Atarax

By B. Aschnu. The College of Metaphysical Studies.

Changes in gene expression foreshadow diet-induced obesity in genetically identical mice generic atarax 10 mg. Hypothalamic proopiome- lanocortin promoter methylation becomes altered by early overfeeding: an epigenetic model of obesity and the metabolic syndrome discount atarax 25mg with mastercard. Differential epigenomic and transcriptomic responses in subcutaneous adipose tissue between low and high responders to caloric restriction. Timing is everything: The when and how of environmentally induced changes in the epigenome of animals. Epigenetic regulation of gene expression: how the genome integrates intrinsic and envi- ronmental signals. Methylation of the estrogen receptor-alpha gene promoter is selectively increased in proliferating human aortic smooth muscle cells. Adult phenotype in the mouse can be affected 293 by epigenetic events in the early embryo. Developmental origins of the metabolic syndrome: prediction, plasticity, and programming. Maternal diet and aging alter the epigenetic control of a promoter-enhancer interaction at the Hnf4a gene in rat pancreatic islets. Cytosine methylation dysregu- lation in neonates following intrauterine growth restriction. Developmental origins of metabolic disease: life course and intergenerational perspectives. Infant mortality, childhood nutrition, and ischaemic heart disease in England and Wales. Persistent epigenetic differences associated with prenatal exposure to famine in humans. Comparing maternal and paternal intergenerational transmission of obesity risk in a large population-based sample. Metabolic plasticity during mammalian development is directionally dependent on early nutritional status. Developmental and epigenetic pathways to obesity: an evolutionary- developmental perspective. Early development of visceral fat excess after spontaneous catch-up growth in children with low birth weight. Insulin resistance early in adulthood in subjects born with intrauterine growth retardation. The fetal insulin hypothesis: an alternative explanation of the association of low birthweight with diabetes and vascular disease. Fetal origins of hyperphagia, obesity, and 294 hypertension and postnatal amplication by hypercaloric nutrition. Prenatal inuences on susceptibility to diet-induced obesity are mediated by altered neuroendocrine gene expression. Epigenetic Gene Promoter Methylation at Birth Is Associated With Childs Later Adiposity. Childhood obesity and metabolic imprinting: the ongoing effects of maternal hyperglycemia. Overweight and the metabolic syndrome in adult offspring of women with diet-treated gestational diabetes mellitus or type 1 diabetes. Programming of the appetite-regulating neural network: a link between maternal over- nutrition and the programming of obesity? Leptin gene expression in human preadipocytes is switched on by maturation-induced demethylation of distinct CpGs in its proximal promoter. High fat diet-induced obesity modies the methylation pattern of leptin promoter in rats. Human leptin tissue distribution, but not weight loss-dependent change in expression, is associated with methylation of its promoter. Evolution in health and medicine Sackler colloquium: Stochastic epigenetic vari- ation as a driving force of development, evolutionary adaptation, and disease. Paternally induced transgenerational envi- ronmental reprogramming of metabolic gene expression in mammals. Chronic high-fat diet in fathers programs beta-cell dysfunction in female rat offspring. Personalized epigenomic signatures that are stable over time and covary with body mass index. Increased expression of inammation- related genes in cultured preadipocytes/stromal vascular cells from obese compared with non-obese Pima Indians. Potential etiologic and functional implications of genome-wide association loci for human diseases and traits. Epigenetic epidemiology of common complex disease: prospects for prediction, prevention, and treatment.

