By V. Dan. University of Montana, Missoula. 2019.

Pan-histone deacetylase inhibitors inhibit pro- inammatory signaling pathways to ameliorate interleukin-18-induced cardiac hypertrophy buy doxycycline with mastercard. The cyclin-dependent kinase inhibitor p21 is a crucial target for histone deacetylase 1 as a regulator of cellular proliferation quality 100 mg doxycycline. Histone deacetylase inhibitors suppress inammatory activation of rheumatoid arthritis patient synovial macrophages and tissue discount doxycycline 200 mg. The word epigenetics was originally coined by Waddington in 1942 as a portmanteau of epigenesis and genetics to describe the process by which the genotypes give rise to phenotypes during development [3]. Nowadays, Waddingtons denition would be considered to apply to the eld of developmental biology in general whereas the meaning of the word epigenetics has narrowed to specically refer to non-genetic factors that inuence gene expression. Many other specic factors as well as general alterations in chromatin structure also correlate with different states of gene activity but are not considered primary epigenetic modications as they are not stable through cell division independent of their initial trigger. However, it also leads some to question the use of the term for systems widely referred to as epigenetic such as histone modication, whose independent heritability through cell division is uncertain. Differences in chromatin structure are seen between genes in active and inactive states and reect underlying epigenetic modications. Other alterations observed include changes in large-scale chromatin conformation and physical interactions between normally distant regions of chromatin. In mammals, it is well established to have a mitotically stable silencing effect on genes when present at CpG dense promoter sequences [4]. However, the large majority of silent genes do not have a methylated CpG island at their promoter, indicating that other means of epigenetic control must exist. The contribution of dynamic/tissue-specic changes in methylation in the control of gene expression remains unclear [12,13]. Primordial germ cells undergo genome-wide demethylation early in development, like other post-zygotic cell types and are largely demethylated until gonadal differentiation. The overall level of methylation is somewhat higher in sperm than eggs and sex-specic differences occur at imprinted loci. It occurs before meiosis in male germ cells and during meiotic prophase arrest I in female germ cells. Following this, somatic embryonic cells show the high level of methylation at sequences other than CpG islands that are seen in maturity. Trophoblast cells undergo de novo methylation but remain relatively less methylated. Many post- translational modications involve histones, often in combination with one another, and exert epigenetic control on gene expression. Foremost amongst these are the methylation and acetylation of lysine residues in the N-terminal tails of histones H3 and H4 (Table 13. H3 lysine 9 and H3 lysine 27), trimethylation of H3K4, and acetylation at H3K9 and H3K14. Repressive modications include dimethylation of H3K4 and trimethylation of H3K9, H3K27. Several models have been proposed to explain the heritability of histone modications through cell division, but none is proven (reviewed in [19]). While this uncertainty remains, some authors argue that histone modications should not be regarded as true epigenetic modications. The best established of these are the Polycomb and Trithorax group proteins which promote transcriptional repression and activation respectively, and both of which act stably through cell division. The two systems interact closely with one another and with other epigenetic systems and have been implicated in the regulation of genes in early development and stem cell renewal. The Polycomb repressor complex 1, the so-called maintenance complex, recognizes this repressive mark and is crucial in the resultant transcriptional repression. A detailed exposition of these inter- actions is beyond the scope of this chapter. Epigenetics in Human Disease Around 60 genes have been shown to be consistently imprinted in man (Geneimprint data- base 2008; Catalogue of Parent of Origin Effects 2009) [74,75]. Some are imprinted in all cell types examined, while others show tissue-specic imprinting, or are only imprinted at certain stages of development. Imprinted genes are often arranged in clusters, each cluster spanning up to several megabases (Table 13. One theory that perhaps best explains the evolution of imprinting is that of parental genome conict. This theory suggests that there is a conict of evolutionary advantage between the paternal genome with the maternal genome which is as a result of the mother carrying the offspring in utero. The maternal genome must preserve herself and resources for future offspring so limits supplies to