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Internists are experts in complexity, and the COVID-19 pandemic is disclosing complex and unexpected interactions between communicable and non-communicable diseases, environmental factors, and socio-economic disparities. The medicine of complexity cannot be limited to facing comorbidities and to the clinical management of multifaceted diseases. Evidence indicates how climate change, pollution, demographic unbalance, and inequalities can affect the spreading and outcomes of COVID-19 in vulnerable communities. These elements cannot be neglected, and a wide view of public health aspects by a "one-health" approach is strongly and urgently recommended. According to World Health Organization, 35% of infectious diseases involving the lower respiratory tract depend on environmental factors, and infections from SARS-Cov-2 is not an exception. Furthermore, environmental pollution generates a large burden of non-communicable diseases and disabilities, increasing the individual vulnerability to COVID-19 and the chance for the resilience of large communities worldwide. In this field, the awareness of internists must increase, as privileged healthcare providers. They need to gain a comprehensive knowledge of elements characterizing COVID-19 as part of a syndemic. This is the case when pandemic events hit vulnerable populations suffering from the increasing burden of chronic diseases, disabilities, and social and economic inequalities. Mastering the interplay of such events requires a change in overall strategy, to adequately manage not only the SARS-CoV-2 infection but also the growing burden of non-communicable diseases by a "one health" approach. In this context, experts in internal medicine have the knowledge and skills to drive this change.

Ozone production and loss in surface air is determined by ambient temperature, chemical conditions and precursor emissions. Despite efforts to abate surface ozone air pollution, the daily maximum 8-hour average ozone target value for the protection of human health is regularly exceeded at several monitoring sites in Austria especially during the warm seasons. Here we investigate projected changes in the surface ozone burden and effects of climate warming and changes in precursor emissions over the next decades in a series of tailored chemistry-transport model (CTM) experiments, performed with WRF-Chem and CAMx. Specifically we contrast changes in ozone air quality in decadal time slices for 2026-2035 and 2046-2055 with the recent past (2007-2016). Our CTM ensemble comprises simulations following the Representative Concentration Pathways (RCPs) 2.6, 4.5 and 8.5. Our results show a persistent large variability in ozone abundances driven by the large intra- and interannual variability in meteorological conditions. Overall we find general improvements in the surface ozone burden for low emission scenarios (RCP2.6 and RCP4.5) driven by ambitious NOx controls. In contrast under RCP8.5 we find, on the one hand an increase in the frequency of non-attainment days and on the other a shift in the prime ozone season from summer towards spring. These increases are driven by both a climate penalty and changes in the chemical production regime (NOx vs. VOC limitation) and increasing methane and ozone backgrounds. Furthermore, we investigate impacts of projected ozone changes on human health at the municipal level in Austria.

The Alpine region in Central Europe and its populations in principle face the same types of threats to their health due to climate change as those in other parts of the world. But special geographical and climatic aspects of that region warrant closer and special examination of the connections between health and climate change in the Alps. These include small-scale variation, in some instances steep mountain slopes, and, above all, a larger-than-average increase in near-surface temperatures. To that end, there are main pathways between climate change and health: “Direct effects” describe rather short-term health effects of extreme weather events. Such events have occurred in the past, and therefore ample epidemiological evidence is available for the assessment of their impact. With climate change, such extreme events are predicted to change in frequency and intensity. “Indirect effects” refer to a more complex pathway where long-term changes of various natural and anthropogenic systems in reaction or adaptation to climate change exert adverse or sometimes also beneficial impacts on health. Such systems include ecosystems in which, for example, the prevalence of disease vectors or the allergenicity of pollen will change. But agriculture and forestry or the built environment are also affected by climate change and in turn affect the health of people. “Distant effects” are also rather indirect in nature. But in this pathway, changes due to climate change in other parts of the world affect the health in the Alpine region. Increasing migration into the Alpine region and changing migration patterns are important examples of this pathway. In some instances, most importantly regarding mental health, there is still a need for more studies focusing on the Alpine environments. But apart from these especially understudied topics, as the climate crisis evolves, there is generally a need for continuous research on the health effects of climate change and the potential of health promotion to create co-benefits.

