By S. Frithjof. University of Puerto Rico, Rio Piedras. 2018.

You get a call from the nursing home that three of Indeed order zithromax 100 mg on line antibiotic resistance ted ed, the organisms later prove to be MRSA zithromax 100 mg free shipping antibiotic h pylori, and four bottles of blood cultures drawn the day before neither nafcillin nor any other -lactam or cephalo- were positive for gram-positive cocci in clusters. A sporin would be effective in management of his in- correct statement with regard to his management is fection. The mycobacteria are slow- include HIV-infected persons, immigrants from coun- growing intracellular organisms that require the admin- tries with high rates of tuberculosis, the homeless, health istration of a combination of drugs for extended periods care professionals, intravenous drug users, persons tak- to achieve effective therapy and to prevent the emer- ing immunosuppressive agents, and those in institu- gence of resistance. The risk of adverse reactions there- tional settings, such as nursing homes and correctional fore must be a major consideration in drug selection. Along with the recent increase in cases of tu- The three basic concepts in tuberculosis treatment berculosis, there is a progressive increase in multidrug- are as follows: (1) Regimens must contain multiple resistant (MDR) tuberculosis. Traditionally, antituberculosis An active tuberculosis cavity may contain as many drugs that are classified as first-line drugs are superior in as 107 to 1010 microorganisms. Most patients with tu- is readily selected out if isoniazid is given as the sole berculosis can be treated successfully with these drugs. If a second drug having a similar drug resistance Second-line drugs are more toxic and less effective, (1in 106) is combined with isoniazid, the odds that a and they are indicated only when the M. Therapy Therefore, it is vital to combine at least two antitubercu- with second-line agents may have to be prolonged be- lar agents to which the organism is susceptible. The second-line agents include cycloserine, Isoniazid is water soluble and is well absorbed when ethionamide, aminosalicylic acid, rifabutin, quinolones, administered either orally or parenterally. Isoniazid does not bind to serum proteins; it diffuses FIRST-LINE ANTITUBERCULOSIS readily into all body fluids and cells, including the DRUGS caseous tuberculous lesions. The drug is detectable in significant quantities in pleural and ascitic fluids, as well Isoniazid as in saliva and skin. The concentrations in the central nervous system (CNS) and cerebrospinal fluid are gen- Isoniazid (isonicotinic acid hydrazide, or INH) is the erally about 20% of plasma levels but may reach close most active drug for the treatment of tuberculosis to 100% in the presence of meningeal inflammation. It is a synthetic agent with Isoniazid is acetylated to acetyl isoniazid by N-acetyl- a structural similarity to that of pyridoxine. Individuals who are genetically rapid acetylators will have Mechanism of Action a higher ratio of acetyl isoniazid to isoniazid than will slow Isoniazid is active against susceptible bacteria only when acetylators. The may continue to undergo one or two divisions before slow or rapid acetylation of isoniazid is rarely important multiplication is arrested. Isoniazid can inhibit the syn- clinically, although slow inactivators tend to develop pe- thesis of mycolic acids, which are essential components of ripheral neuropathy more readily. The mycobacterial enzyme cata- azid and small amounts of unaltered drug are excreted in lase–peroxidase KatG activates the administered isoni- the urine within 24 hours of administration. The target sites for the Clinical Uses activated isoniazid action are acyl carrier protein AcpM and Kas A, a -ketoaceyl carrier protein synthetase that Isoniazid is among the safest and most active mycobac- blocks mycolic acid synthesis. It is also included in the Antimicrobial Activity first-line drug combinations for use in all types of tu- berculous infections. The minimal tuberculostatic inhibitory concen- action with no radiological or other clinical evidence of tration (MIC) of isoniazid is 0. Mycobacterium kansasii is usually suscep- tible to isoniazid, and it is included in the standard mul- Resistance tidrug treatment regimen. Risk factors for hepatitis include underlying liver therapeutic levels are achieved in all body fluids, in- disease, advanced age, pregnancy, and combination cluding cerebrospinal fluid. Early recognition and ducing its own metabolism, so its half-life can be re- prompt discontinuation of the drug is recommended to duced to 2 hours within a week of continued therapy. The deacetylated form of