prosthetics & Orthotics Journal Volume 4, Issue2, No.3, 2021. In it we present the perspective of the current Alberta Association of Orthotists and Prosthetists (AAOP) and provide additional context and information on historical events. Finally, we provide additional clarity on how costing is approached in the Province of Alberta (Canada) and the purported inequity in compensation between the two disciplines.

A Simple Evaluation Tool (ET-CET) Indicates Increase of Diagnostic Skills From Small Bowel Capsule Endoscopy Training Courses: A Prospective Observational European Multicenter Study.

Small bowel capsule endoscopy (SBCE) has become a first line diagnostic tool. Several training courses with a similar format have been established in Europe; however, data on learning curve and training in SBCE remain sparse.Between 2008 and 2011, different basic SBCE training courses were organized internationally in UK (n = 2), Italy (n = 2), Germany (n = 2), Finland (n = 1), and nationally in Germany (n = 10), applying similar 8-hour curricula with 50% lectures and 50% hands-on training. The Given PillCam System was used in 12 courses, the Olympus EndoCapsule system in 5, respectively. A simple evaluation tool for capsule endoscopy training (ET-CET) was developed using 10 short SBCE videos including relevant lesions and normal or irrelevant findings. For each video, delegates were required to record a diagnosis (achievable total score from 0 to 10) and the clinical relevance (achievable total score 0 to 10). ET-CET was performed at baseline before the course and repeated, with videos in altered order, after the course.Two hundred ninety-four delegates (79.3% physicians, 16.3% nurses, 4.4% others) were included for baseline analysis, 268 completed the final evaluation. Forty percent had no previous experience in SBCE, 33% had performed 10 or less procedures. Median scores for correct diagnosis improved from 4.0 (IQR 3) to 7.0 (IQR 3) during the courses (P < 0.001, Wilcoxon), and for correct classification of relevance of the lesions from 5.0 (IQR 3) to 7.0 (IQR 3) (P < 0.001), respectively. Improvement was not dependent on experience, profession, SBCE system, or course setting. Previous experience in SBCE was associated with higher baseline scores for correct diagnosis (P < 0.001; Kruskal-Wallis). Additionally, independent nonparametric partial correlation with experience in gastroscopy (rho 0.33) and colonoscopy (rho 0.27) was observed (P < 0.001).A simple ET-CET demonstrated significant improvement of diagnostic skills on completion of formal basic SBCE courses with hands-on training, regardless of preexisting experience, profession, and course setting. Baseline scores for correct diagnoses show a plateau after interpretation of 25 SBCE before courses, supporting this number as a compromise for credentialing. Experience in flexible endoscopy may be useful before attending an SBCE course.

Management of lower gastrointestinal tract bleeding.

Acute bleeding from the colon and rectum is less frequent and less dramatic than haemorrhage from the upper gastrointestinal tract. In most cases, bleeding from the colon and rectum is self-limiting and requires no specific therapy. Diverticula and angiectasias are the most frequent sources of bleeding. Malignancy, colitis (inflammatory bowel disease, non-steroidal anti-inflammatory drugs, and infectious colitis), ischaemia, anorectal disorders, postpolypectomy bleeding, and HIV-related problems are less frequent causes. The recurrence rate, especially in diverticular bleeding, is high. Resuscitation and haemodynamic stabilisation of the patient is the first step in the management of colonic bleeding. Urgent colonoscopy is the method of choice for diagnosis and therapy. By analogy with peptic ulcer bleeding, risk stratification using stigmata of haemorrhage is gaining more importance. Modern endoscopic techniques such as injection therapy, thermocoagulation and mechanical devices seem to be effective in achieving haemostasis and avoiding precarious surgery. Angiography and nuclear scintigraphy are reserved for those patients in whom colonoscopy is not possible or has repeatedly failed to localise the bleeding site.

[Long-Lasting Odynophagia and Haematemesis - the Only Clinical Signs of a Pemphigus vulgaris]. / Langjährige Schluckschmerzen und Hämatemesis - einziges Zeichen eines ungewöhnlich manifestierten Pemphigus vulgaris.

