Multiple chemical sensitivity syndrome (MCS)--suggestions for an extension of the U.S. MCS-case definition

PURPOSE: To validate and extend the US case definition for the Multiple Chemical Sensitivity Syndrome (MCS) from 1999 by a systematic literature-review. DATA SOURCE: MEDLINE-research from 1997 to August 2003, research in the Cochrane-Library in August 2003, earlier reviews since 1997. STUDY SELECTION: Headings and abstracts were screened by one reviewer. All references dealing with multiple chemical sensitivities (MCS) which covered topics of interest such as symptom-profiles, differential diagnostic procedures, etc. were included in the analysis. DATA EXTRACTION AND SYNTHESIS: Topic-specific data extraction and synthesis was done by one reviewer. Data interpretation was discussed by all other authors. RESULTS: Out of 1429 references 36 publications proved to be suitable for the review. The results can be summarized as follows: exposure-related symptoms associated with self-reported multiple chemical sensitivities can be divided into non-specific complaints of the central nervous system--CNS (main characteristics) and functional disturbances in other organ systems (optional complaints). There is a significant overlap of MCS, CFS and fibromyalgie. At present no standards for a diagnostic procedure based on the criteria outlined above are existing CONCLUSIONS: MCS should only be diagnosed in patients who are mainly suffering from exposure-related non-specific complaints of the Central nervous system. The suggested diagnostic procedure follows the guidelines for CFS which are extended by diagnostic clarification of functional disturbances in other organ systems.     

Ideal versus reality: physicians perspectives on patients with chronic fatigue syndrome (CFS) and fibromyalgia

Encountering patients with chronic fatigue syndrome (CFS) or fibromyalgia can cause dilemmas for physicians due to the uncertainty inherent in these illnesses. The aim of this study was to investigate: (1). How physicians in a Swedish sample describe and categorize patients with CFS and fibromyalgia; (2). What the character of CFS and fibromyalgia, with regard to diagnosing, treatment and medical knowledge/aetiology, mean to the physicians in encounters with patients; and (3). Which strategies physicians describe that they use in the encounter with these patients. Semi-structured interviews were carried out with 26 physicians, specialists in various fields who all had some experience of either CFS or fibromyalgia. The results suggest that there is a discrepancy between the ideal role of the physician and reality in the everyday work in interaction with these patients. This may lead to the professional role being questioned. Different strategies are developed to handle the encounters with these patients. The results also illuminate the physician's interpretations of patients in moralising terms. Conditions given the status of illness were regarded, for example, as less serious by the physicians than those with disease status. Scepticism was expressed regarding especially CFS, but also fibromyalgia. Moreover, it is shown how the patients are characterised by the physicians as ambitious, active, illness focused, demanding and medicalising. The patient groups in question do not always gain full access to the sick-role, in part as a consequence of the conditions not being defined as diseases.     

Multiple chemical sensitivity and chronic fatigue syndrome in British Gulf War veterans

The objective of this study was to measure the prevalence of multiple chemical sensitivity (MCS) and chronic fatigue syndrome (CFS) in British Gulf War veterans and to investigate their association with reported exposures and psychologic morbidity. In 1997--1998, the authors undertook a cross-sectional survey of three cohorts of British military personnel comprising Gulf veterans (n = 3,531), those who had served in Bosnia (n = 2,050), and those serving during the Gulf War but not deployed there (Era cohort, n = 2,614). MCS and CFS were defined according to operational criteria. The prevalence of MCS in the Gulf, Bosnia, and Era cohorts was 1.3%, 0.3%, and 0.2%, respectively. For CFS, the prevalence was 2.1% (Gulf cohort), 0.7% (Bosnia cohort), and 1.8% (Era cohort). In Gulf veterans, MCS was strongly associated with exposure to pesticides (adjusted odds ratio = 12.3, 95% confidence interval: 5.1, 30.0). Both syndromes were associated with high levels of psychologic morbidity. These findings suggest that CFS and MCS account for some of the medically unexplained illnesses reported by veterans after deployment to the Gulf. MCS was particularly associated with Gulf deployment and self-reported exposure to pesticides, findings that merit further exploration given the controversial status of this diagnosis and the potential for recall bias in a questionnaire survey.     