rifampin is active and under- Peripheral neuropathy is observed in 10 to 20% of goes biliary excretion and enterohepatic recirculation. Most of the drug is excreted into the GI tract and a Patients with underlying chronic disorders such as alco- small amount in the urine. Moderate dose adjustment is holism, malnutrition, diabetes, and AIDS are at particu- required in patients with underlying liver disease. Isoniazid promotes renal excretion of pyridoxine, treatment of all forms of pulmonary and extrapul- resulting in a relative deficiency and neuropathy. Rifampin is an alternative to iso- toxicity may range from excitability and seizures to psy- niazid in the treatment of latent tuberculosis infection. The neurotoxic effects are reversed without al- Rifampin also may be combined with an antileprosy tering the antimycobacterial action by the administra- agent for the treatment of leprosy and to protect those tion of 10 to 50 mg/day of pyridoxine. Drug Interactions High isoniazid plasma levels inhibit phenytoin metabo- Adverse Reactions lism and potentiate phenytoin toxicity when the two The most commonly observed side effects are GI dis- drugs are coadministered. The serum concentrations of turbances and nervous system symptoms, such as nau- phenytoin should be monitored, and the dose should be sea, vomiting, headache, dizziness, and fatigue. It is a large lipid- zymes, leading to an increased metabolism of many soluble molecule that is bactericidal for both intracellu- drugs; this action has especially complicated the treat- lar and extracellular microorganisms. Rifampin binds ment of tuberculosis in HIV-infected patients whose reg- strongly to the -subunit of bacterial DNA-dependent imen includes protease inhibitors and nonnucleoside re- RNA polymerase and thereby inhibits RNA synthesis.

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Short-term benefits in acute neck pain have support in the literature zithromax 100 mg low cost antibiotic 875mg 125mg, although the duration of these responses is unknown discount 500 mg zithromax amex bacteria good and bad. Manipulation as an isolated intervention for neck pain has less literature support than do interventions incorporating a program of exercise and rehabilitation. It is also unclear whether manipulation is better 40 than mobilization or whether it is better in terms of outcome or cost than a program of 68,45,72 intensive rehabilitation. Manipulation summary Of all the CAM therapies for back and neck pain, spinal manipulation enjoys the broadest support base in the literature, with dozens of studies examining its efficacy and many systematic reviews evaluating this literature (Table 2). Patients treated with manipulation appear to fare better than those treated by conventional conservative medical treatments, such as analgesics and self- education materials. In the short term, manipulation appears to produce improvements in pain and range of motion in acute neck pain. For both neck and back pain, the literature indicates that treatment programs combining spinal manipulation with stretching or rehabilitation exercises appear to offer a greater benefit than manipulation alone. OTHER COMPLEMENTARY AND ALTERNATIVE THERAPIES FOR NECK AND BACK PAIN Although the physical methods of treatment reviewed above are the most commonly used and most researched forms of CAM therapy for neck and back pain, other CAM therapies have also been used in an attempt to alleviate these symptoms. These include laser Complementary and alternative medicine treatment of back and neck pain 303 therapy, magnets, homeopathy and nutritional supplements. Laser therapy Low-power lasers have been used to treat several musculoskeletal conditions, including back and neck pain. The proposed mechanism of action is unclear, and various types of laser and application techniques or protocols have been suggested, including its application trigger points or acupuncture meridians. Laser therapy for back pain Klein and Eek73 randomized 22 patients with chronic low back pain to exercise therapy in combination with low-energy laser treatment or placebo laser treatments. Pain and disability scores improved in both groups at the end of treatment and 1 month thereafter, but there were no significant differences between the active and placebo laser treatments. The active treatment group perceived significantly greater improvement and had more improvement in function, though there was no relative improvement in range of motion. These effects decreased with time, although the improvement in function was still noted at 1-month follow-up. The authors concluded that the observed benefits of laser therapy were small, despite their statistical significance, and