Many countries, including Indonesia, were gravely affected by the COVID-19 pandemic. While younger people were rarely severely affected by an infection, they still served as important spreaders of the disease. Therefore, the knowledge, perception and attitudes regarding COVID-19 of a mostly younger population was assessed in this study using a quantitative survey and semi-structured questionnaire. Out of 15 questions on COVID-19, males answered fewer questions (−1.26) correctly. Persons reporting more diseases in the last year (+0.49 per disease) that lived in a central area of Indonesia, and that had a better socio-economic status defined through household condition scores, had better knowledge of the symptoms, causes of and measures against COVID-19. Better knowledge independently predicted more responsible attitudes and stated behavior. Knowledge and understanding should be enhanced through information campaigns targeted specifically towards men, persons with poor socio-economic backgrounds and those living in the periphery of the state.

SummaryWe performed a time series analysis in Vienna, Austria, investigating the temporal association between daily air pollution (nitrogen dioxide, NO2 and particulate matter smaller than 10 µm, PM10) concentration and risk of coronavirus disease 2019 (COVID-19) infection and death. Data covering about 2 months (March–April 2020) were retrieved from public databases. Infection risk was defined as the ratio between infected and infectious. In a separate sensitivity analysis different models were applied to estimate the number of infectious people per day. The impact of air pollution was assessed through a linear regression on the natural logarithm of infection risk. Risk of COVID-19 mortality was estimated by Poisson regression. Both pollutants were positively correlated with the risk of infection with the coefficient for NO2 being 0.032 and for PM10 0.014. That association was significant for the irritant gas (p = 0.012) but not for particles (p = 0.22). Pollutants did not affect COVID-19-related mortality. The study findings might have wider implications on an interaction between air pollution and infectious agents.

Record linkage of human biomonitoring (HBM) survey data with administrative register data can be used to enhance available datasets and complement the possible shortcomings of both data sources. Through record linkage, valuable information on medical history (diagnosed diseases, medication use, etc.) and follow-up information on health and vital status for established cohorts can be obtained. In this study, we investigated the availability of health registers in different EU Member States and EEA countries and assessed whether they could be linked to HBM studies. We found that the availability of administrative health registers varied substantially between European countries as well as the availability of unique personal identifiers that would facilitate record linkage. General protocols for record linkage were similar in all countries with ethical and data protections approval, informed consent, approval by administrative register owner, and linkage conducted by the register owner. Record linkage enabled cross-sectional survey data to be used as cohort study data with available follow-up and health endpoints. This can be used for extensive exposure-health effect association analysis. Our study showed that this is possible for many, but not all European countries. Record linkage of human biomonitoring (HBM) survey data with administrative register data can be used to enhance available datasets and complement the possible shortcomings of both data sources. Through record linkage, valuable information on medical history (diagnosed diseases, medication use, etc.) and follow-up information on health and vital status for established cohorts can be obtained. In this study, we investigated the availability of health registers in different EU Member States and EEA countries and assessed whether they could be linked to HBM studies. We found that the availability of administrative health registers varied substantially between European countries as well as the availability of unique personal identifiers that would facilitate record linkage. General protocols for record linkage were similar in all countries with ethical and data protections approval, informed consent, approval by administrative register owner, and linkage conducted by the register owner. Record linkage enabled cross-sectional survey data to be used as cohort study data with available follow-up and health endpoints. This can be used for extensive exposure-health effect association analysis. Our study showed that this is possible for many, but not all European countries.

Enforcement of a smoke-free policy is of vital concern in support of the health of smokers and bystanders. Indonesia has issued a smoke-free law, but implementation and enforcement lie with the regional and municipal governments. In a survey of 225 respondents recruited via schools, knowledge about the health effects of smoking and the smoke-free regulation, as well as attitudes towards and commitment and support of the enforcement of the smoke-free regulation in the Kendari City through an electronic whistleblowing system was examined. Furthermore, the participants were asked about the smoking status and smoking behavior. About half of the respondents were students (teenagers), the other half—their parents. Male respondents were strongly overrepresented (85%). Only 18% of the respondents declared to be smokers, mostly adults and males. Both the smokers and the non-smokers supported the smoke-free law and its enforcement through a whistleblowing system. Representatives of the local government were interviewed and participated in focus group discussions. In general, they also exhibited strong support of an electronic enforcement tool. However, issues of efficiency, costs, and responsibility must still be resolved. Nevertheless, an electronic whistleblowing system has the potential to further the health and livelihoods in a community like the Kendari City.

