BACKGROUND AND OBJECTIVE Cutaneous warts are common in primary schoolchildren; however, knowledge on the routes of transmission of human papillomavirus (HPV) causing warts is scarce. This study... Show moreBACKGROUND AND OBJECTIVE Cutaneous warts are common in primary schoolchildren; however, knowledge on the routes of transmission of human papillomavirus (HPV) causing warts is scarce. This study examines the association between the degree of HPV exposure and incidence of warts in primary schoolchildren to support evidence-based recommendations on wart prevention. METHODS In this prospective cohort study, the hands and feet of all children in grades 1 to 7 (aged 4-12 years) of 3 Dutch primary schools were inspected for the presence of warts at baseline and after 11 to 18 months of follow-up. Data on the degree of HPV exposure included information obtained from parental questionnaires: preexistent warts, warts in family, prevalence of warts at baseline in the class, and use of public places (eg, swimming pools). RESULTS Of the 1134 eligible children, 97% participated; the response rate from parental questionnaires was 77%, and loss to follow-up was 9%. The incidence for developing warts was 29 per 100 person-years at risk (95% confidence interval [CI] 26-32). Children with a white skin type had an increased risk of developing warts (hazard ratio [HR] 2.3, 95% CI 1.3-3.9). Having family members with warts (HR 2.08, 95% CI 1.52-2.86) and wart prevalence in the class (HR 1.20 per 10% increase, 95% CI 1.03-1.41) were independent environmental risk factors. CONCLUSIONS The degree of HPV exposure in the family and school class contributes to the development of warts in schoolchildren. Preventive recommendations should focus more on limiting HPV transmission in families and school classes, rather than in public places. Show less
BACKGROUND: Cryotherapy is effective for common warts, but for plantar warts available treatments often fail. OBJECTIVES: Within a pragmatic randomised controlled trial, we examined whether... Show moreBACKGROUND: Cryotherapy is effective for common warts, but for plantar warts available treatments often fail. OBJECTIVES: Within a pragmatic randomised controlled trial, we examined whether subgroups of common and plantar warts have a favourable natural course or response to treatment based on wart-associated HPV type. STUDY DESIGN: Consecutive patients with new common or plantar warts were recruited in 30 Dutch family practices. Patients (n=250) were randomly allocated to liquid-nitrogen cryotherapy, 40% salicylic acid self-application, or wait-and-see policy. Before treatment, swabs were taken from all separate warts and analysed by a broad spectrum HPV genotyping assay. At 13 weeks, cure rates with 95% confidence intervals of common and plantar warts on intention to treat basis were compared between treatment arms for the different wart-associated HPV types. RESULTS: In total, 7% of swabs tested negative for HPV DNA and 16% contained multiple types, leaving 278 of 371 common swabs (75%) and 299 of 373 plantar swabs (80%) with a single type for analysis. After wait-and-see policy, cure rates were 2/70 (3%, 95% confidence interval 1-10) for HPV 2/27/57-associated common warts, 4/58 (7%, 3-16) for HPV 2/27/57-associated plantar warts, and 21/36 (58%, 42-73) for HPV 1-associated plantar warts. After cryotherapy, cure rates were 30/44 (68%, 53-80), 6/56 (11%, 5-21), and 15/23 (65%, 45-81); after salicylic acid 16/87 (18%, 12-28), 15/60 (25%, 16-37), and 24/26 (92%, 76-98), respectively. CONCLUSIONS: HPV type influenced the natural course and response to treatment for plantar warts. HPV testing potentially optimises wart treatment in primary care. Show less
ABSTRACT: BACKGROUND: Internet-based self-management (IBSM) support cost-effectively improves asthma control, asthma related quality of life, number of symptom-free days, and lung function in... Show moreABSTRACT: BACKGROUND: Internet-based self-management (IBSM) support cost-effectively improves asthma control, asthma related quality of life, number of symptom-free days, and lung function in patients with mild to moderate persistent asthma. The current challenge is to implement IBSM in clinical practice. METHODS/DESIGN: This study is a three-arm cluster randomized trial with a cluster pre-randomisation design and 12 months follow-up per practice comparing the following three IBSM implementation strategies: minimum strategy (MS): dissemination of the IBSM program; intermediate strategy (IS): MS + start-up support for professionals (i.e., support in selection of the appropriate population and training of professionals); and extended strategy (ES): IS + additional training and ongoing support for professionals. Because the implementation strategies (interventions) are primarily targeted at general practices, randomisation will occur at practice level.In this study, we aim to evaluate 14 primary care practices per strategy in the Leiden-The Hague region, involving 140 patients per arm. Patients aged 18 to 50 years, with a physician diagnosis of asthma, prescription of inhaled corticosteroids, and/or montelukast for ≥3 months in the previous year are eligible to participate. Primary