recommended further investigation. Laser therapy for neck pain 75–77 There have been several studies investigating the possible effects of laser therapy on 78 neck pain. A systematic review of this literature, pooling data from three studies, found no significant benefit, although the authors noted that these studies had small sample sizes and were thus unlikely to detect small differences. More recently, Ozdemir and co- 75 workers compared outcomes in 60 patients with neck pain due to cervical spondylosis treated with active laser therapy or a control laser treatment. They reported a significant short-term improvement in the active treatment group, with no change in the control group. Laser therapy summary There appears to be little support in the literature for the use of laser therapy for back and 78,79 neck pain. The two systematic reviews of this topic have concluded that there is insufficient evidence to support the use of low-power lasers in the treatment of musculoskeletal conditions, although the paucity of good studies indicates the need for further investigation. Magnets The use of magnets to treat medical conditions dates back hundreds of years. More recently, there has been great interest in the possible use of magnets in the treatment of 80 81 82,83 84, chronic pain for conditions as diverse as fibromyalgia, arthritis, pelvic pain 85 86 peripheral neuropathy, post-polio syndrome or other localized musculoskeletal 87 pains. This interest has been fueled by both the popular press and numerous testimonials from well-known figures making claims for its benefit in wrist pain, foot pain as well as neck and back pain. These magnets may be applied to the body area directly or in the form of magnetic mattress pads, shoe inserts, bracelets, etc. Additionally, various techniques have been utilized, ranging from static magnetic fields, usually by way of magnets of relatively low field strength worn directly next to the body, to pulsed or highintensity treatment. There is no reason at the present time to believe that one procedure is more effective than another, however. Studies examining the potential effect of magnets on neck and back pain have only recently been attempted. There was no significant difference in pain response between application of placebo and real magnet in this small study. Of course, this small study ran the risk of failing to detect a small change and the findings only apply to the particular magnetic parameters studied. The patients were randomized to 2 weeks of magnetic field treatment or control treatment that consisted of continued out- patient medication. The patients in the group receiving magnetic therapy showed significantly more improvement in terms of back and leg pain (lumbar radiculopathy) or headache and neck pain (whiplash) than the control group. However, placebo cannot be excluded as a major factor in this recovery, since therapy was not carried out in a blinded manner. One 84 difficult problem with studies is potential difficulties with blinding of patients, particularly when employing magnetic devices that patients take home. The popularity of this treatment, combined with some intriguing albeit very preliminary investigations, should prompt more rigorous study before final conclusions can be reached regarding this popular treatment.

Women are not usually affected by X-linked eral effective zithromax 100mg antibiotics for uti philippines, the DDs are less severe generic zithromax 500 mg with amex antimicrobial floor mats, progress more slowly, and conditions, since they will likely have one unaltered copy involve fewer muscles than the other dystrophies. Some female carriers of usually begins in middle age or later, causing weakness DMD have a mild form of the condition, probably in the muscles of the feet and hands. It is most common because their one unaltered gene copy is shut down in in Sweden, and rare in other parts of the world. A son born without the altered gene will be free of weakness, and usually progresses slowly. A son called Fukuyama CMD, also involves mental retarda- born with the altered gene will have the condition. The muscular dystrophies are genetic conditions, Not all genetic alterations are inherited. Genes, one third of the cases of DMD are due to new mutations which are linked together on chromosomes, have two that arise during egg formation in the mother. New muta- functions; they code for the production of proteins, and tions are less common in other forms of muscular dys- they are the material of inheritance. DMD, BMD, CMD, and most forms of LGMD, are due Because both parents contribute genetic material to to alterations in the genes for a complex of muscle pro- their