Zusammenfassung Der Klimawandel stellt eine der größten Herausforderungen unserer Zeit dar. Er hat massive Auswirkungen auf die menschliche Gesundheit. Daher ist das Gesundheitswesen gefordert a) aktiv einen Beitrag zum Klimaschutz zu leisten und b) sich verstärkt auf die Auswirkungen des Klimawandels vorzubereiten. In Österreich wurde die Thematik im Rahmen einer „Klimamahnwoche“ aufgegriffen und es wurden Schritte gesetzt, um auf Ebene des Gesundheitswesens das Bewusstsein zu schärfen.

Summary A previously presented study investigated the impact of recent pesticide exposure on cytological signs of genotoxicity and on symptoms of intoxication in 71 male coffee workers in the Dominican Republic. An unexpected finding of this study was that conventional farming workers, among other symptoms, reported fewer children than controls working in organic farms without pesticide use. This study set out to investigate possible reasons for the latter difference. One statistical problem of this analysis is that the age of the workers is a strong predictor for the number of children and available data on the exposure determinants “duration of pesticide exposure” as well as “age at first pesticide exposure” are correlated with age. To correctly control statistics for these confounding parameters, different approaches to best control for age were explored. After careful elimination of the age-related confounding factors, a reduced number of children was still observed in exposed workers. The clearest effect is seen in those workers that reported first exposure before the age of 20 years. Socioeconomic factors could still confound that finding, but a direct effect of early life pesticide exposure is the most likely explanation of the observation.

The Republic of Kosovo is a small country in the Balkans. The capital city of Pristina hosts most of its population and is situated in a mountain basin with poor air exchange, especially during winter. Domestic heating, road transport, industry and coal-fired power plants contribute to high levels of air pollution. We performed a time-series analysis on effects of particulate air pollution (PM2.5) on respiratory health of children and adolescents, using hospital admission and ambulatory visit numbers from the pediatric university clinic. From 2018 until 2020, daily mean concentrations of PM2.5 ranged between 2.41 and 161.03 µg/m³. On average, there were 6.7 ambulatory visits per day with lower numbers on weekends and during the first COVID-19 wave in 2020. An increase in PM2.5 led to an immediate increase in visit numbers that lasted over several days. Averaged over a full week, this amounted to about a 1% increase per 10 µg/m³. There were, on average, 1.7 hospital admissions per day. Two and three days after a rise in air pollution, there was also a rise in admission numbers, followed by a decline during the consecutive days. This might indicate that the wards were overstressed because of high admission numbers and restricted additional admissions.

Perfluorooctane sulfonic acid (PFOS) is a ubiquitous environmental pollutant. In humans, PFOS exposure has been associated with a number of adverse health outcomes, including reduced birth weight. Whether PFOS is capable of affecting angiogenesis and thus possibly fetal development is unknown. Therefore, we investigated 1) the metabolic activity of PFOS-exposed endothelial cells (human umbilical vein endothelial cells, HUVECs), fibroblasts (normal colon fibroblasts, NCFs), and epithelial cells (human colorectal carcinoma cells, HCT116), 2) PFOS-specific inhibition of vascular endothelial growth factor receptor (VEGFR)2 stimulation in KDR/NFAT-RE HEK293 cells, and 3) the antiangiogenic potential of PFOS in a 3D in vitro angiogenesis model of HUVECs and NCFs. In terms of metabolic activity, endothelial cells (HUVECs) were much more sensitive to PFOS than fibroblasts (NCFs) or epithelial cells (HCT116). VEGFR2 signaling in KDR/NFAT-RE HEK293 cells decreased with increasing PFOS concentrations. In co-culture (angiogenesis assay), PFOS treatment resulted in a dose-dependent reduction in tip and branch formation, tip length (μm), and total structural area (μm2) with stable metabolic activity of HUVECs up to high concentrations. We conclude that PFOS possesses antiangiogenic properties. Inhibition of VEGFR2 signaling indicates a possible mechanism of action that can be linked to an existing Adverse Outcome Pathway (AOP43) containing the AO reduced birth weight. Further studies are needed to confirm PFOS-specific adverse effects on angiogenesis, placental perfusion, and fetal growth.