Screening rec- breast cancer today are treated by a multidisciplinary ommendations are also different for patients with a team comprised of several specialties best atarax 25 mg. This discussion is for women who daily in the diagnosis and treatment of breast cancer purchase atarax 10 mg online. Women should be encouraged that management of Much research in the last 40 years has been done early-detected breast cancer involves increasingly less on screening for breast cancer, but guidelines do not invasive approaches and will be addressed through the always agree on what type of screening method to use interaction of a team of dedicated specialists. Breast tissue Suggested Resources extends from the breastbone medially to the underarm CancerSource. Mammography Breast Enlargement see Breast has been shown to be effective in decreasing breast can- Augmentation cer mortality. Since mammography is known to be an effective screening tool, a clinical trial that excludes it would be unethical. Some of the indirect Breast Examination A breast examination is evidence comes from studies including the meta-analy- a simple means of detecting changes in breast tissue. From these trials we see that breast cancer mortality decreased by about 25% in women aged 5069 years and by 18% in women in their 40s. One of the studies reviewed by Barton 1999 was the Canadian National Breast Screening Study. Top figure shows the lateral portion of the breast conducted with early mammography techniques, but and bottom the medial portion of the breast. The com- ponents include palpation, examination pattern, and duration and inspection. The entire breast is palpated using the boundaries previously outlined in a vertical strip pattern or lawnmower pattern. Levels of pressure for palpation of breast tissue in a cross- sectional view of the right breast. The examiner should make three outer edge of a dime at a superficial, intermediate, and circles with the finger pads, increasing the level of pressure (superfi- deep pressure. Checking the armpit and area above the collarbone for enlarged a useful prognostic sign for cancer. However, sponta- lymph nodes is usually performed, but has not been clin- neous nipple discharge may need further evaluation. Expression of fluid from a nipple is not formed every 12 years for all women over age 40. Canadian National discuss individual screening recommendations with Breast Screening Study-2: 13-year results of a randomized trial in women aged 5059 years. There is some overlap with mammogra- National Alliance of Breast Cancer Organizations. This is a simple means for women Breast-Feeding Human breast milk is now to detect changes in their own breast tissue. It is per- widely acknowledged to be the most complete form of formed each month, usually within a week after men- nutrition for infants, with a range of physiological and struation, when the breast is least bumpy. Patients should ask Through the ages, humans have been dependent on it for their health care providers for help in learning the its sustenance and even contraceptive attributes. The proper technique includes look- supports the observation of benefits for infants growth, ing at the breast and systematically examining the breast immunity, and development, as well as reduced financial using the middle three fingers. Likewise, breast-feeding has been shown to improve of breast cancer is reduced by breast self-examination. Patients need to be aware that risk of premenopausal breast cancer, and reduced risk of the evidence for self-breast examination is unproven osteoporosis. Yet, in spite of these advantages, ambiva- and that it may increase their chances of having a lence surrounds the practice because of the myriad of benign breast biopsy. The American Academy of Family factors that influence a womans ability and decision to Physicians, the American College of Obstetricians and commit to breast-feeding. Gynecologists, and the American Cancer Society all recommend routine teaching of breast self-examination. A breast health assessment, including Suggested Reading a review of breast self-examination and nipple evaluation, is prudent. Does this patient physiology of lactation (milk production) is an essential have breast cancer? The screening clinical breast examination: complement to successful breast-feeding. Findings from 752 081 thus, when you are born, you already have breast tissue clinical breast examinations reported to a national screening pro- (as does your newborn). Journal of the National Cancer secretory glands undergo most of their maturation post- Institute, 92, 971. Effect of breast self-examination techniques on the risk of death from sidered mature once capable of producing milk, and fully breast cancer. The external dome is comprised first-time mother, father, or friend, understanding our of the nipple that is the exit point for all the milk ducts health beliefs is an integral component of making healthy (aka lactiferous ducts) and the pigmented areola that behavior choices.

I atarax 10mg generic, put the scissors into the cut order atarax 25mg fast delivery, and open them, so as to separate the peritoneum. Gently insert theatre staff present just before the spinal anaesthetic, the gynaecologist your hand to lift out the foetal head. S, remove the placenta by controlled cord traction and fundal babies born by Caesarean Section, it became an easy vaginal delivery. It is usually rotated to the anaesthetist inhibit you in performing an emergency right, so that the left round ligament is usually more anterior Caesarean Section. Prevent the supine hypotensive syndrome (pressure on the If you find that the left side of the incision always bleeds vena cava) by tilting her about 5 to the left. Find some way of preventing her slipping If the foetal head is impacted in the pelvis and needs to be off the table. A moderate head down (Trendelenburg) disimpacted from below, ask yourself if a symphysiotomy position, after the spinal anaesthetic is fixed at the correct (21. Ask an assistant, with sterile gloves, to put his hand It will make delivering the foetal head easier if there is a into the vagina, and to disimpact the foetal head. Unfortunately, it is difficult to predict that the head needs Make a cut through the skin and subcutaneous tissue down disimpaction, until after you have