Discourses of influence and autonomy in physicians' accounts of treatment decision making for depression

Models of patient-physician decision making are typically framed on a continuum of discourses and practices ranging from patient autonomy to physician paternalism, with the middle ground being occupied by terms such as shared decision making. Critiques of these models center on the gulf between these idealized models and actual practice and on how context influences decision-making practices. In this article I focus on how 11 Canadian family physicians talked about patient-physician decision making in interviews about their diagnostic and treatment practices for depression. I adopt a discursive approach to analyzing extracts from these interviews, and show how these physicians constructed themselves as engaging in acts of professional judgment and persuasion, and patients as having the final say in decision making about treatment for depression. I argue that whether the intertwining of discourses of physician influence and patient autonomy is understood as a balance of power between physicians and patients is an open question.     

The Role of the Message Convergence Framework in Medical Decision Making

This study investigated numerous complexities in medical decision making among obstetricians treating high-risk or complex pregnancies. Obstetricians in a southeastern state (N = 28) were interviewed using a guide based on the framework of message convergence. The study assessed how the physicians manage uncertainty surrounding patient care and engage in medical decision making in the midst of either unclear evidence or competing messages. As a result, the study found that message convergence plays a notable role in the obstetricians’ clinical decision making. Conclusions and practical recommendations are provided, and theoretical extensions to the message convergence framework in the clinical and communicative practices of the physicians are also advanced.     

Diagnostic decision making: The last refuge for general practitioners?

Nurses and pharmacists gained the right to prescribe as independent prescribers in the UK in 2007. Independent prescribers are responsible for the initial assessment of patients with diagnosed and undiagnosed conditions. Public policy discourse and the views expressed by health care professionals have conceptualised diagnostic decision making as being at a 'higher level' and more difficult than prescribing decision making. This paper presents five themes related to this premise. Firstly diagnostic decision making is put into the broader context of clinical reasoning which underpins all types of clinical decisions including both diagnostic and prescribing decisions. Secondly, the nature of diagnostic decision making is discussed as to whether it is indeed separable from the prescribing decision making process. Thirdly, the conception that all diagnostic decisions are inherently more difficult is contested when difficulty in decision making is more appropriately applied to all types of clinical decisions which involve greater complexity and uncertainty. The fourth topic concerns whether this perception of diagnoses as being more difficult is a response by the medical profession to the threat of independent prescribing, reflecting their wish to maintain professional power and dominance over other professions. The final section considers how expertise in diagnoses could be developed in nurse and pharmacist independent prescribers. To develop their expertise in making accurate diagnoses, medicine uses the model of learning basic science mechanisms followed by engagement with patient clinical problems followed by years of clinical experience. However this may be just one way of achieving diagnostic expertise. Other approaches, such as the use of deliberate practice and feedback, may be more suitable to the diverse range of knowledge and experiences of nurse and pharmacist prescribers.     

A method to describe physician decision thresholds and its application in examining the diagnosis of coronary artery disease based on exercise treadmill testing.

The authors developed a method that utilizes logistic regression analysis to 1) calculate the disease probability with confidence intervals at which any specified proportion of physicians reaches a clinical decision, 2) statistically test whether factors other than disease probability affect this clinical decision, and 3) statistically test whether physician decision making in relation to disease probability varies by other factors. They apply the method to analyze the relationship between disease probability and the proportion of physicians who diagnosed coronary artery disease (CAD) in 127 consecutive subjects who completed the treadmill exercise tolerance test (ETT) at two hospitals. Twenty-five percent of the physicians decided that CAD was possible or definite at a post-ETT disease probability of 0.24 (95% CL= 0.07-0.35); 50% at 0.54 (95% CL = 0.43-0.70); and 75% at 0.82 (95% CL = 0.67-1.0). Multivariate logistic regression analysis revealed three factors significantly and independently related to the diagnosis of CAD: post-ETT disease probability, positive ETT result, and cigarette smoking. The proportion of physicians who reached a diagnosis of CAD did not differ by hospital setting (VA versus university), level of training (attending versus housestaff/fellow), or diagnosing service (cardiology versus other internal medicine). It is concluded that factors other than disease probability may affect physician diagnostic decisions.     

