Italian Expert Consensus on Clinical and Therapeutic Management of Multiple Chemical Sensitivity (MCS)

The Impact of COVID-19 Health Measures on Adults With Multiple Chemical Sensitivity: Cross-Sectional Study

BACKGROUND

Multiple chemical sensitivity (MCS) develops in response to repeated small-level chemical exposures or a major exposure in a subset of people, who then experience symptoms that can range from mild to debilitating when exposed to chemicals. The arrival of the COVID-19 pandemic and the stringent health measures put in place may have increased the burden for those living with MCS, as it became more challenging to avoid chemicals that trigger their condition.

OBJECTIVE

This study aimed to better understand the lived experience of Canadians living with MCS during the first year of the COVID-19 pandemic.

METHODS

An online questionnaire was created to ask participants to compare daily living during the pandemic to before March 11, 2020. Data were collected in January and February 2021. Three areas were investigated: (1) environmental exposures to chemical triggers from ambient air (pollution from industry, farming, and traffic) and indoor air (the smell of cleaning products, cooking odors, and smoke); (2) access to, and satisfaction with, health care visits; and (3) how people experiencing MCS rated contact with their social network.

RESULTS

In all, 119 Canadians who had lived with MCS for more than a year completed the questionnaire. The participant sample was mostly female (86.6%, n=103) and highly educated, with 57.1% (n=68) having a university degree. Slightly more than half (57.1%, n=68) were older than 55 years. McNemar chi-square and Wilcoxon signed rank tests were used to evaluate if there were statistically significant changes before ("prepandemic period") and after ("postpandemic period") March 11, 2020. Perceived exposure to pollution from a highway or a road was significantly decreased from the prepandemic to postpandemic period (z=-3.347; P<.001). Analysis of industry or power plants also suggested a significant decrease in the perceived exposure from the prepandemic to postpandemic period (z=-2.152; P=.04). Participants reported an increase in exposure to odors from disinfectants or sanitizers that entered their living environment (P<.001). There was a significant decrease between prepandemic and postpandemic levels of satisfaction when attending in-person meetings with a physician (z=-2.048; P=.04), yet there were no significant differences between prepandemic and postpandemic levels of satisfaction for online or telephone meetings with a physician. Although people with MCS experienced increased social isolation (P<.001), they also reported an increase in understanding from family (P=.03) and a decrease in stigma for wearing personal protective equipment (P<.001).

CONCLUSIONS

During the first year of the COVID-19 pandemic, people with MCS were impacted by inaccessibility, loss of social support, and barriers to accessing health care. This study highlights unique challenges and possible benefits associated with the COVID-19 pandemic public health measures for individuals living with MCS. These findings can guide decision makers to improve policies on accessibility through appropriate accommodation measures.

The potential role of ocular and otolaryngological mucus proteins in myalgic encephalomyelitis/chronic fatigue syndrome

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a debilitating illness associated with a constellation of other symptoms. While the most common symptom is unrelenting fatigue, many individuals also report suffering from rhinitis, dry eyes and a sore throat. Mucin proteins are responsible for contributing to the formation of mucosal membranes throughout the body. These mucosal pathways contribute to the body's defense mechanisms involving pathogenic onset. When compromised by pathogens the epithelium releases numerous cytokines and enters a prolonged state of inflammation to eradicate any particular infection. Based on genetic analysis, and computational theory and modeling we hypothesize that mucin protein dysfunction may contribute to ME/CFS symptoms due to the inability to form adequate mucosal layers throughout the body, especially in the ocular and otolaryngological pathways leading to low grade chronic inflammation and the exacerbation of symptoms.

Probiotics and Prebiotics Orally Assumed as Disease Modifiers for Stable Mild Atopic Dermatitis: An Italian Real-Life, Multicenter, Retrospective, Observational Study

