Restless Leg Syndrome (RLS)

Restless leg syndrome explained Tuesday, October 26, 2004 Restless leg syndrome (RLS) is probably caused by iron-deficient brain cells that trigger the central nervous system to send confusing signals to the arms and legs, according to research by Penn State College of Medicine scientists. Lack of iron to blame? "Our previous studies established a physical cause for RLS showing certain cells in the brain were iron-deficient. We have now found a sequence of events that may connect that cellular iron deficiency to the uncontrollable movements of the disorder," James Connor, a professor and vice chairman for neurosurgery, said in a prepared statement. In studies with rats and human brain tissue, Connor and his team concluded that a lack of iron results in problems with production of dopamine, a chemical that transmits messages from the brain and central nervous system to the body. The research was presented Oct. 25 at the annual meeting of the Society for Neuroscience in San Francisco. Treatment options investigated "Our next steps are to continue investigations of treatment strategies for RLS involving iron supplementation and dopamine agents to attempt to reach for normal balance between iron and dopamine in the brain," Connor said. RLS is characterised by irresistible urges to move the legs and arms. This is often accompanied by creepy-crawly sensations in the limbs. These sensations, which are relieved only by movement, become worse at night and cause sleeplessness for people with RLS. – (HealthDayNews) To see this article in its original context, please go to: http://www.health24.com/news/Other/1-934,29841.asp Fatigue Syndromes Prof. Garth L. Nicolson Chronic Fatigue Syndrome, Fibromyalgia Syndrome and Other Fatigue Conditions Chronic fatigue is reported by 20% of all patients seeking medical care and is considered as a nonspecific sign that is associated with many well known medical conditions. Chronic Fatigue Syndrome (CFS), Myalgic Encephalomyelitis (ME), and Fibromyalgia Syndrome (FMS) patients suffer from complex overlapping signs and symptoms. (see 'Signs/Symptoms' Questions, above) CFS is primarily characterized by persisting or relapsing fatigue without previous history of comparable symptoms that does not resolve with rest. In these patients other clinical conditions are absent that can explain the signs and symptoms such as malignancies or autoimmune diseases. In contrast, FMS patients have overall muscle pain, tenderness, and weakness as primary complaints, but they have most if not all of the commonly found signs and symptoms for CFS. We previously proposed that CFS/ME patients might be suffering from chronic infections that can cause, in part, their complex signs and symptoms. For example, systemic mycoplasmal infections can cause chronic fatigue, muscle pain and a variety of additional signs and symptoms, some of which are related to dysfunctional immune responses and in extreme cases autoimmune-like disorders. Some mycoplasmas can invade virtually every human tissue and can compromise the immune system, permitting opportunistic infections by other bacteria, viruses, fungi and yeast. When mycoplasmas exit certain cells, such as synovial cells, nerve cells, among others that can be infected, they can stimulate autoimmune response. Our recently published studies demonstrated a possible link between mycoplasmal infections and CFS and FMS, since we found high frequencies of mycoplasmal infections in these patients. Previously we examined patients with chronic illnesses for the presence of mycoplasmal infections. We found that about one half of patients with Gulf War Illness and two third of patients with CFS/ME and FMS were positive for mycoplasmal infections in their blood. The Gulf War Veterans suffer from signs and symptoms similar to patients diagnosed with CFS and FMS. They can be treated using antibiotics effective against mycoplasmal infections, and once they recover, their blood is no longer positive for the presence of mycoplasmal infections. Our recent results indicate that Rheumatoid Arthritis is also associated with mycoplasmal infections. (see 'Autoimmune Diseases') Recent reports and publications indicate that in addition to mycoplasmal infections, CFS/ME and FMS patients have other chronic infections caused by other intracellular bacteria and viruses. For example, patients with Lyme Disease, caused by intracellular Borrelia infections, have been diagnosed with CFS/ME. Also, CFS/ME and FMS patients can have intracellular Chlamydia species infections. These patients can also have infections by other bacteria that enter their bodies through 'leaky gut' problems. Chronically ill patients often have inflammatory bowel syndrome and other gut problems, and this can allow pathogenic bacteria to enter their systems. Patients with CFS/ME and FMS can also have viral infections that complicate their conditions and cause morbidity. Such infections can occur with or without the bacterial infections described above. Viruses that have been associated with CFS/ME and FMS are Human Herpes Virus-6 (HHV-6) and Cytomeglovirus (CMV). These viruses have been found at high incidence in chronically ill patients, and especially those with CFS/ME. Patients with CFS/ME or FMS can have predominantly intracellular bacterial infections, predominantly viral infections, or a combination of intracellular bacterial and viral infections. This may be one reason why the underlying causes of these chronic illnesses are so difficult to determine and effectively treat. The other reason could be the persistent nature of the infections and their ability to hide inside cells where they are essentially refractory to immune system responses, their slow growing natures and their relative insensitivity to therapeutic drugs. Chronic or Complex Regional Pain Syndrome (CRPS) What is Complex Regional Pain Syndrome? Complex regional pain syndrome (CRPS) is a chronic pain condition. The key symptom of CRPS is continuous, intense pain out of proportion to the severity of the injury, which gets worse rather than better over time. CRPS most often affects one of the arms, legs, hands, or feet. Often the pain spreads to include the entire arm or leg. Typical features include dramatic changes in the color and temperature of the skin over the affected limb or body part, accompanied by intense burning pain, skin sensitivity, sweating, and swelling. Doctors aren’t sure what causes CRPS. In some cases the sympathetic nervous system plays an important role in sustaining the pain. Another theory is that CRPS is caused by a triggering of the immune response, which leads to the characteristic inflammatory symptoms of redness, warmth, and swelling in the affected area. Is there any treatment? Because there is no cure for CRPS, treatment is aimed at relieving painful symptoms. Doctors may prescribe topical analgesics, antidepressants, corticosteroids, and opioids to relieve pain. However, no single drug or combination of drugs has produced consistent long-lasting improvement in symptoms. Other treatments may include physical therapy, sympathetic nerve block, spinal cord stimulation, and intrathecal drug pumps to deliver opioids and local anesthetic agents via the spinal cord. What is the prognosis? The prognosis for CRPS varies from person to person. Spontaneous remission from symptoms occurs in certain individuals. Others can have unremitting pain and crippling, irreversible changes in spite of treatment. What research is being done? The National Institute of Neurological Disorders and Stroke (NINDS) and other institutes of the National Institutes of Health (NIH) conduct research relating to CRPS in laboratories at the NIH and also support additional research through grants to major medical institutions across the country. NINDS-supported scientists are studying new approaches to treat CRPS and intervene more aggressively after traumatic injury to lower the chances of developing the disorder. Reflex Sympathetic Dystrophy Syndrome (RSDS) Reflex sympathetic