Traditional medicine

The following terms are extracted from the General Guidelines for Methodologies on Research and Evaluation of Traditional Medicine.

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Traditional medicine

Traditional medicine is the sum total of the knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness.

Complementary/alternative medicine (CAM)

The terms "complementary medicine" or "alternative medicine" are used inter-changeably with traditional medicine in some countries. They refer to a broad set of health care practices that are not part of that country's own tradition and are not integrated into the dominant health care system.

Herbal medicines

Herbal medicines include herbs, herbal materials, herbal preparations and finished herbal products, that contain as active ingredients parts of plants, or other plant materials, or combinations.

• Herbs: crude plant material such as leaves, flowers, fruit, seed, stems, wood, bark, roots, rhizomes or other plant parts, which may be entire, fragmented or powdered.
• Herbal materials: in addition to herbs, fresh juices, gums, fixed oils, essential oils, resins and dry powders of herbs. In some countries, these materials may be processed by various local procedures, such as steaming, roasting, or stir-baking with honey, alcoholic beverages or other materials.
• Herbal preparations: the basis for finished herbal products and may include comminuted or powdered herbal materials, or extracts, tinctures and fatty oils of herbal materials. They are produced by extraction, fractionation, purification, concentration, or other physical or biological processes. They also include preparations made by steeping or heating herbal materials in alcoholic beverages and/or honey, or in other materials.
• Finished herbal products: herbal preparations made from one or more herbs. If more than one herb is used, the term mixture herbal product can also be used. Finished herbal products and mixture herbal products may contain excipients in addition to the active ingredients. However, finished products or mixture products to which chemically defined active substances have been added, including synthetic compounds and/or isolated constituents from herbal materials, are not considered to be herbal.

Traditional use of herbal medicines

Traditional use of herbal medicines refers to the long historical use of these medicines. Their use is well established and widely acknowledged to be safe and effective, and may be accepted by national authorities.

Therapeutic activity

Therapeutic activity refers to the successful prevention, diagnosis and treatment of physical and mental illnesses; improvement of symptoms of illnesses; as well as beneficial alteration or regulation of the physical and mental status of the body.

Active ingredient

Active ingredients refer to ingredients of herbal medicines with therapeutic activity. In herbal medicines where the active ingredients have been identified, the preparation of these medicines should be standardized to contain a defined amount of the active ingredients, if adequate analytical methods are available. In cases where it is not possible to identify the active ingredients, the whole herbal medicine may be considered as one active ingredient.

Key facts

In some Asian and African countries, 80% of the population depend on traditional medicine for primary health care.

• Herbal medicines are the most lucrative form of traditional medicine, generating billions of dollars in revenue.
• Traditional medicine can treat various infectious and chronic conditions: new antimalarial drugs were developed from the discovery and isolation of artemisinin from Artemisia annua L., a plant used in China for almost 2000 years.
• Counterfeit, poor quality, or adulterated herbal products in international markets are serious patient safety threats.
• More than 100 countries have regulations for herbal medicines.

Traditional medicine is the sum total of knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures that are used to maintain health, as well as to prevent, diagnose, improve or treat physical and mental illnesses.

Traditional medicine that has been adopted by other populations (outside its indigenous culture) is often termed alternative or complementary medicine.

Herbal medicines include herbs, herbal materials, herbal preparations, and finished herbal products that contain parts of plants or other plant materials as active ingredients.

Who uses traditional medicine?

In some Asian and African countries, 80% of the population depend on traditional medicine for primary health care.

In many developed countries, 70% to 80% of the population has used some form of alternative or complementary medicine (e.g. acupuncture).

Herbal treatments are the most popular form of traditional medicine, and are highly lucrative in the international marketplace. Annual revenues in Western Europe reached US$ 5 billion in 2003-2004. In China sales of products totaled US$ 14 billion in 2005. Herbal medicine revenue in Brazil was US$ 160 million in 2007.

Challenges

Traditional medicine has been used in some communities for thousands of years. As traditional medicine practices are adopted by new populations there are challenges.

International diversity: Traditional medicine practices have been adopted in different cultures and regions without the parallel advance of international standards and methods for evaluation.

National policy and regulation: Not many countries have national policies for traditional medicine. Regulating traditional medicine products, practices and practitioners is difficult due to variations in definitions and categorizations of traditional medicine therapies. A single herbal product could be defined as either a food, a dietary supplement or an herbal medicine, depending on the country. This disparity in regulations at the national level has implications for international access and distribution of products.

Safety, effectiveness and quality: Scientific evidence from tests done to evaluate the safety and effectiveness of traditional medicine products and practices is limited. While evidence shows that acupuncture, some herbal medicines and some manual therapies (e.g. massage) are effective for specific conditions, further study of products and practices is needed. Requirements and methods for research and evaluation are complex. For example, it can be difficult to assess the quality of finished herbal products. The safety, effectiveness and quality of finished herbal medicine products depend on the quality of their source materials (which can include hundreds of natural constituents), and how elements are handled through production processes.

Knowledge and sustainability: Herbal materials for products are collected from wild plant populations and cultivated medicinal plants. The expanding herbal product market could drive over-harvesting of plants and threaten biodiversity. Poorly managed collection and cultivation practices could lead to the extinction of endangered plant species and the destruction of natural resources. Efforts to preserve both plant populations and knowledge on how to use them for medicinal purposes is needed to sustain traditional medicine.

Patient safety and use: Many people believe that because medicines are herbal (natural) or traditional they are safe (or carry no risk for harm). However, traditional medicines and practices can cause harmful, adverse reactions if the product or therapy is of poor quality, or it is taken inappropriately or in conjunction with other medicines. Increased patient awareness about safe usage is important, as well as more training, collaboration and communication among providers of traditional and other medicines.

WHO response

WHO and its Member States cooperate to promote the use of traditional medicine for health care. The collaboration aims to:

• support and integrate traditional medicine into national health systems in combination with national policy and regulation for products, practices and providers to ensure safety and quality;
• ensure the use of safe, effective and quality products and practices, based on available evidence;
• acknowledge traditional medicine as part of primary health care, to increase access to care and preserve knowledge and resources; and
• ensure patient safety by upgrading the skills and knowledge of traditional medicine providers.

Related links

Imperforate Hymen (2)

Treatment

Medical Therapy

After initial presentation and suspected diagnosis of an obstructive anomaly, the use of continually-administered oral contraceptive pills to suppress menses allows symptomatic relief and essential time needed to obtain further diagnostic studies. In addition, the use of nonsteroidal anti-inflammatories can provide pain relief.

Surgical Therapy

The timing of surgical therapy is based on the presence of symptoms. A symptomatic mucocele manifesting in a neonate should be treated expediently but is not considered a surgical emergency. If an asymptomatic patient is diagnosed with an imperforate hymen without a mucocele during childhood, this patient can be treated after the onset of puberty and prior to the development of a hematocolpos or hematometra. The presence of estrogen stimulation in puberty facilitates surgical repair and healing.

While expedient treatment of an imperforate hymen is appropriate when it manifests in an adolescent with hematometra and hematocolpos, the procedure should not be performed on an emergent basis without an appropriate preoperative evaluation. Surgical correction should be definitive. A diagnostic technique (eg, needle aspiration in the office setting) should not be used to confirm the diagnosis because this can allow the introduction of bacteria into what had been a sterile hematocolpos or hematometra, setting the stage for pyocolpos or pyometrium, with the potential to adversely affect fertility.