the baby, whereas the paternal genome only needs to consider the baby and encourages growth. Proponents of the theory point to the existence of a number of imprinted genes that regulate growth and the tendency for paternally expressed genes to promote growth and for maternally expressed genes to suppress growth [26,27]. This can be technically challenging as human tissues are difcult to obtain, limiting systematic expression analysis of the human genes. Instead, known imprinted loci have often been identied following the observation of features suggestive of imprinting, including: 1. Parent-of-origin-specic effects of mutation, copy number abnormality or chromosomal rearrangement 3. Parent-of-origin-specic epigenetic modications in the region (for example differential methylation) 258 5. Even in this small number of loci, the variety of different mechanisms oper- ating is striking. This differential methylation is associated with main- tenance of differential (i. A single differentially methylated imprinting center often appears to control imprinting of multiple genes in a cluster. A further feature shared by a number of loci is the presence of multiple overlapping, often untranslated, transcripts that may play a regulatory function. Unlike the majority of other sequences, imprinted loci appear to escape the genome-wide demethylation that occurs after fertilization, allowing them to retain the differential methylation of the paternal and maternal alleles established during germ cell development. The region has been studied extensively in man and is disrupted in the human disorders BeckwitheWiedemann syndrome and SilvereRussell syndrome. In the simplest terms, the paternal 11p15 allele promotes growth through the expression of growth-promoting genes and the silencing of growth-suppressing genes and the maternal 11p15 allele suppresses growth through the expression of growth-suppressing genes and the silencing of growth-promoting genes. Each domain contains a cluster of imprinted genes which include growth promoters and growth suppressors. The region is arranged in two imprinted domains, the more telomeric imprinted domain 1 and the more centromeric imprinted domain 2. This is methylated on the paternal allele (lled lollipops) and unmethylated on the paternal allele (open lollipops). This is methylated on the maternal allele and unmethylated on the paternal allele. This is similar to that seen in the process of X inactivation and it has been proposed that silencing of these genes on the paternal allele occurs by a similar process to that seen on the inactive X: through repressive histone H3K27 methylation mediated by Polycomb group proteins. There is currently limited evidence to provide mechanistic under- standing of this model [45].

Frequently buy line doxycycline, patients continue to be patterns suggestive of other dementing illnesses discount 200mg doxycycline overnight delivery. Other congenital muscular dystrophies are hip dislocation or sublimation is frequently seen order 200 mg doxycycline with visa. The incidence of Fukuyama congenital disease and Walker-Warburg syndrome but not in Eye abnormalities are present in muscle-eyebrain Fukuyama congenital muscular dystrophy. The incidence of other types of congenital congenital muscular dystrophy, Walker-Warburg muscular dystrophies is unknown. Muscle- Early spine contractures, rigidity, and scoliosis typical clinical features include congenital or eye-brain disease is described most often in Finland. Delayed motor milestones and mental retardation Onset is from birth to first few months of life in all Severe cardiac involvements are reported in have been reported in integrin-a -deficient 7 types of congenital muscular dystrophies. Fukuyama congenital muscular dystrophy is linked to Congenital myasthenic syndrome Muscle biopsy reveals dystrophic changes and chromosome 9q31-q33 (gene product: fukutin). Rigid spine congenital muscular In all types of congenital muscular dystrophies, dystrophy is linked to chromosome 1p35-36 (gene there are generalized hypotonia, diffuse muscle product: selenoprotein Ni). Ulrich weakness and atrophy, variable early and multiple joint contractures, and onset from birth or the first few months of life. Muscle Nerve 2000; 23: Patients should be followed regularly for seizure 1456-1471. Semin In Fukuyama congenital muscular pacemaker placement to prevent sudden death. Most die of respiratory failure Philadelphia: Lippincott Williams & Wilkins, epilepsy. Special eyeglasses Those with muscle-eye-brain disease also complete laminin a2-deficiency, cortical dysplasia, may be needed in patients with visual problems. Dystrophinopathies are muscular mutation and may not be detectable by routine Onset of gait abnormalities evident by 3 to 5 dystrophies in which the primary abnormality clinical testing. Dystrophin is an intracellular Female Duchenne phenotype presents occa- Calf hypertrophy can be