South African Family Practice - Volume 53, Issue 1, January 2011

Osteoporosis is defined as a systemic skeletal disease that is characterised by low bone mass and micro-architectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fractures. Therefore, the diagnosis of osteoporosis is based on measurement of bone mineral density (BMD) using central (axial) dual energy X-ray absorptiometry (DXA), and clinical evidence of a fragility fracture (history or radiological evidence). Osteoporosis is a major public health problem, affecting about 30% of postmenopausal women of Caucasian origin, and 70% of those aged 80 years. The risk factors for osteoporosis include lifestyle factors, genetic/ethnic factors, specific diseases causing secondary osteoporosis, ageing factors, qualitative factors, and drugs that are toxic to bone. In addition, there are specific additional risk factors for falls that need to be considered. It is well established that lifestyle factors, including physical activity, nutritional intervention, psychosocial intervention, smoking cessation and other lifestyle factor interventions are key elements in the prevention and management of osteoporosis. Guidelines for these lifestyle interventions in the prevention and management of osteoporosis are reviewed.

The choice of continuing professional development (CPD) articles in this issue is diverse, but they are all common conditions encountered by family practitioners from time to time.

Burning mouth syndrome (BMS) is a chronic condition characterised by a burning sensation of the tongue and other sites, usually without associated clinical or laboratory findings. These patients, mainly postmenopausal women, often present with dry mouth (xerostomia) and taste alterations. BMS may present in an idiopathic (primary) form or in association with local or systemic abnormalities (secondary). A detailed history and oral examination are important to help direct patient management.

Familial hypercholesterolaemia (FH) is a monogenic disorder of low-density lipoprotein (LDL) metabolism. It is characterised by markedly elevated LDL cholesterol, autosomal dominant inheritance, premature cardiovascular disease and tendon xanthomata. FH is a genetically heterogeneous disorder, but the most common underlying molecular cause is mutation of the LDL receptor gene. The worldwide prevalence of FH is 1:500. South Africa has three founder populations in which the prevalence of FH may be as high as 1:70. FH is diagnosed clinically, but the diagnosis can be confirmed by DNA analysis. DNA testing cannot always identify the causative mutation because there are several genes to examine and more than 1 500 different mutations have been identified in the LDL receptor alone. Statins are the treatment of choice for patients with FH. Ezetimibe or cholestyramine can be added if additional LDL lowering is required, or if patients are unable to tolerate high statin doses.

A wide variety of anatomical structures can be involved in a sports injury. To return to play as soon as possible is of utmost importance to an athlete, and in order to achieve this, a correct, all-inclusive diagnosis, a well-focused treatment plan, and a management plan that strives to offer protection are essential.

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This article aims to give an overview of acute and overuse (chronic) sports injuries in adults, the approach to an accurate diagnosis and the management strategies that are available.

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A literature review was conducted of scientific journals, text and internet material, including a Medline and PubMed search. Literature was selected for its in-depth data and well-researched information. Key search terms included "acute and overuse injuries", as well as "sports injuries diagnosis and management" to address current and relevant scientific data on the examination and management of sports injuries in adults.

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The literature review indicated that sports injuries (both acute and overuse) are increasing in number due to the growing interest in physical activity and sport, as well as the enhanced intensity of training programmes. Adults are vulnerable to both types of sports injuries, and the age of occurrence of overuse injuries varies in competitive and non-competitive athletes. The importance of making an accurate diagnosis cannot be overemphasised. To assist the clinician in making an accurate diagnosis, a comprehensive history, physical examination and appropriate special investigations are mandatory. Familiarity with the demands of the athlete's sport may also prove useful. The approach to the management of acute and overuse injuries differs, with the emphasis in acute injuries being on treating the effect (torn, broken, displaced) and in chronic injuries on treating the cause (intrinsic or extrinsic). There have been numerous advances in the management of sports injuries, however further research is still warranted in this area. Follow-up articles will focus more in-depth on specifics with regard to clinical examination, special investigations and management options.

Hypertension is a major risk factor for cardiovascular disease, but it is also very prevalent in the community. These two factors combined prompted the World Health Organization (WHO) to report that high blood pressure is the first cause of death worldwide. The prevalence of hypertension has been estimated to be approximately one in four, and this increases with age to such an extent that almost two-thirds of people over the age of 60 years have hypertension.

Impetigo is a contagious, superficial bacterial infection of the skin, most frequently encountered in children. Causative organisms are almost always Staphylococcus aureus or streptococci, or a combination of the two. Predisposing factors are nasal and perineal colonisation, overcrowding, poor personal hygiene, minor skin trauma and pre-existing skin diseases with disrupted skin barrier function, like eczema. Infection is mainly acquired through contact with sufferers or nasal carriers. Treatment should be given to avoid spread of the disease, and to minimise the risk of infecting others. Although the majority of cases of impetigo are self-limiting, under certain circumstances complications like toxic shock syndrome, staphylococcal osteomyelitis, septic arthritis and pneumonia can occur. Furthermore, certain strains of group A ß-haemolytic streptococci causing impetigo may result in poststreptococcal glomerulonephritis, just like streptococcal throat infections can result in rheumatic fever in children, but the pathogenesis remains poorly understood. It appears to be due to abnormal immune response or hypersensitivity to streptococcal antigens.

