Letters to the Editor

Multiple Chemical Sensitivity

TO THE EDITOR: In their recent letter to the editor,¹ Drs. Fung and Kennon misrepresented the position of the World Health Organization (WHO) when they stated that WHO recommends changing the name of multiple chemical sensitivities (MCS) to "idiopathic environmental intolerances." The reference² that the authors cited in their letter was anonymously published and was not authorized by the workshop's sponsors (UNEP-ILO-WHO). It contained the following disclaimer:

"These conclusions and recommendations contain the collective views of an international group of experts and do not necessarily represent the decisions or the stated policy of the United Nations Environment Programme (UNEP), the International Labour Organization (ILO) or the World Health Organization (WHO)."²

Despite this disclaimer, some of the workshop participants began to misrepresent WHO's position on MCS after the meeting. In response, WHO issued a statement to participants,³ which reaffirmed the disclaimer and stated that "(w)ith respect to 'MCS', WHO has neither adopted nor endorsed a policy or scientific opinion."

ANN MCCAMPBELL, M.D.
P.O. Box 23079
Santa Fe, NM 87502

REFERENCES

1. Fung F, Kennon R. Understanding patients with multiple chemical sensitivity [Letter]. Am Fam Physician 1999;59:2108-9.
2. UNEP-ILO-WHO. Conclusions and recommendations of a workshop on multiple chemical sensitivities (MCS). Regul Toxicol Pharmacol 1996;24:188-9.
3. World Health Organization. Note to Invited Participants in "MCS" Workshop, 21-23 February 1996, Berlin, Germany, June 7, 1998.

IN REPLY: Dr. McCampell's letter¹ appears to mis-state the content of our previous letter² and then claims that the mis-stated information is a misrepresentation. In the era of evidence-based medicine, we have not seen validated evidence to support any pathophysiologic basis for "multiple chemical sensitivity." We also would like to point out that the position papers^3,4 previously used the term "idiopathic environmental intolerances" based on a published article.⁵

We remain comfortable about the objectivity and the contribution to the discussion presented in our letter.² Staudenmayer⁶ states it best, "If all concerned would adhere to the scientific method and respect the principles of physics and chemistry that are the foundation of toxicological and biological medicine, this phenomenon will more likely find a resolution."

FREDERICK FUNG, M.D., M.S.
Sharp Rees-Stealy Medical Group
2001 Fourth Ave.
San Diego, CA 92101
ROY KENNON, M.D., J.D.

REFERENCES

1. McCampell A. Understanding patients with multiple chemical sensitivity [Letter]. Am Fam Physician 1999;59:2111-2.
2. Fung F, Kennon R. Understanding patients with multiple chemical sensitivity [Letter]. Am Fam Physician 1999;59:2108-9.
3. Terr AI, Bardana EJ, Altman LC. Idiopathic environmental intolerances (IEI) [Position Paper]. AAAAI Board of Directors. J Allergy Clin Immunol, Academy News June/July, 1997.
4. Idiopathic environmental intolerances (IEI) [Position Paper]. AAAAI Board of Directors. J Allergy Clin Immunol 1999;103:36-40.
5. UNEP-ILO-WHO. Conclusions and recommendations of a workshop on multiple chemical sensitivities (MCS). Regul Toxicol Pharmacol 1996;24:188-9.
6. Staudenmayer H. Environmental illness and multiple chemical sensitivity [Letter]. J Occup Environ Med 1996;38:17.

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Family Physicians and HIV Care

See article in this issue.

TO THE EDITOR: In the "Medicine and Society" piece titled "The Changing Spectrum of HIV Care,"¹ Dr. Reyes and colleagues summarize the challenges of the changes facing physicians who are treating patients living with human immunodeficiency virus (HIV) infection. Family physicians and other primary care providers are well suited and situated to treat these patients who, in addition to their HIV infection, must deal with other stressful life events that may require the services of a caring physician.