Preoperative Details

The patient and family should be prepared for the surgical procedure, which can be described as a hymenotomy (opening up the hymenal membrane). Some authors advocate concurrent diagnostic and possible operative laparoscopy in a young woman presenting with hematocolpos, because pelvic adhesions and intra-abdominal endometriosis may be present. Anecdotal evidence suggests that endometriosis and pelvic adhesions associated with obstructive anomalies spontaneously resolve once the obstruction is treated. Thus, other authors do not believe that laparoscopy is indicated. The potential risks and benefits of this component of the surgical procedure should be explained to the young woman and her parents in an effort to facilitate informed decision-making and consent.

Intraoperative Details

The objective of a hymenotomy procedure is to open the hymenal membrane in such a way as to leave a normally patent vaginal orifice that does not scar. Infiltration of the membrane prior to the incision with a long-acting local anesthetic (eg, 0.25% bupivacaine) provides preemptive analgesia.

If a large hematocolpos is present, it typically is under pressure, and the surgeon should be prepared to dodge the pressure-driven stream of thickened old blood (typically the consistency and color of chocolate syrup) and to evacuate the hematocolpos and hematometra using one or more suction cannulae. Often, the revision of the incision in the hymenal membrane must await the evacuation of the hematocolpos.

The hymenal orifice is enlarged using a circular incision following the lines of the normal annular hymenal configuration. Alternatively, a cruciate incision along the diagonal diameters of the hymen, rather than anterior to posterior, avoids injury to the urethra and can be enlarged by removal of excess hymenal tissue. In either approach, the vaginal epithelium is then sutured to the hymenal ring using interrupted stitches with fine absorbable suture (eg, 4-0 polyglycolic acid suture). The application of 2% lidocaine jelly to the suture line is suggested to provide postoperative analgesia. A running interlocking suture is discouraged to minimize circumferential scarring. Relaxing incisions (a radial incision in the hymen that is closed horizontally) may be helpful for ensuring adequate vaginal diameter and minimizing the need for a repeat procedure due to scarring.

Aspiration or puncture of the mucocolpos or hematocolpos without definitive enlargement of the vaginal orifice should be avoided because a pyocolpos or ascending infection may develop.

Dane et al present a new technique where an oval-centralized closure around an insufflated Foley catheter (10 cm³) is left in place for 2 weeks.³ This was used to prevent hymenal architecture destruction, thus creating circumferential stenosis around the Foley catheter. The authors of this article do not recommend this technique, as efforts to create a small hymenal opening with persistent hymenal tissue could lead to stenosis with reaccumulation of hematocolpos and/or subsequent laceration at the time of first intercourse due to tissue rigidity from scarring.

Postoperative Details

The surgical procedure of hymenotomy and evacuation of hematocolpos is performed in an outpatient setting. The patient and family should be instructed to expect continued drainage of dark, thick, old blood for several days to a week after the procedure. Mild cramping may occur as the hematometra resolves and evacuates.

Ibuprofen or other NSAIDs may be prescribed for the uterine cramping. Topical lidocaine jelly is recommended for the vaginal orifice. The patient is instructed to apply the jelly sparingly to the area a few minutes prior to urinating and as needed for soreness. Baths are not prohibited and, in fact, may provide some soothing comfort and help keep the area clean. The use of a hair dryer on the cool setting to dry the area avoids the abrasion of towel drying.

Topically applied estrogen cream has been shown to improve vascularity and promote healing of mucosal tissue in animal studies. Application of estrogen cream to the surgical repair site may be recommended for use on a daily basis for the first 2 weeks after the procedure is performed.

Patients and/or parents are instructed to call the physician's office if the patient experiences severe cramping unrelieved by ibuprofen or develops a fever. The family should also be informed that all sutures are absorbable and dissolve, sometimes with the observation of the ends of the suture as small threads.

Follow-up

Schedule a postoperative office visit 1-2 weeks after the surgical procedure. At that visit, inspect the area for signs of inflammation or infection. Topical lidocaine jelly facilitates the examination and helps relieve the patient's anxiety. A 3- to 6-month course (or longer) of menstrual suppression with continuous oral contraceptive pills may be indicated and should be discussed at the postoperative visit.

If a laparoscopic procedure was performed and demonstrated endometriosis, the potential benefits of using a gonadotropin-releasing hormone agonist and subsequent hormonal suppression must be weighed against the increased risk of scarring due to a hypoestrogenic state.

Complications

Infectious complications to the procedure are rare, and prophylactic antibiotics are not required. However, data on which to base this decision are few. A careful surgical technique with adequate opening of the vaginal orifice prevents stenosis and reaccumulation of the hematocolpos or mucocele, which carries a risk for pelvic inflammatory disease with pyocolpos, pyometra, endomyometritis, salpingitis, or tubo-ovarian abscess. The development of pelvic inflammatory disease clearly has implications and risks for subsequent infertility, pelvic pain, and ectopic pregnancy.

Injury to the adjacent urethra, rectum, or bladder is possible if the anatomic defect is not defined clearly and if the actual condition is vaginal agenesis or a complicated müllerian abnormality rather than a simple imperforate hymen.

Imperforate Hymen (1)

Introduction

Imperforate hymen is at the extreme of a spectrum of variations in hymenal configuration. Variations in the embryologic development of the hymen are common and result in fenestrations, septa, bands, microperforations, anterior displacement, and differences in rigidity and/or elasticity of the hymenal tissue. Inspection of the external genitalia and anus are important components of the physical examination of the female neonate and child. While this examination can and should be accomplished by the pediatrician, the observant delivering obstetrician can learn much about the normal variations in genital configuration by examining the female neonate in the delivery room, keeping in mind the influence and structural changes induced by maternal estrogens. Under this influence, the labia majora are plump, the hymen is elastic and often fimbriated, and the mucosal surfaces (ie, introitus, fossa navicularis, vaginal vestibule) are pale pink.

Problem

Imperforate hymen has been diagnosed with prenatal ultrasound documentation of bladder outlet obstruction due to hydrocolpos or mucocolpos. However, in spite of the recommendations for inspection of the external genitalia during the neonatal and early childhood period, variations in hymenal anatomy commonly escape diagnosis until the time of menarche.

Different normal variants in hymenal configuration are described, varying from the common annular, to crescentic, to navicular ("boatlike" with an anteriorly displaced hymenal orifice). Hymenal variations are rarely clinically significant before menarche. In the case of a navicular configuration, urinary complaints (eg, dribbling, retention, urinary tract infections) may result. Sometimes, a cribriform (fenestrated), septate, or navicular configuration to the hymen can be associated with retention of vaginal secretions and prolongation of the common condition of a mixed bacterial vulvovaginitis.

Occasionally a hymenal tag will protrude from the vaginal vestibule, leading to concerns about a tumor or other significant pathology. These hymenal tags are of no clinical significance, and they do not require therapy if vaginal origin can be excluded based on findings from a careful examination.

Imperforate hymen in infancy or childhood

On occasion, an infant or young child may be thought to have an imperforate hymen. However, after the neonatal period when maternal estrogen levels have declined, examination of the area may be challenging. Careful examination with pressure applied to the fourchette may reveal microperforations, sometimes with an anteriorly displaced opening just beneath the urethra. Capraro described a surgical technique similar to a perineotomy to correct such a defect; however, in asymptomatic patients, waiting until puberty is generally recommended before deciding whether such a technique is necessary. The hymenal changes that result from estrogenization (increased elasticity and fimbriation) may preclude the need for surgery. In addition, surgical procedures to the vagina and hymen during childhood, when endogenous estrogen levels are low, may result in scarring and the need for subsequent surgical revision. Thus, surgery during this time generally should be avoided if possible.

Sexual abuse

Accurate description of the morphology and integrity of the hymen is critical in the diagnosis of female sexual abuse. Imperforate hymen has been described as occurring as a result of scarring from penetration and abuse, thus emphasizing the importance of an early examination to document the congenital, rather than acquired, etiology. Concerns about hymenal disruption and lacerations associated with sexual abuse with digital or penile penetration have led to discussions of the normal hymenal diameter.