Conventional banana farming is pesticide-intensive and leads to high exposure of farmworkers. Ecuador is the world&rsquo, s biggest exporter of bananas. In this field study in 5 communities in Ecuador, we recorded potentially pesticide-associated subjective health symptoms in farmworkers and compared pesticide users to workers in organic farming. With one exception, symptom rates were always higher in the pesticide-exposed group. Significance was reached in 8 out of 19 investigated symptoms with the highest odds ratios (and smallest p-values) for local irritation like skin and eye irritation (OR = 3.58, CI 1.10&ndash, 11.71, and 4.10, CI 1.37&ndash, 12.31, respectively) as well as systemic symptoms like dizziness (OR = 4.80, CI 1.55&ndash, 14.87) and fatigue (OR = 4.96, CI 1.65&ndash, 14.88). Moreover, gastrointestinal symptoms were reported more frequently by pesticide users: nausea (OR = 7.5, CI 1.77&ndash, 31.77) and diarrhea (OR = 6.43, CI 1.06&ndash, 30.00). The majority of farmworkers were not adequately protected from pesticide exposure. For example, only 3 of 31 farmworkers that had used pesticides recently reported using gloves and only 6 reported using masks during active spraying. Improved safety measures and a reduction in pesticide use are necessary to protect the health of banana farmworkers.

We determined the impact of air pollution on COVID-19-related mortality and reported-case incidence, analyzing the correlation of infection case numbers and outcomes with previous-year air pollution data from the populations of 23 Viennese districts. Time at risk started in a district when the first COVID-19 case was diagnosed. High exposure levels were defined as living in a district with an average (year 2019) concentration of nitrogen dioxide (NO2) and/or particulate matter (PM10) higher than the upper quartile (30 and 20 &micro, g/m3, respectively) of all districts. The total population of the individual districts was followed until diagnosis of or death from COVID-19, or until April 21, 2020, whichever came first. Cox proportional hazard regression was performed after controlling for percentage of population aged 65 and more, percentage of foreigners and of persons with a university degree, unemployment rate, and population density. PM10 and NO2 were significantly and positively associated with the risk of a COVID-19 diagnosis (hazard ratio (HR) = 1.44 and 1.16, respectively). NO2 was also significantly associated with death from COVID-19 (HR = 1.72). Even within a single city, higher levels of air pollution are associated with an adverse impact on COVID-19 risk.

In epidemiological studies, both spatial and temporal variations in nitrogen dioxide (NO2) are a robust predictor of health risks. Compared to particulate matter, the experimental evidence for harmful effects at typical ambient concentrations is less extensive and not as clear for NO2. In the wake of the &ldquo, Diesel emission scandal&mdash, Dieselgate&rdquo, the scientific basis of current limit values for ambient NO2 concentrations was attacked by industry lobbyists. It was argued that associations between NO2 levels and medical endpoints were not causal, as NO2 in older studies served as a proxy for aggressive particulate matter from incineration processes. With the introduction of particle filters in diesel cars, NO2 would have lost its meaning as a health indicator. Austria has a high percentage of diesel-powered cars (56%). If, indeed, associations between NO2 concentrations and health risks in previous studies were only due to older engines without a particle filter, we should expect a reduction in effect estimates over time as an increasing number of diesel cars on the roads were outfitted with particle filters. In previous time series studies from Vienna over shorter time intervals, we have demonstrated distributed lag effects over days up to two weeks and previous day effects of NO2 on total mortality. In a simplified model, we now assess the effect estimates for moving 5-year periods from the beginning of NO2 monitoring in Vienna (1987) until the year 2018 of same and previous day NO2 on total daily mortality. Contrary to industry claims of a spurious, no longer valid indicator function of NO2, effect estimates remained fairly stable, indicating an increase in total mortality of previous day NO2 by 0.52% (95% CI: 0.35&ndash, 0.7%) per 10 &micro, g/m3 change in NO2 concentration.

COVID-19 is an infectious disease caused by a novel coronavirus, which first appeared in China in late 2019, and reached pandemic distribution in early 2020. The first major outbreak in Europe occurred in Northern Italy where it spread to neighboring countries, notably to Austria, where skiing resorts served as a main transmission hub. Soon, the Austrian government introduced strict measures to curb the spread of the virus. Using publicly available data, we assessed the efficiency of the governmental measures. We assumed an average incubation period of one week and an average duration of infectivity of 10 days. One week after the introduction of strict measures, the increase in daily new cases was reversed, and the reproduction number dropped. The crude estimates tended to overestimate the reproduction rate in the early phase. Publicly available data provide a first estimate about the effectiveness of public health measures. However, more data are needed for an unbiased assessment.

