br Conclusion br Introduction Spigelian hernia accounts for only

Conclusion

Introduction
Spigelian hernia accounts for only about 2% of all hernias. It occurs as a defect formed in the Spigelian aponeurosis and can be congenital or acquired. In 1645, Adriann van der Spieghel, a Flemish anatomist, was the first to describe a defect in the semilunar line (linea Spigeli). In 1764, Josef Klinkosch defined the Spigelian hernia as a defect in the semilunar line. In most cases, the hernial sac contains the omentum, and in some cases may also contain a segment of AZD8055 or colon that may cause intestinal obstruction. Several cases of congenital Spigelian hernia with undescended testis also have been reported. Preoperative diagnosis is very difficult, because the sac is usually located between muscle layers of the abdominal wall, and therefore abdominal computed tomography (CT) or ultrasound is usually the first choice for confirming the diagnosis. As the incarceration rate of Spigelian hernia is very high, prompt surgery should be performed, either by open or laparoscopic repair. We report a male patient presenting with left lower abdominal pain and a palpable mass, which was later diagnosed as incarcerated Spigelian hernia. He underwent conventional surgery without mesh repair. After surgery, he recovered well without complications or recurrence.

Case Report
A 57-year-old man presented at our hospital with a mass in the left lower abdomen. His body height is 162 cm and body weight is 69 kg (body mass index: 26.29 kg/m²). He had had pain in this area for about 1 month, but without nausea or vomiting. He worked as a gardener and had to lift heavy things before he had symptoms. On physical examination, an ill-defined mass measuring about 3 cm was palpable, accompanied with mild tenderness. It was more prominent while standing up. Abdominal echography was performed and it revealed a hypoechoic cystic lesion protruding through the muscle layer of the abdominal wall (Fig. 1). Abdominal CT was then performed and it showed a herniation of omentum through the fascial defect of the left lower abdominal wall (Fig. 2).
An impression of incarcerated Spigelian hernia was made and surgery was performed. Intraoperatively, a herniated sac with part of the omentum incarcerated inside the muscle layers through a 1 cm × 1 cm fascial defect was noted (Figs. 3 and 4). The defect was closed with interrupted sutures after reduction of the hernia. The patient was uneventfully discharged from the hospital 5 days later.

Discussion
These hernias are frequently seen between the 4th decade and 7th decade. The male to female ratio is 1:1.18. Certain conditions such as obesity, rapid weight loss, multiple pregnancies, chronic obstructive pulmonary disease, chronic constipation, ascites, traumas, and previous surgery are all predisposing factors, because they not only increase the intra-abdominal pressure, but also cause a greater weakness of the abdominal wall. Patients most often present with swelling in the mid-to-lower abdomen just lateral to the rectus muscle. They may complain of a sharp pain or tenderness at this site. The hernia is usually reducible in the supine position. The reducible mass may be palpable, even if it sits below the external oblique musculature.
The physical findings are usually equivocal, and imaging studies are needed for confirming the diagnosis. Ultrasound can provide detailed images of the abdominal wall defect, the hernia sac and its contents, and the relationship of the contents to the Spigelian fascia, as well as the rectus, external oblique, and internal oblique muscles. CT of the abdomen will also confirm the presence of a Spigelian hernia. CT is reported to have a sensitivity of 100% and a positive predictive value (PPV) of 100%, whereas ultrasonography has a sensitivity of 90% and a PPV of 100%, and clinical assessment alone has a sensitivity of 100% and a PPV of 36%. The hernia sac of Spigelian hernias consists of extraperitoneal fat and peritoneum; it may or may not have splanchnic contents. Spigelian hernias usually contain only the small bowel or omentum, but the large bowel, stomach, gallbladder, Meckel\’s diverticulum, ovary, testis, leiomyoma of the uterus, and even urinary bladder have also been reported to be contained in the hernia sacs. The incidence of incarceration is about 20%, and therefore once Spigelian hernia is diagnosed, surgery for immediate hernia repair is mandatory. Our case was diagnosed by means of ultrasound and confirmed by a CT scan. A visible fascial defect can be seen in both studies.