Historically, the diameter of the hymenal opening (measured within the hymenal ring) was proposed to be approximately 1 mm for each year of age. Clearly, this guideline does not apply in the neonatal stage, when maternal estrogens lead to an elastic hymen; however, in the prepubertal stage, marked enlargement, according to this guideline, should prompt consideration of the possibility of abuse. An important difficulty with this generalized rule is that the degree of the child's relaxation and comfort with both the examination and the examiner clearly affects measurements, as does the type of measuring device used. While the possibility of abuse should be considered, these size guidelines should be used with caution during an evaluation.

Experts in sexual abuse assessment have used unaided visual examination and colposcopy to examine the integrity of the hymenal ring. Lacerations through the hymen into the fossa navicularis and introitus suggest a penetrating injury. Frequently, sexual abuse evaluations are conducted at some time remote from the immediate injury; thus, healed or healing lacerations are noted.

Muram concluded that the use of the colposcope by an experienced examiner adds little to an evaluation by an experienced colposcopist with expertise in abuse. In addition, Muram proposed a scale that the examiner can use to evaluate physical findings as normal, abnormal and nonspecific, abnormal and suggestive of abuse, and definitive for abuse. The latter category includes only the situation in which sperm are found during the examination. Additional aids to the examination of the hymen have been described, including the trick of inserting a Foley catheter into the vagina and inflating the balloon behind the hymen to stretch the hymenal margin and allow for a better examination.

Anatomic anomalies

Consider anatomic anomalies that can be confused with imperforate hymen in the differential diagnosis. These anomalies include the following:

• Acquired labial adhesions
• Obstructing or partially obstructing vaginal septa (longitudinal or transverse)
• Vaginal cyst
• Vaginal agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome) with or without the presence of a uterus or functional endometrium
• Androgen insensitivity syndrome (testicular feminization)

Frequency

Imperforate hymen is likely the most frequent obstructive anomaly of the female genital tract, but estimates of its frequency vary from 1 case per 1000 population to 1 case per 10,000 population. Heger et al examined 147 premenarchal girls with a mean age of 63 months to collect normative data on genital anatomy; an imperforate hymen was found in only one patient (<1%)>1

Imperforate hymen usually occurs sporadically, but a handful of cases have been reported to be familial.

Etiology

Imperforate hymen and related genital tract anomalies result from abnormal or incomplete embryologic development.

Pathophysiology

The genital tract develops during embryogenesis, from 3 weeks' gestation to the second trimester. The initial development of both the male and female genital tracts occurs concurrently and is referred to as the indifferent stage of development.

• Paired wolffian (mesonephric) ducts connect the mesonephric kidney to the cloaca. The metanephric or true kidney derives from the ureteric bud (arising from the mesonephric duct) at about the fifth embryonic week.
• The paramesonephric or müllerian ducts can be identified during the sixth week of embryologic development and lie lateral to the wolffian ducts until they reach the caudal end of the mesonephros, where they come toward the midline.
• During the seventh week, the urorectal septum forms to separate the rectum from the urogenital sinus.
• By the ninth week, the müllerian ducts move caudally to reach the urogenital sinus, forming the uterovaginal canal and inserting into the urogenital sinus.

By the 12th week, the paired müllerian ducts have fused into a single tube (ie, primitive uterovaginal canal). Two solid evaginations form from the distal aspects of the müllerian tubercle from the sinovaginal bulbs (of urogenital sinus origin) or vaginal plate. The initial or cephalad portion of the müllerian ducts forms the fimbria and fallopian tubes; the more distal segment forms the uterus and upper vagina. The canalization of the paramesonephric ducts and/or upper vagina joins with the vaginal plate, which canalizes beginning caudally and creates the lower vagina. By the fifth month of gestation, the canalization of the vagina is complete. The hymen itself is formed from the proliferation of the sinovaginal bulbs, becoming perforate before or shortly after birth. An imperforate hymen results when this "sheet" of tissue fails to completely canalize. Varying degrees of perforation result in findings such as a cribriform or septate hymen.

Gonadal development

The development of the gonads occurs from the migration of primordial germ cells to the genital ridge, while the genital tract itself develops from the müllerian ducts (paramesonephric ducts), urogenital sinus, and vaginal plate. Thus, anomalies of the vagina, hymen, and uterus are not accompanied by abnormalities of ovarian development, and hormonal and endocrinologic function is without abnormality, leading to expected pubertal breast and pubic hair development.

Because the mesodermal layer contributes to the development of the kidneys, gonads, and ductal structures, defects or insults in embryologic development may result in congenital defects of the kidneys that accompany abnormalities of the vagina and uterus.

The lining of the urethra and urinary bladder derives from endoderm, and the urogenital sinus forms the urethra and vestibule in females. The ectoderm fuses with the endoderm to contribute to the patency and canalization of the genital tract. Defects in this process lead to fusion failures and imperforate and obstruction defects.

Familial occurrence

Familial occurrence, although rare, is reported and screening by history or examination of family members is warranted. Dominant transmission (either sex-linked or autosomal) and sibships suggesting a recessive mode of inheritance are described. The inheritance of müllerian defects likely is polygenic or multifactorial, although some syndromes of heritable disorders are described with associated genital and nongenital anomalies.

Anomalies of the female reproductive tract

Anomalies of the female reproductive tract can result from agenesis or hypoplasia, vertical fusion and/or canalization defects, lateral fusion and/or duplication abnormalities, or failure of resorption, resulting in septa.

Presentation

Diagnosis in infancy or childhood

The diagnosis is infrequently made during infancy in the neonatal nursery. The infant may have a bulging, yellow-gray mass at or beyond the introitus. The presence of an abdominal mass has been described in association with urinary obstruction. Diagnosis has been made in utero with obstetric ultrasonography.

Ultrasonography is an essential first step in diagnosis, precluding unwise and unplanned surgical intervention with resultant injury to the urethra or other pelvic structures, and excluding other more complicated anomalies.

Routine examination of the female genitalia by primary care clinicians during childhood is strongly recommended so that genital abnormalities can be diagnosed early. Observation with a planned hymenotomy during puberty is a reasonable course of action in most cases diagnosed in infancy or childhood, assuming no urinary symptoms or obstruction is present. If the diagnosis is equivocal (ie, imperforate hymen vs labial adhesions vs partial congenital adrenal hyperplasia), referral to a pediatric gynecologist may be warranted. Typically, a mucocele is not present even if the condition is noted at birth. If a patient is diagnosed with an asymptomatic imperforate hymen in infancy or childhood beyond the neonatal period, the optimal time for surgical repair is after the onset of puberty and prior to menarche.

Diagnosis and surgical repair in adolescence

Surgical repair after the onset of puberty but before menarche prevents the situation in which a young woman presents with intermittent abdominal pelvic pain, which can become severe over the course of several months. Walsh and Shih present a case of a 14-year-old elite athlete who presented to the emergency department and her pediatrician on multiple occasions over the course of several months with symptoms of cyclic abdominal pain, urinary retention and constipation.² This is an all too common presentation. Even after placement of a Foley catheter for urinary retention on 2 separate occasions, the diagnosis of imperforate hymen was not made.

In addition, surgery in the presence of adequate estrogenization avoids the scarring and potential need for a repeat surgery that can occur when surgery is performed on the unestrogenized hymen and vagina. While these young adolescents typically present to an emergency department with relatively acute pain, this condition should generally not be managed as an acute emergency. Defining the anatomy with appropriate imaging techniques, with a plan for the most skilled and experienced gynecologist to perform surgery on a scheduled rather than emergent basis, is essential.