offspring, each child carries two copies of almost teins. For some conditions to thin sheath that surrounds each muscle cell) to unite a occur, both copies must be altered. Such conditions are fibrous network on the interior of the cell with a fibrous called autosomal recessive conditions. Theory holds that by linking LGMD and DD exhibit this pattern of inheritance, as these two networks, the complex acts as a “shock does CMD. A person with only one altered copy, called a absorber,” redistributing and evening out the forces gen- carrier, will not have the condition, but may pass the erated by contraction of the muscle, thereby preventing altered gene on to his children. Alterations in the pro- children, the chances of having a child with the condition teins of the complex lead to deterioration of the muscle is one in four for each pregnancy. Other conditions occur when only one altered gene Symptoms of these conditions set in as the muscle grad- copy is present. Either the fluid itself or cells from affects young boys and causes progressive muscle the fluid can be used for a variety of tests to obtain weakness, usually beginning in the legs. Both Duchenne muscular dystrophy Autosomal dominant—A pattern of genetic inheri- and Becker muscular dystrophy are caused by flaws tance where only one abnormal gene is needed to in the gene that instructs the body how to make this display the trait or disease. Autosomal recessive—A pattern of genetic inheri- Facioscapulohumeral muscular dystrophy (FSH)— tance where two abnormal genes are needed to dis- This form of muscular dystrophy, also known as play the trait or disease. Landouzy-Dejerine condition, begins in late child- Becker muscular dystrophy (BMD)—A type of mus- hood to early adulthood and affects both men and cular dystrophy that affects older boys and men, women, causing weakness in the muscles of the and usually follows a milder course than Duchenne face, shoulders, and upper arms. Limb-girdle muscular dystrophy (LGMD)—Form of Chorionic villus sampling (CVS)—A procedure muscular dystrophy that begins in late childhood to used for prenatal diagnosis at 10-12 weeks gesta- early adulthood and affects both men and women, tion. Form of muscular dystrophy affecting adults of both Distal muscular dystrophy (DD)—A form of mus- sexes, and causing weakness in the eye muscles and cular dystrophy that usually begins in middle age or throat. Both DMD and BMD are caused by alterations in causes the muscle cell membrane to lose some of its the gene for the protein called dystrophin. The genes responsible include leading to DMD prevents the formation of any dys- LGMD2D on chromosome 17, which codes for the trophin, while that of BMD allows some protein to be alpha-sarcoglycan protein; LGMD2E on chromosome 4, made, accounting for the differences in severity and age which codes for the beta-sarcoglycan protein; LGMD2C of onset between the two conditions. Differences among on chromosome 13, which codes for the gamma-sarco- the other muscular dystrophies in terms of the muscles glycan protein; and LGMD2F on chromosome 5, which involved and the ages of onset are less easily explained. Some cases of A number of genes have been found to cause autosomal recessive LGMD are caused by an alteration LGMD. A majority of the more severe autosomal reces- in a gene, LGMD2A, on chromosome 15, which codes sive types of LGMD with childhood-onset are caused by for a muscle enzyme, calpain 3. The relationship between alterations in the genes responsible for making proteins this alteration and the symptoms of the condition is called sarcoglycans. Alterations in a gene called LGMD2B on chro- proteins that are normally located in the muscle cell mosome 2 that codes for the dysferlin protein, is also membrane along with dystrophin. Loss of these proteins responsible for a minority of autosomal recessive LGMD GALE ENCYCLOPEDIA OF GENETIC DISORDERS 771 cases. Their linkage to alterations in the LGMD2G gene on chromosome 17 any other chromosome or genetic feature is under inves- which codes for a protein, telethonin, is responsible for tigation. The • The gene(s) responsible for DD have not yet been exact role of telethonin is not known. The autosomal dominant LGMD genes merosin, which is made by a gene called laminin. These merosin protein usually lies outside muscle cells and types of LGMD are considered quite rare. When merosin is not produced, the muscle fibers degenerate soon after The genes causing these types of LGMD, their chro- birth. A second gene called integrin is responsible for mosomal location, and the proteins they code for (when CMD in a few individuals but alterations in this gene known) are listed below: are a rare cause of CMD.