dystrophy syndrome: Local pain and hypersensitivity Reflex sympathetic dystrophy syndrome: Reflex sympathetic dystrophy syndrome (RSDS) is a chronic condition characterized by severe burning pain, pathological changes in bone and skin, excessive sweating, tissue swelling, and extreme sensitivity to touch. The syndrome is a nerve disorder that occurs at the site of an injury (most often to the arms or legs). It occurs especially after injuries from high-velocity impacts such as those from bullets or shrapnel. However, it may occur without apparent injury. General information about symptoms of Reflex sympathetic dystrophy syndrome: The symptom information on this page attempts to provide a list of some possible symptoms of Reflex sympathetic dystrophy syndrome. This symptom information has been gathered from various sources, may not be fully accurate, and may not be the full list of symptoms of Reflex sympathetic dystrophy syndrome. Furthermore, symptoms of Reflex sympathetic dystrophy syndrome may vary on an individual basis for each patient. Only your doctor can provide adequate diagnosis of symptoms and whether they are indeed symptoms of Reflex sympathetic dystrophy syndrome. The list of symptoms mentioned in various sources for Reflex sympathetic dystrophy syndrome includes: Shiny skin Burning pain Temperature hypersensitivity Severe burning pain Bone changes Skin changes - warm and shiny red skin that later becomes cool and bluish. Excessive sweating Tissue swelling Extreme sensitivity to touch Symptoms of Reflex sympathetic dystrophy syndrome: One visible sign of RSDS near the site of injury is warm, shiny red skin that later becomes cool and bluish.The pain that patients report is out of proportion to the severity of the injury and gets worse, rather than better, over time. Eventually the joints become stiff from disuse, and the skin, muscles, and bone atrophy. The symptoms of RSDS vary in severity and duration. About complications: Complications of Reflex sympathetic dystrophy syndrome are secondary conditions, symptoms, or other disorders that are caused by Reflex sympathetic dystrophy syndrome. In many cases the distinction between symptoms of Reflex sympathetic dystrophy syndrome and complications of Reflex sympathetic dystrophy syndrome is unclear or arbitrary. Irritable Bowels Syndrome Irritable bowel syndrome (IBS) is a disorder that interferes with the normal functions of the large intestine (colon). It is characterized by a group of symptoms—crampy abdominal pain, bloating, constipation, and diarrhea. One in five Americans has IBS, making it one of the most common disorders diagnosed by doctors. It occurs more often in women than in men, and it usually begins around age 20. IBS causes a great deal of discomfort and distress, but it does not permanently harm the intestines and does not lead to intestinal bleeding or to any serious disease such as cancer. Most people can control their symptoms with diet, stress management, and medications prescribed by their physician. But for some people, IBS can be disabling. They may be unable to work, go to social events, or travel even short distances. What causes IBS? What causes one person to have IBS and not another? No one knows. Symptoms cannot be traced to a single organic cause. Research suggests that people with IBS seem to have a colon that is more sensitive and reactive than usual to a variety of things, including certain foods and stress. Some evidence indicates that the immune system, which fights infection, is also involved. IBS symptoms result from the following: The normal motility of the colon may not work properly. It can be spasmodic or can even stop temporarily. Spasms are sudden strong muscle contractions that come and go. The lining of the colon (epithelium), which is affected by the immune and nervous systems, regulates the passage of fluids in and out of the colon. In IBS, the epithelium appears to work properly. However, fast movement of the colon's contents can overcome the absorptive capacity of the colon. The result is too much fluid in the stool. In other patients, colonic movement is too slow, too much fluid is absorbed, and constipation develops. The colon responds strongly to stimuli (for example, foods or stress) that would not bother most people. In people with IBS, stress and emotions can strongly affect the colon. It has many nerves that connect it to the brain. Like the heart and the lungs, the colon is partly controlled by the autonomic nervous system, which has been proven to respond to stress. For example, when you are frightened, your heart beats faster, your blood pressure may go up, or you may gasp. The colon responds to stress also. It may contract too much or too little. It may absorb too much water or too little. Research has shown that very mild or hidden (occult) celiac disease is present in a smaller group of people with symptoms that mimic IBS. People with celiac disease cannot digest gluten, which is present in wheat, rye, barley, and possibly oats. Foods containing gluten are toxic to these people, and their immune system responds by damaging the small intestine. A blood test can determine whether celiac disease is present. (For information about celiac disease, see the Celiac Disease fact sheet from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).) The following have been associated with a worsening of IBS symptoms: large meals bloating from gas in the colon medicines wheat, rye, barley, chocolate, milk products, or alcohol drinks with caffeine, such as coffee, tea, or colas stress, conflict, or emotional upsets Researchers have also found that women with IBS may have more symptoms during their menstrual periods, suggesting that reproductive hormones can exacerbate IBS problems. What does the colon do? The colon, which is about 5 feet long, connects the small intestine with the rectum and anus. The major function of the colon is to absorb water, nutrients, and salts from the partially digested food that enters from the small intestine. Two pints of liquid matter enter the colon from the small intestine each day. Stool volume is a third of a pint. The difference in volume represents what the colon absorbs each day. Colon motility (the contraction of the colon muscles and the movement of its contents) is controlled by nerves and hormones and by electrical activity in the colon muscle. Contractions move the contents slowly back and forth but mainly toward the rectum. During this passage, water and nutrients are absorbed into the body. What remains is stool. A few times each day, strong muscle contractions move down the colon, pushing the stool ahead of them. Some of these strong contractions result in a bowel movement. The muscles of the pelvis and anal sphincters have to relax at the right time to allow the stool to be expelled. If the muscles of the colon, sphincters, and pelvis do not contract in a coordinated way, the contents do not move smoothly, resulting in abdominal pain, cramps, constipation or diarrhea, and a sense of incomplete stool movement. What are the symptoms of IBS? Abdominal pain or discomfort in association with bowel dysfunction is the main symptom. Symptoms may vary from person to person. Some people have constipation (hard, difficult-to-pass, or infrequent bowel movements); others have diarrhea (frequent loose stools, often with an urgent need to move the bowels); and still others experience alternating constipation and diarrhea. Some people experience bloating, which is gas building up in the intestines and causing the feeling of pressure inside the abdomen. IBS affects the motility or movement of stool and gas through the colon and how fluids are absorbed. When stool remains in the colon for a long time, too much water is absorbed from it. Then it becomes hard and difficult to pass. Or spasms push the stool through the colon too fast for the fluid to be absorbed, resulting in diarrhea. In addition, with spasms, gas may get trapped in one area or stool may collect in one place, temporarily unable to move