Urinary pressure and even retention with hydroureter and/or hydronephrosis may occur due to the mass effect and resultant obstruction. Frequently, vaginal and rectal pressure is present. Severe constipation and low-back pain are described as presenting symptoms. The laborlike menstrual cramps may be severe and cyclic, although the cyclic nature of the symptoms may not be easily or immediately noticed by the young woman or her family.

Unfortunately, the typical findings at diagnosis may include a large collection of blood within the uterus (hematometra) and an even larger collection of blood within the distensible vagina (hematocolpos). Additional findings may include blood-filled fallopian tubes (hematosalpinges) and signs of retrograde menses, occasionally to the point of the development of intra-abdominal endometriosis and severe pelvic adhesions. The classic teaching is that endometriosis associated with obstructive anomalies resolves spontaneously and does not cause problems with subsequent pain and infertility compared with endometriosis arising spontaneously; however, this assertion is anecdotal rather than evidence based.

Clinically, families are often concerned about whether the ovaries are normal when vaginal or hymenal anomalies are present; the course of separate embryologic development allows assurance of normal hormonal function without any need for hormonal testing or ovarian imaging. The exception to this is the diagnosis of androgen insensitivity syndrome.

Differential diagnosis

The differential diagnosis of an imperforate hymen includes many conditions, some rare and others relatively common. Absolute confirmation of the diagnosis of an imperforate hymen is imperative prior to any attempted surgical repair in order to prevent vaginal scarring that can occur if a thick vaginal septum is inadvertently confused with a thin imperforate hymen.

• Labial adhesions
  • The presence of acquired labial adhesions in a prepubertal girl is a common situation that is often confused with absence of the vagina. Labial adhesions, sometimes incorrectly termed vaginal adhesions, are not congenital and result from labial agglutination most commonly due to inflammation. Small areas of labial adhesions can be managed expectantly. Extensive labial adhesions or those associated with such symptoms as recurrent urinary tract infections, urinary dribbling, or recurrent vulvovaginitis can be managed easily using the topical application of estrogen cream for 2-6 weeks. Such treatment results in marked thinning of the adhesions, often with spontaneous resolution.
  • Separation of thick adhesions is possible in an office setting with a child who can be restrained; however, this procedure ultimately is counterproductive because the examination frequently is difficult and traumatic, resulting in the subsequent inability to adequately examine the genital area due to the child's refusal because of memories of pain. Such traumatic lysis should be avoided. General anesthesia in an operative setting may thus be required.
  • Management of labial adhesions can be problematic as recurrence is common. Parents or caretakers must be instructed on how to ensure the child maintains excellent perineal hygiene and avoids vulvovaginitis. The daily application of a topical emollient (such as A&D ointment) helps reduce the risk of recurrence until endogenous pubertal estrogen stimulation alleviates the risk. Thus, the application of a topical emollient should be continued until the child shows signs of estrogen-stimulated breast development.
  • Rarely, an adopted child will be found to have what appears to be labial adhesions, and these may be suggestive of female genital mutilation that occurred at a young age. The thick adhesions that result from this trauma may require surgical separation and management by a gynecologist with experience in managing female genital mutilation.
  • Labial adhesions may be confused with posterior labial fusion encountered in persons with congenital adrenal hyperplasia and may be differentiated by careful physical examination with attention to the presence or absence of clitoromegaly.
• Incomplete hymenal obstruction
  • In the case of incomplete hymenal obstruction due to a cribriform hymen or hymenal band, the typical presenting symptom is difficulty inserting a tampon or even the inability to achieve vaginal intercourse in an adolescent. Anatomic variations must be distinguished from involuntary vaginismus or contraction of the perineal and pelvic musculature or levator ani muscles, which can be associated with the learning process of tampon insertion, becoming a vicious cycle when persistent insertion is attempted without success and causes pain.
  • Hymenotomy occasionally may be indicated in the case of a rigid inelastic hymen, particularly for young female athletes (eg, swimmers, divers, gymnasts, cheerleaders) who are eager to use tampons. A reasonable alternative to surgical correction involves the use of progressive dilation in a motivated young woman. In athletes with a rigid hymen, an evaluation for possible hypoestrogenism associated with vigorous physical activity should be considered; if present, estrogen replacement improves the hymenal characteristics and increases hymenal elasticity.
• Hymenal bands: This condition is typically amenable to division using a local anesthetic in the office; however, the young woman's age and tolerance of such an office procedure must be predicted and judged. Her degree of motivation for tampon use or intercourse impacts the timing at which she requests such a procedure. A typical presenting history of an individual with a hymenal band is the ability to insert a tampon but extreme difficulty removing it. One of the authors has encountered a patient in whom the tampon string became wrapped around the hymenal band, leading to marked edema and pain when removal was attempted.
• Obstructing longitudinal or transverse septa: These conditions require careful preoperative evaluation to define the anatomy prior to any attempted surgical reconstruction. The repair of such complicated anomalies should usually be referred to a gynecologist at a tertiary care center where these cases are not a rarity. MRI is usually the criterion standard for defining the female reproductive anatomy.
• Vaginal agenesis or androgen insensitivity: The evaluation and management of vaginal agenesis or androgen insensitivity syndrome is beyond the scope of this article, but these conditions should be considered in the differential diagnosis. These patients should be referred to a gynecologist who specializes in adolescents and who has experience in managing these conditions. The options for creation of a neovagina are operative, such as a McIndoe, Davydov, Vecchietti or Williams procedure, or nonoperative, using progressively larger Lucite dilators. Most gynecologists recommend the latter form of treatment, which minimizes the potential for scarring and has high rates of success.

Indications

An imperforate hymen must be corrected surgically. The surgical decision-making process should focus on appropriate diagnosis and timing of surgical repair. While the patient may present with acute pain, the repair should not be performed emergently without carefully defining the anatomy. The surgery should be performed by a gynecologist who is skilled and experienced in the care of adolescents with genital anomalies.

Relevant Anatomy

An imperforate hymen is visible upon examination as a translucent thin membrane just inferior to the urethral meatus that bulges with the Valsalva maneuver. If a hematocolpos is present, bluish discoloration is visible behind the translucent membrane. Vaginal septa do not typically appear translucent.

Depending on the size and volume of the hematometra, hematocolpos, or hematosalpinges, a pelvic or abdominal mass may be palpable during abdominal or rectal examination.

Radiographic documentation must demonstrate that the true diagnosis is not an obstructing transverse vaginal septum or other anomaly. Pelvic ultrasonography via the transabdominal, transperineal, or transrectal route is indicated as the initial diagnostic test, followed by MRI if any questions remain about the anatomy. Transperineal ultrasonography can be helpful in measuring the thickening of the septum. Because renal and urologic abnormalities are associated with müllerian abnormalities, imaging of the upper urinary tract can help diagnose ipsilateral renal agenesis, duplex collecting systems, and other complex renal anomalies.

The prevalence of renal agenesis is estimated at 1 case per 600-1200 persons on the basis of autopsy studies. As many as 25-90% of women with renal anomalies are suggested to have concurrent genital anomalies; thus, abdominal and pelvic imaging of these patients is also warranted.

Health Tip: Treating Bunion Pain

If you've got a painful, swollen bump at the base of your big toe known as a bunion, you probably want to know what can be done for relief.

The American Podiatric Medical Association offers these possible options:

• Apply a non-medicated bunion pad.
• Wear comfortable shoes with plenty of room in the toes, and a low heel.
• Apply an ice pack over the bunion when it becomes swollen, red or painful.
• Tape up the foot to help keep the toe in position.
• Take an anti-inflammatory medication to ease swelling and pain. Ask your podiatrist if you're a candidate for a cortisone injection.
• Use orthotic shoe inserts to help keep the feet in better alignment

epidural steroid injection

What is an epidural steroid injection?