However, the issue of clinical experience cannot be overemphasized. Developing the "art" of selecting an appropriate treatment regimen from the complex and ever-expanding range of antiretroviral medications that matches the particular virus's resistance pattern and meets the lifestyle of the patient is challenging and time consuming. Special skills are required of physicians to determine "the regimen" (up to 23 tablets per day) that best fits with the patient's lifestyle and is one that the patient can follow. Physicians must then monitor and coach the patient into compliance with a difficult regimen.

The "guidelines"² represent starting points that are based on current knowledge and seem to change on a daily basis. Thus, maintaining up-to-date information requires substantial effort by physicians. Studies have demonstrated that HIV-infected patients have better outcomes if they receive care from a physician who regularly manages and treats such patients. Family physicians who practice in rural or other areas with a low prevalence of HIV infection face significant challenges. It is advisable for these physicians to establish a relationship with an HIV-experienced physician who is available for regular consultation.

JENS L. WENNBERG, P.A.
Infectious Disease Clinic
Harlem Hospital
506 Lenox Ave.
New York, NY 10037

REFERENCES

1. 1Reyes EM, Liljestrand P, Goldschmidt RH. The changing spectrum of HIV care [Medicine and Society]. Am Fam Physician 1999;59:545-8.
2. Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents. HIV/AIDS Treatment Information Service. Retrieved May 1999 from the World Wide Web at http://www.hivatis.org/trtgdlns.html.

IN REPLY: We agree with Mr. Wennberg that clinical experience with human immunodeficiency virus (HIV) cannot be overemphasized in attempting to assure quality care. It appears, however, that much work remains to be done before all vulnerable populations living with HIV infection (particularly minorities, women and uninsured patients) receive even standard care.¹ The best study of HIV care delivery to-date indicates that at least one third of HIV-infected persons do not see a physician on a regular basis for care.²

As the epidemic continues in rural and urban populations, innovative strategies continue to be devised to address quality of care issues. The National AIDS Education and Training Centers of the Health Resources and Services Administration (HRSA) has devised a Targeted Training Plan that addresses the needs of physicians who have a high volume, intermediate volume or low volume of HIV-infected patients in their practice. For example, for high-volume physicians (those with more than 50 HIV-infected patients in their practice), the program emphasizes content directed at complex antiretroviral therapy regimens and salvage therapy; for low-volume physicians (those with less than five HIV-infected patients in their practice), the program emphasizes risk assessment, case identification and use of referral networks and other resources. Information about these local and regional training programs is available at the HRSA Web site (http://www.hrsa.dhhs.gov/hab/educating.html).

In an ideal world, all physicians who see a low volume of HIV-infected patients would have access to expert HIV consultation; however, this is not the reality of the practice landsape. HRSA, in collaboration with the American Academy of Family Physicians, has also funded the National HIV Telephone Consultation Service (Warmline). The Warmline provides free expert HIV consultation to family physicians and other health care providers during weekdays at 800-933-3413. Since 1991, the Warmline has provided nearly 30,000 consultations to a relatively equal distribution of physicians who have a high, intermediate or low volume of HIV-infected patients in their practice. Of key importance is the Warmline's role in supporting family physicians and other health care providers, who, although they might manage only a few HIV-infected patients, remain the principle source of HIV care in their communities.

E. MICHAEL REYES, M.D., M.P.H.
Pacific AIDS Education and Training Center
University of California, San Francisco,
School of Medicine
1855 Folsom, Suite 520
San Francisco, CA 94103-0661
PETRA LILJESTRAND, PH.D.
Pacific AIDS Education and Training Center
University of California, San Francisco,
School of Medicine
RONALD H. GOLDSCHMIDT, M.D.
University of California, San Francisco,
School of Medicine

REFERENCES

1. Shapiro MF, Morton SC, McCaffrey DF, Senterfitt JW, Fleishman JA, Perlman JF, et al. Variations in the care of HIV-infected adults in the United States: results from the HIV Cost and Services Utilization Study. JAMA 1999;281:2305-15.
2. Bozzette SA, Berry SH, Duan N, Frankel MR, Leibowitz AA, Lefkowitz D, et al. The care of HIV infected adults in the United States. HIV Cost and Services Utilization Study Consortium. N Engl J Med 1998;339:1897-904.