In Europe and many countries worldwide, a half-yearly changing time scheme has been adopted with the aim of optimizing the use of natural daylight during working hours and saving energy. Because the expected net economic benefit was not achieved, the discussion about the optimal solution has been reopened with a shifted focus on social and health related consequences. We set out to produce evidence for this discussion and analysed the impact of daylight saving time on total mortality of a general population in a time series study on daily total mortality for the years 1970&ndash, 2018 in the city of Vienna, Austria. Daily deaths were modelled by Poisson regression controlling for seasonal and long-term trend, same-day and 14-day average temperature, humidity, and day of week. During the week after the spring transition a significant increase in daily total mortality of about 3% per day was observed. This was not the case during the week after the fall transition. The increase in daily mortality as observed in the week after spring DST-transition is most likely causally linked to the change in time scheme.

Higher rates of nuclear anomalies in buccal cells of coffee workers exposed to pesticides in comparison to their unexposed peers were detected in our field study. Here, we extend our findings by examining other exposure indicators in this sample. Occupational exposure of 38 exposed and 33 non-exposed farmworkers was assessed as exposure days in the last month (0-25 days) and as years of exposure (0-47 years). Genotoxic and cytotoxic markers in buccal cells were analysed following standard procedures for buccal micronucleus cytome assay. Both exposure markers were associated with a higher frequency of nuclear anomalies with odds ratios more than 1. After restricting the analysis to the exposed workers only, this association remained only with the marker of recent exposure. In a secondary analysis also environmental exposure defined as proximity of the home to the nearest sprayed field (distance

This short paper reports on the Austrian experiences with the Corona pandemic in the first quarter of 2020. In the beginning Austrian experts neglected the threat but a cluster in a skiing resort including international visitors served as a wake-up call and quickly after that strict and successful measures were applied. The paper proceeds describing the development of SARS-CoV-2 PCR testing and upgrading of testing facilities in Austria. The Austrian Agency for Health & Food Safety (AGES) played a leading role in this process. International cooperation and information exchange were fundamental to the successful implementation of specific and sensitive laboratory methods.

The advent of a new Corona virus, SARS-CoVi-2, causing COVID-19, which first began in Wuhan, China, and then spread worldwide, has created a global public health crisis [1]. The sudden and far-reaching pandemic has raised many immediate questions. A very important goal of public health is to identify environmental factors that affect the spread and severity of the disease. Air pollution is one of the most well-known causes of long-term inflammation, which ultimately leads to increased immune system hyperactivity [2]. Air pollution is one of the leading causes of death and is estimated to play a role in nearly 5 million premature deaths worldwide in 2017 alone. Numerous scientific studies have linked air pollution to a variety of health concerns, including premature death in patients with heart or lung disease, non-fatal heart attacks, irregular heartbeats, and severe asthma [3].

Substantial knowledge is available on the association of the indoor school environment and its effect among schoolchildren. In the same context, the SINPHONIE (School indoor pollution and health: Observatory network in Europe) conducted a study to collect data and determine the distribution of several indoor air pollutants (IAPs), physical and thermal parameters and their association with eye, skin, upper-, lower respiratory and systemic disorder symptoms during the previous three months. Finally, data from 115 schools in 54 European cities from 23 countries were collected and included 5175 schoolchildren using a harmonized and standardized protocol. The association between exposures and the health outcomes were examined using logistic regression models on the environmental stressors assessed in classroom while adjusting for several confounding factors; a VOC (volatile organic compound) score defined as the sum of the number of pollutants to which the children were highly exposed (concentration > median of the distribution) in classroom was also introduced to evaluate the mul tiexposu re - outcome association. Schoolchildren while adjusting for several confounding factors. Schoolchildren exposed to above or equal median concentration of PM2.5, benzene, limonene, ozone and radon were at significantly higher odds of suffering from upper, lower airways, eye and systemic disorders. Increased odds were also observed for any symptom (sick school syndrome) among schoolchildren exposed to concentrations of limonene and ozone above median values. Furthermore, the risks for upper and lower airways and systemic disorders significantly increased with the VOCs score. Results also showed that increased ventilation rate was significantly associated with decreased odds of suffering from eye and skin disorders whereas similar association was observed between temperature and upper airways symptoms. The present study provides evidence that exposure to IAPs in schools is associated with various health problems in children. Further investigations are needed to confirm our findings. (C) 2020 Elsevier B.V. All rights reserved.

