Consensus-based Diagnostic Criteria Research Articles

Diagnosis of vocal cord dysfunction/inducible laryngeal obstruction: An International Delphi Consensus Study

Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) is characterized by breathing difficulties in association with excessive supraglottic or glottic laryngeal narrowing. The condition is common and can occur independently; however, it may also be comorbid with other disorders or mimic them. Presentations span multiple specialties and misdiagnosis or delayed diagnosis is commonplace. Group-consensus methods can efficiently generate internationally accepted diagnostic criteria and descriptions to increase clinical recognition, enhance clinical service availability, and catalyze research. We sought to establish consensus-based diagnostic criteria and methods for VCD/ILO. We performed a modified 2-round Delphi study between December 7, 2021, and March 14, 2022. The study was registered at ANZCTR (Australian New Zealand Clinical Trials Registry; ACTRN12621001520820p). In round 1, experts provided open-ended statements that were categorized, deduplicated, and amended for clarity. These were presented to experts for agreement ranking in round 2, with consensus defined as ≥70% agreement. Both rounds were completed by 47 international experts. In round 1, 1102 qualitative responses were received. Of the 200 statements presented to experts across 2 rounds, 130 (65%) reached consensus. Results were discussed at 2 international subject-specific conferences in June 2022. Experts agreed on a diagnostic definition for VCD/ILO and endorsed the concept of VCD/ILO phenotypes and clinical descriptions. The panel agreed that laryngoscopy with provocation is the gold standard for diagnosis and that ≥50% laryngeal closure on inspiration or Maat grade ≥2 define abnormal laryngeal closure indicative of VCD/ILO. This Delphi study reached consensus on multiple aspects of VCD/ILO diagnosis and can inform clinical practice and facilitate research.

Consensus on diagnostic criteria for deficiency syndrome in hypertension: a modified Delphi study.

To reach consensus on the diagnostic criteria for deficiency syndrome in hypertension (YDSH) patients by a modified Delphi method. Our study was consistent with T/CACM 1032-2017. The methodology of RAND/UCLA appr-opriateness was used to develop consensus guidance statements. A nationwide panel of experienced clinical experts from 19 provinces was constructed. These experts were all prominent in Traditional Chinese Medicine (TCM) of cardiovascular diseases. This con-sensus process consisted of two rounds of ques-tionnaires and a final round of consultation to analyze the weight score of each item. Moreover, the data extraction process is carried out independently by third-party researchers (LIANG Junya, SUN Yang, and DU Xiaona). When there is disagreement in all three rounds, the expert panel group (odd number) are invited to vote, and the one with more votes wins. In the questionnaires, participants were asked to rate the appropriateness of each syndrome item using a nine-point Likert scale. The consensus was defined as a panel median rating 1-3 or 7-9 without disagreement. And then the diagnostic criteria of YDSH were formed according to the weight score in the final round. Twenty-eight experts (84.8%) participated in the first round, and thirty-one (93.9%) finished the second round. After two rounds, the consensus of YDSH was reached on 11 items (25.6%), including symptoms, signs, and pulse condition. Twenty-one experts (63.6%) com-pleted the final round in which they used a grading system for each item. Red tongue with scanty fur had the highest weighting (22.8%), followed by heat in the palms and soles (20.1%). The consensus-based diagnostic criteria for YDSH, formed by a modified Delphi method, can be widely incorporated in TCM. A further clinical study will be conducted to analyze the diagnosis value and cut-off score of our YDSH criteria.

In pursuit of inter-specialty consensus on excited delirium syndrome: a scoping literature review.

Excited delirium syndrome (ExDS) is a controversial and disputed diagnosis involving altered mentation, agitation, and, frequently, substance abuse. Recently, it has become a common pre-hospital diagnosis, serving as justification for use of force, restraint, and/or medication administration.To conduct a scoping review across three databases to describe the most frequently reported diagnostic criteria for ExDS, as well as to explore its use as a diagnosis for deaths of individuals in the custody of law enforcement.In 2021, three literature databases were searched: Ovid Medline, PsycInfo, and Scopus. Studies were included if they were peer-reviewed, English articles describing (1) ExDS symptoms, (2) substance intoxication with at least 2 ExDS symptoms present, or (3) centering on deaths occurring in the custody of law enforcement and attributed to ExDS. Key study data were extracted and the current literature was described qualitatively. Analysis took place between March and December 2021. A total of 97 studies were identified through initial abstract and secondary full-text review, with noted discrepancies in the definition of ExDS itself.After review, differences in ExDS diagnosis among organizations were explored, along with subsequent clinical impact, particularly in the pre-hospital setting. Resulting impact on patients, particularly those of minoritized ethnic and racial groups, was also noted. Prone aggressive restraint, in particular, is noted as an established risk factor for fatalities in ExDS cases. At this time, ExDS should not be utilized as a diagnosis; major medical organizations have an urgent responsibility to convene to formalize consensus-based diagnostic criteria or to propose alternate management guidelines for agitated and altered persons.