as early as 1 to 2 protein localized to the subsarcolemmal region of sionally in Turner syndrome and has clinical years skeletal and cardiac muscle. They are caused by a abnormalities presenting mostly as infantile clinical signs and symptoms similar to male mutation in the dystrophin gene, which is hypotonia Duchenne, with laboratory findings of partial located on chromosome Xp21. Precautions Multidisciplinary approach involving neuro- Bakker E, Goor N, Wrogemann K, et at. Molecular and clinical correlations of Encouragement of active exercise as much Deflazacort 1. Malignant hyperthermia Physical and occupational therapies may be 3- to 6-month clinic visits depending on susceptibility in x-linked muscular dystrophies. Contractures occur early and severity and need for services Pediatr Neurol 1986;2:356. Though the clinical shoulder and/or neck pain, followed by weakness develop hip-girdle as well as knee extensor and flexor presentation is typical in the majority of cases, there and atrophy of shoulder girdle muscles, usually weakness. Side-to-side asymmetry of muscle is considerable heterogeneity both in the pattern and separates idiopathic brachial plexopathy from weakness is characteristic and often striking. It is an autosomal- no progression interrupted by periods of more rapid dominant disorder. These are readily differentiated on is unusual and suggests an alternative diagnosis critical number of a 3. A higher level suggests an alternative deletion, causing a toxic gain of function. Examination reveals facial weakness in essentially Approximately 30% may experience a worsening of all patients (an inability to bury the eyelashes fully, symptoms during pregnancy. Patients should be pout the lips, or whistle, and dimples may be noted cautioned that proximal lower extremity weakness at the corners of the mouth with resultant reduction may increase fall risk. This, in combination with relative preservation of the forearm muscles, gives the arm a distinctive "Popeye" appearance. Management Facioscapulohumeral dystrophy: a distinct Follow-Up regional myopathy with a novel molecular pathogenesis. Moreover, individuals adapt remarkably well to their bilateral surgical fixation of the scapula also reduces disabilities and remain relatively functional. Careful consideration of However, about 20% of patients become residual muscle strength, rate of disease nonambulatory. Several bracing techniques Genetic Testing have been devised to improve shoulder mobility Athena Diagnostics, 377 Plantation St. These pregnancies may patients usually manifest neonatal hypotonia, be complicated by polyhydramnios and poor fetal feeding difficulties, failure of development, movements. However, this nuclei, small angular atrophic fibers, and nuclear disease was found to have high incidence in certain clumps. The myotonic The recognition of manifestations in nonmuscular to weakness of respiratory muscles and impaired dystrophy gene codes for a protein termed " systems is very important. Weakened bulbar muscles may cause repeats in successive generations is associated with and respiration are the leading causes of mortality dysphagia and an increased risk for aspiration increased severity of the disease. Can J Neurol Sci 1990;17( breathing exercises, postural draining block, and trifascicular conduction disturbance 4):410-415. Nature 1992;355:545- failure and significant disturbances of cardiac required to detect cataracts and other 546. These patients generally have does not shorten the P-R interval and is the significantly progressive muscle weakness and other preferred agent. They have very slow progression of muscle weakness without Although effective agents to treat myotonia, cardiac involvement. Death was caused Similarly, other antiarrhythmic agents should be by respiratory problems in 43% of patients. The feature is muscular weakness, which is made worse test is considered positive when there is unequivocal by continuing activity, relieved by rest, and Diagnosis improvement in an objectively weak muscle. A improved by the administration of fractionated test is performed in which 2 mg are anticholinesterase drugs. Patients with acute generalized weakness can be Age and Sex Management misdiagnosed with botulism or Guillain-Barr The most common age at onset is the second and syndrome. Bulbar muscle weakness is screened for drugs that can exacerbate while 20% have thymic tumors. Muscle-like (myoid) the initial symptom in 15% of patients with eventual cells in the thymus gland bear surface acetylcholine myasthenia, and these should be discontinued or involvement in 70% to 80% of cases. Thymectomy is not recommended moderate association with human leukocyte antigens to the ocular muscles for 2 years or more; and (b) generalized, in which disease spreads beyond the for patients with ocular myasthenia. Exacerbations in the third trimester respond best to treatment in the euthyroid state.

