HPV type-specific distribution among family members and linen in households of cutaneous wart patients.

BACKGROUND: Common and plantar warts are caused by human papillomaviruses (HPV). Mode of transmission of wart HPVs within families is largely unknown. OBJECTIVE: To demonstrate similarity of HPV type(s) among wart cases, family members and household linen. METHODS: In a cross-sectional study, swabs taken from 123 warts and foreheads of 62 index patients and 157 family members and from 58 kitchen towels and 59 bathroom mats were tested for DNA of 23 cutaneous wart-associated HPV types. Generalized estimating equations (GEE) were used to estimate the chance of detecting the same HPV type as was found in the index patients on the family contacts and on the kitchen towels and bathroom mats. RESULTS: HPV1, HPV2, HPV27 and HPV57 were the most prevalent types in the warts of the index patients. Altogether, 60 (42.3%) of the 142 family members without warts had HPV DNA on their foreheads. When HPV1 and HPV2 were found in the warts, these types were also frequently (>50%) found on the foreheads of index patients and their family members, as well as on the kitchen towels and the bathroom mats. HPV27 and HPV57 were less frequently found (<25%) on foreheads and linen. No associations were found for age, sex and site of HPV DNA presence. CONCLUSION: Dissemination of skin wart-causing HPV types, from wart cases to household contacts and linen, such as kitchen towels and bathroom mats, is more likely for HPV1 and HPV2 than for HPV27 and HPV57. The role of towels and bathroom mats in HPV transmission deserves further investigation.

Developing and validating the Cutaneous WARTS (CWARTS) diagnostic tool: a novel clinical assessment and classification system for cutaneous warts.

BACKGROUND: The clinical appearance of cutaneous warts is highly variable and not standardized. OBJECTIVES: To develop and validate a reproducible clinical tool for the standardized assessment of cutaneous warts to distinguish these lesions accurately. METHODS: Nine morphological characteristics were defined and validated regarding intra- and interobserver agreement. Based on literature and semistructured interviews, a systematic dichotomous assessment tool, the Cutaneous WARTS (CWARTS) diagnostic tool was developed. The validation consisted of two independent parts performed with photographs from the recent WARTS-2 trial. In part A, the CWARTS diagnostic tool was tested by 28 experienced physicians who assessed photographs of 10 different warts to investigate interobserver concordance. In part B, morphological characteristics were validated by masked and independent scoring of 299 photographs by six different observers. Part B also entailed reassessment of the photographs after at least 1 week. The primary outcome measurement was the intraclass correlation coefficient (ICC). RESULTS: Presence of black dots (capillary thrombosis) had the greatest ICC (0·85) for interobserver agreement in part A, followed by arrangement (0·65), presence of border erythema (0·64) and sharpness of the border (0·60). In part B, results were similar for interobserver agreement with presence of black dots having the highest ICC (0·68), followed by border erythema (0·64), arrangement (0·58) and colour (0·55). For intraobserver agreement, presence of black dots had the highest agreement (0·70), followed by presence of border erythema (0·694) and colour (0·59). CONCLUSIONS: Wart phenotype can be reliably assessed using the CWARTS diagnostic tool.

Morphological characteristics and human papillomavirus genotype predict the treatment response in cutaneous warts.

BACKGROUND: Cutaneous warts have a cure rate after therapy of no more than approximately 50%. Recently, we developed and validated a standard assessment tool for warts (Cutaneous WARTS diagnostic tool, CWARTS) based on phenotypical characteristics. OBJECTIVES: To assess whether patient and morphological wart characteristics predict the human papillomavirus (HPV) type in a specific wart and whether these characteristics as well as the HPV type predict a favourable treatment response. METHODS: Photographs were used to score nine morphological wart characteristics using the newly developed CWARTS tool. Genotyping of 23 wart-associated HPV types was performed using the hyperkeratotic skin lesion-polymerase chain reaction/multiplex genotyping assay. The results were correlated with a favourable response to treatment with monochloroacetic acid, cryotherapy or a combination of cryotherapy and salicylic acid. Odds ratios were calculated using logistic regression in a generalized estimating equations model. RESULTS: Black dots (capillary thrombosis) strongly predicted the presence of any HPV type in a wart. From all characteristics tested, the HPV type most strongly predicted the treatment response when the warts were treated with monochloroacetic acid or a combination of cryotherapy and salicylic acid with a significantly decreased treatment response if the warts contained HPVs of the alpha genus (HPV2, HPV27 or HPV57). When cryotherapy alone was used for common warts, HPV type did not play a role, but cryotherapy was less effective in the presence of callus and when the wart was located deeper in the skin. CONCLUSIONS: Morphological characteristics of the warts and the HPV genotype influence treatment outcome and thus potentially influence future treatment decisions for common and plantar warts.

