Renal disease is the first clinical state to be associated with elevated plasma motilin concentrations. What is the physiologic significance of the elevation? Motilin causes fundic, antral and duodenal contractions,7 inhibits gastric emptying,8 increases the pressure on the lower esophageal sphincter9'10 and induces migrating myoelectric complexes in the gut.11'11 Elevated plasma motilin concentrations may cause abnormalities in the pattern of migrating myoelectric complexes resulting in disturbed gut motility, which may produce diarrhea, constipation, nausea and vomiting in patients with chronic renal failure. Acid regurgitation, eructation and heartburn may be secondary to abnormalities in the competence of the lower esophageal sphincter mediated by motilin. Further studies are necessary to assess the etiologic role of elevated plasma motilin concentrations in the disorders associated with renal disease. We thank Professor J.C. Brown, department of physiology, University of British Columbia, for supplying the motilin antibody (GP7I) and natural porcine motilin used in this study, and Drs. C.J. Cardella, G.A. de Veber, D.G. Oreopoulos and P.R. Uldall for their support and for allowing us to study their patients. R.S. MCLEOD, MD N.S. TRACK, PH D
Departments of surgery and clinical biochemistry University of Toronto and Mount Sinai Hospital L.E. REYNOLDS, RN
Renal unit Toronto Western Hospital Toronto, Ont.
References 1. DOHERTY
CC,
O'CONNOR
FA,
BUCHANAN KD, et al: Treatment of peptic ulcer in renal failure. Proc Eur
Dial Transplant Assoc 14: 386, 1977 2. KORMAN MG, LAyER MC, HANSKY J: Hypergastrinemia in chronic renal
failure. Br Med J 1: 209, 1972 3. O'Doiusio TM, SIRINEK KR, MAZZAFERRI EL, et al: Renal effects on serum gastric inhibitory polypep-
tide (GIP). Metabolism 26: 651, 1977 4. HXLLGREN R, LuNIX?vIsT G, CHANCE RE: Serum levels of human pancreatic polypeptide in renal disease.
Scand J Gastroenterol 12: 923, 1977 5. DRYBURGH JR, BROWN JC: Radio-
immunoassay for motilin. Gastroenterology 68: 1169, 1975 6. TRACK NS, WATTERS LM, GAULDIE J: Motilin, human pancreatic poly-
erythromycin (1.0 p.g/ml) and trimethoprim-sulfamethoxazole (1.5Cliii Biochem (in press) BROWN JC, MUTT V, DRYBURGH JR: 28.5 .g/ml). The other two strains The further purification of motilin, demonstrated resistance to these a gastric motor activity stimulating three drugs. The MIC of tetrapolypeptide from the mucosa of the cycline and erythromycin was 5 .g/ small intestine of hogs. Can I Physiol ml, and that of trimethoprim-sulPharmacol 49: 399, 1971 3.0-57.0 .g/ml. RUPPIN H, DOMSCHKE S, DOMSCHKE famethoxazole W, et al: Effects of I 3-Nie-motilin MICs of kanamycin were between in man - inhibition of gastric 12 and 25 .g/ml. The only drug to evacuation and stimulation of pepsin which all the strains were suscepsecretion. Scand J Gastroenterol 10: tible was spectinomycin; the MIC 199, 1975 was 15 .g/ml. Lux 0, RoscH W, DOMSCHKE S, et It is important that susceptibility al: Intravenous 1 3-Nie-motilin increases human lower esophageal testing be done to monitor the treatsphincter pressure. Scand J Gastroen- ment of infections due to penicillinterol 11 (suppl 39): 75, 1976 resistant N. ganorrhoeae strains. As HELLEMANS J, VANTRAPPEN 0, BLOOM SR: Endogenous motilin and spectinomycin appears to be an exLES pressure. Ibid, p 67 cellent drug in the treatment of these LEE KY, CHEY WY, TA! H-H, et al: special cases, it should be used Radioimrnunoassay of motilin: validation and studies on the relationship wisely and cautiously since there is between plasma motilin and inter- already a tendency to increasing redigestive myoelectric activity of the sistance of some N. gonorrhoeae duodenum of dog. Am I Dig Dis 23: strains to this antibiotic.3-5 peptide (HPP) and gastrin plasma concentrations
7.
8.
9.
10.
11.
in fasting subjects.