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Sleeping sickness affects remote and rural areas where health 121 systems are least effective discount doxycycline 100mg visa, or non-existent buy doxycycline overnight delivery. It spreads with socio- economic problems such as political instability doxycycline 200 mg with mastercard, displacement of populations, war and poverty. Within a given focus, the intensity of the disease can vary considerably from one village to the next. Human African trypanosomiasis takes two forms, depending on the parasite involved: Trypanosoma brucei gambiense (T. A person can be infected for months or even years without obvious symptoms of the disease emerging. It is more virulent than the other strain and develops more rapidly, which means that it is more quickly detected clinically. Major epidemics There have been three severe epidemics in Africa over the last century: one between 1896 and 1906, mostly in Uganda and the Congo Basin, one in 1920 in several African countries, and one that began in 1970 and is still in progress. The 1920 122 epidemic was arrested due to mobile teams systematically screening millions of people at risk. After that success, screening and effective surveillance were relaxed, and the disease has reappeared in endemic form in several foci over the last thirty years. The geographical distribution of the disease Sleeping sickness threatens over 60 million people in 36 countries of sub-Saharan Africa. Only 3 to 4 million people at risk are under surveillance, with regular examination or access to a health centre that can provide screening. Detection of the disease calls for major human and material resources, such as well-equipped health centers and qualified staff. Because such resources are lacking, most people with sleeping sickness die before they can ever be diagnosed. The 45 000 case figure shows not the true situation but rather the lack of screening in many foci. Reported cases in recent years are from countries where surveillance coverage is no more than 5%. In certain villages of many provinces of Angola, the Democratic Republic of Congo and southern Sudan, the prevalence is between 20% and 50%. In each country the spatial distribution of the disease is very diverse; it is found in foci and micro-foci. Infection and symptoms The disease is transmitted with the bite of the tsetse fly. At first the trypanosomes multiply in the blood, and that process can last for years with T. Causative agent Protozoan parasites of the genus Trypanosoma, which enter the blood stream via the bite of blood Feeding tsetse flies (Glossina spp. Transmission Its transmission is via the bite of infected bloodsucking male and female tsetse flies that transfer the parasites from human to human. Tsetse flies can acquire parasites by feeding on these animals, or on an infected person. Early symptoms, which include fever and enlarged lymph glands and spleen, are more severe and acute in T. A range of symptoms including headache, anaemia, joint pains and 126 swollen tissues follows early signs; advanced symptoms include neurological and endocrine disorders. As the parasites invade the central nervous system, mental deterioration begins, leading to coma and death. The early phase entails bouts of fever, headaches, pains in the joints and itching. The second, known as the neurological phase, begins when the parasite crosses the blood-brain barrier and infests the central nervous system. This is when the characteristic signs and symptoms of the disease appear: confusion, sensory disturbances and poor coordination. Disturbance of the sleep cycle, which gives the disease its name, is the most important feature. If the patient does not receive treatment before the onset of the second phase, neurological damage is irreversible even after treatment. The two human and animal forms of the disease remain a major obstacle to the development of rural regions of sub-Saharan Africa: human loss, decimation of cattle and abandonment of fertile land where the disease is rife. The very complex developmental cycle of the trypanosome within the tsetse vector is further complicated by several of other factors related to the biology of the vector, pathogen, and host. In addition, there are wide intraspecific variations in both morphology and pathogenicity of trypanosomes. Certain parasite antigens that stimulate production of protective antibodies by the host change before the parasites are completely eliminated; new antibodies are then produced by the host, and the parasites change their antigenic constitution again to maintain themselves. Animal trypanosomiasis is greatest hinderance in animal production and agricultural development in tropical Africa. In the past, this has involved extensive clearance of bush to destroy tsetse fly breeding and resting sites, and widespread application of insecticides Control Measures: - Clearing forest and bushy habitat of tsetse clear 10 - 12 meters on both sides of forest crossing roads. Trapping adults, killing pupa use nets or / odor attracted traps, use animals as bait / visual targets to trap, Inspection of people and treating cases. Since the vector ecology varies, it is necessary to identify the species common to a specific area before taking appropriate pest management measures. Strict vegetation management includes clearing dense brush along waterways and around contaminated areas (preferably up to a mile away if possible). Aircraft pesticidal applications that give a small droplet size (approximately 250 microns or less) can be effective in areas where it is not practical to eliminate or reduce thick brush for at least a quarter of a mile. Contingency considerations The only time human trypanosomiasis is a contingency consideration is when operations are necessary in the tsetse fly infested areas. If this is the situation, troop staging, and as much of the support operations as possible, should be kept outside of the known fly breeding areas. Aircraft spray operations should be applied to brushy areas surrounding containment areas and strict brush control should be practiced within the containment area itself and within a mile of a large containment Strict use of individual protective measures such as the repellent jacket and proper uniform wear must be strictly enforced. To date the only cost- effective success has been with large scale use of ox-odor-baited traps. Describe the possible applicable environmental friendly control measures of tsetse flies. There are four narrow black stripes located on the thorax or area just behind the head. In order to feed on a piece of food, the fly must first regurgitate some saliva on the food to soften it. Hind wings are not developed and are reduced to 2 short slender threads with a knob at the end (may be used for balancing). The mouth parts and feeding habits The structure of the mouth part is made in such a way that the fly is unable to feed any solid matter except in liquid form. The solvent (liquid) for dissolving the food (solute) into solution form is stored in a special container called crop, connected to the proboscis by the crop duct. Thus whenever the fly tries to feed it vomits the crop through the proboscis on to the surface of the food in order to dissolve it and eat it. This have it of feeding by vomiting and sucking is known as regurgitation and is commonly employed on almost all surfaces the fly test with its proboscis.