Do Physicians Attend to Base Rates? Prevalence Data and Statistical Discrimination in the Diagnosis of Coronary Heart Disease

Objective. To examine whether physicians attend to gender prevalence data in diagnostic decision making for coronary heart disease (CHD) and to test the hypothesis that previously reported gender differences in CHD diagnostic certainty are due to discrimination arising from reliance on prevalence data (“statistical discrimination”). Data Sources. A vignette‐based experiment of 256 randomly sampled primary care physicians conducted from 2006 to 2007. Study Design. Factorial experiment. Physicians observed patient presentations of cardinal CHD symptoms, standardized across design factors (gender, race, age, socioeconomic status). Data Collection. Structured interview. Principal Findings. Most physicians perceived the U.S. population CHD prevalence as higher in men (48.4 percent) or similar by gender (44.9 percent). For the observed patient, 52 percent did not change their CHD diagnostic certainty based on patient gender. Forty‐eight percent of physicians were inconsistent in their population‐level and individual‐level CHD assessments. Physicians' assessments of CHD prevalence did not attenuate the observed gender effect in diagnostic certainty for the individual patient. Conclusions. Given an adequate presentation of CHD symptoms, physicians may deviate from their prevalence data during diagnostic decision making. Physicians' priors on CHD prevalence did not explain the gender effect in CHD certainty. Future research should examine personal stereotypes as an explanation for gender differences.     

Efficient diagnosis of common complaints: a comparative study in the United States and England

BACKGROUND. The purpose of this investigation was to compare the diagnostic efficiency of American and British family and general practitioners, as measured by their utilization of health care resources and the average length of the diagnostic interval, in diagnosing common complaints. METHODS. Several hundred charts from teaching practices in the United States and England were identified by computer search and reviewed. The charts were those of patients who had presented between 1978 and 1988 with a complaint of chest pain and were subsequently diagnosed as having angina pectoris or reflux esophagitis, or who presented with a complaint of shortness of breath and were subsequently diagnosed as having heart failure or asthma. RESULTS. The results of this study, which compared teaching family medicine practices in the United States and England, suggest that American family physicians diagnose common complaints such as chest pain and dyspnea in a shorter time with fewer visits and fewer consultations than their English counterparts, but order approximately the same number of diagnostic tests. CONCLUSIONS. This study demonstrates the difficulties in interpreting international (cross-cultural) comparisons. Differences may be due to varying health care systems, economic factors, physician training, and physician practice styles, as well as patient expectations.     

Chronic Fatigue Syndrome: a survey of GPs' attitudes and knowledge

BACKGROUND: GPs need evidence and guidance to help them diagnose and manage Chronic Fatigue Syndrome (CFS)/ME appropriately. OBJECTIVES: The aim of this survey was to obtain baseline data and identify the factors associated with GPs' attitudes to and knowledge of CFS/ME. The attitude of GPs to the condition is an important indicator of likely prognosis. METHODS: A postal questionnaire was sent to 1054 GPs served by Taunton, Bristol and Gloucester laboratories. GPs' attitudes to nine statements about CFS/ME were assessed and the factors associated with positive or negative responses were determined. Knowledge of the clinical features was also assessed. RESULTS: 811 GPs (77%) returned the questionnaire. 48% of GPs did not feel confident with making a diagnosis of CFS/ME and 41% did not feel confident in treatment. 72% of GPs accepted CFS/ME as a recognisable clinical entity and those GPs had significantly more positive attitudes. Three other key factors that were significantly, positively associated with GPs' attitudes were knowing someone socially with CFS/ME, being male and seeing more patients with the condition in the last year. CONCLUSION: Despite the publication of guidance for GPs on CFS/ME, confidence with making a diagnosis and management was found to be low. Educational initiatives and guidance for GPs should stress the importance of accepting CFS/ME as a recognisable clinical entity, as this is linked to having a positive attitude and could lead to improved confidence to make a diagnosis and treat CFS/ME patients.     