forward. Sometimes people with IBS have a crampy urge to move their bowels but cannot do so or pass mucus with their bowel movements. Bleeding, fever, weight loss, and persistent severe pain are not symptoms of IBS and may indicate other problems such as inflammation or rarely cancer. How is IBS diagnosed? If you think you have IBS, seeing your doctor is the first step. IBS is generally diagnosed on the basis of a complete medical history that includes a careful description of symptoms and a physical examination. No particular test is specific for IBS. However, diagnostic tests may be performed to rule out other diseases. These tests may include stool or blood tests, x rays, or endoscopy (viewing the colon through a flexible tube inserted through the anus). If these tests are all negative, the doctor may diagnose IBS based on your symptoms: that is, how often you have had abdominal pain or discomfort during the past year, when the pain starts and stops in relation to bowel function, and how your bowel frequency and stool consistency are altered. Criteria for IBS Diagnosis Abdominal pain or discomfort for at least 12 weeks out of the previous 12 months. These 12 weeks do not have to be consecutive. The abdominal pain or discomfort has two of the following three features: It is relieved by having a bowel movement. When it starts, there is a change in how often you have a bowel movement. When it starts, there is a change in the form of the stool or the way it looks. What is the treatment for IBS? No cure has been found for IBS, but many options are available to treat the symptoms. Your doctor will give you the best treatments available for your particular symptoms and encourage you to manage stress and make changes to your diet. Medications are an important part of relieving symptoms. Your doctor may suggest fiber supplements or occasional laxatives for constipation, as well as medicines to decrease diarrhea, tranquilizers to calm you, or drugs that control colon muscle spasms to reduce abdominal pain. Antidepressants may also relieve some symptoms. Medications available to treat IBS specifically are the following: Alosetron hydrochloride (Lotronex) has been re-approved by the U.S. Food and Drug Administration (FDA) for women with severe IBS who have not responded to conventional therapy and whose primary symptom is diarrhea. However, even in these patients, it should be used with caution because it can have serious side effects, such as severe constipation or decreased blood flow to the colon. Tegaserod maleate (Zelnorm) has been approved by the FDA for the short-term treatment (usually 4 weeks) of women with IBS whose primary symptom is constipation. With any medication, even over-the-counter medications such as laxatives and fiber supplements, it is important to follow your doctor's instructions. Laxatives can be habit forming if they are not used carefully or are used too frequently. It is also important to note that medications affect people differently and that no one medication or combination of medications will work for everyone with IBS. You need to work with your doctor to find the best combination of medicine, diet, counseling, and support to control your symptoms. How does stress affect IBS? Stress—feeling mentally or emotionally tense, troubled, angry, or overwhelmed—stimulates colon spasms in people with IBS. The colon has a vast supply of nerves that connect it to the brain. These nerves control the normal rhythmic contractions of the colon and cause abdominal discomfort at stressful times. People often experience cramps or "butterflies" when they are nervous or upset. But with IBS, the colon can be overly responsive to even slight conflict or stress. Stress also makes the mind more tuned to the sensations that arise in the colon and makes the stressed person perceive these sensations as unpleasant. Some evidence suggests that IBS is affected by the immune system, which fights infection in the body. The immune system is also affected by stress. For all these reasons, stress management is an important part of treatment for IBS. Stress management comprises stress reduction (relaxation) training and relaxation therapies, such as meditation counseling and support regular exercise such as walking or yoga changes to the stressful situations in your life adequate sleep Can changes in diet help IBS? For many people, careful eating reduces IBS symptoms. Before changing your diet, keep a journal noting the foods that seem to cause distress. Then discuss your findings with your doctor. You may also want to consult a registered dietitian, who can help you make changes to your diet. For instance, if dairy products cause your symptoms to flare up, you can try eating less of those foods. You might be able to tolerate yogurt better than other dairy products because it contains bacteria that supply the enzyme needed to digest lactose, the sugar found in milk products. Dairy products are an important source of calcium and other nutrients. If you need to avoid dairy products, be sure to get adequate nutrients in the foods you substitute or take supplements. In many cases, dietary fiber may lessen IBS symptoms, particularly constipation. However, it may not help pain or diarrhea. Whole grain breads and cereals, fruits, and vegetables are good sources of fiber. High-fiber diets keep the colon mildly distended, which may help prevent spasms. Some forms of fiber also keep water in the stool, thereby preventing hard stools that are difficult to pass. Doctors usually recommend a diet with enough fiber to produce soft, painless bowel movements. High-fiber diets may cause gas and bloating, but these symptoms often go away within a few weeks as your body adjusts. (For information about diets for people with celiac disease, please see the Celiac Disease fact sheet from NIDDK.) Drinking six to eight glasses of plain water a day is important, especially if you have diarrhea. But drinking carbonated beverages, such as sodas, may result in gas and cause discomfort. Chewing gum and eating too quickly can lead to swallowing air, which again leads to gas. Also, large meals can cause cramping and diarrhea, so eating smaller meals more often or eating smaller portions should help IBS symptoms. It may also help if your meals are low in fat and high in carbohydrates, such as pasta, rice, whole-grain breads and cereals (unless you have celiac disease), fruits, and vegetables. Is IBS linked to other diseases? IBS itself is not a disease. As its name indicates, it is a syndrome—a combination of signs and symptoms. But IBS has not been shown to lead to any serious, organic diseases, including cancer. Through the years, IBS has been called by many names, among them colitis, mucous colitis, spastic colon, or spastic bowel. However, no link has been established between IBS and inflammatory bowel diseases such as Crohn's disease or ulcerative colitis. Hope Through Research The NIDDK conducts and supports research into many kinds of digestive disorders, including IBS. Researchers are studying gastrointestinal motility and sensitivity to find possible treatments for IBS. These studies include the structure and contraction of gastrointestinal muscles as well as the mechanics of fluid movement through the intestines. Understanding the influence of the nerves, hormones, and inflammation in IBS may lead to new treatments to better control the symptoms. Points to Remember IBS is a disorder that interferes with the normal functions of the colon. The symptoms are crampy abdominal pain, bloating, constipation, and diarrhea. IBS is a common disorder found more often in women than in men and usually begins around age 20. People with IBS have colons that are more sensitive and react to things that might not bother other people, such as stress, large meals, gas, medicines, certain foods, caffeine, or alcohol. IBS is diagnosed by its symptoms and by the absence of other diseases. Most people can control their symptoms by taking medicines (laxatives, antidiarrhea medicines, tranquilizers, or