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Bernier J, Fournier F, Blais Y, Lombardi P, Chevalier G, & Krzystyniak K (1988) Immunotoxicity of aminocarb. Betterle C, Dal Pra C, Mantero F, & Zanchetta R (2002) Autoimmune adrenal insuffi ciency and autoimmune polyendocrine syndromes: autoantibodies, autoantigens, and their applicability in diagnosis and disease prediction. Black C, Pereira S, McWhirter A, Welsh K, & Laurent R (1986) Genetic susceptibility to scleroderma-like syndrome in symptomatic and asymptomatic workers exposed to vinyl chloride. Chemically-induced alterations in sexual and functional development: the wildlife/human connection. Chemically-induced alterations in sexual and functional development: the wildlife/human connection. Bogliun G & Beghi E (2004) Incidence and clinical features of acute inflammatory polyradiculoneuropathy in Lombardy, Italy, 1996. Bouma G & Strober W (2003) the immunological and genetic basis of inflammatory bowel disease. Part 2: Dermatologic and joint disease, the antiphospholipid antibody syndrome, pregnancy and hormonal therapy, morbidity and mortality, and pathogenesis. Bovenzi M, Barbone F, Betta A, Tommasini M, & Versini W (1995) Scleroderma and occupational exposure. Brik R, Tenenbaum G, Blank M, Shoenfeld Y, Barzilai D, Bloch K, & Vardi P (1995) D penicillamine-induced autoantibodies in a mouse model. Brostoff J, Blanca M, Boulton P, & Serrano S (1982) Absence of specific IgE antibodies in toxic oil syndrome. Cantagrel A, Navaux F, Loubet-Lescoulie P, Nourhashemi F, Enault G, Abbal M, Constantin A, Laroche M, & Mazieres B (1999) Interleukin-1? Caplan A (1953) Certain unusual radiological appearances in the chest of coalminers suffering from rheumatoid arthritis. Casciola-Rosen L, Wigley F, & Rosen A (1997) Scleroderma autoantigens are uniquely fragmented by metal-catalyzed oxidation reactions: implications for pathogenesis. Chen M, Hemmerich P, & Von Mikecz A (2002) Platinum-induced autoantibodies target nucleoplasmic antigens related to active transcription. Choquet-Kastylevsky G, Vial T, & Descotes J (2001) Drug allergy diagnosis in humans: possibilities and pitfalls. Czirjak L & Kumanovics G (2002) Exposure to solvents in female patients with scleroderma. D?Alfonso S, Rampi M, Bocchio D, Colombo G, Scorza-Smeraldi R, & Momigliano Richiardi P (2000) Systemic lupus erythematosus candidate genes in the Italian population: Evidence for a significant association with interleukin-10. D?Cruz D (2000) Autoimmune diseases associated with drugs, chemicals and environ mental factors. Deng C, Lu Q, Zhang Z, Rao T, Attwood J, Yung R, & Richardson B (2003) Hydralazine may induce autoimmunity by inhibiting extracellular signal-regulated kinase pathway signaling. Final report of the Subcommittee on Risk Management of the Committee to Co-ordinate Environmental Health and Related Progams. Dianzani U, Bragardo M, DiFranco D, Alliaudi C, Scagni P, Buonfiglio D, Redoglia V, Bonissoni S, Correra A, Dianzani I, & Ramenghi U (1997) Deficiency of the Fas apop tosis pathway without gene mutations in pediatric patients with autoimmunity/lympho proliferation. An immunohistochemical study using cryostat sections of the whole knee joint of rat. Brown Norway rats treated with D-penicillamine develop autoantibodies, circulating immune complexes, and disseminated intravascular coagulation. Ezendam J (2004) Mechanisms of hexachlorobenzene-induced adverse immune effects [thesis]. Fabris P, Floreani A, Tositti G, Vergani D, De Lalla F, & Betterle C (2003) Type 1 diabetes mellitus in patients with chronic hepatitis C before and after interferon therapy. Gaubitz M, Jackisch C, Domschke W, Heindel W, & Pfleiderer B (2002) Silicone breast implants: correlation between implant ruptures, magnetic resonance spectroscopically estimated silicone presence in the liver, antibody status and clinical symptoms. Gleichmann H (1981) Studies on the mechanism of drug sensitization: T-cell-dependent popliteal lymph node reaction to diphenylhydantoin. Goebel C, Griem P, Sachs B, Bloksma N, & Gleichmann E (1996) the popliteal lymph node assay in mice: screening of drugs and other chemicals for immunotoxic hazard. Goebel C, Vogel C, Wulferink M, Mittmann S, Sachs B, Schraa S, Abel J, Degen G, Uetrecht J, & Gleichmann E (1999) Procainamide, a drug causing lupus, induces prostaglandin H synthase-2 and formation of T cell-sensitizing drug metabolites in mouse macrophages.