High prevalence of cutaneous warts in elementary school children and the ubiquitous presence of wart-associated human papillomavirus on clinically normal skin.

BACKGROUND: One-third of Dutch primary school children have cutaneous warts; each year around 20% of them seek medical treatment. However, little is known about the epidemiology of the types of human papillomavirus (HPV) causing these warts. OBJECTIVES: To investigate the distribution of cutaneous wart-associated HPV types in three primary school classes by analysing skin swabs taken from warts, and the forehead, hand dorsum and sole of the foot of included children. METHODS: Using the hyperkeratotic skin lesion polymerase chain reaction/multiplex genotyping assay, each swab sample was used to genotype for 23 cutaneous wart-associated HPV types. RESULTS: Thirty-one (44%) of the 71 children had a total of 69 warts, with a maximum of six warts per child. In the wart swabs, HPV2, HPV27 and HPV57, members of Alphapapillomavirus species 4, were most frequently detected (27%, 32% and 14%, respectively), whereas HPV1 was only found in two plantar warts. The prevalence of HPV carriage, detected in swabs of clinically normal skin of the forehead, left hand and left sole was 80%, with the most prevalent types being HPV1 (59%), HPV2 (42%), HPV63 (25%) and HPV27 (21%). CONCLUSIONS: Cutaneous wart-associated HPV types were highly prevalent in primary school children, but did not correlate with the HPV types in warts. In contrast to the existing literature, HPV1 was frequently detected on clinically normal skin but was much less frequent in warts.

Lesional HPV types of cutaneous warts can be reliably identified by surface swabs.

BACKGROUND: Large numbers of HPV types infect the human skin and members from the HPV genera alpha, gamma and mu are associated with cutaneous warts. OBJECTIVES: The aim of this study was to test if the HPV genotypes in swabs of the overlying skin are identical to the types present within these warts. STUDY DESIGN: To this purpose, 25 persons being treated for persistent cutaneous warts were enrolled. Swabs of the overlying skin of the wart were collected from each participant. Additionally, scabs of the wart and deeper portions of the warts were surgically removed. HPV genotyping was performed on all samples using the novel HSL-PCR/MPG assay and the HPV genotyping results were compared. RESULTS: From the 25 wart biopsies one was HPV negative. 15 were positive for HPV27, 3 for HPV57, 2 for HPV2, 2 for HPV1, 1 for HPV3 and 1wart biopsy was positive for both HPV41 and HPV65. Scabs and swabs of the warts both showed identical typing results as the biopsies in 24 of the 25 cases (sensitivity: 96%). CONCLUSIONS: There was an excellent agreement between HPV types in the swabs of the skin that overlies the warts and the biopsies of these warts validating the use of wart swabs for future studies of wart-associated HPV types. HPV27 was highly prevalent (70%) in the in adults of the investigated population of patients with persistent cutaneous warts.

Minor derm ailments: how good is the evidence for common treatments?

Oral flucloxacillin is less effective than local antibiotics for impetigo in limited disease. Topical metronidazole and azelaic acid are effective for rosacea. Betadine is effective for minor infections following partial thickness burns. Terbinafine is effective against fungal infections of the nail. Miconazole is effective against oral thrush.

Warts in primary schoolchildren: prevalence and relation with environmental factors.

BACKGROUND: Warts are very common in primary schoolchildren. However, knowledge on wart epidemiology and causes of wart transmission is scarce. OBJECTIVES: To determine the prevalence of warts in primary schoolchildren and to examine the relation with environmental factors in order to provide direction for well-founded recommendations on wart prevention. METHODS: In this cross-sectional study, the hands and feet of 1465 children aged 4-12 years from four Dutch primary schools were examined for the presence of warts. In addition, the children's parents completed a questionnaire about possible environmental risk factors for warts. RESULTS: Thirty-three per cent of primary schoolchildren had warts (participation rate 96%). Nine per cent had hand warts, 20% had plantar warts and 4% had both hand and plantar warts. Parental questionnaires (response rate 76%) showed that environmental factors connected to barefoot activities, public showers or swimming pool visits were not related to the presence of warts. An increased risk of the presence of warts was found in children with a family member with warts [odds ratio (OR) 1.9, 95% confidence interval (CI) 1.3-2.6] and in children where there was a high prevalence of warts in the school class (OR per 10% increase in wart prevalence in school class 1.6, 95% CI 1.5-1.8). CONCLUSIONS: One-third of primary schoolchildren have warts. This study does not find support for generally accepted wart prevention recommendations, such as wearing protective footwear in communal showers and swimming pool changing areas. Rather, recommendations should focus on ways to limit the transmission of wart viruses within families and school classes.