opened the uterus. Take care if there has been a previous Caesarean peritoneum over the uterus, just below the point where the Section (21. Then tear the peritoneum with your fingers to left and right, If necessary, extend the skin incision further down. If you use a Pfannenstiel incision, use your fingers aim your fingers in a more cephalic direction, so that the tear in a similar way for the tissues under the skin and above the in the peritoneum is curved (21-12J). Try to leave a bare fascia, even the fascia and also, now directed vertically, area about 2cm wide and 12cm long. Use two haemostats to pick up (2) Do not denude the lower segment for >5cm: if the cervix peritoneum near the upper end of the incision (21-12E). Meconium is irritant, longitudinally from above downwards to just above the and if it becomes infected peritonitis may follow. If you cut the bowel by mistake, Make a superficial incision over the full trajectory of the clamp it and close it later (11-5). This should be Clamp any active bleeding vessels if they are big, 2cm below the peritoneal reflection, and at least but postpone tying them until later in order to save time. They usually stop bleeding on their own anyway, although Do not make your transverse incision too low in the lower this does not always happen if you use a Pfannenstiel segment. Then go somewhat deeper in the midline because the current may cause foetal cardiac dysrhythmias. Do not try to aspirate the nose especially fingers bleed less and the extent of the opening is easy to with a big Yankauer sucker: it may push maternal blood into control. A major advantage is that you cannot in this way cut the nose and/or traumatise the nasal passages. Ergometrine occasionally makes a conscious patient sick, and may raise the blood pressure. Protect it with a finger will often not notice relaxation because bleeding will not be between the membranes and the uterine wall if you use overt. An oxytocin infusion at the end of the operation and scissors instead of tearing with your fingers. Also, when you because blood loss from the injured sinuses of the placenta suture it, you will be less likely to suture the ureters. If you can feel the foetal vertex through the uterine wall, Now deliver the uterus by lifting the fundus out of the the placenta is probably lying in the fundus or posteriorly, abdomen; it is easier then to see what you are doing. If you are a quick operator, apply one Green-Armytage If you tear the placenta as you open the uterus, try to clamp (or sponge-holding forceps) at one angle of the detach it, and deliver the foetus around it. There can be severe bleeding from a lacerated placenta, so clamp the umbilical cord If you are a slow operator, apply several Green-Armytage quickly (21. Do not pull on the clamps during suturing as this will result in an asymmetric If there are large veins over the lower segment, closure. The veins will probably stop bleeding soon by a combination of controlled cord traction and fundal after. If necessary, help it to contract by massaging the fundus from inside the abdomen. If there is a placenta praevia grown into a previous Then put your hand outside the lower flap of the incision, Caesarean Section scar, there is serious danger of serious and lift the foetal head up (21-12P). If you cannot remove the placenta manually (the practical If the incision is not long enough to deliver the foetus definition of placenta accreta) then you may be forced to without a lateral tear, extend its ends upwards and laterally proceed to hysterectomy.

The disc florets are generally complete proven 25mg atarax, bisexual and actinomorphic discount atarax 25 mg, whereas the ray florets are incomplete, pistillate or neutral and zygomorphic. Calyx In many species calyx is reduced to numerous hairy appendages called pappus, arranged on top of the ovary. Corolla Petals 5, gamopetalous showing valvate aestivation, regular and tubular in disc florets and irregular and ligulate or bilabiate in ray florets. Fruit Cypsela, single seeded, dry indehiscent fruit developing from an inferior ovary. Leaf Simple, opposite, exstipulate and margins dentate showing reticulate venation. Inflorescence A terminal heterogamous head and receptacle of the head is convex and surrounded by green involucre. The tubular florets occupy the centre and the ligulate florets are found at the margins. Calyx Reduced into numerous hairy outgrowths called pappus arranged on top of ovary and persistent. Calyx Reduced into numerous hairy outgrowths called pappus arranged on top of the ovary and persistent. Oil plants Oil extracted from the seeds of Helianthus annuus (sunflower) is edible and used as a cooking medium. Oil extracted from the seeds of Carthamus tinctorius (safflower) is edible and also used in the manufacture of soap. It contains less amount of cholesterol and therefore it is recommended for heart patients. Medicinal plants The entire plant, Eclipta prostrata (Karisalankanni) is used in the preparation of bathing oil and also in the treatment of jaundice, spleen and liver disorders. The drug santonin obtained from the heads of Artemesia maritima is used for expelling intestinal round worms. Dye plants A natural red dye obtained from Carthamus tinctorius is used for dyeing silks. A yellow dye obtained from the flowers of Tagetus erecta is used for dyeing cotton. Pesticides A dried powder called Pyrethrum obtained from the flower heads of Chrysanthemum cinerarifolium and C. Beverage Powder obtained from the seeds of Cichorium intybus (chicory/ kasini keerai) is mixed with coffee powder. Ornamental plants Helianthus annuus (sunflower), Tagetus petula (French marigold), Calendula officinalis (pot marigold) and Zinnia elegans are grown in gardens for their beautiful flowers. Datura stramonium) or extra axillary scorpioid cyme called rhipidium (fan shaped cyme) as in S. Androecium Stamens 5, epipetalous, alternate with the petals, usually not equal in length and filaments are inserted in the middle or basal region of corolla tube and basifixed. Anthers dithecous, introrse, usually basifixed or dorsifixed, dehiscing longitudinally or through apical pores (eg. In Schizanthus pinnatus, two stamens are fertile and three stamens are reduced to staminodes. In Lycopersicon esculentum, the fruit is a berry and in species of Datura and Petunia, the