Although pregnancy and childbirth are natural processes, many women suffer poor health and even death as a result of the process of becoming a mother. This is particularly true of the developing world. In South Africa, the notification of maternal deaths is required by law and the National Committee for the Confidential Enquiry into Maternal Deaths regularly reports on the causes of these deaths, and makes recommendations in an attempt to improve the situation. The first report was published in 1997. The latest report covers the period 2005-2007 and makes for sad reading.

Aim: The main purpose of this study was to determine whether general practitioners (GPs) in the Cape Town metropole have sufficient knowledge to diagnose and treat primary care ophthalmic conditions correctly, and to assess their own perceptions of their levels of knowledge. Secondary objectives included identifying the need for courses to improve the ophthalmic knowledge of GPs and assessing whether there is a need to revise the undergraduate curriculum in ophthalmology in general.

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Method: A cross-sectional survey was done. A questionnaire of 10 primary care level ophthalmology questions, including a self-assessment section, was sent to each of 140 randomly chosen GPs in Cape Town.

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Results: A response rate of 79.2% was obtained. Respondents included graduates from all eight medical schools in South Africa. Most of the responding GPs were practising for more than 10 years (78.2%). The mean test score was 52.5% (standard deviation [SD]: 22.2). The mean self-rating was 51.9% (SD: 14.5). There was no statistically significant difference between the test score and the self-rating score (p = 0.5840). Responding GPs felt that there is a need for ophthalmology up-skilling courses and 99.9% of them would attend such courses. Also, 82% of GPs felt that primary care doctors, not optometrists, should deliver primary eye care.

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Conclusion: GPs appear to lack sufficient knowledge to manage primary health eye care problems, presumably due to a lack of adequate training in the field. Clinical up-skilling courses are needed to improve core knowledge in ophthalmology.

Background: Caregivers, when providing care under the community home-based care (CHBC) programme, experience many burdens of a physical, emotional, financial or social nature. However, these problems are hardly ever considered by the planners of CHBC programmes. A comprehensive overview of the experiences of caregivers is desirable to help policy makers and public health planners formulate intervention measures to address caregivers' burdens.

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Methods: The sample size calculator programme that allows for 95% confidence (and an error margin of 4%) was used: the estimated sample size for the study was 272. This number was derived from the eight sampled CHBC groups using probability proportional to size. Simple random sampling was employed in identifying the specific caregivers to be interviewed. Questionnaires were administered on this selected sample at their homes or CHBC headquarters by trained research assistants who ensured that all ethical considerations were observed. In the end, 169 caregivers responded within the study period.

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Results: The study shows that very little support is given to caregivers. In addition, while men's burdens are mainly economic, those of women are overwhelmingly emotional. Furthermore, there is an insignificant association between caregivers' expected and received support while providing care to people living with HIV/AIDS.

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Conclusion: The study concludes that, to reduce caregivers' burdens, a comprehensive CHBC programme, that will ensure that the role of CHBC caregivers is adequately recognised by the government and community, is needed.

Background: Sexually transmitted infections (STIs) are among the most common infectious diseases in the world today. There are few reliable statistics on the true prevalence of STIs in developing countries, especially in the general practice setting, hence the need to determine the prevalence in each locality. With the scourge and pandemicity of human immunodeficiency virus (HIV) and the fact that STIs are recognised as independent risk factors for its transmission, determining the risk profiles for STIs has become paramount. The aim of this study was to describe the pattern of STIs among patients attending a Nigerian general practice (GP) clinic.

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Methods: This was a descriptive, cross-sectional, hospital-based study. Consenting patients were recruited serially between February and April 2006 until the sample size of 415 was reached. Subjects' genital symptoms were considered according to the four common STI syndromes according to National AIDS/STD Control Programme guidelines.

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Results: The age range of the subjects was 15 to 95 years (mean 45.16 years, standard deviation 18.83 years, median 44 years). The median age at coitarche was 21 years while the median age at marriage was 25 years. The prevalence rates of current, past and lifetime STI were 18.8%, 22.4% and 32% respectively. Only 28 (6.8%) study subjects had laboratory evidence of STIs at the time of study. Previous sex with a commercial sex worker, previous history of STIs, premarital sex, first intercourse before or at 21 years of age and multiple sexual partners were significantly associated with STIs. Previous history of STIs was a strong predictor of current STI in this study while premarital sex and previous sex with a commercial sex worker were strong predictors of past STI. The frequency of HIV infection among subjects with STIs was more than double that of the control and a co-infection rate of 17.9% was found.

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Conclusions: The findings of this study indicate a high prevalence of STIs in the study community in association with prevailing high sexual risk behaviours, hence the need for reliable control programmes targeting the latter.