Diagnosis and Monitoring of White Coat Hypertension in Pregnancy: an ISSHP Consensus Delphi Procedure.

There is no accepted definition or standardized monitoring for white coat hypertension in pregnancy. This Delphi procedure aimed to reach consensus on out-of-office blood pressure (BP) monitoring, and white coat hypertension diagnostic criteria and monitoring. Relevant international experts completed three rounds of a modified Delphi questionnaire. For each item, the predefined cutoff for group consensus was ≥70% agreement, with 60% to 70% considered to warrant reconsideration at the subsequent round, and <60% considered insufficient to warrant consideration. Of 230 experts, 137 completed the first round and 114 (114/137, 83.2%) completed all three. For out-of-office BP monitoring, there was consensus that home BP monitoring (HBPM) should be chosen; instructions given, pairs of BP values taken, opportunity given for women to qualify values they do not regard as valid, and BP considered evaluated when ≥25% of values are above a cutoff. For HBPM, BP should be taken at least 2 to 3 d/wk, at minimum in the morning; however, many factors may affect frequency and timing. Experts endorsed a clinic BP <140/90 mm Hg as normal. While not reaching consensus, most agreed that HBPM values should be lower than clinic BP. Among those, HBPM <135/85 mm Hg was considered normal. There was consensus that white coat hypertension warrants: HBPM at least 1 d/wk before 20 weeks, 2 to 3 d/wk after 20 weeks or if persistent hypertension develops, and symptom monitoring (ie, headache, visual symptoms, and right upper quadrant/epigastric pain). Consensus-based diagnostic criteria and monitoring strategies should inform clinical care and research, to facilitate evaluation of out-of-office BP monitoring on pregnancy outcomes.

New Consensus Criteria for Traumatic Encephalopathy Syndrome

Sponsoring Organization: National Institute of Neurological Disorders and StrokeBackground and ObjectiveTo develop consensus-based diagnostic criteria

Subgroup comparison according to clinical phenotype and serostatus in autoimmune encephalitis: a multicenter retrospective study.

Autoimmune encephalitides (AE) include a spectrum of neurological disorders whose diagnosis revolves around the detection of neuronal antibodies (Abs). Consensus-based diagnostic criteria (AE-DC) allow clinic-serological subgrouping of AE, with unclear prognostic implications. The impact of AE-DC on patients' management was studied, focusing on the subgroupofAb-negative-AE. This was a retrospective multicenter study on patients fulfilling AE-DC. All patients underwent Ab testing with commercial cell-based assays (CBAs) and, when available, in-house assays (immunohistochemistry, live/fixed CBAs, neuronal cultures) that contributed to defining final categories. Patients were classified as Ab-positive-AE [N-methyl-d-aspartate-receptor encephalitis (NMDAR-E), Ab-positive limbic encephalitis (LE), definite-AE] or Ab-negative-AE (Ab-negative-LE, probable-AE, possible-AE). Commercial CBAs detected neuronal Abs in 70/118 (59.3%) patients. Testing 37/48 Ab-negative cases, in-house assays identified Abs in 11 patients (29.7%). A hundred and eighteen patients fulfilled the AE-DC, 81 (68.6%) with Ab-positive-AE (Ab-positive-LE, 40; NMDAR-E, 32; definite-AE, nine) and 37 (31.4%) with Ab-negative-AE (Ab-negative-LE, 17; probable/possible-AE, 20). Clinical phenotypes were similar in Ab-positive-LE versus Ab-negative-LE. Twenty-four/118 (20.3%) patients had tumors, and 19/118 (16.1%) relapsed, regardless of being Ab-positive or Ab-negative. Ab-positive-AE patients were treated earlier than Ab-negative-AE patients (P=0.045), responded more frequently to treatments (92.3% vs. 65.6%, P<0.001) and received second-line therapies more often (33.3% vs. 10.8%, P=0.01). Delays in first-line therapy initiation were associated with poor response (P=0.022; odds ratio 1.02; confidence interval 1.00-1.04). In-house diagnostics improved Ab detection allowing better patient management but was available in a patient subgroup only, implying possible Ab-positive-AE underestimation. Notwithstanding this limitation, our findings suggest that Ab-negative-AE and Ab-positive-AE patients share similar oncological profiles, warranting appropriate tumor screening. Ab-negative-AE patients risk worse responses due to delayed and less aggressive treatments.