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Elevation of alanine aminotransferase and aspartate aminotransferase is predictive of gallstone pancreatitis. Radiological Testing Abdominal radiographs and standard chest films should routinely be performed on patients with severe abdominal pain. Patients with pancreatitis may have a variety of radiological findings, such as pleural effusion, intestinal gas patterns, colonic obstruction, loss of psoas margins, and increased separation between the stomach and colon, suggesting inflammation of the pancreas. Ultrasonography is not a sensitive test because overlying intestinal gas and fatty tissue may obscure the pancreas in over one third of patients. However, ultrasound is very sensitive for the detection of gallstones, bile duct stones, and bile duct dilatation. Endoscopic Diagnosis Gastrointestinal endoscopy allows the physician to visualize and biopsy the mucosa of the upper gastrointestinal tract. During these procedures, the patient may be given a pharyngeal topical anesthetic that helps to prevent gagging. An endoscope, a thin, flexible, lighted tube, is passed through the mouth and pharynx and into the esophagus. The endoscope transmits an image of the esophagus, stomach, and duodenum to a monitor, which is visible to the physician. The endoscope also introduces air into the stomach, expanding the folds of tissue and enhancing the examination of the stomach. During this procedure, the physician inserts a side-viewing endoscope (Figure 14) in the duodenum facing the major papilla (Figure 15). The side-viewing endoscope (duodenoscope) is specially designed to facilitate placement of endoscopic accessories into the bile and pancreatic duct. The endoscopic accessories may be passed through the biopsy channel (Figure 14) into the bile and pancreatic ducts. A catheter is used to inject dye into both pancreatic and biliary ducts to obtain x-ray images using fluoroscopy (Figure 15). During this procedure, the physician is able to see two sets of images: the endoscopic image of the duodenum and major papilla, and the fluoroscopic image of the bile and pancreatic ducts. The scope is designed to be held in the left hand with the thumb operating up and down angulation. The right hand is responsible for advancing, withdrawing and torquing the insertion tube. The right hand also operates left and right angulation of the endoscope, and passes accessories through the instrument. Lithotripsy devices, injection devices, brushes, forceps, scissors, and magnetic extraction devices may also be inserted through the endoscope. Video cameras may also be attached for full-color motion picture viewing during endoscopic procedures or for later review. Measurements are obtained using a special system of manometry catheters, a hydraulic capillary infusion system, and a computer software program. The fluid infusion system is of low compliance, allowing direct measurements of the sphincter of Oddi pressure. The standard manometry catheters are triple lumen and made of polyethylene or Teflon. The pneumatic capillary system perfuses de-ionized, bubble-free water at a pressure of 750 mm Hg at a rate of 0. Basal sphincter pressure, amplitude, and frequency of contractions as well as sequences of sphincter contractions may be obtained (Figure 16). Sphincter of Oddi dysfunction is diagnosed when the basal sphincter pressure is greater than 40 mm Hg. Sphincter of Oddi manometry; A, Room set-up; B, B, endoscopic image and position of manometry catheter. This includes replacement of fluid and electrolytes, correction of metabolic abnormalities such as symptomatic hypercalcemia, and nutritional support. Other measures such as the use of nasogastric suction and antibiotics should be decided on a case-by-case basis. Medical Therapy Agents that have been used to inhibit pancreatic secretion, including somatostatin and glucagon, have not been found to be useful in altering the course in acute pancreatitis. Protease inhibitors, which are effective in laboratory studies, have not been shown to be useful in clinical pancreatitis. Some surgical procedures such as resection of necrotic tissue and peritoneal lavage may have a role in select patients with severe, progressive necrotizing pancreatitis or pancreatic abscess.

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It was shown that effluent was entering from the main sewage into the circulating pool water. An epidemiological investigation confirmed a link between head immersion and illness (Joce et al. In 1990 an outbreak of cryptosporidiosis was reported from British Columbia, Canada. A case-control study involving the first 18 case patients showed no association between illness and attendance at a day care centre, drinking municipal water or drinking untreated surface water. However, 9 of the 18 case patients reported swimming at the local wave pool, whereas none of the controls indicated this activity. Of the 18 case patients, 17 were eventually identified as swimming in the same wave pool and it was concluded that the outbreak of cryptosporidiosis was likely to have been caused by exposure to faecally-contaminated wave pool water (McAnulty et al. In August 1993, a young girl from Wisconsin, United States, was reported to be ill with a laboratory-confirmed Cryptosporidium infection and members of her swimming team were also reported to be suffering from severe diarrhoea (Anonymous 1994). Out of 31 people attending the pool who were interviewed 55% reported having watery diarrhoea for two or more days. Seven of the nine reported swimming in a large outdoor pool which was implicated in the outbreak. An outbreak of gastrointestinal illness was experienced by 61 resort hotel guests during April 1993 in Oshkosh, Wisconsin, United States. Of the guests reporting symptoms, 51 individuals met the case definition for cryptosporidiosis. A case-control study was undertaken among groups who reported illness and among those who stayed at the hotel during the risk period. Swimming in the hotel pool was significantly associated with case status and found to be the only risk factor significantly associated with illness (MacKenzie et al. From December 1997 to April 1998, 1060 laboratory-confirmed cases of cryptosporidiosis were reported in New South Wales, Australia. In a case control study it was found that compared with controls, those infected were more likely to be younger (average age 4. As only 59% of the cases reported swimming during