The role of the skin-gut axis in atopic dermatitis (AD) remains a subject of debate, limiting non-pharmacological interventions such as probiotics and prebiotics. To improve understanding of their potential as a monotherapy for stable mild cases, we conducted a real-life, multicenter, retrospective observational study in Italy. We administered three selected bacteria (Bifidobacterium animalis subsp. lactis BS01, Lactiplantibacillus plantarum LP14, and Lacticaseibacillus rhamnosus LR05) orally to patients with mild atopic dermatitis without a placebo control group, following up for 12 weeks. Clinical assessments using the Scoring Atopic Dermatitis (SCORAD), Eczema Area and Severity Index (EASI), and Three-Item Severity (TIS) score were conducted on 144 enrolled patients (average age: 25.1 ± 17.6 years). Notably, both pruritus and AD-related lesions (erythema, edema/papules, excoriation) exhibited significant clinical and statistical improvement (p < 0.001) after 12 weeks of exclusive probiotic and prebiotic use. These preliminary results suggest a potential link between the skin-gut microbiome and support the rationale for using specific probiotics and prebiotics in mild AD, even for maintenance, to reduce flares and dysbiosis.

Cutaneous Toll-like Receptor 9 Pre-Defines Hydroxychloroquine Dosage in Patients with Both Discoid and Subacute Lupus Erythematosus

Background and Objectives: Cutaneous lupus erythematosus (CLE) presents clinically heterogeneous manifestations, partially explained by the different expression of Toll-like receptors (TLRs) type 8 and 9, located to endosomal compartments where they are poised to recognize microbial nucleic acids. This disease is empirically treated with hydroxychloroquine (HCQ), which is hallmarked with a safe and effective profile, but induces a slow and sometimes clinically insufficient therapeutic response. Currently, no biomarkers predictive of response are validated or even proposed in the scientific literature. We aimed to evaluate endosomal TLR type 7, 8 and 9 as predictive biomarkers of HCQ efficacy. Materials and Methods: We conducted a case-control study comparing CLE patients retrospectively assigned to three subgroups based on 3-6-month Cutaneous LE Disease Area and Severity Index (CLASI) reduction upon treatment with HCQ (I = <40% vs. II = 40-80% vs. III = >80%). Before HCQ, lesional skin specimens were collected in untreated CLE and through immunohistochemistry; TLR-7, -8 and -9 expression was evaluated in the epidermis and the lymphocytic infiltrate was evaluated in the dermis. Results: Sixty-six lesional skin biopsies were compared with healthy controls. CLE patients displayed lower epidermal expression of total TLR 8 and 9 as well as infiltrating TLR-8, TLR9 + lymphocytes compared to controls. High HCQ responders differed from low responders for TLR-9 positivity (high vs. low) and for the lymphocytic dermal infiltrate (high vs. low). Conclusions: TLR9 could be envisaged as a possible biomarker to predict HCQ response level and dosage in CLE patients.

Chemical Intolerance and Mast Cell Activation: A Suspicious Synchronicity

Background: Chemical Intolerance (CI) is characterized by intolerances for chemicals, foods, and drugs with multi-system symptoms. As yet, the biomechanism remains unclear. One study reported converging lines of evidence supporting a substantive association between mast cell activation syndrome (MCAS) and CI. The purpose of this study is to (1) confirm a previous report demonstrating that 60% of MCAS patients report CI and (2) examine the parallels between symptoms and intolerances in CI and MCAS. Methods: Five hundred forty-four MCAS patients were assigned a clinical MCAS score using a validated assessment instrument and were assessed for CI using the validated Quick Environmental Exposure Sensitivity Index. Results: Our outcomes confirm the previously published study where the majority of MCAS patients also have CI. There was a clear overlap between various ICD-10 diagnostic categories and CI symptoms, providing further support for a potential shared mechanism. Conclusions: Exposures to pesticides, volatile organic compounds, combustion products, and mold have previously been reported as initiators of CI. However, until recently, little was known about the biological mechanism involved that could explain the multisystem symptoms associated with CI. This paper addresses a newly identified biomechanism for disease, which may underlie a host of "medically unexplained symptoms" triggered by xenobiotics.

Multiple chemical sensitivity scoping review protocol: overview of research and MCS construct

INTRODUCTION

Multiple chemical sensitivity (MCS) has been characterised by reported adverse responses to environmental exposures of common chemical agents (eg, perfumes, paint, cleaning products and other inhaled or ingested agents) in low doses considered non-toxic for the general population. There is currently no consensus on whether MCS can be established as a distinct disorder.

