Review of Multiple Chemical Sensitivity: Identifying
Clinical Approaches to MCS in Australia
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4.5Clinical Approaches to MCS in AustraliaIn Australia, clinical medical approaches to MCS involve not only general practitioners but also potentially a variety of medical specialists. In order to determine currently how medical practitioners in Australia respond to individuals with patterns of chemical sensitivity suggestive of MCS, a survey of clinical approaches to the diagnosis and management of MCS was commissioned by the Office of Chemical Safety and Environmental Health (OCSEH) and the National Industrial Chemicals Notification and Assessment Scheme (NICNAS) in 2006. The survey comprised a literature survey, interviews with professional organisations, medical practitioners and other stakeholders, and a workshop to examine the diagnostic and therapeutic practices for MCS currently used by Australian medical practitioners. Further detail regarding the background and outcomes for this survey are available in Appendix 1. The workshop revealed little consensus on effective interventions (Appendix 1). No evidence was forwarded for any medication, dietary supplements or other therapies as a treatment for MCS. Basic management strategies currently used by practitioners involve strategies common to all chronic illnesses - engaging with the patient, encouraging self-management and maintaining a long-term supportive relationship. The lack of official recognition of MCS as a distinct clinical entity, together with difficulties in establishing aetiology and inconsistencies in the diagnosis of MCS, are reflected directly within different clinical views on the approach to treatment/management of MCS as found in the Australian clinical review. Nevertheless, as the result of interviews with clinicians, responses to questionnaires and subsequently confirmed in workshop discussion, common ground was identified amongst Australian clinicians (see Appendix 1). The Australian clinical review found that, commonly, people expressing symptoms attributed to MCS often report that their medical advisers have not listened to their concerns. These people believe that they have been rejected or that their symptoms have been disbelieved. This concern and belief may well impact on their ability to come to terms with their illness or recover their health. Some patients and clinicians have observed that people presenting with symptoms ascribed to MCS experience symptoms that fluctuate over time. This is another complicating factor and a better understanding of the extent to which these occur would be important for clinical management. Clinicians involved in the clinical review of MCS agreed a set of general principles that are useful for the management of MCS (from Appendix 1). MCS Clinical Management Principles
4.6clinical research needsViews expressed in the scientific literature on MCS and also through the Australian clinical survey of MCS (Appendix 1) highlight subtly different approaches to diagnosing MCS (despite the availability of Consensus Criteria), differing views on the underlying pathological process(s) in MCS and differing approaches to treating or managing MCS other than recommending the avoidance of initiators and/or triggering agents. Information from available reports is currently insufficient to establish whether reactions in MCS individuals from chemical exposures conform to a dose-response relationship. Dose response is an important aspect of characterising health risks from toxicological agents. Some challenge tests of inhaled chemicals suggest that it is the odour of an airborne triggering agent, or an expectation of harm from exposure, rather than any pharmacological or toxicological properties per se that elicits MCS symptoms. Although not all chemicals or chemical products implicated in MCS are airborne, a pivotal role for inhaled chemicals is suggested from particular hypothesised modes of action for MCS such as respiratory disorder/neurogenic inflammation, limbic kindling/neural sensitisation and behavioural conditioning which involve limbic excitability, olfaction and respiratory function. Unfortunately, the design, conduct and reporting of current challenge tests for MCS and their conclusions with regards to physiological versus psychological mechanisms are highly debated (see Section 3.2.2). However, as much as arguments continue as to whether MCS is primarily physiological or primarily psychological in nature from individual tests, current systematic reviews of the scientific literature on challenge testing conclude at least that MCS may be the result of interplay between physiological and psychological influences. If so, this has implications for treatment. Overall, a number of primary clinical research needs are evident:
Prevalence estimates need standardised criteria and surveys of sufficient power to distinguish MCS from other types of chemical sensitivity. A recently developed and validated symptom profile inventory (the Idiopathic Environmental Intolerance Symptom Inventory) could be utilised for reliably and rapidly studying symptom prevalence in MCS. This inventory has advantages over previously used inventories for chemical sensitivity such as the Chemical Sensitivity Scale, The Chemical Odour Sensitivity Scale, the Chemical Odour Intolerance Index or the Quick Environment Exposure Sensitivity Inventory as it deliberately assesses specific symptoms linked to MCS rather than just groups of symptoms or merely the severity of reactions (Andersson et al., 2009). Challenge testing is helpful to elucidate modes of action. For example, the NO/ONOO cycle theory implicates only those chemicals that can upregulate this biochemistry. However, there is a wide spectrum of chemicals implicated in MCS and any that provoke MCS symptoms and physiological effects unrelated to this biochemistry would suggest additional modes of action. Challenge testing can also explore the relative contributions of physiological and psychological influences in responses to chemical exposures. Both clinical challenge testing and longitudinal studies could additionally be employed to explore potential therapeutic agents, such as those which downregulate NO/ONOO biochemistry, thus exploring mode of action as well as potentially establishing an avenue of treatment. Longitudinal StudyTo get a better understanding of MCS in Australia there is a need to look more closely at the natural history of people with MCS. A longitudinal clinical and sociological study (i.e. how MCS is initiated and how sensitivities vary over time) should assist in identifying elements of MCS and areas that may have been overlooked to date. Such a study should examine eliciting agents/events, diagnostic experiences, clinical course and impacts of treatment/management strategies. To undertake such a longitudinal study it would be necessary to identify people with MCS who would be prepared to be involved. Findings in Appendix 1 provide some suggested practical steps on how a longitudinal study could be established. Education/TrainingThere is unlikely to be coverage of MCS within the current Australian medical curriculum given the relatively small amount of time devoted to minor specialties. Notwithstanding the recent availability of MCS hospital guidelines in Western Australia and South Australia, there are also currently no clinical guidelines for medical practitioners to provide appropriate care for MCS individuals. In order to improve the quality of care provided by medical practitioners, the development of a clinical education program for MCS should be investigated. Such a program should be based on evidence currently available, utilise any findings from clinical research in Australia (such as a longitudinal investigation) and consider the practical guidance on approaches to MCS clinical management agreed by participants in the recent clinical review of MCS. Directory: data -> assets -> word doc word doc -> Northern territory of australia word doc -> Number: caveat in the [Will/Will and Codicil/Estate of] word doc -> List of accessible executive records word doc -> National Industrial Chemicals Notification and Assessment Scheme word doc -> This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth word doc -> οΈο Commonwealth of Australia 2002 word doc -> Commonwealth of Australia 2000 word doc -> Priority Existing Chemical word doc -> Rail safety news issue 6 β October 2011 word doc -> Board Endorsed October 2009 amended 13-09-11 with extra units Download 454.32 Kb. Share with your friends:
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