antidepressants), reducing stress, and changing their diet. IBS does not harm the intestines and does not lead to cancer. It is not related to Crohn's disease or ulcerative colitis. For More Information International Foundation for Functional Gastrointestinal Disorders P.O. Box 170864 Milwaukee, WI53217 Phone: 1–888–964–2001 or 414–964–1799 Fax: 414–964–7176 Email: iffgd@iffgd.org Internet: www.iffgd.org Food Allergy Food Allergy Diagnosis of an adverse reaction to a food may be easy if the person consistently exhibits the same symptoms after eating a food. However the diagnosis is most usually more complex as the person is reacting to more than one food, there may be a time delay before the onset of symptoms, and many symptoms can have other causes than an adverse reaction to a food. The same foods can cause different symptoms to different persons, and even with the same person the range of symptoms can change on different occasions. It is therefore important for a patient who believes that they are suffering from an adverse reaction to a food to consult an Allergist or other suitably qualified and experienced specialist doctor who can determine whether the symptoms are indeed related to a food, or is there some other cause. 1. Physical Examination The diagnosis starts with a complete physical examination followed by laboratory tests to exclude any medical condition not related to adverse reactions to foods. 2. Medical History It is very important for the doctor to determine the medical history of the patient in order to ascertain the type and severity of the symptoms, to try to rule out any other medical cause of the symptoms, and to try to determine the identity of the problem food(s). 3. Family History The family history is also important as allergies tend to run in families, so if one or more parents or siblings are allergic, even if with different symptoms to inhalant allergens, then this would increase the chance of the patient also being allergic. Similarly, it is believed that other types of intolerance such as Non-IgE Mediated Immune and Enzymatic Intolerance may also be familial linked. 4. Food History Information on the personal food pattern is necessary and patients may be required to keep an accurate diary of foods eaten and symptoms experienced over a certain period. 5. Supplementary Tests After the Medical, Family and Food History have been established, and adverse reaction to food is suspected, then supplementary tests are needed to reach a final and reliable diagnosis. For a patient with a food allergy, as the immune system has been activated and IgE has been produced, then measurement of allergen-specific IgE is used to prove food allergy. Therefore for the diagnosis of food allergy, skin tests and blood tests (Specific IgE) are used to provide further information. For Food Intolerance, there is no evidence that the immune system is involved, and so the skin and blood tests do not give a positive answer. For the diagnosis of food intolerance, the medical, family and food history, and a selective elimination diet, may give evidence supporting the diagnosis. 5(a) Skin Prick Test Different types of skin tests can be used to diagnose food allergy. In the skin prick test, a diluted extract or fresh part of the suspected food is placed on the skin of the forearm or the back, which is then scratched or punctured. The skin test is more sensitive and reproducible when fresh food items are used, rather than extracts from commercial manufacturers. The fresh food is punctured with a special needle and then the skin. This is called the "prick-prick method". If, after the prick, a local swelling (wheal) surrounded by redness (flare) forms within 15 minutes, similar to a mosquito bite or larger, then the skin test is positive and the person may be allergic to the tested food. Because food allergen extracts are not standardised, and their stability often remains poorly established, it is important that only experienced doctors interpret results of skin tests. Skin prick testing should be performed only in places equipped to treat anaphylaxis in case of a risk of a systemic reaction. Skin tests are unreliable if a patient has extensive eczema. Another problem can be medication that will interfere with the result of a skin test and that cannot be discontinued for 2 to 14 days because of the severity of the illness, for example antihistamines. 5(b) Blood Test ("ImmunoCAP® Specific IgE") It is vitally important to distinguish between the blood tests that are used routinely world-wide for the diagnosis of IgE-Mediated Food Allergy, and the unconventional blood tests claiming to identify Food Intolerance. The blood test used routinely world-wide and in South Africa by thousands of doctors and the medical opinion leaders for the diagnosis of food allergy and the identification of the problem food allergens is the Pharmacia ImmunoCAP® Specific IgE test. This test was originally developed by Pharmacia Diagnostics of Uppsala Sweden in 1972 and has been developed into it's present form. The ImmunoCAP® Specific IgE test is today acknowledged to be the best diagnostic test in the world to measure allergen-specific IgE and is used exclusively throughout all South African pathology laboratories. The ImmunoCAP® Specific IgE test and it's predecessor from Pharmacia have been evaluated over the past 25 years by thousands of independent clinical researchers and their results published in tens of thousands of medical publications throughout the world. Points to Remember IBS is a disorder that interferes with the normal functions of the colon. The symptoms are crampy abdominal pain, bloating, constipation, and diarrhea. IBS is a common disorder found more often in women than in men and usually begins around age 20. People with IBS have colons that are more sensitive and react to things that might not bother other people, such as stress, large meals, gas, medicines, certain foods, caffeine, or alcohol. IBS is diagnosed by its symptoms and by the absence of other diseases. Most people can control their symptoms by taking medicines (laxatives, antidiarrhea medicines, tranquilizers, or antidepressants), reducing stress, and changing their diet. IBS does not harm the intestines and does not lead to cancer. It is not related to Crohn's disease or ulcerative colitis. For More Information International Foundation for Functional Gastrointestinal Disorders P.O. Box 170864 Milwaukee, WI53217 Phone: 1–888–964–2001 or 414–964–1799 Fax: 414–964–7176 Email: iffgd@iffgd.org Internet: www.iffgd.org Food Allergy Food Allergy Diagnosis of an adverse reaction to a food may be easy if the person consistently exhibits the same symptoms after eating a food. However the diagnosis is most usually more complex as the person is reacting to more than one food, there may be a time delay before the onset of symptoms, and many symptoms can have other causes than an adverse reaction to a food. The same foods can cause different symptoms to different persons, and even with the same person the range of symptoms can change on different occasions. It is therefore important for a patient who believes that they are suffering from an adverse reaction to a food to consult an Allergist or other suitably qualified and experienced specialist doctor who can determine whether the symptoms are indeed related to a food, or is there some other cause. 1. Physical Examination The diagnosis starts with a complete physical examination followed by laboratory tests to exclude any medical condition not related to adverse reactions to foods. 2. Medical History It is very important for the doctor to determine the medical history of the patient in order to ascertain the type and severity of the symptoms, to try to rule out any other medical cause of the symptoms, and to try to determine the identity of the problem food(s). 