An epidural steroid injection is a common procedure to treat spinal nerve irritation that is caused by tissues next to the nerve pressing against it. The beginning of the nerve (nerve root) is most often irritated by an inflamed intervertebral disc, or disc contents, directly touching the spinal nerve.

[Drawing of a disc herniation compressing the spinal nerve root]

An epidural steroid injection involves bathing an inflamed nerve root in steroids (potent anti-inflammation medicine) in order to decrease the irritation of the nerve root that is causing pain.

How is an epidural steroid injection performed?

The epidural steroid injection procedure is quick and simple. While it is common for people to be concerned prior to the procedure, it is actually frequent to hear from patients afterwards: "Is that all?"

The spinal cord rests in the spinal canal. The nerve roots branch out from the spinal cord at each level of a spinal vertebra (the bony building blocks of the spine). The cord is protected by cerebrospinal fluid (CSF), which serves as a shock absorber for the cord. The CSF is held in place by a membrane with several layers, one of which is called the dura, from the Greek for tough (think of "durable"). The Greek word "epi" means "outside of." So, the epidural space is outside of this tough membrane. During an epidural steroid injection, a needle and syringe are used to enter the epidural space and deposit small amounts of long-lasting steroids around the inflamed spinal nerve. A fluoroscope (a viewing instrument using X-rays) is used to visualize the local anatomy during the injection. The epidural steroid injection specifically targets the inflamed area and treats it with a maximal amount of steroids, thereby minimizing exposure of the rest of the body to the steroids.

[Epidural steroid injection with injection needle visible in the epidural space using a fluoroscope)

When are epidural steroid injections used?

Epidural steroid injections are most commonly used in situations of radicular pain, which is a radiating pain that is transmitted away from the spine by an irritated spinal nerve. Irritation of a spinal nerve in the low back (lumbar radiculopathy) causes pain that goes down the leg. Epidural injections are also used to treat nerve compression in the neck (cervical spine), referred to as cervical radiculopathy.

How to Cure Infant Fever?

A normal body temperature ofa baby should be about ninety eight degrees Fahrenheit. If it becomes one degree to three degrees above its normal value, then it is considered asa fever. An infant’simmune system is not fully formed and not as efficient in fighting off infections especially on the first few months of the baby’s life. This is the reason why it is very important to learn how to accurately take a baby’s temperature. In case it gets higher than the normal temperature, you need to know how to cure infant fever.

Fever can be caused by a lot of things. However, more often than not, fever is caused by an infection. When the body’s immune system perceives a ‘trespasser’ like a certain bacteria or virus, a chemical message is transmitted to the brain’s temperature center making the inside of the body hotter than the usual. Sometimes, it is better to be thankful if a baby has a fever because it tells us that there may be an infection and that something is wrong.

If a baby is not more than two or three months old, it is crucial that he or she gets a proper medical attention. Fever on babies of four to six months, depending on the gravity, can be well taken care at home. Be sure to keep the appropriate and accurate thermometer, while the digital one is probably much better. If the baby’s temperature spikes up beyond the normal temperature, give your baby plenty of fluids to drink in order prevent dehydration. This also helps in cooling the baby’s body, thereby decreasing the possibility of making the fever even higher. Plenty of rest is also recommended for the child to feel much better afterwards. Ensure that the baby gets plenty of sleep when sick. Moreover, you can keep the room temperature at around seventy to seventy four degrees Fahrenheit as much as possible. This also helps the body temperature cool down. Dressing the baby in light cotton fabric will help the heat escape from the body.

A bath in lukewarm water can also sometimes help lower a fever. Before the bath however, acetaminophen may be given to the child. In the event that the baby is chilled especially after the bath, remember to put on an extra blanket and monitor it closely. As soon as the chills stop, remove the extra blanket to help maintain the temperature of a child. Be mindful of how the medicine is given. Always read the label for instructions.

Taking these steps on how to cure infant fever helps, but if you feel that it is going out of hand, immediately call your pediatrician. Especially if the baby experiences constant vomiting and diarrhea, or a fever that comes and goes for a couple of days, seizures, stomach pains, skin rashes, unusually high pitch crying, sore or swollen joints, wheezing or problems breathing, swelling of the soft spot of the head, and limping or unresponsiveness, it is crucial to take action at once. After all, it is always better to be safe than sorry.

Coughing

Coughing is often caused by allergies. It can also be caused by common colds or sometimes may also be an indication of something even worse.For babies,coughingshould be of a major concern. But, before you freak out, let us consider a few things to understand its nature and at the same time become skilled on how to cure baby cough.

One thing you must remember is that when you hear your baby cough is to listen to how it sounds. Is it a dry cough or does it sounds just like an ordinary one? It is also best to observe the environment. Always check for dusts, smoke, pets, pollen, and plants as it may be an indication of an allergy. Make sure that the floors, cabinets and carpets are always clean and free of pets’ hair and dust.

Before calling a doctor, there are several methods you can try to cure it yourself. Honey is one of them. This is excellent for colds, soothes the throat and even kills certain infections. If honey does not work, you can also try ginger. This is a natural anti-inflammatory that helps relieve chest congestion. This may sound like unique ingredients for a special salad but vinegar can also do the trick. Since vinegar is a natural anti-septic combined with many other properties, it is ideal that you also give it a try. Another thing you can put into the bargain is a mixture of warm water, salt and a pinch of turmeric that your child can gargle every night. This mixture helps kill infection, cure the cough, keep tonsils in healthy shape and add overall immunity against certain bacteria.

In the event that the suggestions above do not work, do not try to use prescription drugs. Cough medicines are not highly advised by physicians because it can sometimes be potentially dangerous especially to infants. Before giving your child any drugs you can by over the counter, consult your doctor first.

It is very important that you observe and keep an eye to symptoms that may persist. A cough that lasts more than a week especially for infants should get a medical attention. Coughs and colds can also be indication of a more serious ailment such as bronchitis, asthma, sinusitis, and cystic fibrosis. If a child is coughing nonstop for twenty to thirty seconds and experiences difficulty in breathing before another non-stop coughingbegins, it can be a sign of whooping cough; which can be dangerous for babies under a year old. Be aware of the symptoms of whooping cough such as runny nose, watery eyes, a mild fever, diarrhea and loss of appetite.

If your baby is less than three months old, do not even try vinegar or honey. Also, if your child is breathing more rapidly than usual or if he looks like he is having a hard time breathing, or has little streaks of blood in the mucus when he coughs up, wheezing, has a fever, or has a chronic illness like heart and lung disease, immediately go to your doctor. During these cases, the best way on how to cure baby cough is to consult the experts as you cannot put the life of your baby on the line.

Chondromalacia Patellae

What is Chrondromalacia Patellae?

Chondromalacia patellae (CMP) results from damage to the cartilage which covers the posterior aspect (back) of the patella (knee cap). This is known as articular cartilage and acts to allow smooth movement and shock absorbtion between the patella and the groove through which it runs (formed by the Femur and Tibia).

The cause of this damage can be either acute or due to a long-standing overuse injury. Acute injuries normally occur when the front of the knee cap suffers an impact, such as falling directly onto it, or being hit from the front. This results is small tears or roughening of the cartilage.

In overuse cases, the cause of the damage is usually repetitive rubbing of part of the cartilage against the underlying bone. In a healthy knee the movement of the Patella across the knee is a gliding, smooth movement. In individuals with CMP, the knee cap rubs against the part of the joint behind it, resulting in inflammation, degeneration and pain. The can be for a number of reasons, but is usually due to the position of the patella itself.