Background: A growing body of literature supports the view that people infected with HIV suffer significant pain and that pain is not well recognised or managed by health care professionals. This study investigated the prevalence, severity, recognition and management of pain in adult patients with HIV infection in a South African hospital setting.

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Methods: The Brief Pain Inventory (BPI) (short form) questionnaire was administered to 100 consecutive, consenting HIV-positive patients admitted to an urban district-level hospital in KwaZulu-Natal. Convenience sampling was employed with participants recruited on consecutive days. Data sources comprised patient interviews and review of hospital records. A Pain Management Index derived from the BPI was calculated to establish the adequacy of pain management. Descriptive statistics were tabulated for the recognition of pain, pain severity and appropriateness of analgesia. Correlation analyses were used to assess the association between pain and daily life.

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Results: Ninety-one per cent of participants reported pain with 83% experiencing significant pain, in other words a "worst pain" rating of five or above on the BPI (short form) questionnaire. The correlation analysis between the severity of pain and its interference with daily life suggests that moderate and severe pain interferes with the patients' daily functioning. Pain was documented on 71% of the patients' medical charts that were reviewed; however, only 34% were considered to be adequately managed for their pain.

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Conclusion: Pain prevalence is high in the sample. While pain was recognised and noted in the majority of patients' medical records, the management of pain was considered to be inadequate in a third of those experiencing pain.

Background: Most children and adolescents recover fully from injuries. However, permanent disabilities may occur. The objective of the study was to investigate the prevalence and profile of injuries in children and adolescents five to 19 years of age seen at the emergency department of the National District Hospital in Bloemfontein.

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Methods: A retrospective descriptive study was conducted. Demographic and injury-specific information obtained from hospital records of 2006 was entered into a data-capturing form. Data were analysed by using descriptive statistics.

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Results: The prevalence of injuries in this age group was 20.3%. Two hundred and nine records were investigated. The majority of cases were male (68.3%). The median age was 15 years, and 43.5% of injuries occurred in the age group 15 to 19 years. Approximately half (51.7%) were Afrikaans-speaking and resided in suburban areas (50%). Most injuries occurred at home (40.2%) between 12h00 and 17h00 (38.7%). Falls (33.7%) were the most common cause of injury. Soft tissue injuries (35.9%) occurred most commonly, followed by lacerations (33.0%) and fractures (16.7%). Upper limb injuries (42.1%) were seen more than lower limb injuries (27.8%). Facial injuries occurred in 12% of cases. X-rays were performed in 57.9% of cases. Most patients (93.3%) received medication, while 22% were referred for specialist treatment. All cases except one were discharged from the emergency department. Parents accompanied patients in 65.6% of cases.

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Conclusions: Optimal treatment should be given to the injured child or adolescent to avoid possible long-term injury-related sequelae. Preventive strategies should be formulated, enforced and evaluated.

Purpose: In South Africa, there has been an increase in illicit drug trafficking and consumption and associated problems since the 1990s. Mitchells Plain in Cape Town is seen as a community battling with crime, gangsterism, unemployment, overcrowding, substance abuse and poverty. This study evaluated the actual prevalence of substance abuse amongst high school students in this community and factors associated with substance use. In particular, the study evaluated the use of tik (crystal methamphetamine), a relatively new drug.

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Method: A cross-sectional study was performed amongst 12 secondary schools in Mitchells Plain; Grade 8 and Grade 11 classes were randomly selected to produce a sample of 438 learners. The students completed an anonymous questionnaire that contained enquiries on substance use, demographic and school performance details, and personal and sexual risks.

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Results: Lifetime and annual prevalence rates were: alcohol (50.6%/41.0%), tobacco smoking (49.7%/36.2%), cannabis (32.1%/21.1%), crystal methamphetamine (9.2%/4.6%), ecstasy (4.4%/2.7%), mandrax (2.1%/0.9%), solvents (3.0%/0.9%) and cocaine (0.9%/0.9%). Illicit substance use was significantly associated with age (OR 1.6; CI 1.2-2.2), substance use by other members of the household (OR 2.8; CI 1.2-6.3), carrying a knife (OR 10.9; CI 4.2-28.8), attempted suicide (OR 3.7; CI 1.4-9.5) and higher sexual risk (OR 1.6; CI 1.2-2.3).

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Conclusion: The prevalence of substance use amongst adolescent students attending high schools in Mitchells Plain, Cape Town, is high for all substances relative to national and international figures. Government officials, educators and health care workers are alerted to the need for more comprehensive interventions to prevent and treat substance abuse in this and similar communities.

To the editor: Interest in economic evaluation of health care and medical technologies has increased substantially during the past decade, which is reflected in the growing literature. However, there has been little research devoted to understanding the demand side of economic evaluations, e.g. attitudes toward pharmacoeconomics among decision makers and actual use patterns.

I was supervising an intern recently and we were examining a two-week-old baby when the intern noticed me hovering close to the baby's abdomen and asked me what I was doing. I said I was smelling the baby's umbilicus. She said she had never seen or heard of anyone doing that before.