SUN-395 Intermittent Hypogonadotropic Hypogonadism Associated with Cyclic Cushing’s Disease

Introduction: Cyclic Cushing’s syndrome is defined as cortisol excess which fluctuates with periods of normal cortisol secretion, usually associated with Cushing’s disease (CD). Majority of cyclic CD patients exhibit clinical features of hypercortisolism which vary with the “cycle” of disease. We present a case of a patient without overt signs or symptoms of CD and biochemical evidence of intermittent hypogonadism which was associated with the cyclic nature of CD. Case: A 67 year old male with history of mild diabetes mellitus type 2 and hypertension was referred to endocrinology for evaluation of hypercortisolism after a routine screening CT chest revealed a 1.1 cm mass in the right adrenal gland. He had no typical manifestations of hypercortisolism other than mild fullness of bilateral supraclavicular fossae. His screening labs showed 24 hour urine free cortisol level of 243.3 ug (ref. range 4-50) with aldosterone-renin ratio, plasma renin activity and metanephrines within normal limits. After 1 mg dexamethasone suppression, AM serum cortisol was 24 mcg/dL (7-23) with ACTH 42 pg/mL (7-69). AM cortisol remained unsuppressed after 8 mg of dexamethasone as well. MRI brain showed no evidence of pituitary adenoma. Inferior petrosal sinus sampling (IPSS) revealed significantly increased central-peripheral ACTH ratio of 57 at 2 minutes post IV Acthrel 100 ug. Surprisingly, another AM Cortisol was found to be 8 mcg/dL with ACTH of 43 pg/mL. This prompted further 24h-urine cortisol tests with at least 3 elevated and 2 normal results (ranging from 9.1-203 mcg) meeting the consensus-based diagnostic criteria of cyclic Cushing’s disease. He also had intermittent hypogonadotropic hypogonadism with testosterone levels associated with rise and fall of cortisol levels. His free testosterone was 24 and 53 pg/mL (47-244) measured a few months apart which correlated with PM cortisol of 25 ug/dL (3-12) and AM cortisol of 11 ug/mL, respectively. He was also diagnosed with primary hyperparathyroidism. Genetic testing did not detect MEN1 gene mutation. He underwent partial transsphenoidal hypophysectomy and parathyroidectomy, following which he was treated with daily prednisone being gradually tapered off. Up till date he has had clinical improvement in his physical exam and diabetes, along with free testosterone level of 62 pg/mL and normal serum calcium levels. Conclusion: Clinicians should have a high index of suspicion for cyclic CD in patients being screened for hypercortisolism particularly those with mild or no clinical manifestations. Paradoxical responses to dynamic testing are often noted and thus IPSS results may be confounded if not in the active Cushing phase. It is important to remember while interpreting lab results that comorbid disorders like hypogonadism may also show cyclic nature dependent on the cycle of CD the patient may be in.

Version 3 of the National Alzheimer's Coordinating Center's Uniform Data Set.

In 2015, the US Alzheimer's Disease Centers (ADC) implemented Version 3 of the Uniform Data Set (UDS). This paper describes the history of Version 3 development and the UDS data that are freely available to researchers. UDS Version 3 was developed after years of coordination between the National Institute on Aging-appointed Clinical Task Force (CTF), clinicians from ∼30 ADCs, and the National Alzheimer's Coordinating Center (NACC). The CTF recognized the need for updates to align with the state of the science in dementia research, while being flexible to the diverse needs and diseases studied at the ADCs. Version 3 also developed a nonproprietary neuropsychological battery. This paper focuses on the substantial Version 3 changes to the UDS forms related to clinical diagnosis and characterization of clinical symptoms to match updated consensus-based diagnostic criteria. Between March 2015 and March 2018, 4820 participants were enrolled using UDS Version 3. Longitudinal data were available for 25,337 of the 37,568 total participants using all UDS versions. The results from utilization of the UDS highlight the possibility for numerous research institutions to successfully collaborate, produce, and use standardized data collection instruments for over a decade.