789, 1978
12. IToH Z, TAKEUCHI 5, AIZAW,A I, et al: Changes in plasma motilin concentration and gastrointestinal contractile activity in conscious dogs. Ibid, p 929
Susceptibility pattern in vitro of the peniciflinase-producing Neisseria gonorrhoeae strains To the editor: In our laboratory, between December 1978 and March 1979, we had a sudden increase of penicillinase-producing Neisseria gonorrhoeae strains from Toronto and the surrounding area.1'2 A total of 1436 N. gonorrhoeae cultures were tested for penicillinase production. Seven strains (0.5%) isolated from seven patients were identified as producing penicillinase. Susceptibility testing of these strains against seven antibacterial drugs - penicillin, ampicillin, spectinomycin, tetracycline, erythromyci kanamycin and trimethoprimsulfamethoxazole - yielded the following results: All seven penicillinase-producing strains showed resistance to penicillin and ampidihin; however, the minimum inhibitory concentrations (MICs) of the antibiotics varied. The MIC of penicilun ranged from 25 IU/ml to greater than 400 IU/ml, and that of ampicillin ranged from 10 to 800 .sg/ml. Five strains were susceptible to tetracycline (1.0 p.g/ml),
ROSA SHTIBEL, M SC
Clinical bacteriology section Provincial public health laboratories Ontario Ministry of Health Toronto, Ont.
References 1. /3-lactamase producing Neisseria gonorrhoeae in Canada. Can Dis Wkly Rep 4: 181, 1978 2. Penicillinase-producing strains of Neisseria gonorrhoeae isolated in Ontario. Can Dis Wkly Rep 5: 41, 1979 3. PANG R, TEH LB, RAJAN VS, et al: Gonococcal ophthalmia neonatorum caused by beta-lactamase-producing Neisseria gonorrhoeae. Br Med J 1: 380, 1979 4. SHTIBEL R: Resistance of cultures of Neisseria gonorrhoeae to spectinomycm (C). Can Med Assoc J 119: 1006, 1978 5. Idem: Resistance of Neisseria gonorrhoeae to antibacterial drugs in Ontario. Health Lab Sd 13: 49, 1976
Allied health professions To the editor: It was interesting to read David C. Blair's editorial on allied health professions and the non-physician-referred practice of physiotherapy (Can Med Assoc J 120: 519, 1979). It may be that physiotherapists should emerge with more independence. If they succeed, perhaps this will control the rather alarming increase in numbers of chiropractors who are already in direct contact
CMA JOURNAL/AUGUST 4, 1979/VOL. 121 273
with the patient without being "coordinated from the highest level". For years physiotherapists in Ontario have been tied to institutional apron strings with substantial constraints from government. The opportunities for private practice have been few; it is surprising that this chauvinistic put-down of a hardworking group (mostly women) has been accepted so passively for so many years. It is questionable whether most hospital departments could finance a physiatrist as a full-time department head. Dr. Blair has suggested that part-time physicians may not be able to contribute adequately to the education of therapists if they are "too busy seeing patients". On the contrary, I suggest that busy clinicians are perhaps the ideal persons to assist in clinical training. It may be that most of the pioneer spirit in the West is associated with the oil rigs. Surely we should encourage physiotherapists to spread their wings and fly, with the understanding that the marketplace will help to keep their feet on the ground. I find it hard to believe that a group of conscientious university-trained physiotherapists will stray far from the medical profession. We should encourage another group of freedom fighters. PAUL F. MCGOEY, MD