Odynophagia and dysphagia are clinical signs associated with a wide spectrum of potential causes. Our patient was an 84-year-old woman, who suffered from odynophagia and dysphagia for over 10 years. The interstinoscopy showed blister-like lesions and signs of inflammation only in the proximal part of the oesophagus. The diagnosis of pemphigus vulgaris was supported by immunohistological results. Typical oropharyngeal and cutaneous lesions of pemphigus were missing in our patient. Involvement of the oesophagus is described in literature, but it seems to be underdiagnosed in clinical everyday's work. Restriction of the lesions to the oesophagus without oropharyngeal and cutaneous manifestation - as we have seen in our patient - is rare.

Dyspepsia in AIDS is correlated to ultrasonographic changes of antral distension.

OBJECTIVES: Patients with acquired immune deficiency syndrome (AIDS) frequently complain about dyspeptic symptoms. We set out to test whether changes in antral emptying or antral distension may account for these dyspeptic symptoms in AIDS. METHODS: We studied antral emptying in ten patients with HIV infection (CDC 1993 classification stage C) by means of an established real-time ultrasonographic method. Organic abdominal lesions had been excluded. Six upper gastrointestinal symptoms were evaluated using a score ranging from 0 to 3. Fifteen subjects without any abdominal complaints and without any abdominal history served as controls. Antral cross sectional area was measured after an overnight fast and at 0, 15, 30, 45, 60, 90, 120 min after an semisolid test meal. Antral postprandial distension was expressed using an antral expansion ratio (postcibal antral area/fasting antral area). Gastric emptying of the test meal was derived from the measurement of the area under the postcibal antral distension curve (AUC). RESULTS: Fasting antral cross sectional area and AUC (gastric emptying) were similar in both groups. Antral postprandial expansion tended to be lower in AIDS patients compared to controls (mean+/-S.D.): 288+/-84 versus 397+/-156%; P=0.08. In AIDS patients the symptom score of dyspepsia showed a positive correlation (r=0.55; P<0.05) with fasting antral area and a negative correlation (r=-0.62; P<0.05) with postprandial expansion. No signs of autonomic neuropathy were to be found in the AIDS patients tested in this study. CONCLUSION: A wider fasting antral cross sectional area and an impaired antral postprandial expansion are related to dyspeptic symptoms in AIDS patients. This suggests the same relationship between dyspeptic symptoms and disturbed antral distension as seen in other patients with functional dyspepsia.

Autonomic dysfunction and the gastrointestinal tract.

Autonomic neuropathy of the gastrointestinal tract may represent a primary disorder, but much more often it is secondary due to systemic disorders like diabetes mellitus. This review gives an overview about the common clinical manifestations and the principles and limitations in diagnostic work-up of autonomic dysfunction of the gastrointestinal tract. Diagnostic evaluation usually includes a combination of screening tests for autonomic neuropathy and specialized diagnostic procedures for the detection of sequela of autonomic neuropathy in gastrointestinal motility.

Postprandial gastric relaxation in achalasia.

BACKGROUND: In achalasia the incidence of autonomic neuropathy is increased, indicating that achalasia is not a disease of the oesophagus only. Little information is available concerning the function of the stomach in achalasia. We compared the postprandial gastric fundus relaxation in patients with achalasia to that of healthy controls. METHODS: In six patients with achalasia and six healthy controls postprandial fundus relaxation after a liquid test meal (500 ml, 500 kcal) was studied using an intragastric bag connected to an electronic barostat. The postprandial gastric relaxation was measured as an increase of intragastric bag volume; bag pressure was set at a constant level of 1 mmHg above the intra-abdominal pressure. All data are given as means +/- SEM, and the Mann-Whitney test was used for statistical analysis. RESULTS: The intragastric volume before ingestion of the test meal was not different between groups. The maximum relaxation in patients with achalasia was significantly lower than in controls (132+/-46 ml vs 238+/-70 ml, P< 0.02). Postprandial relaxation was diminished and shortened in patients with achalasia as compared with controls. Similarly, the area under the volume curve was significantly smaller in patients with achalasia than in controls (29.8+/-28.9 ml/h vs 102.9+/-58.4 ml/h, P< 0.03) consistent with a diminished postprandial relaxation. CONCLUSION: Patients with achalasia show a decreased postprandial gastric relaxation compared with healthy controls. We hypothesize that the neural damage in achalasia is not restricted to the oesophagus, but also involves the proximal stomach.