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Treatment and clinical trials decision making: The impact of the Cancer Information Service zithromax 100 mg lowest price antimicrobial plastic, Part 5 zithromax 500 mg line antibiotic xifaxan. Sense-making theory and practice: An overview of user interests in knowledge seeking and use. Social equity and information technologies: Moving toward infor- mation democracy. Health information and health reform: Understanding the need for a national health information system. Knowledge networks: Emerging knowledge work infrastructures to support innovation and knowledge management. How internet users decide what information to trust when they or their loved ones are sick. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. The emergence, maintenance, and dissolution of structural hole brokerage within consortia. The Cancer Information Service Telephone Evaluation and Reporting System (CISTERS): A new tool for assessing quality assurance. The role of the physician data query on-line cancer system in health information dissemination. Paper presented to the annual convention of the Association for Education in Journalism and Mass Communication, Miami Beach, FL. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. The first 15 years: What has been learned about the Cancer Information Service and the implications for the future. The knowledge-creating company: How Japanese companies create the dynamics of innovation. Lessons learned about academic and public health collaborations in the conduct of community-based research. The control revolution: How the Internet is putting individuals in charge and changing the world we know. Four-nation survey shows widespread but different levels of Internet use for health purposes. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Clinical Decision Support Systems 251 ChapterXIV Clinical Decision Support Systems: Basic Principles and Applications in Diagnosis and Therapy Spyretta Golemati, National Technical University of Athens, Greece Stavroula Mougiakakou, National Technical University of Athens, Greece John Stoitsis, National Technical University of Athens, Greece Ioannis Valavanis, National Technical University of Athens, Greece Konstantina S. Nikita, National Technical University of Athens, Greece Abstract This chapter introduces the basic principles of Clinical Decision Support (CDS) systems. CDS systems aim to codify and strategically manage biomedical knowledge to handle challenges in clinical practice using mathematical modelling tools, medical data processing techniques and Artificial Intelligence (AI) methods. CDS systems cover a wide range of applications, from diagnosis support to modelling the possibility of occurrence of various diseases or the efficiency of alternative therapeutic schemes, using not only individual patient data but also data on risk factors and efficiency of available therapeutic schemes stored in databases. Computer-Aided Diagnosis (CAD) systems can enhance the diagnostic capabilities of physicians and reduce the time required for accurate diagnosis. Modern Therapeutic Decision Support (TDS) systems Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. CDS systems aim to improve the overall health of the population by improving the quality of healthcare services, as well as by controlling the cost-effectiveness of medical examinations and treatment. Introduction Advances in the areas of computer science and Artificial Intelligence (AI) allow the development of computer systems that support clinical diagnostic or therapeutic decisions based on individualised patient data (Berner & Ball, 1998; Shortliffe, Perrault, Wiederhold, & Fagan, 1990). Clinical Decision Support (CDS) systems aim to codify and strategically manage biomedical knowledge to handle challenges in clinical practice using mathematical modelling tools, medical data processing techniques and AI methods (Bankman, 2000). CDS systems cover a wide range of applications, from diagnosis support to modelling the possibility of occurrence of various diseases or the efficiency of alternative therapeutic schemes, using not only individual patient data but also data on risk factors and efficiency of available therapeutic schemes stored in databases. To diagnose a disease, a physician is usually based on the clinical history and physical examination of the patient, visual inspection of medical images, as well as the results of laboratory tests. In some cases, confirmation of the diagnosis is particularly difficult because it requires specialisation and experience, or even the application of interventional methodologies (e. Computer-Aided Diagnosis (CAD), defined as a diagnosis made by a physician who uses the output from a computerised analysis of medical data as a “second opinion” in detecting lesions, assessing disease severity, and making diagnostic decisions, is expected to enhance the diagnostic capabilities of physicians and reduce the time required for accurate diagnosis. The first CAD systems were developed in the early 1950s and were based on production rules (Shortliffe, 1976) and decision frames (Engelmore & Morgan, 1988). More complex systems were later developed, including blackboard systems (Engelmore & Morgan, 1988) to extract a decision, Bayes models (Spiegelhalter, Myles, Jones, & Abrams, 1999) and Artificial Neural Networks (ANNs) (Haykin, 1999). Recently, a number of CAD systems have been implemented to address a series of diagnostic problems.