their exposure periods it was concluded that the remaining cases are likely to have been infected through person-to-person transmission or through other unidentified routes (Puech et al. Cryptosporidiosis and surface waters There are a number of reports of people being infected with Cryptosporidium spp. The first reported outbreak in the United States of cryptosporidiosis associated with a recreational lake was reported by Kramer et al. A cohort study was organised with 185 people, 38 of whom had laboratory-confirmed Protozoa and Trematodes 155 cryptosporidiosis or gastrointestinal illness meeting clinical definitions. The most likely sources of the outbreak were contaminated rainwater run-off and infected bathers. This investigation highlights the fact that even a large and ongoing epidemic may not be detected for several weeks. Significant risk factors included swimming in surface water, although this was not the only risk factor. Fountains Between August 7 and 27 1999, 38 people experienced gastrointestinal illnesses following visits to a beachside park in Florida, United States (Anonymous 2000b). The most common symptoms included diarrhoea (97%), abdominal cramps (90%), fever (82%), vomiting (66%) and bloody diarrhoea (13%). All 38 people had entered an interactive water fountain at the beach and all but two had ingested water from it. This fountain used water that recirculated from wet deck/play area flooring into an underground reservoir. This water did not pass through a filtration system but was passed through a hypochlorite tablet chlorination system. However, chlorine levels were not monitored and hypochlorite tablets had not been replaced. The local health department closed the fountain for over three months while several control measures were employed. A cartridge filtration system was installed and a chlorine monitor put in place to automatically stop the fountain when levels fell beneath 3 ppm. A sign was posted advising visitors to shower before entering the fountain and to avoid drinking the water. Several cases of gastroenteritis were identified in visitors to the Minnesota Zoo, United States, in July 1997 (Anonymous 1998).

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Thus, the diabetic shoes may be covered if the requirements for this section are met, while the brace may be covered if the requirements of 130 are met. Substitution of Modifications for Inserts An individual may substitute modification(s) of custom-molded or depth shoes instead of obtaining a pair(s) of inserts in any combination. Payment for the modification(s) may not exceed the limit set for the inserts for which the individual is entitled. The following is a list of the most common shoe modifications available, but it is not meant as an exhaustive list of the modifications available for diabetic shoes. Rigid Rocker Bottoms these are exterior elevations with apex positions for 51 percent to 75 percent distance measured from the back end of the heel. The apex must be positioned behind the metatarsal heads and tapered off sharply to the front tip of the sole. The heel of the shoe tapers off in the back in order to cause the heel to strike in the middle of the heel;. Roller Bottoms (Sole or Bar) these are the same as rocker bottoms, but the heel is tapered from the apex to the front tip of the sole;. Metatarsal Bars An exterior bar is placed behind the metatarsal heads in order to remove pressure from the metatarsal heads. The bars are of various shapes, heights, and construction depending on the exact purpose;. Wedges (Posting) Wedges are either of hind foot, fore foot, or both and may be in the middle or to the side. The function is to shift or transfer weight bearing upon standing or during ambulation to the opposite side for added support, stabilization, equalized weight distribution, or balance; and. Offset Heels this is a heel flanged at its base either in the middle, to the side, or a combination, that is then extended upward to the shoe in order to stabilize extreme positions of the hind foot. Other modifications to diabetic shoes include, but are not limited to flared heels, Velcro closures, and inserts for missing toes. Separate Inserts Inserts may be covered and dispensed independently of diabetic shoes if the supplier of the shoes verifies in writing that the patient has appropriate footwear into which the insert can be placed. This footwear must meet the definitions found above for depth shoes and custom-molded shoes. Certify that the patient is being treated under a comprehensive plan of care for diabetes, and that the patient needs diabetic shoes; and. Furnishing Footwear the footwear must be fitted and furnished by a podiatrist or other qualified individual such as a pedorthist, an orthotist, or a prosthetist. The certifying physician may not furnish the diabetic shoes unless the certifying physician is the only qualified individual in the area. It is left to the discretion of each carrier to determine the meaning of in the area. In addition to the following, see Pub 100-01, the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, Definitions and Pub 3, the Medicare National Coverage Determinations Manual for specific services which may be covered when furnished by a dentist. If an otherwise noncovered procedure or service is performed by a dentist as incident to and as an integral part of a covered procedure or service performed by the dentist, the total service performed by the dentist on such an occasion is covered. However, when the reconstruction of a ridge is performed as a result of and at the same time as the surgical removal of a tumor (for other than dental purposes), the totality of surgical procedures is a covered service. The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease is also covered. This is an exception to the requirement that to be covered, a noncovered procedure or service performed by a dentist must be an incident to and an integral part of a covered procedure or service performed by the dentist. When an excluded service is the primary procedure involved, it is not covered, regardless of its complexity or difficulty. Similarly, an alveoplasty (the surgical improvement of the shape and condition of the alveolar process) and a frenectomy are excluded from coverage when either of these procedures is performed in connection with an excluded service. In a like manner, the removal of a torus palatinus (a bony protuberance of the hard palate) may be a covered service.