fruit is a capsule. Androecium Stamens 5, free from one another epipetalous, alternate the petals and are inserted in the middle of the corolla tube. Anthers are basifixed, dithecous with long filament, introrse and longitudinally dehiscent. Datura metal 45 Fruit Spinescent capsule opening by four apical valves with persistent calyx. Food plants Tubers of Solanum tuberosum (potato) are used as common vegetable throughout the world. Leaves and flowers of Datura stramonium are the sources of drug stramonium used to treat asthma and whooping cough. Leaves, flowers, berries of Solanum trilobatum (thoodhuvalai) are used to treat cough. Roots and leaves of Withania somnifera (Amukkara) are used to treat nervous disorder and are diuretic apart from useful tonic. Tobacco Leaves of Nicotiana tabacum (tobacco) contain alkaloids nicotine, nornicotine and anabasine. Nicotine is considered to be the principal alkaloid in commercial tobaccos such as cigarette, bidi, pipes and hukkah as well as chewing and snuffing. In which of the following plants the midrib and veins are found with yellowish spines a. It is world wide in distribution, but particularly well represented in Africa and South America.

Dysthymia is a more minor agoraphobia discount 25 mg atarax mastercard, panic disorder atarax 25 mg online, generalized anxiety disor- mood change lasting for 2 years or more. Women often affective disorder is a mood change that occurs during have other mental disorders that accompany the depres- times of the year when there is less light. Rapid cycling sive ones, such as anxiety problems or alcohol and sub- bipolar disorder refers to a manic depressive illness stance abuse. Men tend to have higher rates of alcohol and where there are four or more episodes of mania or drug abuse. While the causes for week or more before the onset of menses and are usu- gender differences remain unclear some theories have ally relieved with bleeding. However, most likely explanation is that biological and psycho- about 45% of women experience much more severe logical factors may be involved. Since differences symptoms that can interfere with their functioning at appear between men and women in the likelihood of school, work, or with interpersonal relationships. Research is under way to clarify the relationship tribute to the gender differences in the rates of depres- of ovarian hormones to brain neurotransmitters, adrenal sion between men and women. Some of the normal psychological changes shown the effectiveness of preventive treatment by include anxiety, mood lability, and concerns about giving medications during pregnancy or right after bodily changes and well-being of the fetus. The most common symptoms are emo- distractibility, and inability to focus attention. These feelings come as hospitalization is indicated plus treatment with antipsy- a surprise to many women who are so pleased to have chotic medications as well as psychotherapy. Often, rest viduals should not be left alone until they show marked is helpful but no other special treatments are needed. Milder forms of period, which is a major hormonal transition like depressive illnesses are called adjustment reactions with puberty, may present women with more depressive and depressed mood. Recent always include a careful physical exam plus laboratory work interestingly suggests that women with major tests for thyroid function. It is important to Pregnancy weigh the risk benefits of use of medications in the pregnant and postpartum woman who is nursing. Some medications can be used safely and should be Suggested Reading carefully considered. This is a common con- Stasis dermatitis usually occurs on the lower legs dition that has a variety of different causes and presen- and is characterized by itchy red and scaly patches. It may be acute or chronic and extent of Over time, it leaves behind brown patches that are gen- involvement may be localized or generalized. The cause is attributed to fluid Depending on the specific features, various types of accumulation in the tissues beneath the skin, and is dermatitis have been classified. Itching is a common often seen in association with varicose veins or ankle feature. Improving the condition that is causing fluid Atopic dermatitis is most common in infants and buildup in the legs is the most beneficial treatment, and children and is often seen in individuals with family topical corticosteroids are often used if the situation is members who have asthma or hayfever. Because stasis dermatitis is usually asymptom- infancy and many children outgrow it by adolescence. Over time, the skin in these areas becomes thickened with a leathery appear- Suggested Reading ance. Archives of steroids or newer nonsteroid prescription medications Dermatology, 125, 276286. Fishers contact dermatitis are often required to reduce the itching that can be so (4th ed. Moisturization with bland emollients and avoidance of overly drying the skin such as bathing too frequently are also helpful. Contact dermatitis arises as a result of an allergic Diabetes Diabetes mellitus is a disease in which or irritant reaction due to substances touching the skin. Insulin Examples include poison ivy, costume jewelry, or per- is the hormone that regulates blood glucose levels by fumes in soaps or laundry detergent. Signs and symp- signaling cells to take glucose out of the bloodstream toms include redness and itching, and depending on and by signaling the liver not to put more glucose into the severity there can be significant swelling and for- the bloodstream. These skin changes are limited to the organ that lies in the upper abdomen, just below and site of exposure to the substance that elicits the allergic behind the stomach. Treatment consists primarily of iden- pancreas fails to produce enough insulin (type 1 dia- tifying the cause and avoiding it; however, resolution betes) or because cells do not respond normally to can be hastened with topical corticosteroids and, in insulin (type 2 diabetes). Only about 510% of all chronic and the inciting substance is unclear, skin patch diabetes is type 1. About 17 million people in the United States have dia- Seborrheic dermatitis is characterized by greasy betes, accounting for 6. Another yellowish scaling on the scalp and, in severe cases, the 6 million or so cases are undiagnosed.