Systematic review of outcome measures in pediatric eosinophilic esophagitis treatment trials

BackgroundHeterogeneity has been noted in the selection and reporting of disease-specific, pediatric outcomes in randomized controlled trials (RCTs). The consequence is invalid results or difficulty comparing results across trials. The primary objective of this systematic review was to assess primary outcome and outcome measure selection and reporting, in pediatric eosinophilic esophagitis (EoE) treatment trials. As secondary objectives, we compared trial disease definition to established concensus guidelines, and the efficacy of current EoE treatments.MethodsWe searched MEDLINE, EMBASE, The Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL since 2001. We also searched clinical trial registries (portal.nihr.ac.uk; clinicaltrials.gov; isrctn.com; and anzctr.org.au) and references of included studies. We included RCTs of EoE treatment in patients 0–18 years. Two authors independently assessed articles.ResultsEleven studies met inclusion criteria. All identified primary outcomes, however, of 9 unique primary outcomes, only 2 were used in more than one study. In total, 25 unique primary and secondary outcome measures were employed for pediatric EoE treatment trials. Measurement properties and rationale for their selection was rarely provided. Uptake of consensus-based diagnostic criteria was 25 % in trials initiated after 2011. Due to the small number and heterogeneity of studies obtained, no meta-analysis of treatment efficacy could be undertaken. This SR was limited to exclusively pediatric RCTs.ConclusionsThe results of this study confirm the need for a standardized set of core outcomes that are universally reported in pediatric EoE trials. Consistent disease definition and standardized outcome reporting will facilitate meta-analyses across similar trials and inform future clinical decision-making.Systematic review registration number CRD42013003798

How is pneumonia diagnosed in clinical stroke research? A systematic review and meta-analysis.

Diagnosis of pneumonia complicating stroke is challenging, and there are currently no consensus diagnostic criteria. As a first step in developing such consensus-based diagnostic criteria, we undertook a systematic review to identify the existing diagnostic approaches to pneumonia in recent clinical stroke research to establish the variation in diagnosis and terminology. Studies of ischemic stroke, intracerebral hemorrhage, or both, which reported occurrence of pneumonia from January 2009 to March 2014, were considered and independently screened for inclusion by 2 reviewers after multiple searches using electronic databases. The primary analysis was to identify existing diagnostic approaches for pneumonia. Secondary analyses explored potential reasons for any heterogeneity where standard criteria for pneumonia had been applied. Sixty-four studies (56% ischemic stroke, 6% intracerebral hemorrhage, 38% both) of 639 953 patients were included. Six studies (9%) reported no information on the diagnostic approach, whereas 12 (19%) used unspecified clinician-reported diagnosis or initiation of antibiotics. The majority used objective diagnostic criteria: 20 studies (31%) used respiratory or other published standard criteria; 26 studies (41%) used previously unpublished ad hoc criteria. The overall occurrence of pneumonia was 14.3% (95% confidence interval 13.2%-15.4%; I(2)=98.9%). Occurrence was highest in studies applying standard criteria (19.1%; 95% confidence interval 15.1%-23.4%; I(2)=98.5%). The substantial heterogeneity observed was not explained by stratifying for other potential confounders. We found considerable variation in terminology and the diagnostic approach to pneumonia. Our review supports the need for consensus development of operational diagnostic criteria for pneumonia complicating stroke.

An analysis of IgG4-related disease (IgG4-RD) among idiopathic orbital inflammations and benign lymphoid hyperplasias using two consensus-based diagnostic criteria for IgG4-RD

AimTo determine the proportion of idiopathic orbital inflammation (IOI) and orbital benign lymphoid hyperplasia (OBLH) accounted for by immunoglobulin (Ig)G4-related orbital disease (IgG4-ROD) using the comprehensive diagnostic criteria for IgG4-related...