["Alternative" therapy methods in functional disorders of the gastrointestinal system]. / "Alternative" Behandlungsmethoden bei funktionellen Erkrankungen des Gastrointestinaltraktes.

Patients with functional disorders of the gastrointestinal tract often respond poorly to standard therapeutic regimes. Therefore, "alternative" forms of treatment (e.g. homocopathy, acupuncture, phytotherapy, diet modifications, psychotherapy, hypnosis) often come into play. Critical assessment of these forms of therapy is difficult: placebo response is high in functional disorders of the gastrointestinal tract and usually no placebo-controlled studies are available to prove the efficacy of these forms of therapy. Up to now no data was able to prove the efficacy of homoeopathy and phytotherapy, and the efficacy of acupuncture has to be questioned. In contrast to this, hyponosis, psychotherapy and some forms of diet modification seem to be useful at least in some patients with functional disorders of the gastrointestinal tract.

[Diagnosis and therapy of fecal incontinence]. / Diagnostik und Therapie der Stuhlinkontinenz.

Fecal incontinence is not a diagnosis, but a symptom which can have multiple causes. The aim of any therapy should be to treat the underlying disorder. This requires a detailed diagnostic procedure in each patient. If no underlying disorder can be found, therapy becomes symptom oriented. Besides drug treatment anal biofeedback training is the most important form of medical therapy. Except for special situations surgery is indicated only if medical therapy has failed.

The effect of cisapride on dysmotility-like functional dyspepsia: reduction of the fasting and postprandial area, but not of the postprandial antral expansion.

OBJECTIVE: To test the effect of cisapride on symptom score and on fasting and postprandial antral area in patients with dysmotility-like functional dyspepsia compared with controls. METHODS: Nineteen consecutive patients with dysmotility-like functional dyspepsia (13 females, six males, aged 18-79 y) and 12 control subjects (six females, six males, aged 19-68 y) were investigated. A symptom score including six upper digestive symptoms rated from 0 to 3 was applied. The patients received in a randomized order cisapride 10 mg t.i.d. (n = 10), or placebo (n = 9) for 3 days. The controls also received cisapride (n = 6) or placebo (n = 6) in the same way. The antral area in fasting condition and immediately after a semiliquid test meal (250 ml, 342 kcal) was assessed by real-time ultrasonography in front of the aorta and mesenteric vein. The measurements were carried out before starting and after finishing the trials with cisapride and placebo. RESULTS: The symptom score (mean +/- SD) was 7.1 +/- 2.4 in dysmotility-like functional dyspepsia vs 0.5 +/- 0.2 in controls (P < 0.0001). The fasting antral area was 4.5 +/- 0.9 cm2 in dysmotility-like functional dyspepsia vs 2.2 +/- 0.2 cm2 in controls (P < 0.0001). Postprandial antral area was also larger in dysmotility-like dyspepsia than in controls (6.2 +/- 1.0 vs 3.0 +/- 0.3 cm2, Pb= 0.0001). Symptom score correlated with fasting antral area in dysmotility-like functional dyspepsia (rb= 0.38, Pb= 0.05). Cisapride decreased the symptom score to 4.5 +/- 2.5 (P = 0.0009) and placebo to 5.3 +/- 2.4 (P = 0.02). Cisapride significantly reduced the fasting antral area and the postprandial antral area in the dyspeptic group, but not in the control group. Postprandial antral expansion was not influenced by cisapride. Placebo did not change the sonographic parameters in both groups. CONCLUSIONS: In dysmotility-like functional dyspepsia, fasting and postprandial antral areas are wider than in controls. Despite a good placebo response, cisapride is effective in improving the symptoms in dysmotility-like functional dyspepsia, associated with the reduction of fasting and postprandial antral areas.

Eradication of Helicobacter pylori in peptic ulcer disease with amoxycillin, 2.0 g, and omeprazole, 80 or 120 mg: a prospective randomized trial.