Thanks are due to the entire staff of the International Diagnostic Center trusted atarax 25 mg, especially the pathologist discount atarax 10 mg visa, Dr. Without their expertise, none of our terminally ill cancer pa- tients could have recovered. I am truly grateful to this forward- looking country that made this venture possible. At one time scurvy, a vitamin C deficiency disease, was so life threatening it required medical care, but it no longer does. It took 400 years from the discovery of its cure (1535) to utilization of the cure by the public in the early 1900s. It took the unrelated orange juice industry to bring it to the publics attention in the early 1900s. Why did it take so long to put into practice a simple truth, like the importance of eating fresh fruit and vegetables? Be- cause ordinary people, not able to read the medical journals, had no way to learn of it. Unless the public has access to the great truths uncovered by scientists, they can not learn them even now. But these discoveries were ignored rather than treasured, as be- fell the scurvy cure. Patients now have easy access to information just like doctors and researchers do. No experiments were done on age-matched pa- tients with similar cancers comparing my treatments to chemo- therapy, radiation or surgery. The good news is that this new method is not incompatible with clinical treatments in most respects. But the use of certain vitamins may be considered undesirable by your oncologist if she/he is planning certain chemotherapies. There is a very large body of research literature that discusses the use of 6 supplements in cancer. Your oncologist may wish to peruse some of the references cited in this research report as well as throughout this book. Most victims of cancer have been given an accurate diagno- sis, meaning a label for their cancer. After this a protocol (procedure) for this particular cancer was applied, taken from a scientifically acquired bank of data. All this data and its efficacy is undoubtedly correct, taken within the boundaries of the varied assumptions made to get them. A huge catalog of such data exists, with the precise protocol for each category and sub-category of cancer. Your doctor may still be creative and flexible within this protocol or use a new 6 Jaakkola, K. Remember that oncologists are highly trained in the sci- ences; they do want the best for you. They must practice within the boundaries of conventional treatments or risk losing their license to practice. They too would like to know the cause and effect relationships that underlie cancer and do not try to cover up ignorance. When you are first contemplating the options available to you, try to choose the best of both worlds for yourself. A fictional example, about a painful toe, may help: One day, you tell your doctor your toe hurts and has been painful for several months. When you return and there has been no change, you are referred to a foot specialist. All the results, put together after a complete workup, give you a label (diagnosis): prosematis. This label is now looked up in a huge catalog that is kept current by professional and government committees. There are very many entries of similar but slightly different conditions, like pseudo prosematis, atypical prosematis, idiopathic prosematis. It is explained to you that the treatment is effective for five years in 30% of cases but you will be carefully followed to catch the earliest recurrence. Yet, this seems like a foolish question when your own edu- cational training tells you the diagnosis was scientifically ac- quired, the measuring devices were all accurate, and a thousand scientific studies support the catalog of protocols for prosema- tis. These rec- ommendations would be hilariously funny to a primitive person who would first of all throw away their shoes! But in your igno- rance, walking to work each day in fashionable shoes, it is en- tirely serious. Being scientifically oriented, you try more changes: a better diet, stopping bad habits, and resting your foot. You cant help wondering how a clinical treatment could be so wrong, when all the data that went into it were so right.