NIH Panel Finds No Alzheimer's Prevention to Endorse

BETHESDA, Md. – Current knowledge about the epidemiology of Alzheimer's disease and cognitive decline has not provided enough evidence to recommend specific, preventive interventions, according to a “state-of-the-science” report issued by a panel of experts assembled by the National Institutes of Health. The 15-member panel found that there is not enough evidence to support the use of pharmaceutical agents or dietary supplements to prevent cognitive decline or Alzheimer's disease, but ongoing additional studies of antihypertensive medications, omega-3 fatty acids, physical activity, and cognitive engagement “may provide new insight into the prevention of delay of cognitive decline or Alzheimer's disease.” “We're hoping that our report is going to supply physicians with accurate information that they can give to their patients” to clarify what interventions may be worth continuing or pursuing and which should be discontinued, said panelist Carl C. Bell, MD, director of the Institute for Juvenile Research in the department of psychiatry at the University of Illinois at Chicago, at a press briefing. A wide range of modifiable factors have been reported to be associated with risk for Alzheimer's disease, such as diabetes, elevated blood cholesterol in midlife, and depression, but also relatively benign changes in diet, medication, or lifestyle. However, the overall quality of evidence from these studies is low, the panel said, and it did not find enough evidence to draw firm conclusions about the association of modifiable risk factors with cognitive decline or Alzheimer's disease. In light of the fact that there are no proven interventions that prevent cognitive decline or Alzheimer's disease, panel member Arnold L. Potosky, PhD, of Georgetown University in Washington said that it is important for physicians to discuss participation in clinical studies with their patients. The panel recommended that further research should include: ▸The development and use of rigorous, consensus-based diagnostic criteria for Alzheimer's disease and mild cognitive impairment.▸The development and use of standardized, validated, and culturally sensitive outcome measures for research.▸The collection of data from caregivers of people with mild cognitive impairment or early Alzheimer's disease in a systematic manner in observational studies and randomized, controlled trials.▸The conduct of large-scale, long-term population-based studies with well-validated exposure and outcome measures in people followed from middle to old age. Existing cohorts from ongoing studies of this type also could be explored for timely, cost-effective identification of individuals at high risk of cognitive decline or Alzheimer's disease.▸The leveraging of alternative research resources and platforms that facilitate long-term longitudinal assessments, such as a multicenter Alzheimer's disease registry or observational studies within large health care delivery systems with defined populations and well-developed electronic health records.▸The creation of a simple, inexpensive, quantitative instrument that can be administered by a trained nonexpert to assess change in cognitive status over time. The statement was restricted to studies of people aged 50 years or older that were conducted in developed countries. The minimum sample size in these studied was at least 50 patients in randomized, controlled trials and at least 300 patients in observational studies. The duration between exposure to a preventive intervention and study outcomes had to be at least 1 year for studies of mild cognitive impairment and at least 2 years for studies of Alzheimer's disease. The panel based its statement on a report from the Evidence-Based Practice Center at Duke University's Clinical Research Institute, which was commissioned by the Agency for Healthcare Research and Quality. The evidence report is available at www.ahrq.gov/clinic/tp/alzcogtp.htm. The statement is available at consensus.nih.gov. Jeff Evans is a clinical news editor with Elsevier Global Medical News.

NEUROFIBROMATOSIS

Neurofibromatosis is a collective term that encompasses at least three distinct conditions, referred to as NF1, NF2, and schwannomatosis. NF1 and NF2 are inherited as autosomal dominant traits with complete penetrance but variable expression. Schwannomatosis most often occurs sporadically, but familial cases have been seen, inherited in an autosomal dominant manner with incomplete penetrance. Early diagnosis can be important as a prelude to surveillance for treatable complications as well as genetic counseling. All three disorders are diagnosed on the basis of clinical signs and consensus-based diagnostic criteria have been established. Although definitive diagnosis is often possible, clinical diagnosis can be difficult in younger individuals who do not yet manifest sufficient signs to fulfill criteria. This is especially true for NF2 and schwannomatosis, but is also the case for children with NF1. The genes for NF1 and NF2 have been identified and both are amenable to genetic testing. Each disorder is associated with a wide variety of distinct mutations, making it necessary to employ a complementary set of techniques to improve detection rate. The University of Alabama at Birmingham Medical Genomics Laboratory has been offering NF1 testing, with a detection rate of >95% in individuals who fulfill diagnostic criteria. Relatively few genotype-phenotype correlations have been established. Individuals with large deletions tend to have a severe NF1 phenotype, including early onset and large numbers of neurofibromas, developmental delay, and dysmorphic features. Otherwise, specific mutations are not yet known to be predictive of specific outcomes. In NF2, mutations that lead to premature termination of translation tend to be associated with more severe disease as compared with missense mutations. Genetic testing can be useful in patients with NF1 who are too young to fulfill diagnostic criteria, or who present with unusual signs or symptoms. It can also provide a basis for prenatal testing or testing of other family members. In NF2, genetic testing is most useful to determine if individuals at genetic risk of inheriting a mutation need to be followed for complications of the disorder.