[Determining the haemoglobin concentration in general practice using the HemoCue method: useful but not completely reliable]. / Bepaling van de hemoglobineconcentratie met de HemoCue in de huisartsenpraktijk: bruikbaar, maar niet volledig betrouwbaar.

OBJECTIVE: To determine whether the HemoCue haemoglobin value measured in fingertip skin puncture blood corresponds to the reference value measured in venous blood. DESIGN: Prospective. METHOD: In two health centres, patients' blood was first drawn from a fingertip skin puncture and the haemoglobin was measured with the HemoCue method (HemoCue B-Haemoglobin AB photometer, Angelholm, Sweden). The same patients were sent to the regional laboratory for laboratory haemoglobin determination. Agreement between the two haemoglobin values was assessed using the method of Bland and Altman. RESULTS: Both haemoglobin measurements were carried out in 58 patients. The mean HemoCue haemoglobin was 8.0 mmol/l (95% CI: 7.6-8.4) and the mean venous haemoglobin was 8.2 mmol/l (95% CI: 7.9-8.6). Of all values, 2 were above the level of agreement of 2 SD and 17 values were above the level of 1 SD. The sensitivity of the HemoCue measurement was 81% (95% CI: 62-100) and the specificity 95% (95% CI: 88-100). In the population investigated, with a prevalence of anaemia of 28%, the predictive value of a positive HemoCue result was 87% and of a negative result 93%. CONCLUSION: According to the test characteristics, the HemoCue is a good device for haemoglobin determination. However, in several cases there is a significant difference between the haemoglobin measured with the HemoCue method and the laboratory haemoglobin value. If a reliable haemoglobin value is needed, a laboratory venous haemoglobin assessment is preferred.

[The practice guideline 'Sore throat' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. / De standaard 'Acute keelpijn' (tweede herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

Compared to the original version and the first revision of the practice guideline 'Sore throat', the second revision by the Dutch College of General Practitioners is clearer and gives practical advice on how to handle. In the Netherlands, most patients who visit their GP due to a sore throat expect antibiotics to be prescribed. Most of these patients will indeed receive a prescription for an antibiotic from their GP. One important lesson included in this guideline for GP daily practice is that it is no longer useful to distinguish between a viral or bacterial cause of the sore throat. Antibiotic treatment is only necessary for severe throat infections. Moreover, most cases of sore throat caused by group A betahaemolytic streptococci will cure spontaneously within one week. It is hoped that this guideline will act as a backup for practicing GPs to enforce critical prescription behaviour.

[Apparent life-threatening event (ALTE) in young children: the importance of recognition of the symptoms]. / 'Apparent life-threatening event' (ALTE) bij kleine kinderen: belang van herkenning van de symptomen.

An Apparent life-threatening event (ALTE) mostly occurs in infants under 6 months of age and can generate considerable anxiety in the parents. In most cases, by the time the child presents in general practice, the general practitioner sees a healthy looking infant and all symptoms have disappeared. There is some discrepancy between the healthy looking child and the alarming history of the event, with an unresponsive, pale or cyanotic, and apparently not breathing child. The general practitioner must take a careful history and perform a thorough physical examination to determine the possible cause of the event and to decide whether clinical observation is necessary. In this article, two cases are presented in which an infant presented to a general practitioner with an ALTE. Clinical observation is indicated in almost all cases of an ALTE, and in 50% of the cases a cause for the event is found. The purpose of the present report is to give the general practitioner information on the practical aspects of the management of infants that have experienced an apparent life-threatening event.

[Early surgery or a wait-and-see policy in lumbosacral radicular syndrome: a randomized study]. / Vroeg opereren of langer afwachten voor het lumbosacraal radiculair syndroom: een gerandomiseerd onderzoek.

OBJECTIVE: To compare early surgery with expectative policy and later surgery if necessary in patients with sciatica that did not resolve within 6 weeks. DESIGN: Randomized multicentre clinical trial (ISRCTN 26872154). METHODS: Patients who had had severe sciatica for 6 to 12 weeks were randomized to early surgery or to prolonged conservative treatment with later surgery if necessary. The primary outcomes were the Roland Disability Questionnaire score, the visual-analogue scale for leg pain score, and the patient's report of their perceived recovery over the first year after randomization. Repeated measures analysis according to the intention-to-treat principle was used to analyse the outcome curves for both groups. RESULTS: A total of 283 patients were included and randomized. Of 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiscectomy after a mean of 2.2 weeks. Of 142 patients assigned to conservative treatment, 55 (39%) still had to undergo surgical treatment after a mean of 18.7 weeks. There was no significant overall difference in disability scores during the first year (p = 0.13). Leg pain lessened more quickly in patients assigned to early surgery (p < 0.001). Patients assigned to early surgery also reported a faster rate of perceived recovery (hazard ratio (HR): 1.97; 95% CI: 1.72-2.22; p < 0.001). In both groups, however, the probability of perceived recovery after 1 year of follow-up was 95%. CONCLUSIONS: The 1-year outcomes were similar for patients assigned to early surgery and those assigned to extended conservative treatment with later surgery if necessary but the rates of reduction of leg pain and of perceived recovery were faster in those assigned to early surgery.