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Studies with animals petite by improving the way the body extracts energy from have shown CLA to reduce breast order zithromax 250mg mastercard virus 800000cb, prostate discount 500 mg zithromax amex antibiotic resistance of bacillus subtilis, stomach, col- less food. The CLA may slow the trying to lose weight or tone muscles, but also for people growth of cells that give rise to cancer. A human study with nutrient absorption disorders and other digestive has shown an association between linoleic acids and a de- problems. A tablespoon of linole- ic acid-rich foods or oils may be added on a daily basis Cystic fibrosis to help improve and moisturize skin. Infants with cystic fibrosis (CF) often have poor Evening primrose oil is taken to help with skin, hair, and weight gain and growth and an inability to absorb fats. Some research suggests that infants with CF can benefit from formula with a high linoleic acid content because it optimizes nutrition, growth, and feeding efficiency. Other uses Animal research suggests that CLA supplementa- Multiple sclerosis tion may limit food allergy reactions and improve glu- cose tolerance. It is also used as a nutritional supplement Multiple sclerosis (MS) is a disease in which de- for allergic respiratory disease, circulation, arthritis, and myelination, loss of myelin sheath material, occurs. CLA is also a potent antioxidant myelin sheath is a fatty substance that surrounds and in- and may help reduce plaque formation in arteries and sulates the axon of some nerve cells. It also believed to be helpful because myelin is composed of helps to control diabetes, liver and kidney damage due to lecithin, which is made of linoleic and other fatty acids. Patients supplementing with linoleic acid show a smaller increase in disability and reduced severi- Linoleic acid appears to have at least one negative ty and duration of attacks than those with no linoleic effect on the human body, however. Doses of sunflower seed oil or evening a progressive loss of vision and eventual blindness. Preparations Evening primrose oil is a fixed oil obtained from the Pregnancy seeds of Oenothera biennis or other spp. One study indicated that low doses of linoleic acid It contains about 72% linoleic acid and 9% gamolenic and calcium can reduce the incidence of preeclampsia in acid. Safflower hypertension with increased protein in the urine or ac- oil is the refined fixed oil obtained from the seeds of the cumulation of watery fluid in cells or tissues or both, due safflower, or false (bastard) saffron, Carthamus tincto- to pregnancy. It contains about 75% linoleic acid as linoleic acid consumption can have a negative effect on well as various saturated fatty acids. GALE ENCYCLOPEDIA OF ALTERNATIVE MEDICINE 2 1221 interactions with evening primrose oil, and should talk to KEY TERMS their doctors before using a supplement. Age-related macular degeneration (ARMD)—An Resources eye disease that appears to be related to high lev- BOOKS els of linoleic acid in the body. Apoptosis is sometimes “Harvard Study Outlines Role of Fats in Blinding Eye Dis- called “cell suicide. Omega-6 fatty acid—A fatty acid with its first dou- ble bond at the sixth carbon in its carbon chain. Frey, PhD Phenothiazines—A parent compound for the syn- thesis of some antipsychotic compounds. Linseed see Flaxseed Live cell therapy see Cell therapy CLA is available in beef and dairy products, but to avoid eating too many fatty animal foods, supplements may be taken. Livingston-Wheeler therapy Definition Precautions CLA appears to be safe and nontoxic at supplemen- Developed by Virginia Livingston-Wheeler, a U. However, using evening primrose oil as a sup- medical doctor, this complex vaccine and nutrition-based plement for linoleic acid can cause symptoms of undiag- cancer therapy assumes that cancer is caused by Progen- nosed temporal lobe epilepsy and should be used with itor cryptocides, a bacterium said to become active only caution in patients with a history of epilepsy. Side effects CLA may cause gastrointestinal upset in isolated Origins cases, and evening primrose oil can cause minor gas- Livingston-Wheeler discovered Progenitor crypto- trointestinal upset and headache. In the following decade, she de- veloped her theory that cancer is caused by this bacteri- Interactions um, and developed a vaccine against it. In 1969, she People who take epileptogenic drugs (drugs which founded what is now the Livingston Foundation Medical cause epilepsy), in particular phenothiazines, may have Center in San Diego. In the years since then, this center 1222 GALE ENCYCLOPEDIA OF ALTERNATIVE MEDICINE 2 claims to have treated more than 10,000 patients. Liv- ingston-Wheeler died in 1990, but her clinic continues to KEY TERMS offer the Livingston protocol to about 500 patients a year. Anaphylaxis—An abnormal reaction to a sub- Benefits stance that the body considers as dangerous or foreign. An analysis by Livingston-Wheeler showed an 82% survival rate among 62 of her patients with confirmed di- Autogenous vaccine—A vaccine made of dead agnoses of various cancers. However, a later, indepen- Sepsis—Bacterial poisoning causing destruction of dent study found no significant difference between sur- body tissues. Versions of the Livingston protocol are also offered to patients with risk of contamination in the preparation of the material is lupus, arthritis, scleroderma, allergies, and stress-in- also possible, depending on the processes and proce- duced syndromes.

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