BACKGROUND: The appropriate dose of proton pump inhibitors needed for eradicating Helicobacter pylori by dual therapy is still controversial. DESIGN: The study was conducted as a single-blind, single-centre trial. METHODS: Fifty-four patients with active duodenal ulcers were treated with amoxycillin tablets, 750 mg three times daily, and omeprazole, either 40 mg twice daily (group 1) or 40 mg three times daily (group 2), for 14 days in a prospective randomized trial. H. pylori eradication was assessed 10 weeks after starting treatment. Biopsies were taken for rapid urease tests and histological analysis and 13C-urea breath tests were ordered. RESULTS: In both groups ulcer healing was complete in 96.3% of patients after 10 weeks. Ten weeks after starting treatment, Helicobacter pylori was eradicated in 76.9% of the patients in group 1 and 74.1% of those in group 2, as shown by rapid urease tests and histological analysis. In the subgroup of fully compliant patients (n = 49) the eradication rates were 80% and 79.2%, respectively. Hyperacidity significantly reduced the eradication rates. Patients showing successful H. pylori eradication were significantly older (59 +/- 14.0 years vs. 49 +/- 15.6 years; P = 0.025). Eradication rates were lower in smokers than in non-smokers (36.4% vs. 83.9%; P = 0.006). CONCLUSION: It is concluded that higher omeprazole doses should be reserved for younger patients and smokers; in others they are not needed.

[Portal vein thrombosis after occlusion of a transjugular intrahepatic portosystemic stent-shunt (TIPSS). Shunt dilatation with subsequent local and systemic thrombolysis]. / Pfortaderthrombose nach Verschluss eines transjugulären intrahepatischen portosystemischen Stent-Shunts (TIPSS). Shunt-Dilatation mit anschliessender lokaler und systemischer Thrombolyse.

HISTORY AND CLINICAL FINDINGS: A transjugular intrahepatic portosystemic stent shunt (TIPSS) had been implanted to lower the portal hypertension in a 56-year-old man with alcoholic liver cirrhosis and several bleedings from fundal varices. A shunt revision with dilatation became necessary one year later. Recently the patient had gained 8 kg in weight in 3 weeks and his abdomen had become distended. The patient's general condition (height 179 cm, weight 82.9 kg) was clearly reduced. He had marked ascites, the liver was enlarged to 17 cm below the costal margin and the right lung base was dull on percussion. INVESTIGATIONS: Abdominal sonography detected marked ascites and liver cirrhosis with splenomegaly. Duplex sonography failed to demonstrate any flow in the shunt, indicating its occlusion. TREATMENT AND COURSE: At retrograde dilatation of the stent a fresh thrombosis was noted in the right branch of the portal vein and a partial one in the main trunk. Recanalization was achieved locally 10 mg and systemically 100 mg recombinant tissue plasminogen activator (r-tPA). Hepatic vein pressure measurements before and after the thrombolysis demonstrated a significantly lower hepatic venous occlusion gradient, and the portal hypertension had been reduced by about 45%. The ascites gradually resolved. CONCLUSION: Combined local and systemic thrombolysis was successful in recanalizing portal vein thrombosis after TIPSS.

Gastric emptying in liver cirrhosis. The effect of the type of meal.

OBJECTIVE: Contradictory reports have been published on gastric emptying in patients with liver cirrhosis. The differences have been attributed to differences in the innervation of the stomach or in the behaviour of the gastric wall. The type of test meal used may, however, have its importance. We looked for the role of the test meal in the assessment of gastric emptying in cirrhosis. DESIGN: In a prospective study, we included 15 patients with liver cirrhosis who had no symptoms of autonomic neuropathy, portal hypertensive gastropathy or antral vascular ectasia and 15 controls. In these subjects we estimated the gastric emptying and varied the type of test meals. METHODS: An ultrasonographic method was used for the estimation of gastric emptying. Antral area was monitored in the aorto-mesenteric plane in the fasting condition and at 0, 15, 30, 45, 60 min after a test meal. Each patient was tested twice on 2 consecutive days in randomized order with a liquid meal (220 kJ) and a semisolid meal (1472 kJ). RESULTS: Fasting antral areas (mean +/- SD) had similar size in both groups with both meals. Gastric emptying (expressed by the area under the curve and half-time (T1/2)) of the semisolid meal was not different in cirrhosis (2347 +/- 1648) compared to controls (2840 +/- 1983). Postprandial antral distension was also similar in both groups (312.2 +/- 133.6% in cirrhosis vs. 397.9 +/- 155.6% in controls). But emptying of the liquid meal was accelerated in the cirrhotic patients with respect to the area under the curve (AUC: 882 +/- 548) and half-time (12 +/- 2 min) vs. controls (AUC: 1863 +/- 1088, P<0.01; T1/2: 18 +/- 7 min, P<0.05). Postprandial antral distension with the liquid meal was decreased (299.4 +/- 76.5% vs. 431.5 +/-154.0%, P<0.01, in controls). CONCLUSION: These data suggest that in patients with liver cirrhosis free of autonomic neuropathy and without portal hypertensive gastropathy or vascular antral ectasia, gastric emptying of liquid low calorie meals is accelerated. The gastric emptying of a semisolid meal richer in calories is normal. Thus, the physical and chemical properties of a meal are major determinants of gastric emptying and may account for the large divergence of results hitherto published on this topic.

