Medically unexplained symptoms in neurology

AIMS - To estimate the proportion of new patients with medically unexplained symptoms (MUS) that present to neurology out -patient services and to examine the impact of such symptoms on the patients in terms of disability, distress and outcome. Methods- Historical (MUS from 2 000 BC to 1965), narrative (non -neurological MUS) and systematic (MUS in neurology 1960 - 2000) reviews of the previous literature were conducted. A prospective cohort study of 300 newly referred out- patients was carried out in the regional neurology service in Lothian, Scotland. Patients were examined at the time of initial presentation and re- examined eight months later. Both primary and secondary care case -note were reviewed at follow up. Measures- Neurologists rated degree to which the patients' symptoms were explained by organic disease. Health status was measured using the SF -36. Anxiety and depressive disorders were examined using the PRIME MD and HAD. Outcome was measured on a Clinical Global Improvement (CGI) scale.RESULTS - The historical review of the literature found that MUS have been described since the first written texts of medicine. The narrative review showed that MUS affected both sexes, all ages, and all cultures. The systematic review of MUS in neurology found that between 30-40% of cases in neurology had MUS and the rate of misdiagnosis was less than 5%. In the field of neurology there was no information on disability, limited information on co- morbid anxiety and depressive disorders, and outcome studies were confined to conversion hysteria only. In the prospective cohort study 30% of new patients presenting to neurology out -patient clinics had MUS. They were as physically disabled by their symptoms as those with neurological disease were by theirs. They suffered from increased levels of pain and increased rates of anxiety and depression. At eight months follow up more than half the MUS patients were `just the same' or `worse'. There were no cases where unexpected neurological disease was diagnosed during the follow up which explained the patient's presenting symptoms. The patients with MUS had had multiple referrals to other specialist services as a result of MUS.CONCLUSIONS - One third of new referrals to general neurology clinics have medically unexplained symptoms. These patients are disabled and distressed. Over half of these patients remain symptomatic at eight months follow up

COLUMBIA MEDICAL CENTER AND THE COCAINE ADDICTED PHARMACIST (A)

Tom Zenor, a pharmacist for Columbia Medical Center, became addicted to cocaine. He checked himself into a rehabilitation center and, upon request, was placed on leave as allowed by the Family Medical Leave Act (FMLA). During his FMLA leave the company decided to terminate his employment upon the completion of his twelve week leave of absence. Columbia, in an attempt to be proactive, is considering any legal recourse Zenor might attempt. Columbia’s Human Resources manager, Carmen Estrada, is preparing evidence to defend the company against a potential Americans with Disabilities Act (ADA) lawsuit. Her primary concern is that Zenor will claim that his cocaine addiction is a qualified disability under the ADA. (Contact author for a copy of the complete report.)Personnel, Unjust Termination, At-Will Employment

Columbia Medical Center and the Cocaine-Addicted Pharmacist: Unjust Termination? (B)

Tom Zenor, a pharmacist for Columbia Medical Center, became addicted to cocaine. He checked himself into a rehabilitation center and, upon request, was placed on leave as allowed by the Family Medical Leave Act (FMLA). Upon his return, the company decided to terminate his employment. Zenor was upset at the dismissal, which he saw as unjust. Columbia Medical Center, in an attempt to be proactive, sought to consider any legal recourse Zenor might attempt. Columbia’s Human Resources manager, Carmen Estrada, attempted to construct evidence to defend the company against a potential unjust discharge case. The company operated in Texas, which was an “at-will” state. Nonetheless, Estrada had concerns which included whether Zenor could claim an exception to the Doctrine of Employment at-will, and if including a disclaimer in an employee handbook that employees are retained “at-will” provided adequate legal protection for the organization. (Contact author for a copy of the complete report.)Personnel, Addiction, ADA