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Comments on Type 2 Diabetes Screening and Treatment

TO THE EDITOR: Drs. Florence and Yeager presented a current and complete outline for the diagnosis and treatment of type 2 diabetes (formerly non­insulin-dependent diabetes) in their recent review.¹ However, their recommendations for screening asymptomatic populations were misleading.

The authors presented the recommendations of the Expert Committee of the Diagnosis and Classification of Diabetes Mellitus as standard criteria for the screening for type 2 diabetes in asymptomatic patients in certain high-risk groups.² In this report, the Committee specifically states that screening for type 2 diabetes in these patients should be "considered" by physicians. The recommendations were not presented as requisite standards for screening. In allowing room for physician consideration, the Committee wisely acknowledged the controversial nature of screening for type 2 diabetes in asymptomatic persons and the important role physicians play in assessing the needs of individual patients.

Other groups differ in their recommendations for type 2 diabetes screening. The United States Preventative Services Task Force states that there is insufficient evidence to recommend for or against routine screening for type 2 diabetes in asymptomatic patients, giving a "C" recommendation.³ The Canadian Task Force on the Periodic Health Exam believes that fair evidence exists in recommending to exclude screening of asymptomatic patients--a "D" recommendation.⁴ In addition, the American College of Physicians⁵ and the American Academy of Family Physicians⁶ do not recommend routine screening. These two groups do agree, however, that screening patients for type 2 diabetes may be reasonable in certain high-risk patients based on other grounds.

The benefits of early diagnosis and treatment of type 2 diabetes before the development of symptoms are poorly defined and may have a negative impact on the quality of life in regard to insurance costs, lifestyle changes and increased physician follow-up visits. However, some high-risk patients may prefer and benefit from early diagnosis and treatment. Screening for type 2 diabetes in asymptomatic patients is certainly worthy of consideration and deserves discussion with patients, but it is not the well-established standard implied in the article.

GERALD KONRAD, M.D.
Duluth Family Practice Residency Program
330 N. 8th Ave. E.
Duluth, MN 55805

REFERENCES

1. Florence JA, Yeager BF. Treatment of type 2 diabetes mellitus. Am Fam Physician 1999;59: 2835-44.
2. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997;20:1183-97.
3. U.S. Preventive Services Task Force. Guide to clinical preventive services, 2nd ed. Baltimore: Williams and Wilkins, 1996.
4. Canadian Task Force on the Periodic Health Examination. Canadian guide to clinical preventive health care. Ottawa, Canada: Canada Communication Group, 1994.
5. Singer DE, Somet JH, Coley CM, Nathan DM. Screening for diabetes mellitus. In: Eddy DM, ed. Common screening tests. Philadelphia: American College of Physicians, 1991.
6. Age charts for periodic health examination. Kansas City, MO: American Academy of Family Physicians, 1994. (Reprint 510).

TO THE EDITOR: Because of its concise, clear and well-illustrated presentation, the article on type 2 diabetes by Florence and Yaeger¹ may attract many readers, and they may not be aware of a couple of inaccurate or incomplete statements about repaglinide (Prandin).

Specifically, we disagree that repaglinide "should be titrated cautiously in elderly patients."¹ In fact, analysis of data from studies that included patients aged 65 years or older failed to document differences in the frequency of hypoglycemia in this population.² Thus, repaglinide appears to be safer than the longer-acting sulphonylureas in this age group.

In addition, repaglinide was not included in Table 4¹ that contained information on the dose response of oral agents for the treatment of patients who have type 2 diabetes. A double-blind, placebo-controlled, three-month dose titration study² demonstrated a mean improvement in two-hour postprandial glucose by 104.1 mg per dL and 47.6 mg per dL, compared with the concurrent placebo and baseline values, respectively.

Finally, in the patient information section, the statement, "You can adjust it [i.e., repaglinide] according to how much you eat,"¹ is inaccurate. In fact, a dose adjustment is not required for meals of different sizes; the total daily dosage depends on the number of meals.