3. Family History The family history is also important as allergies tend to run in families, so if one or more parents or siblings are allergic, even if with different symptoms to inhalant allergens, then this would increase the chance of the patient also being allergic. Similarly, it is believed that other types of intolerance such as Non-IgE Mediated Immune and Enzymatic Intolerance may also be familial linked. 4. Food History Information on the personal food pattern is necessary and patients may be required to keep an accurate diary of foods eaten and symptoms experienced over a certain period. 5. Supplementary Tests After the Medical, Family and Food History have been established, and adverse reaction to food is suspected, then supplementary tests are needed to reach a final and reliable diagnosis. For a patient with a food allergy, as the immune system has been activated and IgE has been produced, then measurement of allergen-specific IgE is used to prove food allergy. Therefore for the diagnosis of food allergy, skin tests and blood tests (Specific IgE) are used to provide further information. For Food Intolerance, there is no evidence that the immune system is involved, and so the skin and blood tests do not give a positive answer. For the diagnosis of food intolerance, the medical, family and food history, and a selective elimination diet, may give evidence supporting the diagnosis. 5(a) Skin Prick Test Different types of skin tests can be used to diagnose food allergy. In the skin prick test, a diluted extract or fresh part of the suspected food is placed on the skin of the forearm or the back, which is then scratched or punctured. The skin test is more sensitive and reproducible when fresh food items are used, rather than extracts from commercial manufacturers. The fresh food is punctured with a special needle and then the skin. This is called the "prick-prick method". If, after the prick, a local swelling (wheal) surrounded by redness (flare) forms within 15 minutes, similar to a mosquito bite or larger, then the skin test is positive and the person may be allergic to the tested food. Because food allergen extracts are not standardised, and their stability often remains poorly established, it is important that only experienced doctors interpret results of skin tests. Skin prick testing should be performed only in places equipped to treat anaphylaxis in case of a risk of a systemic reaction. Skin tests are unreliable if a patient has extensive eczema. Another problem can be medication that will interfere with the result of a skin test and that cannot be discontinued for 2 to 14 days because of the severity of the illness, for example antihistamines. 5(b) Blood Test ("ImmunoCAP® Specific IgE") It is vitally important to distinguish between the blood tests that are used routinely world-wide for the diagnosis of IgE-Mediated Food Allergy, and the unconventional blood tests claiming to identify Food Intolerance. The blood test used routinely world-wide and in South Africa by thousands of doctors and the medical opinion leaders for the diagnosis of food allergy and the identification of the problem food allergens is the Pharmacia ImmunoCAP® Specific IgE test. This test was originally developed by Pharmacia Diagnostics of Uppsala Sweden in 1972 and has been developed into it's present form. The ImmunoCAP® Specific IgE test is today acknowledged to be the best diagnostic test in the world to measure allergen-specific IgE and is used exclusively throughout all South African pathology laboratories. The ImmunoCAP® Specific IgE test and it's predecessor from Pharmacia have been evaluated over the past 25 years by thousands of independent clinical researchers and their results published in tens of thousands of medical publications throughout the world. Also, large meals can cause cramping and diarrhea, so eating smaller meals more often or eating smaller portions should help IBS symptoms. It may also help if your meals are low in fat and high in carbohydrates, such as pasta, rice, whole-grain breads and cereals (unless you have celiac disease), fruits, and vegetables. Is IBS linked to other diseases? IBS itself is not a disease. As its name indicates, it is a syndrome—a combination of signs and symptoms. But IBS has not been shown to lead to any serious, organic diseases, including cancer. Through the years, IBS has been called by many names, among them colitis, mucous colitis, spastic colon, or spastic bowel. However, no link has been established between IBS and inflammatory bowel diseases such as Crohn's disease or ulcerative colitis. Hope Through Research The NIDDK conducts and supports research into many kinds of digestive disorders, including IBS. Researchers are studying gastrointestinal motility and sensitivity to find possible treatments for IBS. These studies include the structure and contraction of gastrointestinal muscles as well as the mechanics of fluid movement through the intestines. Understanding the influence of the nerves, hormones, and inflammation in IBS may lead to new treatments to better control the symptoms. Points to Remember IBS is a disorder that interferes with the normal functions of the colon. The symptoms are crampy abdominal pain, bloating, constipation, and diarrhea. IBS is a common disorder found more often in women than in men and usually begins around age 20. People with IBS have colons that are more sensitive and react to things that might not bother other people, such as stress, large meals, gas, medicines, certain foods, caffeine, or alcohol. IBS is diagnosed by its symptoms and by the absence of other diseases. Most people can control their symptoms by taking medicines (laxatives, antidiarrhea medicines, tranquilizers, or antidepressants), reducing stress, and changing their diet. IBS does not harm the intestines and does not lead to cancer. It is not related to Crohn's disease or ulcerative colitis. For More Information International Foundation for Functional Gastrointestinal Disorders P.O. Box 170864 Milwaukee, WI53217 Phone: 1–888–964–2001 or 414–964–1799 Fax: 414–964–7176 Email: iffgd@iffgd.org Internet: www.iffgd.org Food Allergy Food Allergy Diagnosis of an adverse reaction to a food may be easy if the person consistently exhibits the same symptoms after eating a food. However the diagnosis is most usually more complex as the person is reacting to more than one food, there may be a time delay before the onset of symptoms, and many symptoms can have other causes than an adverse reaction to a food. The same foods can cause different symptoms to different persons, and even with the same person the range of symptoms can change on different occasions. It is therefore important for a patient who believes that they are suffering from an adverse reaction to a food to consult an Allergist or other suitably qualified and experienced specialist doctor who can determine whether the symptoms are indeed related to a food, or is there some other cause. 1. Physical Examination The diagnosis starts with a complete physical examination followed by laboratory tests to exclude any medical condition not related to adverse reactions to foods. 2. Medical History It is very important for the doctor to determine the medical history of the patient in order to ascertain the type and severity of the symptoms, to try to rule out any other medical cause of the symptoms, and to try to determine the identity of the problem food(s). 3. Family History The family history is also important as allergies tend to run in families, so if one or more parents or siblings are allergic, even if with different symptoms to inhalant allergens, then this would increase the chance of the patient also being allergic. Similarly, it is believed that other types of intolerance such as Non-IgE Mediated Immune and Enzymatic Intolerance may also be familial linked. 4. Food History Information on the personal food pattern is necessary and patients may be required to keep an accurate diary of foods eaten and symptoms experienced over a certain period. 