Idiopathic environmental intolerances: overview.

The editor discusses usage of the terms "iidiopathic environmental intolerance," "multiple chemical sensitivity," and "environmental illness." Also addressed are prevalence, theories of etiology, evaluation and treatment, and social and political implications.

Diagnostic evaluation and treatment of the patient presenting with idiopathic environmental intolerance.

This chapter addresses the diagnostic evaluation and treatment of the patient presenting with idiopathic environmental intolerance (IEI). Clinicians with different views about the pathogenesis of IEI may agree on clinical management programs aimed at improved symptom control and functional ability.

The success of the Washington Department of Labor and Industries Managed Care Pilot Project: the occupational medicine-based delivery model.

The Washington State Managed Care Pilot Project (MCP) tested the effects of experience-rated capitation on medical and disability costs, quality of care, worker satisfaction with medical care, and employer satisfaction in MCP-covered workers, compared with matched fee-for-service controls. In the MCP, medical costs were reduced by approximately 27%, functional outcomes remained the same, workers were less satisfied with their treatment and access to care initially, and employers were-much more satisfied with the quality and speed of the information received from the providers. The authors believe that it was the occupational medicine-based delivery model, working in conjunction with the method of reimbursement and the cultural context of managed care, that was the most significant innovation leading to the MCP successes. This article describes the occupational medicine-based delivery model implemented for the MCP.

Multiple chemical sensitivity syndrome: a clinical perspective. I. Case definition, theories of pathogenesis, and research needs.

Multiple chemical sensitivity syndrome (MCS) does not appear to fit established principles of toxicology. Yet social, political, and economic forces are demanding that MCS be defined medically, even though to date scientific studies have not identified pathogenic mechanisms for the condition or any objective diagnostic criteria. Consequently, a working definition of MCS can rely only on an individual's subjective symptoms of distress and attribution to environmental exposures rather than currently measurable objective evidence of disease. Nevertheless, patients labeled with MCS are clearly distressed and many are functionally disabled. In this review, four theories of causation are explored: (1) MCS is a purely biologic/physical or psychophysiologic reaction to low-level chemical exposures. (2) MCS symptoms may be elicited by low-level environmental chemical exposures, but the sensitivity is initiated by psychologic stress. (3) MCS is a misdiagnosis and chemical exposure is not the cause. The symptoms may be due to misdiagnosed physical or psychologic illness. (4) MCS is an illness belief system manifest by culturally shaped illness behavior. Areas for further research regarding the etiologies of MCS are suggested. Recognizing that the cause of the syndrome may be multifactorial, strategies are proposed for clinical evaluation and management in Part II of this manuscript using a biopsychosocial model of illness.

Multiple chemical sensitivity syndrome: a clinical perspective. II. Evaluation, diagnostic testing, treatment, and social considerations.

Multiple chemical sensitivity syndrome (MCS) does not appear to fit established principles of toxicology. Social, political, and economic forces are demanding that MCS be defined medically, even though scientific studies have failed as yet to identify pathogenic mechanisms for the condition or any objective diagnostic criteria. Consequently, a working definition of MCS can only rely on a person's subjective symptoms of distress and attribution to environmental exposures rather than currently measurable objective evidence of disease. Nevertheless, patients labeled with MCS are clearly distressed and many are functionally disabled. Without reconciling the different theories of etiology of MCS discussed in Part I of this report, and recognizing that the cause of the syndrome may be multifactorial, strategies are proposed for clinical evaluation and management of patients with MCS using a biopsychosocial model of illness. The social implications of this illness are also discussed.

Risk characterization, risk communication, and risk management. The role of the occupational and environmental medicine physician.

Physicians who are board-certified in occupational and environmental medicine often have formal training and experience in toxicology, epidemiology, and industrial hygiene, as well as clinical medicine, human physiology, and pathology, and are well suited to be team members in the various phases of risk assessment, communication, and management. Those with several years of experience in the clinical, as well as administrative practice of occupational and environmental medicine, are engaged in the practical application of risk characterization, risk communication, and risk management on an almost daily basis. We propose that the occupational and environmental medicine physician is in a unique position to bridge the communication gap between those professionals who provide various components of the risk assessment process and those who manage those risks in society.

Questionnaire survey of masters, mates, and pilots of a State Ferries System on health, social, and performance indices relevant to shift work.

A questionnaire survey of health, social, and performance indices related to shiftwork among masters, mates, and pilots of a State Ferries System was performed in response to a joint request from labor and management. The questionnaire results for the group as a whole resembled those reported for other groups of shiftworkers. Significantly more sick days, dissatisfaction with work schedules, poor sleep patterns, physician consultations for insomnia, and reports of errors of judgement and near misses attributed to fatigue were reported on the ferry run with one of the most erratic schedules compared to all other runs, suggesting the need for further study.

Depression and panic attacks related to phenol-formaldehyde composite material exposure in an aerospace manufacturing plant.