JERZY W. KOLACZYNSKI, M.D., P.H.D.
Novo Nordisk Pharmaceuticals, Inc.
100 Overlook Center, Suite 200
Princeton, NJ 08540

REFERENCES

1. Florence JA, BF Yaeger. Treatment of type 2 diabetes mellitus. Am Fam Physician 1999;59:2835-44.
2. 1999 Physicians Desk Reference. Montvale, N.J.: Medical Economics. 1999:2107-10.

IN REPLY: The recommendations on screening for type 2 diabetes in our review,¹ which Dr. Konrad refers to, were taken from the report on the American Diabetic Association Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.² The recommendations for screening for diabetes include patients who fall into a "high-risk" category, as well as patients who meet the age-specific guidelines (45 years of age or older).

The factors leading to the recommendations for screening are as follows: (1) the steep rise in the incidence of type 2 diabetes after the age of 45 years, (2) the negligible likelihood of patients developing any of the complications of diabetes within a three-year interval of a negative screening test and (3) knowledge of the well-documented risk factors for the disease.

Patients with undiagnosed diabetes are at significantly increased risk for coronary heart disease, stroke and peripheral vascular disease, and greater risk of dyslipidemia, hypertension and obesity. Along with the American Diabetes Association, we believe that screening for type 2 diabetes in asymptomatic, high-risk patients should be considered the standard of care.

JOSEPH A. FLORENCE, M.D.
East Kentucky Family Practice Residency
Lexington, KY 40536-0284
BRYAN F. YEAGER, PHARM.D.
Division of Pharmacy Practice and Science
University of Kentucky College of Medicine and Pharmacy
Lexington, KY 40536-0284

REFERENCES

1. Florence JA, Yeager BF. Treatment of type 2 diabetes mellitus. Am Fam Physician 1999;59:2835-44.
2. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care, 1999;22(suppl 5):S5-19.

EDITOR'S NOTE: The letter from Dr. Kolaczynski was sent to the authors of "Treatment of Type 2 Diabetes Mellitus," who declined to reply.

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Chronic Abdominal Pain and Abdominal Epilepsy

TO THE EDITOR: I just finished reading the article "Chronic Abdominal Pain in Childhood: Diagnosis and Management"¹ and would like to add one other rare and treatable condition to the list of specific disease states associated with abdominal pain. Many years ago, I had a patient who presented with recurrent abdominal pain. The young man underwent many complete blood counts and other tests, but no conclusions were reached as to a specific diagnosis. One night I was reading an article about abdominal epilepsy, and it could have been written with this young man in mind. All of the symptoms fit perfectly.

I ordered an electroencephalogram on the patient, and the results were positive for epilepsy. The patient was started on phenytoin (Dilantin) and did not have another attack as long as I was able to follow him. I knew that abdominal epilepsy was rare because our local neurologist called me and asked if he could see the patient. He had trained at Cleveland Clinic and had never seen such a case. Of course, I obliged. The family has since moved away, and I lost touch with them. I thought it would be wise to include this diagnosis as a "last resort" consideration.

MELVIN LEVENDORF, M.D.
695 W. Lorraine Dr.
Deltona, FL 32725

REFERENCES

1. Lake AM, Chronic abdominal pain in childhood: diagnosis and management. Am Fam Physician 1999;59:1823-30.

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Corrections

The answer to Question 16 of the January 1, 1999 "Clinical Quiz," pertaining to the article "Snowboarding Injuries," was incorrect as published in that issue, and a correction published in the August 1999 issue (page 404) was also in error. The correct answers are A and C; wrist and ankle injuries are more likely in snowboarders than in skiers.

Table 1 in the article "Malaria Prevention in Travelers" (May 1, 1999, page 2523) contained an error in the pediatric dosage of mefloquine. The correct pediatric dosage is based on a 250-mg tablet, like the adult dosage. The table with corrected pediatric dosages is published on page 52.

*These corrections have been made to the online version of AFP. The links above will take you to the corrected items, which remain part of the online issues in which they were originally published.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax:913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.

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