5. Supplementary Tests After the Medical, Family and Food History have been established, and adverse reaction to food is suspected, then supplementary tests are needed to reach a final and reliable diagnosis. For a patient with a food allergy, as the immune system has been activated and IgE has been produced, then measurement of allergen-specific IgE is used to prove food allergy. Therefore for the diagnosis of food allergy, skin tests and blood tests (Specific IgE) are used to provide further information. For Food Intolerance, there is no evidence that the immune system is involved, and so the skin and blood tests do not give a positive answer. For the diagnosis of food intolerance, the medical, family and food history, and a selective elimination diet, may give evidence supporting the diagnosis. 5(a) Skin Prick Test Different types of skin tests can be used to diagnose food allergy. In the skin prick test, a diluted extract or fresh part of the suspected food is placed on the skin of the forearm or the back, which is then scratched or punctured. The skin test is more sensitive and reproducible when fresh food items are used, rather than extracts from commercial manufacturers. The fresh food is punctured with a special needle and then the skin. This is called the "prick-prick method". If, after the prick, a local swelling (wheal) surrounded by redness (flare) forms within 15 minutes, similar to a mosquito bite or larger, then the skin test is positive and the person may be allergic to the tested food. Because food allergen extracts are not standardised, and their stability often remains poorly established, it is important that only experienced doctors interpret results of skin tests. Skin prick testing should be performed only in places equipped to treat anaphylaxis in case of a risk of a systemic reaction. Skin tests are unreliable if a patient has extensive eczema. Another problem can be medication that will interfere with the result of a skin test and that cannot be discontinued for 2 to 14 days because of the severity of the illness, for example antihistamines. 5(b) Blood Test ("ImmunoCAP® Specific IgE") It is vitally important to distinguish between the blood tests that are used routinely world-wide for the diagnosis of IgE-Mediated Food Allergy, and the unconventional blood tests claiming to identify Food Intolerance. The blood test used routinely world-wide and in South Africa by thousands of doctors and the medical opinion leaders for the diagnosis of food allergy and the identification of the problem food allergens is the Pharmacia ImmunoCAP® Specific IgE test. This test was originally developed by Pharmacia Diagnostics of Uppsala Sweden in 1972 and has been developed into it's present form. The ImmunoCAP® Specific IgE test is today acknowledged to be the best diagnostic test in the world to measure allergen-specific IgE and is used exclusively throughout all South African pathology laboratories. The ImmunoCAP® Specific IgE test and it's predecessor from Pharmacia have been evaluated over the past 25 years by thousands of independent clinical researchers and their results published in tens of thousands of medical publications throughout the world. This ImmunoCAP® Specific IgE test measures quantitatively the amount of allergen specific IgE produced by the patients' immune system against any particular food allergen. There is a range of over 200 different food allergens that can be tested for with the ImmunoCAP® Specific IgE test. These ImmunoCAPR Specific IgE food allergen tests include various meats, dairy products, nuts, seeds, beans, cereals, shellfish, fish, molluscs, spices, vegetables, fruits, etc. There are in addition a range of over 200 other allergens that are not of food origin, for example, grass pollens, weed pollens, tree pollens, moulds, epidermals, drugs, occupationals, etc. A positive result with any ImmunoCAP® Specific IgE test clearly and reliably indicates that the patient has IgE directed against that allergen (food) and is therefore sensitised against that food. However, this does not necessarily mean that the patient will exhibit clinical symptoms against that food, especially when the result is only weakly positive. This may mean that the patient is about to develop symptoms. This is why a positive result should be used to identify those allergens to which the patient should then be challenged in an elimination - reintroduction diet. Conversely, a negative ImmunoCAP® Specific IgE result reliably shows that there is no allergen-specific IgE directed against that food, and the patient is therefore not sensitised against that food and the patient is therefore not allergic to that food. This can be very useful information indeed for small babies who appear to be allergic to many foods and it then becomes important to find some foods to which they are not allergic. In addition to this vast range of individual food allergens with the ImmunoCAP® Specific IgE test, there are various mixes of related foods, such as mixed cereals, mixed seafood, mixed nuts, mixed spices, etc. A particularly useful mixed food allergen test is the Paediatric Food Mix fx5 that tests for allergy to the commonest foods to which a baby or small infant may react, namely egg white, cow's milk, fish, wheat, soya and peanut. These mixed allergen tests are used to screen a blood sample for that type of allergen and a negative result excludes all of those individual components, whereas a positive result would be followed up with tests for the individual component allergens. ImmunoCAP® Specific IgE test results are expressed in classes from 0 to 6 and fully quantitatively in units of kilo units per litre IgE, (kU/l IgE) and is standardised against the World Health Organisation standard. In addition to ImmunoCAP® Specific IgE tests to identify food allergens, there are some other blood tests that can be used in the diagnosis of allergy. The test for Total IgE is a fully quantitative assay that measures the total amount of IgE in the patient, whether it be directed against one or more foods or against inhalant allergens, or drugs or any other allergens. This test is used to give an indication of the degree of allergen load that the patient is being subjected to. For example, a slightly raised Total IgE would indicate that the patient is moderately allergic to just one or a few allergens, whereas a very highly elevated level of Total IgE would indicate that the patient is either highly allergic to one or a few allergens, or is allergic to many allergens. However, due to it's clinical limitations, the test for Total IgE is gradually being replaced by the Phadiatop test and the ImmunoCAP® Specific IgE Paediatric Food Mix fx5. The Phadiatop® test is a qualitative test (i.e. yes or no) that indicates very reliably if a patient is sensitised to one or more inhalant allergens. Although inhalant allergens are not foods, it must be remembered that many foods are also found as inhalant allergens, for example wheat is a grass that produces pollen that can cause an inhalant allergy. In addition, many infants with food allergy go on to develop inhalant allergy after a few years. ImmunoCAP® Specific IgE tests have certain advantages over skin prick tests. ImmunoCAP® Specific IgE tests are: completely unaffected by the symptoms of the patient (e.g. even severe eczema cases) completely unaffected by drug therapy (e.g. anti-histamines) are as sensitive as skin tests (i.e. very few false negative results) are more specific than skin tests (i.e. fewer false positive results) comprehensive range of allergens that can be tested for (over 200 individual allergens) screening tests of mixed allergens (over 40 different mixes) Whether ImmunoCAP® Specific IgE tests or skin prick tests are used depends on the choice of the individual doctor who will base his decision on his own experience and the individual circumstances of each case. Most usually the ImmunoCAP® Specific IgE tests are used due to the advantages stated above, though they are more expensive than skin testing. In South Africa the Total IgE, the Phadiatop and the Specific IgE tests are all fully reimbursed by all Medical Aid Schemes. 