Several studies have shown that the

Several studies have shown that the oocysts of Cryptosporidium are resistant to adverse environmental conditions and survive well under temperate and moist conditions (Ryan et al., 2014). The higher prevalence of Cryptosporidium in the summer compared to in the winter may be related to the high temperature in the summer (Chai et al., 2001). In the case of C. bovis/ryanae, the prevalence associated with season is consistent with the results from previous studies; however, C. parvum showed no association with seasonality according to PCR and ELISA results.
As discussed previously, Cryptosporidium is not considered to cause hemorrhagic diarrhea (Cho and Yoon, 2014). Therefore, the higher prevalence of C. bovis/ryanae in hemorrhagic diarrheal samples in the present study may have resulted from co-infection with other pathogens that cause hemorrhagic diarrhea in calves, such as Clostridium perfringens, Salmonella spp., bovine coronavirus, and Eimeria spp.
No statistically significant differences were observed for sex and type of cattle in the case of C. parvum and C. bovis/ryanae (P>0.05). A previous study showed a higher prevalence of Cryptosporidium in males than in females (Ibrahim et al., 2016); however, in the present study, although a slightly but insignificantly higher prevalence in males was noted.
Many studies have shown that the distribution of Cryptosporidium is related to age (Santín and Zarlenga, 2009; Zhang et al., 2015; Ibrahim et al., 2016). For example, C. parvum is mostly identified in pre-weaned calves; C. bovis and C. ryanae are found in post-weaned calves; and C. andersoni is present in adult cattle. Considering the target AZD8055 in this study (≤3months), the results were consistent with those of previous studies, with a higher prevalence of C. parvum than of C. bovis/ryanae and no detection of C. andersoni.
In previous studies, although diarrheic cattle showed a higher prevalence of Cryptosporidium spp., Cryptosporidium was also identified in non-diarrheic cattle (Azami, 2007; Ibrahim et al., 2016). These previous studies did not report that Cryptosporidium is an apathogenic organism, but suggested that other factors can affect Cryptosporidium infection. Age-related infection of Cryptosporidium in cattle and detection in many small children and immunocompromised individuals suggest that the immune response plays an important role in cryptosporidiosis (Ryan et al., 2014; Ibrahim et al., 2016).
Because there is no gold standard for the diagnosis of Cryptosporidium spp. (Mirhashemi et al., 2015), we used two tests, PCR and ELISA, to identify C. parvum. The κ value was used to evaluate agreement between the two different tests (Thrusfield, 2005a). In the present study, a κ value of 0.65, which indicates good agreement, was obtained. In addition, all C. bovis/ryanae PCR-positive samples yielded negative ELISA results. Our results indicated that the two tests could be applied compatibly to detect C. parvum in feces. While there was good agreement between the two tests, there were still 41 ELISA+/PCR- samples. This discrepancy may be attributed to two factors: first, the presence of PCR inhibitors such as bilirubin, bile salts, and complex polysaccharides, which are included in feces, and second, limitations in the sensitivity and specificity in each assay (Morgan et al., 1998). Thus, additional studies are required to clarify the discrepancy in detecting Cryptosporidium spp. using the two assays.
To date, several genes have AZD8055 been used for the molecular characterization of Cryptosporidium, including 18S rRNA, Cryptosporidium wall protein, hsp70, and gp60 (Xiao, 2010). In the present study, 18S rRNA was successfully used to identify Cryptosporidium spp.; however, because sequence identity is greater than 99% 18S rRNA among some Cryptosporidium spp. (C. bovis, C. ryanae, and C. xiaoi), it is not always possible to differentiate the species by PCR (Santín and Zarlenga, 2009; Mirhashemi et al., 2016). The sequences obtained in the present study also showed 99% 18S rRNA sequence identity for C. bovis and C. ryanae; however, phylogenetic analysis was used to differentiate these two species. In addition, we amplified hsp70 in C. bovis, and this sequence clearly differed from those in C. ryanae (EU410346) and C. xiaoi (FJ896041), with 88.9% and 97.5% identity, respectively. Because there is only one C. bovis hsp70 sequence (AY741306) in the GenBank database and the sequence contains only 384bp, our sequence information will be useful for further investigations. We recommend targeting hsp70, rather than 18S rRNA, to identify C. bovis, C. ryanae, and C. xiaoi.

The assessment of what proportion of cancer

The assessment of what proportion of cancer patients should benefit from radiotherapy is only the first step in the comprehensive estimation of the needs for radiotherapy services in the different European countries. The next step is to consider what the impact of these ranges of OUPs could be, either by tumour site or for all cancers together, on the evidence-based assessment of the need for radiotherapy equipment and staffing [25] and [26]. Other factors that would need to be taken into account are the impact of treatment complexity from evolving technology and dose fractionation, which are both in continuous AZD8055 and certainly will have a specific impact on the present and future need for radiotherapy resources. Also, termination codon should be mentioned that re-treatments need to be considered for planning purposes because they are not included in the CCORE model.
In conclusion, the differences in OUP were most dependent on the relative frequency of the cancer sites. The OUP by country showed a variation that could have an impact on the planning for radiotherapy needs of equipment and staffing. This information can be adapted using European data, allowing for planning the resources required to cope with the demand for radiotherapy in Europe, taking into account the national variability in cancer incidence.