The most common feature of condromalacia patellae is patella mal-tracking. The patella most commonly runs too laterally (to the outside) in the groove. This problem is most regularly caused by muscle imbalances, where the lateral quadriceps muscles and other tissues such as the retinaculum are too tight and the vastus medialis oblique muscle is weak.Other structural problems include Patella alta, which refers to a high patella and patella baja which refers to a low patella.

Chondromalacia patellae is common in young athletes who are often otherwise injury free. Its incidence is also highest in females due to their on average higher Q angle. CMP is also more common in those who have experienced previous traumatic knee injuries such as fractures and dislocations.

CMP is often confused with PatelloFemoral Pain Syndrome (PFPS) as CMP is regularly a result of PFPS. However, they can both occur in isolation.

What are the symptoms of Chondromalacia Patellae?

• A grinding or clicking feeling when straightening the knee (known as crepitus).
• Pain at the front of the knee.
• Pain which is often worse when walking downstairs.
• Pressing down on the knee cap when the knee is straight may be painful.
• Pain when standing after extended periods of sitting (movie-goers knee).
• Minor swelling may be present.

A Sports Injury Specialist or Doctor can:

• Assess the knee joint for pain and function.
• Refer you for x-rays which may confirm the condition. However, standard x-rays are often normal in this condition, although they may rule out other conditions.
• An MRI may be ordered instead of an x-ray as this is more likely to confirm diagnosis.
• Prescribe anti-inflammatory medication such as ibuprofen.
• Refer you to a Physiotherapist to determine and correct the cause of your CMP.
• A Physio will often advise you on a rehabilitation program if the cause of your CMP is muscle imbalance.
• Treatment is very similar to patellofemoral pain syndrome, as in both conditions, patella maltracking is the usual cause.
• They may recommend a knee support which can be worn daily and is easier than taping.
• Surgery is not common although can be a last resort if exercise rehabilitation has not worked. Surgery is via an arthroscopy (key-hole) where the damaged cartilage is removed (shaved off).

Wrist Bursitis

What is wrist bursitis?

A bursa is a small sack of fluid that lubricates where tendons move in joints. If the bursa is subjected to repeated trauma then it can become inflamed and swollen causing pain in the wrist. This can affect people who put weight on their hands a lot e.g. cyclists.

Symptoms include

• Pain in the wrist especially when the wrist is bent back and you put your weight on it.
• A small lump or swelling in the top of the wrist.

What can the athlete do about it

• Rest.
• Apply cold therapy if it is acute or painful.
• Wear a heat retainer or support.
• See a sports injury professional.

What can a sports injury specialist or doctor do?

• Prescribe anti-inflammatory medication.
• Apply ultrasound treatment.
• Aspirate the bursa (stick a needle in and suck out the fluid).

The injury usually dies down after a week or so if it is left to recover.

Sprained Ankle

What is a sprained ankle? A sprained ankle or twisted ankle as it is sometimes known, is a common cause of ankle pain. A sprain is stretching and or tearing of ligaments (you sprain a ligament and strain a muscle). The most common is an inversion sprain (or lateral ligament sprain) where the ankle turns over so the sole of the foot faces inwards, damaging the ligaments on the outside of the ankle. A medial ligament sprain is rare but can occur particularly with a fracture. This happens when the ankle rolls the other way, so the sole of the foot faces outwards, damaging the ligaments on the inside of the ankle. The most common damage sustained in a sprained ankle is to the anterior talofibular ligament shown towards the front of the image opposite. This ligament, as the name suggests, connects the talus (ankle bone) with the fibula (smaller of the two bones in the lower leg). If the sprain is severe there might also be damage to the calcaneofibular ligament (connects the heel bone to the fibula) which is further back towards the heel. This ligament only becomes injured in more severe injuries due to its increased strength and laxity whilst the toes are pointed (a common position for ankle sprains). In addition to the ligament damage there may also be damage to tendons, bone and other joint tissues, which is why it is important to get a professional to diagnose your ankle sprain. If possible an X-ray should be used, as small fractures are not uncommon. Severely sprained ankles, where there are complete ruptures of the anterior talofibular, calcaneofibular and posterior talofibular ligaments, result in dislocation of the ankle joint which are often associated with a fracture. Grades of Severity for Sprained Ankles : Sprained ankles, as with all ligaments sprains, are divided into grades 1-3, depending on their severity: Grade 1 sprain: Some stretching or perhaps minor tearing of the lateral ankle ligaments. Little or no joint instability. Mild pain. There may be mild swelling around the bone on the outside of the ankle. Some joint stiffness or difficulty walking or running. Grade 2 sprain: Moderate tearing of the ligament fibres. Some instability of the joint. Moderate to severe pain and difficulty walking. Swelling and stiffness in the ankle joint. Minor bruising may be evident. Grade 3 sprain: Total rupture of a ligament. Gross instability of the joint. Severe pain initially followed later by no pain. Severe swelling. Usually extensive bruising. Treatment of a Sprained Ankle Treatment of a sprained ankle can be separated into immediate first aid and longer term rehabilitation and strengthening. Immediate First Aid for a sprained ankle: Aim to reduce the swelling by RICE (Rest, Ice, Compression, Elevation) as soon as possible. R is for rest. It is important to rest the injury to reduce pain and prevent further damage. Uce crutches it necessary. Many therapists advocate partial weight bearing as soon as pain will allow. This is thought to accelerate rehabilitation. I is for ICE or cold therapy. Applying ice and compression can ease the pain, reduce swelling, reduce bleeding (initially) and encourage blood flow (when used later). Apply an ice pack or similar immediately following injury for 15 minutes. Repeat this every 2 hours. C is for compression - This reduces bleeding and helps reduce swelling. A Lousiana wrap bandaging technique is excellent for providing support and compression to a recently injured ankle. E is for Elevation - Uses gravity to reduce bleeding and swelling by allowing fluids to flow away from the site of injury. So put your feet up and get someone else to wait on you! Following the initial painful stage, there are other treatments that can help the ankle return to normal as soon as possible. Range of motion exercises such as ankle circles can help to get the ankle moving again, as well as reducing swelling if performed with the leg elevated. The calf muscles often tighten up to protect the joint following a sprained ankle, and so gently stretching the calf muscles can also help to maintain movement at the joint. What can a Sports Injury Specialist do about it? A sports injury specialist will undertake a thorough assessment of the injury so time is not wasted treating the wrong condition. A doctor may prescribe anti-inflammatory medication (e.g. ibuprofen) to help with pain and swelling. Reduce swelling by compression devices or taping techniques. Use ultrasound and laser treatment to reduce pain and inflammation and promote healing. Use cross friction massage to promote healing and reduce scar tissue development. Prescribe a full ankle rehabilitation programme to strengthen the joint and help prevent future ankle sprains.

sprain and a strain

What is the difference between a sprain and a strain?
A sprain is an injury to a ligament. A ligament is a thick, tough, fibrous tissue that connects bones together. Commonly injured ligaments are in the ankle, knee, and wrist. The ligaments can be injured by being stretched too far from their normal position. The purpose of having ligaments is to hold your skeleton together in a normal alignment -- ligaments prevent abnormal movements. However, when too much force is applied to a ligament, such as in a fall, the ligaments can be stretched or torn; this injury is called a sprain.

A strain is an injury to a muscle or tendon. Muscles move your skeleton in an amazing variety of ways. When a muscle contracts it pulls on a tendon, which is in turn connected to your bone. Muscles are made to stretch, but if stretched too far, or if stretched while contracting, an injury called a strain my result. A strain can either be a stretching or tear of the muscle or tendon.

What causes a sprain?
As said earlier, a sprain is caused by a ligament being stretched too far. A common sprain is an injury we often call a 'twisted ankle.' This injury often occurs in activities such as running, hiking, and basketball. People will fall or step on an uneven surface (in basketball this is often another player's foot) and roll their foot to the inside. This stretches the ligaments on the outside of the ankle, called the talofibular and calcaenofibular ligaments.