1020 McNicoll Ave. Scarborough, Ont.
To the editor: Dr. Blair was very critical of the moves being made by physiotherapists to work on a more independent basis of referrals from physicians. Yet he did not offer any explanations as to why physiotherapists are moving in such a direction, nor did he properly evaluate whether such moves might be both necessary and desirable in terms of providing the public with greater community access to more qualified physiotherapists. Over the past decade I have made an extensive study of the status of the physiotherapy profession in the community. At the request of the New Zealand Medical Association and the New Zealand Society of Physiotherapists I recent-
ly travelled to New Zealand to present a paper that dealt in large part with this subject. The basic conclusion of my study was that a more independent referral status is desirable and necessary. It may be the wish of every physician that physiotherapists work only on the direct referral of a physician. I believe that, from the point of view of providing the most complete differential diagnosis possible, such a strict referral system is probably the safest. However, what we might wish and what is reality are two different things. The basic reality is that the person in the community most sought out by patients to provide physiotherapy is neither the physician nor the physiotherapist; rather, it is the chiropractor. The chiropractor works on a completely nonreferral basis. He uses the same instruments the physician does to perform a complete physical examination. He does electrocardiograms, blood tests and biochemical analyses. He claims to be able to treat all manner of disease. He performs all types of roentgenography, and even prescribes drugs. The chiropractor does all these things without any recognized scientific training. The chiropractor, working with unscientific and dangerous theories, has been granted, almost unchallenged, the role of the primary-contact person in the community for the provision of physiotherapy. Physiotherapists have seen their role as private out-ofhospital practitioners almost eliminated by the emergence of chiropractors. Few physicians have recognized the plight of physiotherapists. Organized medicine, as reflected by the attitude of Dr. Blair, who did not once mention in his article the subject of chiropractic, has done nothing to help. In fact, since 1972, requests have repeatedly been made of the Canadian Medical Association (CMA) to inform physicians as to the situation regarding chiropractic. Despite a resolution at the CMA's annual meeting 6 years ago calling for such an educational program for physicians,1 the CMA has not acted. If physicians remain as poorly informed as Dr. Blair, the CMA has only itself to blame. I am a physician, not a physio-
therapist, and therefore I cannot speak on the behalf of physiotherapists. However, it is. my opinion that their direction is toward cooperative referral, not nonreferral, as Dr. Blair has stated. The cooperative referral system allows physiotherapists to see the patient first, but they are obliged to inform the attending physician of the diagnosis and the treatment being undertaken. A form letter has been designed to standardize such a system. As well, the change in referral status is meant to apply to community-based physiotherapists, not hospital-based ones. We physicians are faced with a choice: we can either support physiotherapists and work with them on a cooperative referral basis or we can continue to work, whether we choose to recognize it or not, with chiropractors on a completely nonreferral basis. We can work with physiotherapists, who do not take roentgenograms, do not prescribe drugs, do not do blood tests and do not pretend to be doctors, or we can continue to work with chiropractors, who do all these things. We can work with physiotherapists, who provide safe and scientific care, including, when required, mobilization and manipulation therapy. or we can work with chiropractors, who do not. Reality, not wishful thinking, is what is required. It is my impression that the next few years will witness basic changes in the public role of physiotherapists. This will be especially true in Ontario, where the health disciplines legislation is now before the provincial legislature. Physiotherapists now need and deserve our help. I recommend that we do the following: * Help educate physiotherapists to work on a cooperative referral basis in private practice in the community. * Offer political, legal and financial help to the field of physiotherapy so that it can take its rightful place in the community. * Do not cooperate with chiropractors and stop all forms of patient referral to chiropractors from physicians. For example, the Canadian Association of Radiologists, after an extensive study of the sub-
CMA JOURNAL/AUGUST 4, 1979/VOL. 121
275
Departments of surgery and clinical biochemistry University of Toronto and Mount Sinai Hospital L.E. REYNOLDS, RN
Renal unit Toronto Western Hospital Toronto, Ont.
References 1. DOHERTY
CC,
O'CONNOR
FA,
BUCHANAN KD, et al: Treatment of peptic ulcer in renal failure. Proc Eur
Dial Transplant Assoc 14: 386, 1977 2. KORMAN MG, LAyER MC, HANSKY J: Hypergastrinemia in chronic renal
failure. Br Med J 1: 209, 1972 3. O'Doiusio TM, SIRINEK KR, MAZZAFERRI EL, et al: Renal effects on serum gastric inhibitory polypep-
tide (GIP). Metabolism 26: 651, 1977 4. HXLLGREN R, LuNIX?vIsT G, CHANCE RE: Serum levels of human pancreatic polypeptide in renal disease.