METHODS AND ANALYSIS

The scoping review of the literature will be guided by five questions: How is MCS defined and which diagnostic criteria have been proposed? What methods are used to report prevalence and incidence estimates of MCS? What are the characteristics of the body of scientific evidence that addresses whether MCS is a distinct disorder or syndrome? What underlying mechanisms for MCS have been proposed in the scientific literature? Which treatment and management approaches for MCS have been evaluated in empirical research studies? We will conduct a comprehensive search in 14 research databases. Citation screening will be supported by machine learning algorithms. Two independent reviewers will assess eligibility of full-text publications against prespecified criteria. Data abstraction will support concise evidence tables. A formal consultation exercise will elicit input regarding the review results and presentation. The existing research evidence will be documented in a user-friendly visualisation in the format of an evidence map.

ETHICS AND DISSEMINATION

Determined to be exempt from review (UP-22-00516). Results will be disseminated through a journal manuscript and data will be publicly accessible through an online data repository.

REGISTRATION DETAILS

The protocol is registered in Open Science Framework (osf.io/4a3wu).

The Potential Role of Ocular and Otolaryngological Mucus Proteins in Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a debilitating illness associated with a constellation of other symptoms. While the most common symptom is unrelenting fatigue, many individuals also report suffering from rhinitis, dry eyes and a sore throat. Mucin proteins are responsible for contributing to the formation of mucosal membranes throughout the body. These mucosal pathways contribute to the body's defense mechanisms involving pathogenic onset. When compromised by pathogens the epithelium releases numerous cytokines and enters a prolonged state of inflammation to eradicate any particular infection. Based on genetic analysis, and computational theory and modeling we hypothesize that mucin protein dysfunction may contribute to ME/CFS symptoms due to the inability to form adequate mucosal layers throughout the body, especially in the ocular and otolaryngological pathways leading to low grade chronic inflammation and the exacerbation of symptoms.

Real-World, Retrospective, Multicenter, Observational Study on the Use of the First Liquid AbobotulinumtoxinA in Italy

INTRODUCTION

Randomized controlled trials (RCTs) suggested that liquid formulation of botulinum toxin type A (aboBoNT-A) is safe and effective, but data confirming these characteristics in a real-life heterogenous set of patients are currently lacking. This study aimed to assess the efficacy and safety of the ready-to-use aboBoNT-A solution in adults with moderate-to-severe glabellar wrinkles.

METHODS

In this real-life, multicenter, retrospective, observational study, healthy adults were treated at baseline only with aboBoNT-A solution on the glabellar area and followed up for 24 weeks. Re-treatment after 20-24 weeks could also be combined with other aesthetic procedures. Family history of immune-mediated inflammatory diseases (IMIDs) was not an exclusion criterion. Patient-reported outcomes (patient's satisfaction and injection-related pain) and physician-reported outcomes (Physician Global Assessment, PGA) were collected.

RESULTS

Of the 542 patients enrolled in the study, 38 had IMID family history. Injection-related pain was reported in 128 (23.62%) as mild (pain VAS = 1.34 ± 0.87) mainly by non-botulinum toxin treatment-naïve women under 50 years of age. At 48 h, physicians rated the clinical result as "improved" in 64% of patients, conversely 264 patients (48.71%) self-evaluated as "satisfied"/"very satisfied". At 4 weeks a touch-up (< 10 units) was performed in 11 (2.03%) patients and 98.2% were "highly satisfied". Re-treatment was performed in 330 (61.45%) patients, mainly botulinum-experienced, at 20 weeks and in 207 (38.55%), mainly botulinum naïve, at 24 weeks. A total of 403 (74.35%) patients were re-treated with the three-point technique and 201 (37.08%) also received hyaluronic acid filler in the lower central face and middle third. There were no cases of de novo IMIDs.

CONCLUSIONS

Real-world data confirmed that aboBoNT-A is a fast, efficient, durable, reproducible, and easy-to-use drug which is also well tolerated in patients with family history of IMID.