Sprains are commonly graded according to the extent of the injury. Grade I and Grade II ankle sprains can usually be treated conservatively with treatments such as icing and physical therapy. Grade III ankle sprains can place individuals at higher risk for permanent ankle instability, and an operation may be a necessary part of treatment.

What causes a strain?
Strains are injuries to muscles or the tendons that attach the muscles to your bones. By pulling too far on a muscle, or by pulling a muscle in one direction while it is contracting (called an 'eccentric contraction') in the other direction can cause injuries within the muscle or tendon. Strains can also be caused by chronic activities that develop an overstretching of the muscle fibers.

What activities are common causes of these injuries?
Many sports place participants at risk for sprains and strains; these include football, basketball, gymnastics, volleyball, and many others. These injuries also often occur in normal everyday activities such as a slip on ice, a fall on your wrist, or jamming a finger. Repetitive activities may also cause a sprain or strain.

While not all sprains and strains can be prevented, a few helpful tips can help you avoid this nuisance of an injury:

• Stretch before you workout
• Wear proper footwear for the activity
• Warm up properly before activities
• Do not run on icy or uneven surfaces

What are the symptoms of strain or sprain?
The symptoms of a sprain are typically pain, swelling, and bruising of the affected joint. Symptoms will vary with the intensity of the injury; more significant ligament tears (Grade III injuries) cause an inability to use the affected joint and may lead to joint instability. Less serious injuries (Grade I injuries) may only cause pain with movement.

Swine flu and football

Inter v Barca: Can Mourinho, Swine Flu & Rubin Kazan Down European Champions?

Will we see a huge early Champions League upset for Barça? (Manuel Montilla)

Jose Mourinho, as he is wont to do, has been speaking again. "Only Guardiola and I respected this [Champions League] group. Everyone thought Inter and Barcelona would be first and second and that it would be a stroll in eastern Europe. Butthe other two teams aren't here on holiday and, who knows, they may send one of us to the Europa League and the other one home."

This time however, one gets the feeling that the mischievous Portuguese coach is talking less smack and more sense. The east is rising in Group F, and it could be about to claim two European giants.

Matchday 5's Champions League games in this group pit FC Barcelona against former son Samuel Eto'o and Inter Milan, while in the depths of Russian winter newly crowned champions Rubin Kazan play Dynamo Kyiv. The situation is thus: if Inter Milan grab a win at Camp Nou and Rubin Kazan beat Dynamo, the European champions FC Barcelona go out of the competition as early as the group stage. It would be a huge upset.

Barcelona's task is far from straightforward. Even allowing for the possibility that they beat Inter, if Rubin Kazan win their game Barça would still need something from the final group game in Kiev to guarantee safe passage to the knockout phases. No wonder coach Josep Guardiola is calling on supporters to get fully behind the team on Tuesday.

In order to continue the defence of their Champions League crown past Christmas, Barcelona need safely navigate the following:

Jose Mourinho & Samuel Eto'o

Mourinho's relationship with the Catalan people is as special as his old moniker. But not in a good way. He goads them, they taunt him - everyone is happy in disharmony. Only Jose Mourinho, you feel, would wade proudly onto the Camp Nou turf prior to a crucial Champions League game to soak up the crowd's relentless jeers and boos, waving his arms frantically like a struggling orchestra conductor. He loves it.

The chance to be centre stage in Catalunya once again, this time by helping shove the European champions through the exit door, is highly likely to appeal to his ego. "I want to beat them with all my soul," Mourinho told journalists before Tuesday's game, and quite aside from victory being an appealing string for the coach's managerial bow, his team needs it. A win would send Inter into the next round.

Barça must also securely see off the attacking prowess of their former hero Samuel Eto'o, who Guardiola sold to Inter back in the summer. Eto'o spent five seasons with Barcelona, scoring 109 goals in 144 league appearances including 30 last season. In the Champions League he managed 18 in 43 games, and with goals in two winning finals Eto'o's name is forever etched into Barcelona history.

Now however, he poses a dangerous threat to his former club's current Champions League status. "He [Eto'o] will get the reception he deserves, and he deserves a good one," Guardiola said of his former No9. "The fans understand the player was not responsible for his exit, his coach was." Warm reception or not, Barcelona's defence needs to be on it's toes. Something tells me the Cameroonian hasn't forgotten how to score at the old stomping ground.

Swine flu & injuries

Though Barcelona remain unbeaten in La Liga this season, a string of injuries and a nasty outbreak of swine flu has hindered their recent progress. Deprived several players against Athletic Bilbao last weekend Barça scraped a 1-1 draw, and Guardiola will be without several players against Inter.

With Yaya Toure, Eric Abidal and Rafa Marquez all suffering from the H1N1 virus, swine flu looks to have plonked a massive pork chop in Guardiola's defensive plans for the game. Against Bilbao he lined up with Dani Alves, Gerard Pique, Dmytro Chygrynskiy and Maxwell in defence, and a similar back four will have to deal with Eto'o, Diego Milito and co against Inter.

Barça also have problems in attack with key players Lionel Messi and former Inter hitman Zlatan Ibrahimovic doubtful. Hardly ideal ahead of a must-win game.

The rise of Rubin Kazan

Until they shocked the football world with a 2-1 win at the Nou Camp back in October, few people took Russian champions Rubin Kazan seriously in this competition. But now the Tatarstan outfit hold the keys to Barcelona's Champions Leage destiny in their hands. Rubin took four points from their two meetings with Barcelona. Consequently the Russians sit ahead of Guardiola's side in Group F by virtue of a better head-to-head record. Rubin have a big part to play in the outcome of this group.

Barça's future is still in their own hands at the moment, but if they can't beat Inter at home their progress will most likely depend on how Rubin fare. If Inter win and Rubin beat Dynamo Kyiv it'll all be over for the current European Cup holders.

Rubin Kazan became the first ever Russian team from outside Moscow to win their domestic league more than once last weekend. Having already stunned Barça twice this season they'll be feeling they can now help put the champions out to pasture.

Barcelona’s Rafael Marquez Struck By Swine Flu

Barcelona’s Rafael Marquez Struck By Swine Flu Ahead Of Athletic Bilbao Clash - Report

The Mexican will not feature on Saturday evening and will instead be replaced by youngster Andreu Fontas...

Barcelona confirmed on Friday that Eric Abidal and Yaya Toure are suffering from swine flu, and reports suggest that Rafael Marquez is the third player at the club to succumb to the virus.

According to Marca, the defender woke up on Saturday morning with a fever and is set to undergo a series of tests to determine whether he has become infected with the H1N1 virus.

Though the club have not yet confirmed the reports, the Mexican has been ruled out of Saturday night's game at San Mames against Athletic Bilbao.

Andreu Fontas, a youth team player, will take Marquez's place in the squad for tonight's match. The canterano made his debut for the club this season against Sporting Gijon, when he replaced Gerard Pique in the dying minutes.

Swine flu sidelines Barcelona duo Eric Abidal and Yaya Toure

Barcelona have confirmed defender Eric Abidal has contracted swine flu and midfielder Yaya Toure has shown symptoms of the virus.

Flu bout: Yaya Toure (R), in action against Man City earlier this season, has been hit by the bug

Abidal underwent tests after feeling unwell and developing a fever, and the club doctors diagnosed he is suffering from the disease.

Manchester City target Toure has undergone similar tests after suffering from the same symptoms, but it has yet to be confirmed whether he has swine flu.

'Eric Abidal and Toure Yaya have viral-like symptoms with fever and general discomfort,' a club statement read.

'Relevant tests have been carried out on both players.

'In Abidal's case, these tests confirm he is suffering from swine flu.