So your ability to help a patient with proptosis is limited; but you should try to make a diagnosis 25 mg atarax fast delivery. Do not operate on these buy atarax 10mg low cost, unless you are skilled enough to dissect widely, and have made an accurate Fig. A, retraction of scar tissue everting the eyelid and exposing the (6) A lacrimal pleomorphic adenoma, palpable at the cornea. Epiphora can occasionally be so severe that it audible noise in the head and a bruit heard over the needs surgery (a dacryocysto-rhinostomy). Reassure her, (14)The hyperophthalmopathic form of thyrotoxicosis and use a topical antibiotic if conjunctivitis develops. If the eye is still watering at 2yrs, the nasolacrimal duct needs probing and syringing. If there is a tender swelling between the eye and the (2) Acute ethmoiditis, commonly around 2yrs. The more common causes are listed first; If there is a space occupying lesion in the orbit, it pushes the later ones are mostly very rare. Thyrotoxicosis may cause unilateral proptosis, be difficult to diagnose, but is uncommon. Do not be deceived by the small mass of tumour palpable externally: most of it will be inside the orbit behind the eye. D, carcinoma of the maxillary antrum If there is a swelling which has enlarged slowly (weeks extending into the orbit. This will help to distinguish occurred over several weeks or months, pseudoproptosis, due to the relative widening of one suspect idiopathic orbital inflammation. It will respond well to prednisolone 60mg od for 1wk, reducing slowly to Hold a ruler horizontally, and measure the position of 5mg od by the 4th wk. If this fails, try to arrange surgical Examine the fundi for papilloedema and optic atrophy. The normal intraocular pressure has caused the previously Apply antibiotic eye ointment qid, and especially at night. The globe however remains in its Padding can be dangerous, because the pad may abrade normal position. Take care to curette away any pockets of granulation tissue, which may be hidden by a flap of Meibomian glands secrete oil at each blinking of the conjunctiva, or have herniated themselves through the eyelid; this prevents evaporation of the fluid film on the tarsal plate into the orbicularis muscle. They present as a swelling in Remove the clamp and pinch the lid until it stops either lid, which may become chronically or acutely bleeding. Small asymptomatic ones need no treatment, Place chloramphenicol ointment in the conjunctival sac and may resolve spontaneously. D, chalazion clamp in place ready to incise a chalazion in the centre of the lower lid. Trachoma is the commonest eye infection in the tropics Anaesthetize the conjunctiva with drops of lidocaine 4%, and also amongst Aborigines in Australia, and in its or amethocaine hydrochloride 1%. Infiltrate the lid with blinding hyperendemic form is worldwide the lidocaine and adrenaline around the chalazion. Insert the 2nd commonest single cause of blindness and impaired needle at the upper margin of the upper tarsus, vision (cataract is the first). Carry it which spreads from the eyes of one person to another, forwards to the lid margin, on either side of the chalazion. A single dose of cyst, so that the solid blade lies on the skin of the eyelid, 20mg/kg azithromycin (or 500mg bd erythromycin for and the ring lies on the conjunctiva over the cyst. Always make the incision perpendicular to the lid margin so as to avoid cutting the levator muscle. If the edge of the cornea looks mildly grey, Split the eyelid into two parts along a grey line defined owing to an arcuate (crescent-shaped) grey infiltration, by the orbicularis oculi muscle: just inside are the and blood vessels go beyond the grey area into the cornea, openings of the Meibomian glands and just outside are the there is pannus (meaning a curtain). This causes recurrent attacks of keratitis, which eventually results with a corneal opacity causing blindness. The cornea is grey and scarred, the vision severely impaired, and the lids are deformed. If you work in an endemic area, you are likely to have many patients with entropion, so learn how to correct their eyelids yourself, and if necessary train an assistant to do this. The operation is always worth doing, even if the lids are severely scarred: sight may recover surprisingly. Do not cut the eyelashes short because this makes them If you are a right-handed operator, start with the right eye. Use a scalpel to incise the margin of the upper lid, at the lateral end of the lashes, to a depth of 3mm (28-17A). Evert the lid as you do Trachoma which has distorted the upper tarsus, so that it this, by pressing it with a swab. Then repeat the procedure has curled inwards and made the lashes scratch the globe. Control the considerable bleeding that will result by You can operate on both the eyes at the same time, suturing the conjunctiva to the skin of the eyelid with 3/0 but this will require admission for 3days, to allow the absorbable sutures on a cutting needle.