The Consortium to Investigate Vascular Impairment of Cognition: methods and first findings.

The Consortium to Investigate Vascular Impairment of Cognition (CIVIC) is a Canadian, multi-centre, clinic-based prospective cohort study of patients with Vascular Cognitive Impairment (VCI). We report its organization and the impact of diagnostic criteria on the study of VCI. Nine memory disability clinics enrolled patients and recorded their usual investigations and care. A case report form included all vascular dementia (VaD) individual criteria for each of four sets (National Institute of Neurological Disorders and Stroke (NINDS-AIREN), Alzheimer's Disease Diagnostic Treatment Centers (ADDTC), the ICD-10 Classification of Mental and Behavioural Disorders (ICD-10), and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)) of consensus-based diagnostic criteria and for the Hachinski Ischemia Score (HIS). Investigators, having completed the case report form, were asked to make a clinical judgement about the cognitive diagnosis based on the best available information, including neuroimaging. Of 1,347 patients (mean age 72 years; 56% women), 846 (63%) were diagnosed with dementia and 324 (24%) were diagnosed with VCI. The proportion of patients diagnosed with VaD by the diagnostic criteria was: 23.9% (n = 322) by DSM-IV, 10.2% (n = 137) by HIS, 4.3% (n = 58) by ICD-10, 3.8% (n = 51) by ADTCC, and 3.6% (n = 48) by NINDS-AIREN. Judged against a clinical diagnosis of VaD, the sensitivity/specificity of each was: DSM-IV (0.77/0.80); HIS (0.41/0.92); ICD-10 (0.29/0.98); ADTCC (0.24/0.98); NINDS-AIREN (0.42/0.995). Compared with a clinical diagnosis of VCI, sensitivities were lower for the diagnostic criteria, reflecting the exclusion of patients who did not have dementia. Consensus-based criteria for VaD omit patients who do not meet dementia criteria that are modeled on Alzheimer's disease. Even for patients who do, the proportion identified with VaD varies widely. Criteria based on empirical analyses need to be developed and validated.

Signs and symptoms of the myofascial pain syndrome: a national survey of pain management providers.

The goal of this study was to assess clinical consensus regarding whether myofascial pain syndrome (MPS) is a legitimate and distinct diagnosis as well as the signs and symptoms characterizing MPS. A standardized mailed survey with return postage provided. A total of 1,663 American Pain Society members in medically related disciplines listed in the 1996/1997 directory. A standardized survey assessing clinical opinion regarding whether MPS is a legitimate diagnosis, whether MPS is a clinical entity distinct from fibromyalgia, and the signs and symptoms believed to be "essential to," "associated with," or "irrelevant to" to the diagnosis of MPS. Of the 403 surveys returned, 88.5% respondents reported that MPS was a legitimate diagnosis, with 81% describing MPS as distinct from fibromyalgia. The only signs and symptoms described as essential to the diagnosis of MPS by greater than 50% of the sample were regional location, presence of trigger points, and a normal neurologic examination. Regarding the signs and symptoms considered to be essential or associated with MPS, more than 80% of respondents agreed on regional location, trigger points, normal neurologic examination, reduced pain with local anesthetic or "spray and stretch," taut bands, tender points, palpable nodules, muscle ropiness, decreased range of motion, pain exacerbated by stress, and regional pain described as "dull," "achy," or "deep." Sensory or reflex abnormalities, scar tissue, and most test results were considered to be irrelevant to the diagnosis of MPS by a large proportion of the respondents. There was general agreement across specialties that MPS is a legitimate diagnosis distinct from fibromyalgia. There was a high level of agreement regarding the signs and symptoms essential or associated with a diagnosis of MPS. Differences across specialties are discussed. This survey provides a first step toward the development of consensus-based diagnostic criteria for MPS, which can then be validated empirically.