'As for Toure, during today it could be confirmed whether these symptoms are also a result of swine flu.

Down and out: France defender Eric Abidal has also been sidelined by the virus

'Nevertheless, he is certainly sidelined for Saturday's match against Athletic Club.

'The medical services are working following the protocols established by the health department isolating the players, carrying out symptomatic treatment and giving appropriate hygienic measures.'

It is a big blow for Barcelona as they have a tough week ahead with a Champions League clash with Inter Milan sandwiched between Primera Liga matches against Athletic Bilbao and second-placed Real Madrid.

osteoporosis

What is osteoporosis?

Osteoporosis is a condition characterized by the loss of the normal density of bone, resulting in fragile bone. Osteoporosis leads to literally abnormally porous bone that is more compressible like a sponge, than dense like a brick. This disorder of the skeleton weakens the bone causing an increase in the risk for breaking bones (bone fracture).

Normal bone is composed of protein, collagen, and calcium all of which give bone its strength. Bones that are affected by osteoporosis can break (fracture) with relatively minor injury that normally would not cause a bone fracture. The fracture can be either in the form of cracking (as in a hip fracture), or collapsing (as in a compression fracture of the vertebrae of the spine). The spine, hips, and wrists are common areas of bone fractures from osteoporosis, although osteoporosis-related fractures can also occur in almost any skeletal bone.

What are the symptoms of osteoporosis?

The osteoporosis condition can be present without any symptoms for decades, because osteoporosis doesn't cause symptoms unless bone fractures. Some osteoporosis fractures may escape detection until years later. Therefore, patients may not be aware of their osteoporosis until they suffer a painful fracture. Then the symptoms are related to the location of the fractures.

Fractures of the spine (vertebra) can cause severe "band-like" pain that radiates around from the back to the side of the body. Over the years, repeated spine fractures can cause chronic lower back pain as well as loss of height or curving of the spine, which gives the individual a hunched-back appearance of the upper back, often called a "dowager hump."

A fracture that occurs during the course of normal activity is called a minimal trauma fracture or stress fracture. For example, some patients with osteoporosis develop stress fractures of the feet while walking or stepping off a curb.

Hip fractures typically occur as a result of a fall. With osteoporosis, hip fractures can occur as a result of trivial accidents. Hip fractures may also be difficult to heal after surgical repair because of poor bone quality.

What factors determine bone strength?

Bone mass (bone density) is the amount of bone present in the skeletal structure. Generally, the higher the bone density is, the stronger are the bones. Bone density is greatly influenced by genetic factors, which in turn are sometimes modified by environmental factors and medications. For example, men have a higher bone density than women. African Americans have a higher bone density than Caucasian or Asian Americans.

Normally, bone density accumulates during childhood and reaches a peak by around age 25. Bone density is then maintained for about ten years. After age 35, both men and women will normally lose 0.3% to 0.5% of their bone density per year as part of the aging process.

Estrogen is important in maintaining bone density in women. When estrogen levels drop after menopause, bone loss accelerates. During the first five to ten years after menopause, women can suffer up to two to four percent loss of bone density per year! This can result in the loss of up to 25 to 30% of their bone density during that time period. Accelerated bone loss after menopause is a major cause of osteoporosis in women.

What are the risk factors for developing osteoporosis?

Factors that will increase the risk of developing osteoporosis are:

• Female gender;

• Caucasian or Asian race;

• Thin and small body frames;

• Family history of osteoporosis (for example, having a mother with an osteoporotic hip fracture doubles your risk of hip fracture);

• Personal history of fracture as an adult;

• Cigarette smoking;

• Excessive alcohol consumption;

• Lack of exercise;

• Diet low in calcium;

• Poor nutrition and poor general health;

• Malabsorption (nutrients are not properly absorbed from the gastrointestinal system) from conditions such as celiac sprue;

• Low estrogen levels (such as occur in menopause or with early surgical removal of both ovaries);

• Chemotherapy can cause early menopause due to its toxic effects on the ovaries;

• Amenorrhea (loss of the menstrual period) in young women also causes low estrogen and osteoporosis; Amenorrhea can occur in women who undergo extremely vigorous training and in women with very low body fat (example: anorexia nervosa);

• Chronic inflammation, due to diseases (such as rheumatoid arthritis and chronic liver diseases);

• Immobility, such as after a stroke, or from any condition that interferes with walking;

• Hyperthyroidism, a condition wherein too much thyroid hormone is produced by the thyroid gland (as in Grave's disease) or is caused by taking too much thyroid hormone medication;

• Hyperparathyroidism, a disease wherein there is excessive parathyroid hormone production by the parathyroid gland (a small gland located near the thyroid gland). Normally, the parathyroid hormone maintains blood calcium levels by, in part, removing calcium from the bone. In untreated hyperparathyroidism, excessive parathyroid hormone causes too much calcium to be removed from the bone, which can lead to osteoporosis;

• Vitamin D deficiency. Vitamin D helps the body absorb calcium. When vitamin D is lacking, the body cannot absorb adequate amounts of calcium to prevent osteoporosis. Vitamin D deficiency can result from lack of intestinal absorption of the vitamin such as occurs in celiac sprue and primary biliary cirrhosis;

• Certain medications can cause osteoporosis. These include long-term use of heparin (a blood thinner), anti-seizure medications phenytoin (Dilantin) and phenobarbital, and long term use of oral corticosteroids (such as Prednisone).

How is osteoporosis treated and prevented?

The goal of osteoporosis treatment is the prevention of bone fractures by stopping bone loss and by increasing bone density and strength. Although early detection and timely treatment of osteoporosis can substantially decrease the risk of future fracture, none of the available treatments for osteoporosis are complete cures. In other words, it is difficult to completely rebuild bone that has been weakened by osteoporosis. Therefore, prevention of osteoporosis is as important as treatment. Osteoporosis treatment and prevention measures are:

1. Life style changes including quitting cigarette smoking, curtailing alcohol intake, exercising regularly, and consuming a balanced diet with adequate calcium and vitamin D;
   
   
2. Medications that stop bone loss and increase bone strength, such as alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista), ibandronate (Boniva), calcitonin (Calcimar), and zoledronate (Reclast);
   
   
3. Medications that increase bone formation such as teriparatide (Forteo).

Lifestyle changes

Exercise, quitting cigarettes, and curtailing alcohol

Exercise has a wide variety of beneficial health effects. However, exercise does not bring about substantial increases in bone density. The benefit of exercise for osteoporosis has mostly to do with decreasing the risk of falls, probably because balance is improved and/or muscle strength is increased. Research has not yet determined what type of exercise is best for osteoporosis or for how long. Until research has answered these questions, most doctors recommend weight-bearing exercise, such as walking, preferably daily.

A word of caution about exercise: it is important to avoid exercises that can injure already weakened bones. In patients over 40 and those with heart disease, obesity, diabetes mellitus, and high blood pressure, exercise should be prescribed and monitored by their doctors. Finally, extreme levels of exercise (such as marathon running) may not be healthy for the bones. Marathon running in young women that leads to weight loss and loss of menstrual periods can actually cause osteoporosis.

Smoking one pack of cigarettes per day throughout adult life can itself lead to loss of 5% to 10% of bone mass. Smoking cigarettes decreases estrogen levels and can lead to bone loss in women before menopause. Smoking cigarettes can also lead to earlier menopause. In postmenopausal women, smoking is linked with increased risk of osteoporosis. Data on the effect of regular consumption of alcohol and caffeine on osteoporosis is not as clear as with exercise and cigarettes. In fact, research regarding alcohol and caffeine as risk factors for osteoporosis shows widely varying results, and is controversial. Certainly, these effects are not as powerful as other factors. Nevertheless, moderation of both alcohol and caffeine is prudent.