Nonspecific motility disorders, irritable esophagus, and chest pain

Difficult Patients: Malingerers, Feigners, Chronic Complainers, and Real Imposters

Malingering is the intentional production of false or grossly exaggerated symptoms motivated by internal and external incentives. The true incidence of malingering in the emergency department is unknown because of the difficulty of identifying whether patients are fabricating their symptoms. Malingering is considered a diagnosis of exclusion; a differential diagnosis framework is described to guide emergency physicians. Several case studies are presented and analyzed from a medical ethics perspective. Practical recommendations include use of the NEAL (neutral, empathetic, and avoid labeling) strategy when caring for patients suspected of malingering.

Unexplained Chest Pain and Physical Activity: Balancing Between Existential Uncertainty and Certainty

Chest pain is one of the most common complaints in medical settings, but the majority of cases have no detectable cause. Physical activity is recommended, but is one of the major avoidance behaviors in patients with coronary heart disease. The article aims at achieving an understanding of the meaning of physical activity for people with unexplained chest pain. Fifteen people were interviewed using a phenomenological hermeneutic approach, with the results revealing four themes: "awareness of the influence of previous life experiences on the decision to be physically active," "unanswered questions related to physical activity and unexplained chest pain," "intertwinement of body and mind," and "physical activity as a source of personal growth." Comprehensive understanding was formulated as "Being physically active while living with unexplained chest pain means balancing between existential uncertainty and certainty." The results are discussed in relation to capability. It is suggested that health professionals adopt a person-centered approach.

Shift, Interrupted: Strategies for Managing Difficult Patients Including Those with Personality Disorders and Somatic Symptoms in the Emergency Department

Difficult patients are often those who present with a mix of physical and psychiatric symptoms, and seem refractory to usual treatments or reassurance. such patients can include those with personality disorders, those with somatization symptoms; they can come across as entitled, drug-seeking, manipulative, or simply draining to the provider. Such patients are often frequent visitors to Emergency Departments. Other reasons for difficult encounters could be rooted in provider bias or countertransference, rather than sole patient factors. Emergency providers need to have high awareness of these possibilities, and be prepared to manage such situations, otherwise workup can be sub-standard and dangerous medical mistakes can be made.

Quantitative differences between primary and secondary peristaltic contractions of the esophagus

BACKGROUND AND AIMS

Differences in contraction characteristics between primary and secondary peristalsis have only been scarcely studied. Recently new measures of contractile activity in the human esophagus were developed. The study aims were to use combined manometry and impedance planimetry [pressure-cross-sectional area (P-CSA)] recordings from healthy volunteers to examine esophageal peristalsis, and, furthermore, to investigate the effect of the motility enhancing drug erythromycin to study differential effects on the two types of contractions.

METHODS

Sixteen healthy volunteers participated in the study [mean age 23 (range, 19-34) years, 6 females]. An esophageal probe with a bag for CSA measurement was positioned 10 cm above the lower esophageal sphincter. Bag volume was increased stepwise from 5 to 25 ml before and after intravenous infusion of 250 mg erythromycin. Swallow-evoked primary and distension-evoked secondary esophageal peristalsis were compared with regard to (1) pressure amplitude, (2) CSA amplitude, (3) preload tension (wall tension before an evoked contraction), (4) contractile tension, and (5) work outputs.

RESULTS

Primary peristalsis induced more efficient contractions as the contraction amplitudes, work output and contractile tension were higher compared to secondary peristalsis (P < 0.001). Erythromycin induced change in CSA during distension-evoked secondary peristalsis (CSA before 212.9 ± 26.8 vs. after 180.5 ± 23.3, P < 0.05). The sensitivity to esophageal distension increased with the distending volume both before and during erythromycin. The sensitivity was not changed by erythromycin (P = 0.6).

CONCLUSIONS

Esophageal primary peristaltic contractions were more forceful with longer duration, and higher work output compared to secondary peristalsis contractions. Erythromycin affected peristalsis only to a minor degree.