[The practice guideline 'Vaginal discharge' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. / De standaard 'Fluor vaginalis' (eerste herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

The revised practice guideline by the Dutch College of General Practitioners (NHG) on vaginal discharge is intended to offer general practitioners a handle for management of vaginal complaints. Most general practitioners experience uncertainties in daily practice with respect to the diagnosis of vaginal discharge. In most cases history taking and physical examination fails to provide sufficient valuable information to arrive at a definite diagnosis. No further (microscopic) investigation is only permissible in a very obvious infection with Candida albicans. A recent onset of complaints of itching accompanied by white odourless discharge means a 70% chance of an infection with C. albicans. If the general practitioner also finds vulvar or vaginal inflammation and a nonhomogeneous fluor during examination the chance of an infection with C. albicans increases to 90%. In all other cases microscopic investigation is inevitable. This does not reflect an inadequacy of the NHG guideline but is a consequence of the limited diagnostic possibilities to arrive at a precise diagnosis.

[Summary of the practice guideline 'Hearing impairment' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Slechthorendheid' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The Dutch College of General Practitioners recently issued a revised version of the practice guideline 'Hearing impairment'. The modification of the screening for hearing impairment, which now takes place in neonates, has resulted in a much lower number of false-positive diagnoses of perceptive hearing loss than under the previous version of the practice guideline. The expanded diagnostic possibilities for adults, whether or not implemented by the patients themselves, demand an active approach from the general practitioner towards patients with impaired hearing. This guideline helps general practitioners to select patients that will truly benefit from a hearing aid and that will also be more likely to use one. The general practitioner can play an important role by stimulating patients to be referred for a hearing aid.

[Somatoform disorders in general practice: prevalence, functional limitations and comorbidity with anxiety and depression]. / Somatoforme stoornissen in de huisartspraktijk: prevalentie, functionele beperkingen en comorbiditeit met angst en depressie.

OBJECTIVE: To quantify the prevalence of, and functional impairment associated with, somatoform disorders in general practice and their comorbidity with anxiety and depression. DESIGN: Prevalence study. METHOD: In the first phase of a two-stage prevalence study from April 2000 up to December 2001, a questionnaire was completed by 1046 consecutive attendees at general practices, aged 25-79 years (n = 1778). This was followed in the second phase by a standardised diagnostic interview ('Schedules for clinical assessment in neuropsychiatry'; SCAN 2.1) in a stratified sample of 473 patients. In the analyses, the prevalence figures were estimated by weighting back to the original attending population. RESULTS: The prevalence ofsomatoform disorders was 16% (95% CI: 12.8-19.4). Comorbidity of somatoform disorders and anxiety or depression disorders was 3.3 times more likely than would be expected by chance. Somatoform disorders as well as anxiety or depressive disorders were associated with substantial functional impairment. In patients with comorbid disorders, physical symptoms, depressive symptoms and functional limitations were proportionately increased. CONCLUSION: These findings underline the importance of a comprehensive diagnostic approach covering anxiety and depressive disorders as well as somatoform disorders in general practice.

Progression of cerebral white matter lesions is not associated with development of depressive symptoms in elderly subjects at risk of cardiovascular disease: The PROSPER Study.

BACKGROUND: Cerebral white matter hyperintensities on magnetic resonance imaging (MRI) scans have been associated with vascular disease and late-life depression, both in the general population and in psychiatric patients. Therefore, a cerebrovascular etiology for late-onset depression has been hypothesized. However, longitudinal studies on the causal role of white matter hyperintensities in the development of depressive symptoms in elderly adults are lacking. OBJECTIVE: To investigate the relation between white matter hyperintensities and depressive symptoms in elderly subjects at risk of cardiovascular disease. METHODS: In the Dutch sample of the PROSPER (PROspective Study of Pravastatine in the Elderly at Risk of cardiovascular disease) cohort, 527 non-demented elderly, all aged 70 years or older, received a cranial MRI scan and the 15-item Geriatric Depression Scale, at baseline and 33 months (SD 1.6) later. RESULTS: Presence of white matter hyperintensities at baseline was not related to baseline depressive symptoms nor to the development of depressive symptoms during follow-up. Moreover, no association was found between progression of white matter lesion volume and progression of depressive symptoms. CONCLUSION: This longitudinal study does not confirm the involvement of cerebrovascular disease expressed as MRI white matter hyperintensities in the development of depressive symptoms in elderly subjects.