In a case series study we evaluated 53 composite-materials workers in an aerospace plant who filed workers' compensation claims for illness allegedly related to phenol-formaldehyde resin exposure. Symptoms ranged from mucosal and skin irritation to depression and cognitive impairment. Certain health practitioners implying they had immunologic dysfunction and organic brain injury, led workers to believe they were chemically poisoned. Industrial hygiene evaluation failed to show levels of chemicals above permissible levels. Thorough evaluation by our multidisciplinary panel failed to find significant objective abnormalities by physical exam and laboratory testing. Thirty-nine percent of the workers had sensory irritation and/or skin complaints that generally resolved rapidly with removal from exposure. Psychiatric diagnoses (including major depression and/or panic attacks) were made in 74% of the workers, but only 26% of these had antecedent disease. Fourteen (26%) had multiple somatic complaints that generally persisted despite removal from exposure, but they also had long histories of significant pre-existing psychological illness. Detailed neuropsychologic testing failed to show any definite evidence or organic brain dysfunction in any of the workers tested. We speculate that sensory irritation from low-level volatile organic compounds with autonomic arousal, reinforced by the belief they were "chemically poisoned," led to psychogenic illness.

Allergic to life: psychological factors in environmental illness.

Environmental illness is an increasingly frequent and medically unexplained syndrome of "allergy" to common environmental agents. A recent outbreak of chemical-induced illness allowed study of psychological factors in environmental illness. Thirty-seven symptomatic plastics workers completed structured diagnostic interviews and self-report measures of somatization and psychopathology. The 13 subjects who developed environmental illness scored higher on all measures than those who did not. The greatest differences were in prior history of anxiety or depressive disorder (54% versus 4%) and number of medically unexplained physical symptoms before exposure (6.2 versus 2.9). These findings suggest that psychological vulnerability strongly influences chemical sensitivity following chemical exposure.

An outbreak of illness among aerospace workers.

A multispecialty panel of physicians evaluated a case series of 53 composite-materials workers in a large aircraft manufacturing facility who filed workers' compensation claims for illness labeled by the media as the "aerospace syndrome." Possible skin and respiratory tract exposures included formaldehyde, phenol, particulates, epoxy resins, and trace organic solvents, but measured concentrations were well below all regulatory and consensus standards. Most workers had histories of transient skin or respiratory tract irritation consistent with the known potential toxicity of these materials. None of the workers tested had immunoglobulin IgG or IgE antibodies to human serum albumin complexed with formaldehyde. A majority (74%) met DSM-III-R [Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised] criteria for major depression, panic disorder, or both. Most of these psychiatric disorders were of a recent onset, correlating in time with the use of phenol- and formaldehyde-impregnated composite material. Psychosocial factors were thought to have played a major role in the high prevalence of illness in this group and should be evaluated directly in well-controlled epidemiologic studies of similar crisis-building situations in the future.

Respiratory morbidity among processing and mill workers. A cross-sectional survey in three tire-manufacturing plants.

Three hundred seventy workers in three tire-manufacturing plants were studied to determine the presence of respiratory morbidity among workers with relatively low current exposure to respirable dust (range, 0.04 to 0.70 mg/m3). Workers in the processing, milling, and less dusty areas of the plants were divided into three groups on the basis of their current and past exposure to respirable dust. Significantly more eye irritation (p less than .01) was found among workers in the milling areas. Workers in the milling areas who were current cigarette smokers had significantly (p less than .05) more chronic bronchitis and loose or productive objective cough than all other current cigarette smokers. The mean forced expiratory volume in 1 s (FEV1), when corrected for age and height, decreased significantly (p less than .01) with increasing duration of cigarette smoking. The mean FEV1 and the forced vital capacity (FVC), when corrected for age, height and cigarette smoking, were the lowest in the group with the lowest dust exposure and highest in the group with moderate dust exposure (the milling areas). The measurement of the difference in flow at 50% of FVC on air and on a helium-oxygen mixture is a sensitive test for small-airway obstruction in the laboratory. In the field, however, the helium-oxygen flow difference did not vary with duration of cigarette smoking as expected, and there was no significant variation by exposure category.

Cause of death among jewelry workers.

A proportional mortality analysis of jewelry workers as identified on death certificates is presented. The study group consisted of 931 males who died in Attleboro, Mass., between 1956 and 1975. An excess proportion of pancreas cancer was found in the entire group (16/9; p < 0.05) and was not explained by ethnic or other non-occupational factors. Job titles were specific enough to identify a subset of polishers and findings for this job category were compared to those for all other categories. Excesses of stomach cancer (odds ratio 4.4; p < 0.01) and stomach ulcer (odds ratio 5.0, p < 0.01) were found, but for each the observed number of deaths is small. Possible important exposures in the jewelry industry are reviewed.

Uric acid catabolism in the woolly monkey.

The degradation and excretion of 2-14C-uric acid were examined in three adult woolly monkeys (Lagothrix lagothrichia) to determine the basis for the relatively high serum and urinary uric acid concentrations previously reported in this species. Like man and the great apes which lack uricase, but in distinction to most other mammals, these animals converted very little urate to allantoin. Uric acid turnover, as has been reported for other New World monkeys, was several times that of normal man. Renal urate excretion as well as disposition by extrarenal mechanisms may protect Lagothrix vrom hyperuricemia. The capacity to convert urate to allantoin appears to have been lost late in the evolution of New World monkeys. The woolly monkey deserves further study as a primate model for investigations of enzyme replacement strategies.