Functional Symptoms Research Articles

S0437 Impact of Incorporating Mean Nocturnal Basal Impedance as a Supplemental Metric to Acid Exposure Time in Patients With Esophageal Symptoms

INTRODUCTION: While acid exposure time (AET) predicts response to anti-reflux treatment and is the most validated parameter of pH monitoring, it is limited by daily variations and does not directly evaluate tissue damage. However, Distal mean nocturnal basal impedance (dMNBI) does measure gastroesophageal reflux (GER) related damage (increased mucosal permeability). dMNBI is validated to assess response to anti-reflux treatment and has become a valuable supplemental metric to AET. We report the impact of combining AET with dMNBI for classifications of gastroesophageal reflux disorder (GERD) including pathologic GER, esophageal hypersensitivity (EH), and functional symptoms (FS). METHODS: Patients who underwent pH-impedance monitoring off of proton pump inhibitor (PPI) therapy for refractory GERD at our center from Oct 2013 to March 2020 were included. Those with achalasia, esophagogastric junction outflow obstruction, scleroderma, and those evaluated for cough were excluded. dMNBI was calculated as the average impedance of three uninterrupted 10-minute intervals collected at night 3 cm proximal to the GE junction. dMNBI < 2.29 or AET >6% were considered abnormal. EH was defined as AET< 6% and/or dMNBI< 2.29kOhm with a symptom association probability (SAP) > 95%. FS was defined as AET< 6% and/or dMNBI< 2.29 kOhm and SAP < 95%. RESULTS: A total of 267 patients underwent pH-impedance monitoring off of PPI therapy. 206 patients were included in the analysis. 5 patients completed less than 12 hours of the study and 46 met exclusion criteria. The mean age was 50 (±15) years, 150 (73%) were females, 162 (79%) were Caucasian, 93 (46%) were current or former smokers, and mean BMI was 31 (±7). The AET was abnormal in 53 (26%), intermediate in 19 (9%), and normal in the remainder. With AET alone, 26% were classified as pathological GER, 23% were EH, 32% were FS, and 19% were undetermined (Figure 1). Combined AET and dMNBI based classification resulted in pathological GER in 46%, EH in 13%, FH 23%, and undetermined in 17% (Figure 2). This difference in classification was statistically significant (P < 0.0001). CONCLUSION: Using dMNBI in conjunction with AET identifies a significant proportion of patients with GERD and decreases patients classified with FS. This has an important clinical impact as GERD patients receive different treatment than patients with functional symptoms. Enhancing AET with dMNBI facilitates more accurate diagnoses and aids in the future management of patients with esophageal conditions.Figure 1.: Outcome classification by acid exposure time (AET) alone.Figure 2.: Outcome classification by combined acid exposure time (AET) and distal mean nocturnal basal impedance (dMNBI).

Challenging management of patients with functional symptoms for the physical and rehabilitation medicine specialist: What can we learn from literature?

Functional symptoms (FS) are symptoms for which no “organic” cause is found. They could concern a significant part of physical and rehabilitation medicine (PRM) patients, since they represent 25 to 50% of all symptoms in primary care. Their management is challenging, often generating negative emotions during medical encounter. Their prognosis usually appears to be unfavorable. Is FS treatment worthwhile if the results are so uncertain? How could we be more efficient? Is the referral to a psychiatrist imperative? This literature review attempts to answer to those questions applied to PRM. The MeSH terms «Somatoform Disorders», «Physical and Rehabilitation Medicine», «Prognosis», «Treatment» and «Health Care Costs» were used on PubMed database to find the most recent and relevant articles enlightening the FS management. FS create incongruence between patients’ symptoms and doctors’ explanatory models for biomedical diseases. The explanation is however the key aspect of the diagnostic process. Psychosocial issues relating to the symptoms can bring elements to find congruence between patients’ and practitioners’ views. FS management includes physical rehabilitation that should integrate a cognitive behavioral therapy. Antidepressants are to be considered. Referral to a psychiatrist is a second line treatment. Mindfulness-based cognitive therapy is an arising and promising method for FS. Intensive multidisciplinary treatment is adapted for chronic and severe FD. FS are associated with relevant direct and indirect costs strongly depending on symptoms severity. This burden justifies the allocation of sufficient resources. FS management is based on a positive doctor–patient relationship made of trust, partnership and support. Cognitive behavioral therapy is actually an essential ongoing process that PRM specialists should conduct. It helps patients to think about and to respond to their symptoms differently. Teaching interviewing and information-giving skills to medical students could improve their ability to deal with illnesses beyond the only goal of treating diseases. In conclusion, FS management suggests a conceptual move from curing to caring and coping. Cognitive behavioral therapy is not restricted to psychiatrists. Studies about patients with functional disability in the field of PRM are lacking and no specific recommendations are yet available.

Simulation and Dissimulation in the Folie Tristan d’Oxford

Historians of medieval medicine have argued persuasively for a semiotic understanding of diagnosis, in which externally visible symptoms are understood to signify internally inaccessible humoral imbalances. Successful treatment is predicated on the correct identification and description of a stable symptom-referent pair. Illness can thus be understood as inherently performative: the infirm body performs its illness in representing externally what is present internally. Simulation—the performance of symptoms divorced from their referents—threatens to destabilize the efficacy of medical semiotics, especially in regards to mental illness, due to its inherent interiority. In a complex system of simulation and dissimulation, the twelfth century constellation of Tristan romances exploits to great effect this notion of performative truth. Nowhere is this more significant or problematic than in the Folie Tristan d’Oxford, where Tristan, lovesick for Yseult, masquerades as a madman in order to gain access to his uncle’s court and thus his beloved. Given the proximity of lovesickness to madness, the distance required to produce irony and distinguish between the original and the simulated states is reduced to zero, resulting ultimately in their conflation. Despite this, it is this very act of embodying the madman that allows Tristan’s malady to be cured.

Proteomics and syndrome of Chinese medicine.

Syndrome of Chinese medicine is an understanding of the regularity of disease occurrence and development and its performance of symptoms. Syndrome is the key to recognize diseases and the foundation to treat them. However, because of the complexity of the concept and the limitation of present investigations, the research of syndrome is hard to go further. Proteomics has been received extensive attention in the area of medical diagnosis and drug development. In the holistic and systemic context, proteomics have a convergence with traditional Chinese medicine (TCM) syndrome, which could overcome the one-sidedness and singleness of TCM and avoid the complication and tedious processes. Chinese medicine has a wealth of experience and proteomics has a substantial research potential, the integration of the two aspects will bring a great enhancement of our knowledge of disease.