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The infection can remain limited to a local area of the peritoneum or become generalized cheap doxycycline 200mg visa. Factors which favor localization of the infection include: Anatomical factors (e discount doxycycline. Plain film of the abdomen can also be diagnostic with findings related to underlying pathology e buy 200mg doxycycline free shipping. Early diagnosis &referral when indicated Introduction Hepatobiliary structures have significant surgical importance not only in abdominal surgery but also in general outcome of surgical management on any other sites of human body. They are common sites of different surgical diseases due to their big size and very large and double blood supply. The right lobe is the larger, and gall bladder is attached to its inferior surface. Hepatic artery, portal vein, and the hepatic duct together with lymphatic vessels and nerves enters and leave the liver at the area called porta hepatis,which is found at the interior and posterior aspect of right lobe. Incidence The disease occurs approximately in 3% of patients with intestinal amoebiasis. Hepatic lesion usually occurs in the right lobe and has the following characters: - Is large, single abscess - Contains characteristic liquid material which is reddish brown anchovy paste fluid - Has thin wall with little or no fibrosis Clinical manifestation History: Chief complaints are fever, chills, right upper quadrant pain which may radiate to right shoulder area. There could also be a history of: - Cough, pleuritic chest pain or dyspnea - Painful epigastric swelling if left lobe is involved - History of antecedent diarrhea - Weight loss Physical examination: Physical examination can reveal the following findings: - Tender hepatomegaly : almost constant feature - Tenderness over lower intercostal spaces with /without swelling and skin edema. Rupture: direction of rupture can be into plural cavity, lung, pericardium or peritoneum. The hepatic hydatid cyst is usually superficial and composed of two layers laminated wall. Clinical manifestation - Usually asymptomatic - Symptom of pressure on adjacent organs - Upper abdominal pain and tenderness - Palpable mass or diffuse liver enlargement - weight loss - Jaundice and ascites: uncommon - With secondary infection: fever, chills and tender hepatomegaly - Urticaria and erythema Complications 1. Broncho-pleural and hepato-bronchial fistulas Investigations - U/S of the abdomen :- cyst and daughter cysts - Casoni skin test: if reagents are available. Treatment Expectant: small/dead calcified cyst Medical: Albendazol/mebendazol for 2- 4 weeks for multilocular disease or patients unfit for surgery. Mixed stone (90%): cholesterol is the major component with others like calcium bilirubinate. Pathogenesis: Three important factors implicated in pathogenesis of cholelithiasis are: 1. When bile salt is deficient or when the cholesterol level is in excess in relation to the bile salt, the bile formed is supersaturated or lithogenic 2. Infection: causes increased mucus plug formation and scarring which form a nidus for stone formation. Also many bacteria deconjugate billirubin which will combine with calcium to form insoluble calcium bilirubinate. Clinical Presentation Most (90%) patients with gall stone diseases are asymptomatic. Symptomatic patients present with: History: - Right upper quadrant colicky pain (biliary colicky) - Dyspepsia, fatty food intolerance, flatulence, abnormal post prandial bloating - Symptoms of acute cholecystitis or other complications Physical examination: right upper quadrant tenderness Risk factors can be identified 190 Complications of Gall bladder stone 1. In the gall bladder: chronic cholecystitis acute cholecystitis gangrene perforation empyema mucocele carcinoma 2. The main stay of treatment 2) cholecystostomy for bad risk patients with severe infection (Severe Acute cholecystitis or gall bladder empyema) 191 Acute Cholecystitis Definition Acute cholecystitis is an acute inflammation of gall bladder due to obstruction of neck of gall bladder or cystic duct stone. Another rare form of acute cholecystitis which occurs in absence of stone is called acalculous cholecystitis. Pathogenesis Direct pressure of calculus on the mucosa results in ischemia, necrosis, and ulceration with swelling edema and impairment of venous return. This process increases and extends the extent of inflammation and favors bacterial multiplication. The end result may be:- - Pericholecystic abscess - Fistula formation between gall bladder and bowel - Gall bladder empyema/mucocele - Rarely, perforation of gall bladder and bile peritonitis Commonly involved bacterial species in acute cholecystitis include E. Clinical features History: History of chronic cholecystitis or Cholelithiasis Women more affected than men Moderate to severe right upper quadrant and epigastric pain which may radiate to the back. Differential diagnosis Perforated