Musculoskeletal (MSK) disorders are among the leading reasons why patients consult a family or primary health practitioner, take time off work and become disabled Many of the MSK disorders are more common in the elderly Thus, as the proportion of the elderly increases all over the world, MSK disorders will make a greater contribution to the global burden of disease Epidemiological studies have shown that the spectrum of MSK disorders in developing countries is similar to that seen in industrialised countries, but the burden of disease tends to be higher due to a delay in diagnosis or lack of access to adequate health-care facilities for effective treatment Musculoskeletal pain is very common in the community while fibromyalgia is being recognised as part of a continuum of chronic widespread pain rather than a narrowly defined entity This will allow research to improve our understanding of pain in a variety of diffuse pain syndromes The availability of newer more effective therapies has resulted in efforts to initiate therapy at an earlier stage of diseases The new criteria for rheumatoid arthritis, and the diagnosis of axial and peripheral involvement in spondyloarthritis, permit an earlier diagnosis without having to wait for radiological changes One of the major health challenges is the global shortage of health workers, and based on current training of health workers and traditional models of care for service delivery, the global situation is unlikely to change in the near future Thus, new models of care and strategies to train community health-care workers and primary health-care practitioners to detect and initiate the management of patients with MSK disorders at an earlier stage are required There is also a need for prevention strategies with campaigns to educate and raise awareness among the entire population Lifestyle interventions such as maintaining an ideal body weight to prevent obesity, regular exercises, avoidance of smoking and alcohol abuse, intake of a balanced diet and nutrients to include adequate calcium and vitamin D, modification of the work environment and avoidance of certain repetitive activities will prevent or ameliorate disorders such as osteoarthritis, osteoporosis, rheumatoid arthritis, gout and MSK pain syndromes including low back pain and work-related pain syndromes These prevention strategies also contribute to reducing the prevalence and outcome of diseases such as hypertension, cardiovascular diseases, diabetes and respiratory diseases Thus, prevention strategies require urgent attention globally

Improving musculoskeletal health: Global issues

The ever-spreading incidence of infection with the human immunodeficiency virus (HIV) has introduced a spectrum of unusual, subtle, and often life-threatening lesions that can affect almost every organ and tissue in the body. With the introduction of laboratory serologic evidence of HIV infection, the spectrum of indicator diseases has extended beyond the classic opportunistic infections and Kaposi sarcoma. An analysis of 28 patients in Zimbabwe with focal areas of vascular disease treated during a 4-year period (1989–1993) defined 16 patients ranging in age from 12 to 46 years appropriate for special scrutiny as they evinced none of the usual causes of vascular disease. Twelve of the patients were HIV-positive; in two patients the serologic status was unknown; and two patients were HIV-negative at the time of their presentation. There were special clinical features in this group of patients selected for study: (1) They were young with a mean age of 31 years; (2) they were all indigenous Africans with no evidence of atherosclerosis; and there was (3) rapid development of focal necrotizing vasculitis with aneurysm formation and rupture or (4) slow, progressive development of granulomatous vasculitis. The sites of cardiovascular involvement included the left ventricle; aortic arch; thoracic, thoracoabdominal, and abdominal aorta; and iliac, femoral, gluteal, popliteal, and subclavian arteries. It is inferred that the association between HIV-positive status and arterial aneurysms or fibroproliferative aortic occlusion are causally related and that the principles of vascular surgery can be successfully applied to their treatment.

Pattern of arterial aneurysms in acquired immunodeficiency disease

Arterial aneurysms in patients infected with human immunodeficiency virus: a distinct clinicopathology entity?

An established relationship exists between human immunodeficiency virus (HIV) and the vascular system, which is characterised by clinical expressions of aneurysmal and occlusive disease that emanate from a common pathological process. The exact pathogenesis is currently unknown; attempts to implicate opportunistic pathogens have been futile. Theories converge on leucocytoclastic vasculitis with the vaso vasora as the vasculopathic epicentre. It is thought that the virus itself or viral proteins trigger the release of inflammatory mediators that cause endothelial dysfunction and smooth muscle proliferation leading to vascular injury and thrombosis. The beneficial effects of highly active anti-retroviral therapy alter the natural history of the disease profile and promote longevity but are negated by cardiovascular complications. Atherosclerosis is an emerging challenge. Presently patients are managed by standard surgical protocols because of non-existent universal surgical interventional guidelines. Clinical response to treatment is variable and often compounded by complications of graft occlusion, sepsis and poor wound healing. The clinical, imaging and pathological observations position HIV-associated large-vessel vasculopathy as a unique entity. This review highlights the spectrum of HIV-associated large-vessel aneurysmal, occlusive and atherosclerotic disease in vascular surgical practice.

HIV-associated large-vessel vasculopathy: a review of the current and emerging clinicopathological spectrum in vascular surgical practice.

Healing after dental extractions in men with HIV infection

The experience of surgeons in Africa with patients infected with human immunodeficiency virus (HIV) suggests 5 trends: 1) an increased incidence of surgical sepsis--most commonly in the female genital tract the pleural cavity large joints and the anorectal area--in HIV-infected patients; 2) an increase in surgical tuberculosis of spine bone joints lymph nodes and the peritoneal cavity concomitant with an increased incidence of pulmonary tuberculosis in high-incidence countries; 3) impaired healing of wounds wound breakdown and the development of skin lesions and ulcers; 4) tumors whose aggressiveness is accelerated by HIV infection; and 5) new pathologies such as nonspecific cystitis chronic osteitis and vascular disease. In many cases HIV infection has not been identified until after hospital patients have demonstrated a rapid progressive decline after routine surgery. To date only 1 study has attempted to determine the extent to which HIV infection influences the outcome of surgery. Mortality in an intensive care unit at the University Teaching Hospital in Lusaka Zambia differed significantly between HIV-positive and seronegative patients only in terms of pneumonia; however seropositive patients also have an elevated albeit nonsignificant risk of mortality from severe gynecologic sepsis.

Bayley Ac

Papers

Surgical pathology of HIV infection: lessons from Africa.