5(c) Elimination - Reintroduction Diet When food allergy to one or more foods is suspected based on the results of the history, supported by skin and/or Specific IgE tests, elimination - reintroduction diets can be used to confirm the diagnosis and the identification of the offending allergens, for two reasons: the allergens for skin or Specific IgE tests can be affected by loss of allergenicity during manufacture a substantial number of patients, although demonstrating IgE to that particular food and are therefore sensitised, do not exhibit any clinical symptoms. An elimination diet is used to remove the suspected foods from the diet for a period of two weeks, even including minute quantities of the suspected allergens. Sometimes the patient is asked to follow an oligoallergic diet that excludes almost all-possible potential allergens. During this period the patient keeps a careful record of the foods consumed and any clinical reactions. If the symptoms do not clearly improve within two weeks then it is most unlikely that food allergy is involved, or there could be multiple sensitivities. If however the symptoms do clearly improve, then it is most likely that the offending food allergens have been correctly identified. An open oral challenge is then performed when the suspected food is re-introduced into the diet or is given under controlled circumstances in the doctors rooms (a challenge test). An adverse reaction then confirms the diagnosis and the identification. If the open challenge is positive the result should ideally be confirmed by a Double Blind Placebo Controlled Food Challenge Test (DBPCFC) where neither the patient nor the doctor are aware of whether the patient is being challenged with the suspected food or with a placebo. As this technique removes any psychological effect and any bias by the doctor, it is regarded as the gold standard for food challenge tests. It is however seldom done in clinical practice due to the inconvenience involved. For the diagnosis of Food Intolerance and the identification of the offending foods, DBPCFC is the only proven test that provides reliable results. Provocation tests should only be carried out by an experienced doctor with resuscitation equipment readily available, as a severe reaction and even anaphylactic shock is possible. Diagnosis of Food Intolerance If the defence (immune) system is not involved, food intolerance cannot be diagnosed by a skin or blood (Specific IgE) test. These IgE tests only detect IgE against a food such as is found with food allergy, and do not give positive results when food intolerance is involved. Therefore food intolerance is diagnosed with the help of the medical history, and food history, followed by elimination and reintroduction or provocation of the suspected food or groups of food. DBPCFC is also of great importance for the diagnosis of food intolerance. Unconventional Diagnostic Methods Diagnostic methods used by "clinical ecologists" and others to diagnose and treat patients with the so-called environmental illness (or food and chemical sensitivity / environmentally induced disease / ecologic illness / total allergy syndrome) are expensive and lack scientific foundation in detecting adverse reaction to food, and should be avoided. The theory is that food and chemical sensitivity leads to common somatic complaints such as headache, fatigue, malaise, disorientation and dizziness, among others. This theory has not been proven. There are in South Africa, and in a very few other countries in the world, some of these tests that are promoted for the diagnosis of food intolerance and the identification of the problem foods. The proponents of these tests claim to identify foods to which a patient is intolerant, and a subsequent exclusion diet will relieve a very wide range of symptoms from migraine to irritable bowel syndrome to chronic fatigue syndrome, and including obesity! These tests are being heavily promoted directly to the public, with largely unsupported medical claims, but against the advice of the vast majority of medical opinion leaders and medical researchers. The most widely publicised of these tests are based on the concept of leukocytotoxic testing, whereby a sample of blood is mixed with the food in question, in a test tube, and the subsequent reaction can be measured by a change in the size of the blood cells. This clinical concept and these tests have over the years been evaluated by local and international opinion leaders in medicine and laboratory pathology and the overall conclusion is that these methods are not recommended for use. They are: - not supported by mainstream, conventional doctors and researchers - lacking a scientific rationale, - not reproducible (i.e. are inconsistent) - expensive (approximately R2,000 for a standard panel of 130 tests) These tests are therefore to be regarded as the last line of investigation when all other traditional diagnostic procedures and tests have been used, but to no avail. Treatment Once the diagnosis of food adverse reaction has been established and the problem foods reliably identified, then the only proven therapy is to avoid or eliminate the offending food. This means giving up the food that causes the symptoms. In some special situations, the use of prophylactic medications can be beneficial. If there are several offending foods, or if the foods are a more or less essential part of the diet, such as milk, then a doctor or dietitian with expert knowledge in this area must be consulted. A dietician can be of great help with providing long-term meal planing and can make suggestions for alternative foods or ingredients. Long term dietary guidelines are only justified after a proper diagnosis has been made. In children, the diagnosis should be considered as temporary and should be re-evaluated at intervals as very young children can "out-grow" many food allergies. For milk and egg allergy, this re-evaluation should be done yearly, while peanut allergy is usually life-long. However, whilst one food allergy can disappear, other food allergies can appear. Also, other types of allergy symptoms can develop and sensitisation to other allergens such as to house dust mites, grass pollens, cats and dogs, etc. (inhalant allergens) can arise. Breast-feeding for a period of 6 months should be encouraged for all new-borns. This becomes clinically important if that child has an allergic pre-disposition, and even after that period known allergenic foods should ideally be avoided if possible. Proteins from potentially allergenic foods such as cow's milk, and egg can be transferred from the mother to the bay in the breast milk, so it is also advisable for the breast-feeding mother to also avoid these potentially allergenic foods. If breast-feeding is not successful or not possible, then a child with an atopic pre-disposition should be given a hypoallergenic formula. Soya milk is not a good alternative as approx. 10% of cow's milk allergic babies are also allergic to soya. (include graphic of breast feeding). The Role of the Dietitian The dietician can play a vital role not only in the treatment (i.e. avoidance) of the offending foods, but even in the diagnosis of the type of food hypersensitivity, and the identification of the problem foods. The dietitian is trained and has many years' experience of food hypersensitivities and their management, whereas the great majority of clinicians, even specialist Allergists, will not have this depth of experience. The value of the dietician in the management of the food allergic patient can therefore not be overstated. Food Allergy Prevention There are three main elements to the prevention of food allergy 1. Pre-disposition to Allergy Children with parents or siblings who suffer from allergies will be more inclined to have allergies themselves. (include graphic here of children and percentages) 2. Breast Feeding Breast-feeding for a period of 6 months should be encouraged for all new-borns. This becomes clinically important if that child has an allergic pre-disposition, and even after that period known allergenic foods should ideally be avoided if possible. Proteins from potentially allergenic foods such as cow's milk, and egg can be transferred from the mother to the bay in the breast milk, so it is also advisable for the breast-feeding mother to also avoid these potentially allergenic foods. If breast-feeding is not successful or not possible, then a child with an atopic pre-disposition should be given a hypoallergenic formula. Soya milk is not a good alternative as approx. 