or penetrated peptic ulcer disease Biliary colic Pneumonia Pancreatitis 192 Hepatitis Pleurisy Appendicitis Myocardial ischemia or infarction. Type of the test Pre hepatic hepatic Post hepatic Serum billirubin:- Total + +++ +++ Direct N ++ +++ Indirect +++ ++ N Serum Alkaline N + +++ phos Liver Enzymes N +++ + Urine : billirubin 0 N +++ urobilinogen +++ N 0 Causes of extra hepatic biliary obstruction Obstruction in the lumen Gall stone(the most common) Parasitic occlusion e. To emphasize the importance of early diagnosis & intervention Introduction Abdominal wall hernias are common surgical problems encountered in all levels of health care facilities. Adequate knowledge to reach to the correct diagnosis and appropriate management plan help the care provider to prevent serious complications which could be fatal. General consideration Definitions Hernia is a protrusion of a viscus through an opening in the wall of the cavity Important terminologies Hernial sac - is an out pouch of the peritoneum. It has four parts: mouth, neck, body and fundus Content- Is a viscus or any other organ inside a sac. It can be: - Small bowel and omentum the commonest - Large bowel appendix - The bladder Reducible hernia- when the protruded viscus can be returned back to the abdomen Irreducible hernia- when the contents cant be returned back Obstructed hernia- the content of the hernia (intestine) is occluded but no impairment of vascular supply Strangulated hernia- when the vascularity of protruded viscus is impaired Richters hernia- when only one side of the wall of the intestine is herniated. Here strangulation of the bowel can occur with out intestinal obstruction Sliding hernia- when an extra peritoneal structure form part of the wall of the sac 198 Risk factors for abdominal wall Hernia development Increased intra abdominal pressure resulting from: - Chronic cough - Straining at urination or defecation - Heavy wt lifting - Abdominal distension Weakened abdominal wall - Advanced age - Malnutrition - Congenital defect ppv - Trauma/surgery Clinical features History - Lump which varies in size - Pain, local aching, discomfort - Factors predisposing to increased intra abdominal pressure - Symptoms of int. Strangulation is a surgical emergency Risk of obstruction and strangulation is very high in femoral hernia, paraumblical hernia and indirect inguinal hernia with narrow neck 199 Principles of management - Spontaneous resolution is unlikely - The risks of irreducibility, obstruction and strangulation increase with time. So surgical intervention is needed in most cases Surgical treatment for abdominal wall hernias 1. Herniotomy - removal of the sac and closure of the neck: Done only in infants and children 2. Obstruction and strangulation This is one of the causes of intestinal obstruction (acute abdomen). Therefore, one shouldnt forget to examine the hernial sites during evaluation of the patient with intestinal obstruction. Treatment options Non operative treatment: Gentle reduction (Taxis) can be indicated in obstructed hernia in infants but not advisable in adults due to the risk of mass reduction. Inguinal hernia - accounts for 80% of all external abdominal wall hernia - commonest is all ages and sexes - 20 x more common is males than women - more common on right side Classification 1. Direct type : Bulges through the post wall of inguinal canal Indirect inguinal hernia - 60% on right, 40% Lt side and 20% bilateral - Due to congenital defect or potential defect which is the remnant of processes vaginalis - 20 times more common in men Direct inguinal hernia - due to wear and tear associated with advanced age and increased intra abdominal pressure 201 Femoral Hernia - acquired downward protrusion of intestinal contents into the femoral canal - 4 times more common in females (middle-aged multiparous) - rare in children Clinical features History - Elderly or middle aged woman with thin body build - lump on anterior and upper thigh - may present with complaints associated with int. Risk factors Female sex Multiple parities Obesity Ascites Complications Obstruction Strangulation Rupture Treatment Expectant: - Spontaneous closure is expected in 80% cases of umbilical hernia in under five children. Surgery: - Beyond five years 202 Incisional Hernia Risk Factors Wound infection Poor surgical technique (improper facial repair) Chronic cough or straining Obesity Clinical features Risk of obstruction and strangulation is very rare. It had been one of the intersecting points for the discipline of internal medicine and surgery. Gastric cancer is one of the top five cancers in frequency, however, it is one of the disease entities with the worst prognosis because of the difficulty to diagnose it early. Therefore one has to have a high index of suspicion to diagnose the disease early for the outcome of treatment heavily depends on the stage of the disease at the time of diagnosis.

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