outcome measures are the proportion of referred patients that participate in IBSM, and the proportion of patients that have clinically relevant improvement in the asthma-related quality of life. The secondary effect measures are clinical outcomes (asthma control, lung function, usage of airway treatment, and presence of exacerbations); self-management related outcomes (health education impact, medication adherence, and illness perceptions); and patient utilities. Process measures are the proportion of practices that participate in IBSM and adherence of professionals to implementation strategies. Cost-effective measurements are medical costs and healthcare consumption. Follow-up is six months per patient. DISCUSSION: This study provides insight in the amount of support that is required by general practices for cost-effective implementation of IBSM. Additionally, design and results can be beneficial for implementation of other self-management initiatives in clinical practice. TRIAL REGISTRATION: the Netherlands National Trial Register NTR2970. Show less
AIMS: To investigate whether low systolic blood pressure is predictive for increased mortality risk in 90-year-old subjects without heart failure, defined by low levels of NT-proBNP, as well as in... Show moreAIMS: To investigate whether low systolic blood pressure is predictive for increased mortality risk in 90-year-old subjects without heart failure, defined by low levels of NT-proBNP, as well as in 90-year-old subjects with high levels of NT-proBNP. METHODS AND RESULTS: This study was embedded in the Leiden 85-plus Study, an observational population-based prospective study. All 90-year-old participants (n = 267) were included between 2002 and 2004 and followed up for mortality for at least 5 years. Differences in mortality risks were compared between participants with low systolic blood pressure (≤150 mmHg) and high systolic blood pressure (>150 mmHg) within strata of low NT-proBNP (<284 pg/mL for women and <306 pg/mL for men = lowest tertile) vs. high NT-proBNP (middle and highest tertile) at age 90 years. During maximal follow-up of 7.2 years, 212 participants (79%) died. Among participants with low NT-proBNP, low systolic blood pressure gave a two-fold increased risk (hazard ratio 2.0, 95% confidence interval 1.1-3.4) compared with participants with high systolic blood pressure. For participants with high NT-proBNP, low systolic blood pressure provided a 1.7 increased mortality risk (95% confidence interval 1.2-2.3) compared with high systolic blood pressure. CONCLUSION: Low systolic blood pressure is predictive for increased mortality risk in 90-year-old subjects, irrespective of the NT-proBNP level. Therefore, the absence or presence of heart failure as determined by NT-proBNP does not influence the prognostic value of low systolic blood pressure with regard to mortality in the oldest old. Show less
Drewes, Y.M.; Koenen, J.M.; Ruijter, W. de; Dijk-van Dijk, D.D.A. van; Weele, G.M. van der; Middelkoop, B.J.C.; ... ; Gussekloo, J. 2012
BACKGROUND Preventive care traditionally aims to prevent diseases or injuries. For older people, different aims of prevention, such as maintenance of independence and wellbeing, are increasingly... Show moreBACKGROUND Preventive care traditionally aims to prevent diseases or injuries. For older people, different aims of prevention, such as maintenance of independence and wellbeing, are increasingly important. AIM To explore GPs' perspectives on preventive care for older people. DESIGN AND SETTING Qualitative study comprising six focus groups with GPs in the Netherlands. METHOD The focus-group discussions with 37 GPs were analysed using the framework analysis method. RESULTS Whether or not to implement preventive care for older people depends on the patient's individual level of vitality, as perceived by the GP. For older people with a high level of vitality, GPs confine their role to standardised disease-oriented prevention on a patient's request; when the vitality levels in older people fall, the scope of preventive care shifts from prevention of disease to prevention of functional decline. For older, vulnerable people, GPs expect most benefit from a proactive, individualised approach, enabling them to live as independently as possible. Based on these perspectives, a conceptual model for preventive care was developed, which describes GPs' different perspectives toward older people who are vulnerable and those with high levels of vitality. It focuses on five main dimensions: aim of care (prevention of disease versus prevention of functional decline), concept of care (disease model versus functional model), initiator (older persons themselves versus GP), target groups (people with requests versus specified risk groups), and content of preventive care (mainly cardiovascular risk management versus functional decline). CONCLUSION GPs' perspectives on preventive care are determined by their perception of the level of vitality of their older patients. Preventive care for older people with high levels of vitality may consist of a standardised disease-oriented approach; those who are vulnerable will need an individualised approach to prevent functional decline. Show less