Scand J Gastroenterol 12: 923, 1977 5. DRYBURGH JR, BROWN JC: Radio-
immunoassay for motilin. Gastroenterology 68: 1169, 1975 6. TRACK NS, WATTERS LM, GAULDIE J: Motilin, human pancreatic poly-
erythromycin (1.0 p.g/ml) and trimethoprim-sulfamethoxazole (1.5Cliii Biochem (in press) BROWN JC, MUTT V, DRYBURGH JR: 28.5 .g/ml). The other two strains The further purification of motilin, demonstrated resistance to these a gastric motor activity stimulating three drugs. The MIC of tetrapolypeptide from the mucosa of the cycline and erythromycin was 5 .g/ small intestine of hogs. Can I Physiol ml, and that of trimethoprim-sulPharmacol 49: 399, 1971 3.0-57.0 .g/ml. RUPPIN H, DOMSCHKE S, DOMSCHKE famethoxazole W, et al: Effects of I 3-Nie-motilin MICs of kanamycin were between in man - inhibition of gastric 12 and 25 .g/ml. The only drug to evacuation and stimulation of pepsin which all the strains were suscepsecretion. Scand J Gastroenterol 10: tible was spectinomycin; the MIC 199, 1975 was 15 .g/ml. Lux 0, RoscH W, DOMSCHKE S, et It is important that susceptibility al: Intravenous 1 3-Nie-motilin increases human lower esophageal testing be done to monitor the treatsphincter pressure. Scand J Gastroen- ment of infections due to penicillinterol 11 (suppl 39): 75, 1976 resistant N. ganorrhoeae strains. As HELLEMANS J, VANTRAPPEN 0, BLOOM SR: Endogenous motilin and spectinomycin appears to be an exLES pressure. Ibid, p 67 cellent drug in the treatment of these LEE KY, CHEY WY, TA! H-H, et al: special cases, it should be used Radioimrnunoassay of motilin: validation and studies on the relationship wisely and cautiously since there is between plasma motilin and inter- already a tendency to increasing redigestive myoelectric activity of the sistance of some N. gonorrhoeae duodenum of dog. Am I Dig Dis 23: strains to this antibiotic.3-5 peptide (HPP) and gastrin plasma concentrations
7.
8.
9.
10.
11.
in fasting subjects.
789, 1978
12. IToH Z, TAKEUCHI 5, AIZAW,A I, et al: Changes in plasma motilin concentration and gastrointestinal contractile activity in conscious dogs. Ibid, p 929
Susceptibility pattern in vitro of the peniciflinase-producing Neisseria gonorrhoeae strains To the editor: In our laboratory, between December 1978 and March 1979, we had a sudden increase of penicillinase-producing Neisseria gonorrhoeae strains from Toronto and the surrounding area.1'2 A total of 1436 N. gonorrhoeae cultures were tested for penicillinase production. Seven strains (0.5%) isolated from seven patients were identified as producing penicillinase. Susceptibility testing of these strains against seven antibacterial drugs - penicillin, ampicillin, spectinomycin, tetracycline, erythromyci kanamycin and trimethoprimsulfamethoxazole - yielded the following results: All seven penicillinase-producing strains showed resistance to penicillin and ampidihin; however, the minimum inhibitory concentrations (MICs) of the antibiotics varied. The MIC of penicilun ranged from 25 IU/ml to greater than 400 IU/ml, and that of ampicillin ranged from 10 to 800 .sg/ml. Five strains were susceptible to tetracycline (1.0 p.g/ml),
ROSA SHTIBEL, M SC
Clinical bacteriology section Provincial public health laboratories Ontario Ministry of Health Toronto, Ont.
References 1. /3-lactamase producing Neisseria gonorrhoeae in Canada. Can Dis Wkly Rep 4: 181, 1978 2. Penicillinase-producing strains of Neisseria gonorrhoeae isolated in Ontario. Can Dis Wkly Rep 5: 41, 1979 3. PANG R, TEH LB, RAJAN VS, et al: Gonococcal ophthalmia neonatorum caused by beta-lactamase-producing Neisseria gonorrhoeae. Br Med J 1: 380, 1979 4. SHTIBEL R: Resistance of cultures of Neisseria gonorrhoeae to spectinomycm (C). Can Med Assoc J 119: 1006, 1978 5. Idem: Resistance of Neisseria gonorrhoeae to antibacterial drugs in Ontario. Health Lab Sd 13: 49, 1976
Allied health professions To the editor: It was interesting to read David C. Blair's editorial on allied health professions and the non-physician-referred practice of physiotherapy (Can Med Assoc J 120: 519, 1979). It may be that physiotherapists should emerge with more independence. If they succeed, perhaps this will control the rather alarming increase in numbers of chiropractors who are already in direct contact
CMA JOURNAL/AUGUST 4, 1979/VOL. 121 273
with the patient without being "coordinated from the highest level". For years physiotherapists in Ontario have been tied to institutional apron strings with substantial constraints from government. The opportunities for private practice have been few; it is surprising that this chauvinistic put-down of a hardworking group (mostly women) has been accepted so passively for so many years. It is questionable whether most hospital departments could finance a physiatrist as a full-time department head. Dr. Blair has suggested that part-time physicians may not be able to contribute adequately to the education of therapists if they are "too busy seeing patients". On the contrary, I suggest that busy clinicians are perhaps the ideal persons to assist in clinical training. It may be that most of the pioneer spirit in the West is associated with the oil rigs. Surely we should encourage physiotherapists to spread their wings and fly, with the understanding that the marketplace will help to keep their feet on the ground. I find it hard to believe that a group of conscientious university-trained physiotherapists will stray far from the medical profession. We should encourage another group of freedom fighters. PAUL F. MCGOEY, MD