[Reflux esophagitis: manometry and Ph measurement]. / Refluxösophagitis: Manometrie und pH-Metrie.

Manometry and pH-metry are essential in the examination of functional disturbances of the esophagus. Proven indications for manometry are dysphagia of unknown origin and noncardiac chest pain; in reflux esophagitis manometry is used for measuring pressure of the lower esophageal sphincter and detecting motility disorders of the esophageal body, pH-metry is used as long-term pH-metry to quantify gastroesophageal reflux during day and night; furthermore long-term pH-metry is important in the classification of atypical esophagitis. Recording gastroesophageal reflux and esophageal motility may influence planning of therapy and predict prognosis. Before antireflux surgery manometry and pH-metry are useful in judging the clearance mechanisms of the esophagus. Used critically, manometry and pH-metry can be very helpful as cost-effective diagnostic tools in the long-term therapy of reflux esophagitis.

A hitherto unknown pattern of pathologic gastrointestinal motility--a cause of repeated vomiting?

We report the case of a 20-year-old woman with functional vomiting who presented with symptoms of anorexia nervosa. Antroduodenal and upper jejunal perfusion manometry was performed using an eight-lumen catheter. The investigation revealed a hitherto unknown motility pattern consisting of continuous simultaneous contractions at high frequency from the antrum down to the upper jejunum. The observation suggests that this disorder was related to the patients symptomatology.

24-hour oesophageal motility in gastro-oesophageal reflux disease (GORD): increased occurrence of simultaneous contractions.

Impaired oesophageal peristalsis may play a major pathogenetic role in gastro-oesophageal reflux disease (GORD). Therefore 55 patients with suspected GORD were studied simultaneously by ambulatory 24-hour pH and pressure monitoring with three pressure transducers (3, 8 and 13 cm above the lower oesophageal sphincter) in order to to test for a relationship between oesophageal motility and GOR. Twenty-one patients (38%) had pathological reflux; these patients had significantly more simultaneous contractions than patients without pathological GOR (30.1 +/- 3.3% vs. 19.0 +/- 1.8%, P = 0.002, mean +/- SEM). Further analysis revealed a significant difference between groups in the occurrence of simultaneous contractions in the mid-oesophagus (33.7 +/- 3.8% vs. 23.9 +/- 1.8%, P = 0.012), but not in the distal oesophagus (34.4 +/- 2.7% vs. 33.9 +/- 3.1%, P = 0.90). In addition, a moderate but highly significant correlation between the rate of simultaneous contractions and reflux time was found (r = 0.463, P = 0.0005). Mean amplitude and mean duration of the contractions were no different between groups, neither in the proximal (43.4 +/- 3.3 mmHg vs. 44.9 +/- 1.9 mmHg, P = 0.68 and 2.4 +/- 0.2s vs. 2.5 +/- 0.1s, P = 0.50, respectively) nor in the distal oesophagus (48.8 +/- 4.6 mmHg vs. 54.2 +/- 3.4 mmHg, P = 0.34 and 3.0 +/- 0.2s vs. 2.9 +/- 0.2s, P = 0.71, respectively). It was concluded that pathological GOR is associated with an increased occurrence of simultaneous contractions in the mid, but not in the distal, oesophagus.

[Conservative therapy of fecal incontinence]. / Konservative Therapie der Stuhlinkontinenz.