Air pollution is a threat to the general population, especially to pollen allergy sufferers in urban environments. Different air quality parameters have hitherto been examined which add to the burden of pollen allergy sufferers. Parameters such as NO

In times of rising temperatures, the question arises on how the human body adapts. When assumed that changing climate leads to adaptation, time series analysis should reveal a shift in optimal temperatures. The city of Vienna is especially affected by climate change due to its location in the Alpine Range in Middle Europe. Based on mortality data, we calculated shifts in optimal temperature for a time period of 49 years in Vienna with Poisson regression models. Results show a shift in optimal temperature, with optimal temperature increasing more than average temperature. Hence, results clearly show an adaptation process, with more adaptation to warmer than colder temperatures. Nevertheless, some age groups remain more vulnerable than others and less able to adapt. Further research focusing on vulnerable groups should be encouraged.

(1) Background: When it comes to estimating the annoyance potency of odors, European countries relate to different guidelines. In a previous study we compared complaint rates for different agricultural odors, but due to different guidelines, the results we obtained are hard to generalize. (2) Methods: We compare our findings on complaint rates to Dutch and German findings on annoyance rates, using diverse regression models. We also discuss whether the use of the polarity profile for hedonic odor quality could improve annoyance potency assessment. This is demonstrated by comparing the graphical profiles of two different odor types (swine and cattle). (3) Results: Official complaint rates are comparable to a percentage of annoyed residents. Confounder variables such as personal variables do not greatly contribute to annoyance. However, individual emission sites also showed an important influence on complaints and hence on annoyance. Considering the hedonic quality of odors via the polarity profile method for improving an annoyance potency assessment cannot be recommended when using the given state of the method. This is particularly true when it comes to the rating of specific odors, as the method then seems to lack reliability. (4) Conclusions: Where data on annoyance rates are lacking, complaint data could be used instead.

Panel studies are an efficient means to assess short-term effects of air pollution and other time-varying environmental exposures. Repeated examinations of volunteers allow for an in-depth analysis of physiological responses supporting the biological interpretation of environmental impacts. Twenty-four healthy students walked for 1 h at a minimum of four separate occasions under each of the following four settings: along a busy road, along a busy road wearing ear plugs, in a park, and in a park but exposed to traffic noise (65 dB) through headphones. Particle mass (PM2.5, PM1), particle number, and noise levels were measured throughout each walk. Lung function and exhaled nitrogen oxide (NO) were measured before, immediately after, 1 h after, and approximately 24 h after each walk. Blood pressure and heart rate variability were measured every 15 min during each walk. Recorded air pollution levels were found to correlate with reduced lung function. The effects were clearly significant for end-expiratory flows and remained visible up to 24 h after exposure. While immediate increases in airway resistance could be interpreted as protective (muscular) responses to particulate air pollution, the persisting effects indicate an induced inflammatory reaction. Noise levels reduced systolic blood pressure and heart rate variability. Maybe due to the small sample size, no effects were visible per specific setting (road vs. park).

Clinical research aiming at objectively identifying and characterizing diseases via clinical observations and biological and radiological findings is a critical initial research step when establishing objective diagnostic criteria and treatments. Failure to first define such diagnostic criteria may lead research on pathogenesis and etiology to serious confounding biases and erroneous medical interpretations. This is particularly the case for electrohypersensitivity (EHS) and more particularly for the so-called “provocation tests”, which do not investigate the causal origin of EHS but rather the EHS-associated particular environmental intolerance state with hypersensitivity to man-made electromagnetic fields (EMF). However, because those tests depend on multiple EMF-associated physical and biological parameters and have been conducted in patients without having first defined EHS objectively and/or endpoints adequately, they cannot presently be considered to be valid pathogenesis research methodologies. Consequently, the negative results obtained by these tests do not preclude a role of EMF exposure as a symptomatic trigger in EHS patients. Moreover, there is no proof that EHS symptoms or EHS itself are caused by psychosomatic or nocebo effects. This international consensus report pleads for the acknowledgement of EHS as a distinct neuropathological disorder and for its inclusion in the WHO International Classification of Diseases.