Development of a Simple, Point-of-Care Device to Test Anorectal Function in Patients with Constipation: Randomized Clinical Trial.

Functional constipation (FC) is one of the most frequently encountered gastrointestinal conditions in practice.1 Practice guidelines universally recommend that patients with typical constipation symptoms and no alarm features be treated empirically with dietary/lifestyle interventions and laxative therapy.2,3 Unfortunately, by the time a patient reaches a gastroenterologist, these treatments frequently have already been tried. Anorectal function testing (anorectal manometry [ARM] and balloon expulsion test [BET]) is the next best step in management guidelines in this all-too-common scenario, because treatment can then be targeted toward pelvic floor dysfunction or colon transit abnormalities. Unfortunately, more than 95% of patients continue to take only over-the-counter laxatives and receive empirical dietary advice, whereas fewer than 2% undergo physiologic evaluation to ascertain the cause of their symptoms.4 Indeed, more than 90% of patients desire more effective treatment options. These observations call into question the wisdom of a management strategy that fails to recognize the intrinsic diversity of the constipation universe and reinforces the misguided "one size fits all" empirical treatment strategy.

An Office-Based, Point-of-Care Test Predicts Treatment Outcomes With Community-Based Pelvic Floor Physical Therapy in Patients With Chronic Constipation.

BACKGROUND & AIMS: Rectal evacuation disorders are common among constipated patients. We aimed to evaluate the accuracy of an investigational point-of-care test (rectal expulsion device [RED]) to predict outcomes with community-based pelvic floor physical therapy. METHODS: We enrolled patients meeting Rome IV criteria for functional constipation failing fiber/laxatives for more than 2 weeks. RED was inserted and self-inflated, and then time-to-expel was measured in a left lateral position. All patients underwent empiric community-based pelvic floor physical therapy in routine care with outcomes measured at 12 weeks. The primary end point was global clinical response (Patient Assessment of Constipation Symptoms score reduction, >0.75 vs baseline). Secondary end points included improvement in health-related quality-of-life (Patient Assessment of Constipation Quality of Life score reduction, >1.0) and complete spontaneous bowel movement frequency (Food and Drug Administration complete spontaneous bowel movement responder definition). RESULTS: Thirty-nine patients enrolled in a feasibility phase to develop the use-case protocol. Sixty patients enrolled in a blinded validation phase; 52 patients (mean, 46.9 y; 94.2% women) were included in the intention-to-treat analysis. In the left lateral position, RED predicted global clinical response (generalized area under the curve [gAUC], 0.67; 95% CI, 0.58-0.76]), health-related quality-of-life response (gAUC, 0.67; 95% CI, 0.58-0.77; P < .001), and complete spontaneous bowel movement response (gAUC, 0.63; 95% CI, 0.57-0.71; P < .001). As a screening test, a normal RED effectively rules out evacuation disorders (expected clinical response, 8.9%; P = .042). Abnormal RED in the left lateral position (defined as expulsion within 5 seconds or >120 seconds) predicted 48.9% clinical response to physical therapy. A seated maneuver enhanced the likelihood of clinical response (71.1% response with seated RED retained >13 seconds) but likely is unnecessary in most settings. CONCLUSIONS: RED offers an opportunity to disrupt the paradigm by offering a personalized approach to managing chronic constipation in the community (Clinicaltrials.gov: NCT04159350).

Clinical Life in the Context of the Pandemic.

In this article, six analysts describe theory and practice in the time of COVID-19, examining the quality of après-coup in the way that the pandemic and its attendant crises trigger early memory and early experiences of helplessness. In the clinical events we see that the age of the patient, the circumstances and approach of the analyst, the novelty of the frame are all crucial determinants of clinical outcomes.

Transgender and Analytic Countertransference.

Using theory from philosophy and from race studies, the author explores the countertransference confusions and enactments that can arise in working with trans and gender nonbinary patients. Case material is presented to explore in vivo the potential for enactments and toxic anxiety in the analyst in work with patients exploring or inhabiting new forms of desire and identity. Primitive states of anxiety and dysphoria may inhibit the analyst's capacities to allow freedom and reflection in cases of complex gender construction.

Gender in linear and nonlinear history.

In response to Helen Gediman's notion of premodern, modern, and postmodern eras in the study of gender, an argument is made for a non-linear approach to this history and for situating it in the context of other historical developments-social, personal, intellectual, and institutional. Differences among modern and postmodern positions in the matter of the role of the body and of social construction are discussed. The impact of transgender and intersex communities and voices on psychoanalytic thinking is examined, as are the elements of intergenerational transmission of trauma on gender experience both conscious and unconscious.

Conflict in relational treatments.

Various features of relational perspectives on conflict are outlined. Points of contact and difference between relational and modern conflict theory are discussed. Five approaches to considering conflict are examined: countertransference conflict as the site of interfaces between the social and the intrapsychic; conflict within the register of speech; conflict within a theory of multiple identifications; conflict as the site of psychic change; and conflict in the context of intersubjectivity. Clinical vignettes are introduced to illustrate the scope and function of conflict within one relational perspective.

Fluidez de gênero e gênero como força interpelativa: discussão com Jacqueline Rose / Gender fluidity and gender as interpellative force: a discussion with Jacqueline Rose / Fluidez de género y género como fuerza interpelativa: discusión con Jacqueline Rose / Fluidité de genre et le genre comme force interpellative: discussion avec Jacqueline Rose

Este estudo examina as implicações da fluidez de gênero e da permanência de gênero para fins de experiência clínica e social. Consideram-se as crises de desenvolvimento em torno da separação tanto para desenvolvimento masculino quanto para o feminino. Teorias de desenvolvimento, teoria de sistemas dinâmicos não lineares e interseccionalidade são propostas como modelos úteis, uma vez que contemplam a identificação no desenvolvimento.

This essay examine the implications of gender fluidity and gender fixity for clinical and social experience. The developmental crises around separation are considered for both male and female development. Developmental theories, nonlinear dynamic systems theory and intersectionality are proposed as useful templates for considering identification in development.

Este estudio examina las implicaciones de la fluidez de género y de la permanencia de género para fines de experiencia clínica y social. Se consideran las crisis de desarrollo en relación a la separación tanto para el desarrollo masculino como para el femenino. Teorías de desarrollo, teoría de sistemas dinámicos no lineales e interseccionalidad son propuestas como modelos útiles, pues contemplan la identificación en el desarrollo.

Cette étude examine les implications de la fluidité et de la permanence de genre, ayant pour but une expérience clinique et social. On a pris en compte les crises de développement au tour de la séparation, soit pour le développement masculin, soit pour le féminin. On propose des théories de développement, la théorie de systèmes dynamiques non linéaires et de l'intersectionnalité en tant que modèles utiles, étant donné qu'ils traitent de l'identification dans le développement.