Decision making during serious illness: what role do patients really want to play?

Two surveys were conducted to determine what roles people actually want to assume in selecting cancer treatments. 436 newly diagnosed cancer patients and 482 members of the general public participated. Preferences were elicited using two card sort procedures, each of which described five potential roles in decision making. Findings suggested that the impact of being diagnosed with a life-threatening illness may influence preferences to participate. The majority (59%) of patients wanted physicians to make treatment decisions on their behalf, but 64% of the public thought they would want to select their own treatment if they developed cancer. Most patients (51%) and members of the public (46%) wanted their physician and family to share responsibility for decision making if they were too ill to participate. Sociodemographic variables accounted for only 15% of variance in preferences. These variables are not particularly useful in making predictions about which groups want more or less active roles in medical decision making.     

Management of dementia in primary health care: the experiences of collaboration between the GP and the district nurse

OBJECTIVE: The objective of this study was to explore the context and experiences of collaboration between the GP and the district nurse (DN) in diagnosing dementia, in order to identify possible procedures to improve care. METHODS: Two group interviews were conducted with four DNs and five GPs, respectively, working in the municipality of Copenhagen. RESULTS: The group interviews revealed that the suboptimized collaboration could be due to different inter-professional diagnostic strategies and a lack of understanding of the importance of early, shared, decision making. This could create conflicts between the groups. CONCLUSIONS: This study indicates a possibility for improved collaboration between the two professional groups in diagnosing dementia. Possible approaches for improved care should focus on an inter-professional understanding of the importance of early, shared, decision making, emphasizing early identification and care of diagnosed demented patients. Establishing a shared collaboration model including out-patient memory clinics, GPs and DNs could be a first step. This model should also take into account an evaluation of possible consequences for the diagnosed demented patients in terms of treatment and care and consider the indication for referrals to a comprehensive diagnostic evaluation. We are at present planning a study to address these aspects.     

Physician decision making over the telephone

Physician decision-making behaviors were evaluated for 31 telephone encounters between trained patient simulators and 9 first-year residents, 11 third-year residents, and 8 practicing physicians on after-hours call. The following trends occur as physicians become more experienced: mean call length decreases, less time is spent on diagnosis, fewer diagnostic questions are asked, greater time is spent on management, and diagnostic reasoning becomes more intuitive. These findings suggest that previous models of good telephone decision making, which focused on empirical data collection, may not represent the process used by experienced physicians.     

How are patient characteristics relevant for physicians' clinical decision making in diabetes? An analysis of qualitative results from a cross-national factorial experiment

Variations in medical practice have been widely documented and are a linchpin in explanations of health disparities. Evidence shows that clinical decision making varies according to patient, provider and health system characteristics. However, less is known about the processes underlying these aggregate associations and how physicians interpret various patient attributes. Verbal protocol analysis (otherwise known as 'think-aloud') techniques were used to analyze open-ended data from 244 physicians to examine which patient characteristics physicians identify as relevant for their decision making. Data are from a vignette-based factorial experiment measuring the effects of: (a) patient attributes (age, gender, race and socioeconomic status); (b) physician characteristics (gender and years of clinical experience); and (c) features of the healthcare system in two countries (USA, United Kingdom) on clinical decision making for diabetes. We find that physicians used patients' demographic characteristics only as a starting point in their assessments, and proceeded to make detailed assessments about cognitive ability, motivation, social support and other factors they consider predictive of adherence with medical recommendations and therefore relevant to treatment decisions. These non-medical characteristics of patients were mentioned with much greater consistency than traditional biophysiologic markers of risk such as race, gender, and age. Types of explanations identified varied somewhat according to patient characteristics and to the country in which the interview took place. Results show that basic demographic characteristics are inadequate to the task of capturing information physicians draw from doctor-patient encounters, and that in order to fully understand differential clinical decision making there is a need to move beyond documentation of aggregate associations and further explore the mental and social processes at work.     