Water Is an Active Element: A Randomized Double-Blind Controlled Clinical Trial Comparing Cutaneous Lipidomics in Consumers Drinking Two Different Bicarbonate-Calcic Waters (Medium-Mineral vs. Oligo-Mineral)

Despite the well-known cutaneous beneficial effect of thermal water on the skin, no data exist regarding the potential biological effect of orally consumed water on healthy skin. Thus, in this single-center, double-blind, randomized controlled clinical trial conducted on age and menstrual cycle timing-matched healthy female volunteers (24 + 24) consuming water A (oligo-mineral) or water B (medium-mineral) for 1 month (T1), the cutaneous lipidomics were compared. Interestingly, only water A consumers had a statistically significant (p < 0.001) change in cutaneous lipidomics, with 66 lipids different (8 decreased and 58 increased). The cutaneous lipidomics of consumers of water A vs. water B were statistically different (p < 0.05). Twenty cutaneous lipids were necessary to predict the water type previously consumed (AUC ~70). Our study suggests that drinking oligo-mineral water may change skin biology and may influence the cutaneous barrier, so future dermatological clinical trials should also account for the water type consumed to avoid potential confounders.

Understanding Patient-Provider Interaction, Treatment Acceptance, and Outcomes in Medically Unexplained Symptoms

INTRODUCTION

Medically unexplained symptoms (MUS) is an umbrella term used for chronic and often disabling health symptoms and conditions that remain unexplained after standard medical examinations, testing, and/or appropriate workup. Patients with MUS tend to receive little to no treatment but remain distressed, stigmatized, and disabled by symptoms and iatrogenic factors.

METHODS

A qualitative phenomenological study was conducted to explore daily challenges and psychosocial and iatrogenic factors affecting the management of MUS.

RESULTS

The analysis of the interviews revealed that MUS could cause significant distress to patients, impairing their functioning and leading to permanent disability. Conventional healthcare cannot meet the medical needs of these patients and might be a potential source of harm to them. It should be noted that confirmation of conditions associated with clinically significant psychiatric premorbidity was not provided.

CONCLUSION

Inconsistent diagnostic criteria, lack of proper training and research, diagnostic overshadowing, and implicit bias in healthcare professionals can lead to negative patient outcomes and the overuse of alternative or non-evidence-based services. Guidance, practice-based improvement ideas, and suggestions specific to improving patient-provider relationships can be applied to generate positive health effects.

Multiple Chemical Sensitivity Syndrome: First Symptoms and Evolution of the Clinical Picture: Case-Control Study/Epidemiological Case-Control Study

Multiple chemical sensitivity (MCS) is a chronic condition characterized by the appearance of symptoms caused by exposure to chemical compounds that are tolerable for the general population. It mainly affects middle-aged women. There are very few studies focusing on the most frequent symptoms of MCS considering age groups and gender. The main goal of this study was to find the most frequent symptoms both at the onset of the disease and at the present time describing them by age groups. The QEESI (Quick Environmental Exposure and Sensitivity Inventory) questionnaire, Scale 3 which assesses symptoms and their severity, was used as a diagnostic tool for the disease. A case-control study was conducted with the participation of 210 people. Of the cases, 94.3% were women. The symptoms that most often manifested first were airway and mucous membrane alterations (68.9%). In the development of the disease, we found cognitive alterations (OR = 31.25), heart or chest problems (OR = 22.49), neuromuscular problems (OR = 20.00) and head-related symptomatology (OR = 19.29). Identifying the most frequent pattern of symptoms by age group and sex will allow an early diagnosis of the disease to improve its prognosis and treatment.

Insulin Resistance Is Associated with Multiple Chemical Sensitivity in a Danish Population-Based Study-DanFunD

Multiple chemical sensitivity (MCS) is a multisystem syndrome, and limited knowledge of its pathophysiology exists. Based on the population-based Danish cohort DanFunD, this study investigated metabolic health in people with MCS compared to individuals who did not have MCS. From 9656 cohort participants aged 18–76 years old, 1.95% were categorized as MCS individuals with comorbid functional somatic disorders (MCS +FSD, n = 188), and 1.13% were categorized as MCS without functional somatic disorders (MCS ÷FSD, n = 109). MCS was characterized based on three criteria: the experience of symptoms upon exposure to common odors and airborne chemicals, symptoms related the central nervous systems and others organ symptoms, and significant impact on every day, social, and occupational life. The remaining study population without MCS or any other functional somatic disorders were regarded as controls. We used adjusted multiple linear regression with link-function to evaluate the associations between lipid and glucose metabolism markers and MCS. We also tested the odds ratio of metabolic syndrome in MCS. Results did not point to statistically significant associations between lipid biomarkers or metabolic syndrome and both MCS groups compared to the controls. We found that MCS individuals may be more insulin resistant and that MCS ÷ FSD may have an impaired glucose metabolism when compared to controls.