10% of cow's milk allergic babies are also allergic to soya. (include graphic of breast feeding). 3. Avoidance of Tobacco Smoke and Inhalant Allergens Passive smoking by a baby or infant is to be strongly discouraged, as this can irritate and sensitise the baby's lungs. Similarly, the exposure to inhalant allergens such as pets and house dust mite, should be avoided as much as possible. Chemical and/or Food Sensitivity Chemical Sensitivity: A new Mechanism of Disease? Multiple chemical sensitivity (MCS) is an ailment, or a family of ailments, that has very real consequences for tens of millions of Americans. In various large surveys 15% to 30% of Americans (37 to 75 million people) report that they are unusually sensitive or allergic to certain common chemicals such as detergents, perfumes, solvents, pesticides, pharmaceuticals, foods, or even the smell of dry-cleaned clothes. An estimated 5% (13 million people) have been diagnosed by a physician as being especially sensitive. Many of these people react so strongly that they can become disabled from very low exposures to common substances.[1,pgs.232-233] Typical symptoms include prolonged fatigue, memory difficulties, dizziness, lightheadedness, difficulty concentrating, depression, feeling spacey or groggy, loss of motivation, feeling tense or nervous, shortness of breath, irritability, muscle aches, joint pain, headaches, head fullness or pressure, chest pains, difficulty focusing eyes, nausea, and more. This group of symptoms is known as environmental illness or, more commonly, multiple chemical sensitivity (MCS), meaning "sensitivity to many chemicals." MCS has been recognized by its symptoms for 50 years because MCS sufferers in many geographical areas, researchers studying them, and doctors treating them, have reported a remarkably consistent picture of disease. However, because MCS sufferers react to chemicals at levels that are hundreds or thousands of times lower than allowable occupational exposures, traditional toxicology dictates that their symptoms cannot be caused by chemical exposures. Nor is MCS a true allergy because there are no IgE-mediated reactions involved, so allergists don't know what to make of it. In sum, because MCS does not fit any of the three currently-accepted mechanisms of disease --infectious, immune system, or cancer --traditional medicine has not known how to explain MCS, and so has often labeled it "psychogenic" --originating in the patient's mind. This has left MCS sufferers in limbo. Told they are crazy, or imagining their disease, or making it up, they find themselves passed from physician to physician without any satisfactory answers and often without relief from their very real distress. (Some MCS sufferers DO have psychological symptoms, but that doesn't necessarily mean their disease ORIGINATES in their mind.) Forty percent of MCS sufferers report having seen more than 10 medical practitioners. MCS came to the attention of mainstream science and medicine forcibly in 1987 when U.S. EPA (Environmental Protection Agency) installed 27,000 square yards of new carpeting and painted and remodeled office space at its Waterside Mall headquarters in Washington, D.C. Some 200 agency employees developed symptoms associated with "sick building syndrome"[1,pgs.174,76-77] --and several dozen EPA employees later reported developing MCS. The National Research Council has now accepted that "sick building syndrome" is a real phenomenon, producing MCS-like symptoms. Most recently, MCS has been in the news because there are two new, large populations of people who exhibit some or all of the symptoms of MCS: Gulf War veterans, and women with silicone breast implants. Since 1990, progress has been made defining and understanding MCS, though there is still a long way to go. Nevertheless, real progress has been made. A new book --a second, updated edition of CHEMICAL EXPOSURES; LOW LEVELS AND HIGH STAKES, by Nicholas A. Ashford and Claudia S. Miller[1] --offers a lucid, thoughtful description of the current science and medicine of MCS, suggests a hypothesis (which could be tested) about the origins of the disease(es), and offers real hope to sufferers that one day their ailments will be understood and treated, possibly even prevented. The stakes are enormous, and the chemical industry knows it. If a clearly-defined disease emerges from research on MCS, with chemical causes that are understood, then it can't be too many decades before chemical corporations will have to face liability and compensation claims from millions of victims harmed by their products. Who knows where this might lead in the relationship between corporations and an angry public? Like the tobacco companies before them, the chemical corporations are bent on casting doubt on the serious medical research now being conducted to discover the causes and physiologic mechanisms of MCS. The chemical corporations have labeled such research "junk science," and they have funded a new research arm of their own (modeled on the Tobacco Research Institute?) called the Environmental Sensitivities Research Institute (ESRI). DowElanco, Monsanto, Procter and Gamble, the Cosmetic Toiletries and Fragrances Association, and other companies and trade associations involved in the manufacture of pharmaceuticals, pesticides, and other chemicals, each pay $10,000 per year to keep ESRI going. The head of ESRI is Dr. Ronald Gots, who also runs something called the National Medical Advisory Group, which provides expert witnesses to defend the chemical corporations in tort lawsuits. Dr. Gots has published no original peer-reviewed research on MCS, yet he and ESRI specialize in claiming that MCS is a mental disorder. Dr. Gots says, "Everything that is known about MCS to date strongly suggests behavioral and psychogenic explanations for symptoms."[1,pg.280] In other words, if you exhibit some or all of the symptoms of MCS, you are probably crazy and if your doctor thinks otherwise, he or she is probably a charlatan. Such a claim has special staying power because it cannot be tested scientifically. As long as anyone is around to assert its validity, such a claim surrounds MCS research with an aura of controversy --and controversial topics have trouble attracting mainstream funding.   Here is a typical "advertorial" by ESRI from the February, 1996 issue of THE MERCHANDISER (Spring Grove, Pennsylvania): Multiple Chemical Sensitivities: Fear of Risk or Fact of Life? "Scientists are increasingly concerned that a doubtful new diagnosis--supposedly caused by everything 'man-made' in the environment--is unnecessarily making thousands of Americans miserable each year. One of these so-called 'modern diseases' is called MCS, for Multiple Chemical Sensitivities. Many established scientists and physicians doubt MCS actually does exist; it exists only because a patient believes it does and because a doctor validates that belief. For information on MCS, write the Environmental Sensitivities Research Institute, 6001 Montrose Road, Suite 400, North Bethesda, MD 20852." The authors of the new book on MCS are highly qualified. Nicholas Ashford is professor of technology and policy at Massachusetts Institute of Technology (MIT) with advanced degrees in chemistry and law. Claudia Miller is a medical doctor with a masters degree in environmental health; she teaches at the University of Texas Health Science Center in San Antonio. Their 1989 report on MCS, funded by the New Jersey Department of Health, won the prestigious Macedo award of the American Association for World Health. Their new book is a pleasure to read.