Environmental psychosomatics —an integrative model: Umwelt-Psychosomatik - ein integratives Modell

Patients presenting with new clinical syndromes such as multiple chemical sensitivities (MCS) or other environmental illnesses confront us with the necessity to have valid models of how psychological, environmental, social and biological factors interact with each other.Whilst MCS is influenced by psychiatric and psychological factors, the scientific evidence does not allow to regard MCS as a psychiatric disorder only. Objective environmental factors have to be taken into account as well. As causation of MCS seems to be very complex, a complex model is needed to integrate the various pathogenetical factors. After reviewing the psychiatric research findings on MCS, such a model is introduced in the paper; it is called the dialectical model of environmental psychosomatics. This model has implications for further research and clinical practice; it advocates a process of simultaneous diagnostic processes covering biological environmental analysis as well as psychiatric diagnostics.     

A national assessment of the service, support, and housing preferences by persons with chronic fatigue syndrome. Toward a comprehensive rehabilitation program

Persons with Chronic Fatigue Syndrome (PWCs) completed and returned by mail a brief survey of open- and closed-ended items designed to assess their utilization and preferences for a variety of services. A total of 984 middle-aged adults diagnosed with Chronic Fatique Syndrome (CFS) from across North America returned the survey. During the past 12 months, many of these PWCs reported utilization of a primary care physician, gynecologist, CFS specialist, and self-help group to assist in their recovery from CFS. Most PWCs believed it was important to educate both health-care practitioners and the general public about CFS. In terms of their desire for specific recovery needs, factor analysis of responses indicated that these PWCs preferred self-help/social support services and general advocacy services in the treatment of their illness. The implications of these results for developing rehabilitation programs for PWCs are discussed.     

Chronic Fatigue Syndrome – an occupational therapy programme

The cause of Chronic Fatigue Syndrome (CFS) is as yet undetermined; therefore, precise definitions for diagnosis and research have been developed. The most accepted diagnostic criteria are detailed below. It has been suggested that there are 150 000 cases of CFS in the UK, with a 2:1 predominance of females to males, and that prognosis without treatment is poor. The patterns of illness seen in CFS are identified and the development of an occupational therapy programme for the management of CFS is described. Copyright © 1999 Whurr Publishers Ltd.     

Chronic fatigue syndrome: symptom subtypes in a community based sample

Most studies of Chronic Fatigue Syndrome (CFS) have been based on patients recruited from primary or tertiary care settings. Patients from such settings might not be typical of patients in the general population. The present investigation involved examining individuals with CFS from a community-based study. A random sample of 18,675 respondents in Chicago were first interviewed by telephone. A group of individuals with chronic fatigue accompanied by at least four Fukuda et al. (1994) symptoms associated with CFS were given medical and psychiatric examinations. From this sample, a physician review group diagnosed individuals with CFS. Those diagnosed with CFS were subclassified based on frequency of symptoms. Important differences emerged on measures of sociodemographics and disability. The implications of these findings and others are discussed.     

地奈德乳膏联合怀氏乳膏治疗手部慢性角化皲裂性湿疹效果观察

目的：通过研究早期神经梅毒临床表现及诊断方法,提高对该病诊疗上的认识。方法：对我院2012～2014年诊治的20例早期神经梅毒进行回顾性分析。结果：20例早期神经梅毒血的梅毒血清快速反应素试验（RPR）、荧光密螺旋体抗体（TPPA）检测阳性;脑脊液（cFs）梅毒实验室试验（VDRL、TPPA检测亦阳性;CSF检查,白细胞数升高7例;蛋白升高11例。其中3例伴有头痛头晕症状,2例伴有视物模糊症状,15例为无症状神经梅毒。结论：脑脊液TPPA及VDRL检测有助于神经梅毒的诊断。对于病期大于1年复发梅毒、血清RPR持续阳性患者,应及早进行脑脊液检查并采取神经梅治疗。