1020 McNicoll Ave. Scarborough, Ont.
To the editor: Dr. Blair was very critical of the moves being made by physiotherapists to work on a more independent basis of referrals from physicians. Yet he did not offer any explanations as to why physiotherapists are moving in such a direction, nor did he properly evaluate whether such moves might be both necessary and desirable in terms of providing the public with greater community access to more qualified physiotherapists. Over the past decade I have made an extensive study of the status of the physiotherapy profession in the community. At the request of the New Zealand Medical Association and the New Zealand Society of Physiotherapists I recent-
ly travelled to New Zealand to present a paper that dealt in large part with this subject. The basic conclusion of my study was that a more independent referral status is desirable and necessary. It may be the wish of every physician that physiotherapists work only on the direct referral of a physician. I believe that, from the point of view of providing the most complete differential diagnosis possible, such a strict referral system is probably the safest. However, what we might wish and what is reality are two different things. The basic reality is that the person in the community most sought out by patients to provide physiotherapy is neither the physician nor the physiotherapist; rather, it is the chiropractor. The chiropractor works on a completely nonreferral basis. He uses the same instruments the physician does to perform a complete physical examination. He does electrocardiograms, blood tests and biochemical analyses. He claims to be able to treat all manner of disease. He performs all types of roentgenography, and even prescribes drugs. The chiropractor does all these things without any recognized scientific training. The chiropractor, working with unscientific and dangerous theories, has been granted, almost unchallenged, the role of the primary-contact person in the community for the provision of physiotherapy. Physiotherapists have seen their role as private out-ofhospital practitioners almost eliminated by the emergence of chiropractors. Few physicians have recognized the plight of physiotherapists. Organized medicine, as reflected by the attitude of Dr. Blair, who did not once mention in his article the subject of chiropractic, has done nothing to help. In fact, since 1972, requests have repeatedly been made of the Canadian Medical Association (CMA) to inform physicians as to the situation regarding chiropractic. Despite a resolution at the CMA's annual meeting 6 years ago calling for such an educational program for physicians,1 the CMA has not acted. If physicians remain as poorly informed as Dr. Blair, the CMA has only itself to blame. I am a physician, not a physio-
therapist, and therefore I cannot speak on the behalf of physiotherapists. However, it is. my opinion that their direction is toward cooperative referral, not nonreferral, as Dr. Blair has stated. The cooperative referral system allows physiotherapists to see the patient first, but they are obliged to inform the attending physician of the diagnosis and the treatment being undertaken. A form letter has been designed to standardize such a system. As well, the change in referral status is meant to apply to community-based physiotherapists, not hospital-based ones. We physicians are faced with a choice: we can either support physiotherapists and work with them on a cooperative referral basis or we can continue to work, whether we choose to recognize it or not, with chiropractors on a completely nonreferral basis. We can work with physiotherapists, who do not take roentgenograms, do not prescribe drugs, do not do blood tests and do not pretend to be doctors, or we can continue to work with chiropractors, who do all these things. We can work with physiotherapists, who provide safe and scientific care, including, when required, mobilization and manipulation therapy. or we can work with chiropractors, who do not. Reality, not wishful thinking, is what is required. It is my impression that the next few years will witness basic changes in the public role of physiotherapists. This will be especially true in Ontario, where the health disciplines legislation is now before the provincial legislature. Physiotherapists now need and deserve our help. I recommend that we do the following: * Help educate physiotherapists to work on a cooperative referral basis in private practice in the community. * Offer political, legal and financial help to the field of physiotherapy so that it can take its rightful place in the community. * Do not cooperate with chiropractors and stop all forms of patient referral to chiropractors from physicians. For example, the Canadian Association of Radiologists, after an extensive study of the sub-
CMA JOURNAL/AUGUST 4, 1979/VOL. 121
275