Fecal incontinence is not diagnosis, but a symptom which can result from multiple causes. Therefore, therapy should attempt to treat the underlying disorder whenever possible. If this is not possible, therapy becomes symptom oriented. Besides drug treatment anal biofeedback training is the most important basis of medical therapy. Except for special situations surgery is indicated only if medical therapy has failed.

Intestinal pseudoobstruction as a feature of myotonic muscular dystrophy.

We report two cases of intestinal pseudoobstruction caused by visceral smooth muscle involvement due to myotonic muscular dystrophy. Two patients with myotonic muscular dystrophy presented with abdominal pain, distention, constipation, and vomiting. The exclusion of mechanical obstruction by plain abdominal radiography, contrast studies, and colonoscopy led to the diagnosis of intestinal pseudoobstruction. Diagnosis was confirmed by manometric and cineradiographic findings of abnormal intestinal motility. Conservative management including laxatives and cisapride led to the resolution of the pseudoobstruction syndrome and long-term remission without relapses during a two year follow-up. In patients with known myotonic dystrophy the occurrence of intestinal pseudoobstruction should be considered in order to avoid unnecessary laparotomies.

[Do proton pump inhibitors after endoscopic control of acute ulcer hemorrhage have an advantage over H2 receptor antagonists?]. / Sind Protonenpumpenhemmer nach endoskopischer Stillung der akuten Ulcusblutung gegenüber H2-Rezeptorantagonisten von Vorteil?

During a two year period (1992-1993) we investigated whether or not, after endoscopic therapy of bleeding ulcers, the suppression of gastric acid secretion with an administration of a proton pump blocker (Omeprazol) is more effective than the administration of H2-receptor antagonist (Ranitidin) with respect to prevention of recurrent bleeding episodes, frequency of surgical intervention and mortality. 106 patients (64 men, 42 women) were treated with the proton pump blocker and 126 patients (82 men, 44 women) received the H2-receptor antagonist. Patients were treated either with an initial dose of 80 mg Omeprazol followed by 3 x 40 mg Omeprazol i.v. or with a daily dose of 3 mg/kg body weight Ranitidin i.v. No significant differences could be detected between the two treatment regimes with respect to the parameters mentioned above. Rebleeding which could be controlled by endoscopic hemostasis occurred in 19.8% vs. 17.5% (Omeprazol/Ranitidin) of patients. Surgical intervention because of rebleeding was necessary on 8.5% vs. 8.7% of the patients. Mortality due to hemorrhage was 5.7% vs. 4.0%. From these results we conclude that, following endoscopic hemostasis of bleeding ulcers, Omeprazol has no advantage over Ranitidin using our dosage regimes.

Antral emptying of semisolid meal measured by real-time ultrasonography in chronic renal failure.

The etiology of upper digestive complaints in uremic patients, which frequently cause morbidity, is unclear. By means of ultrasonography we studied the emptying of the gastric antrum in 15 patients suffering from end-stage renal disease and in 15 controls. In addition, we tested for autonomic neuropathy in the chronic renal failure (CRF) patients using cardiovascular tests. The antral filling and emptying of a semisolid standardized test meal was assessed by measuring cross-sectional areas of the antrum along the plane of the mesenteric vein at regular intervals after a semisolid test meal. Postprandial antral cross-sectional areas were similar in controls and in the total of the renal failure patients. CRF patients without autonomic neuropathy (4/15) showed hastened antral emptying as evidenced by significantly diminished postcibal antral expansion. Only the CRF subgroup with symptoms of both parasympathetic plus sympathetic autonomic neuropathy (6/15) had delayed antral emptying compared to controls as assessed by planimetry of the area under the curve in postprandial antral cross-sectional areas. The CRF subgroup with exclusively parasympathetic neuropathy (5/15) had antral emptying similar to the controls. The symptom score as assessed by a standardized questionnaire of the CRF group with autonomic neuropathy (11/15) correlated significantly both with the fasting antral cross-sectional area and inversely with antral expansion immediately after finishing the test meal. Antral emptying showed a trend towards an inverse relationship to the symptom score, which reached statistical significance only in the CRF subgroup with sympathetic plus parasympathetic autonomic damage.(ABSTRACT TRUNCATED AT 250 WORDS)