Sex differences in quality of life after stroke were explained by patient factors, not clinical care: evidence from the Australian Stroke Clinical Registry.

BACKGROUND AND PURPOSE: Women may receive stroke care less often than men. We examined the contribution of clinical care on sex differences and health-related quality of life (HRQoL) after stroke. METHODS: We included first-ever strokes registered in the Australian Stroke Clinical Registry (2010-2014) with HRQoL assessed between 90 and 180 days after onset (EQ-5D-3L instrument) that were linked to hospital administrative data (up to 2013). Study factors included sociodemographics, comorbidities, walking ability on admission (stroke severity proxy) and clinical care (e.g. stroke unit care). Responses to the EQ-5D-3L were transformed into a total utility value (-0.516 'worse than death' to 1 'best' health). Quantile regression models, adjusted for confounding factors, were used to determine median differences (MD) in utility scores by sex. RESULTS: Approximately 60% (6852/11 418) of stroke survivors had an EQ-5D-3L assessment (median 139 days; 44% female). Compared with men, women were older (median age 77.1 years vs. men 71.2 years) and fewer could walk on admission (37.9% vs. men 46.1%, P < 0.001). Women had lower utility values than men, and the difference was explained by age and stroke severity, but not clinical care [MDadjusted = -0.039, 95% confidence interval: -0.056, -0.021]. Poorer HRQoL was observed in younger men (aged <65 years), particularly those with more comorbidities, and in older women (aged ≥75 years). CONCLUSIONS: Stroke severity and comorbidities contribute to the poorer HRQoL in young men and older women. Further studies are needed to understand age-sex interaction to better inform treatments for different subgroups and ensure evidence-based treatments to reduce the severity of stroke are prioritized.

Changes in the prevalence of chronic disability in China: evidence from the China Health and Retirement Longitudinal Study.

OBJECTIVES: Chinese adults are the biggest users of healthcare services, and understanding current trends in disability profiles is relevant to planning healthcare workforce infrastructure. We investigated the trends over time for disability and physical functional limitations from 2011 to 2015 among Chinese adults and identified the factors associated with these limitations. STUDY DESIGN: We used nationally representative data from the China Health and Retirement Longitudinal Study (CHARLS); the CHARLS participants were followed up every 2 years as they moved from work to retirement with an emphasis on their health status and functional abilities. METHODS: Participants aged ≥50 years from three waves of the CHARLS were included. Data were collected on physical functioning limitations, disabilities in activities of daily living (ADLs) and disabilities in instrumental activities of daily living (IADLs). Multilevel logistic regression models were used to test for changes and factors associated with limitations and disabilities between 2011 and 2015 adjusting for sociodemographic, medical history and health measures. RESULTS: There were 44,447 eligible participants (mean age: 63 years; standard deviation [SD], 9 years; 51% female). After adjustment, there was no significant increase in reporting of ADLs or IADLs in the 2015 survey compared with the 2011 survey. After adjustment, there was a 26% significant increase in reporting of physical functioning limitations in the 2015 survey compared with the 2011 survey (odds ratio: 1.26; 95% confidence interval, 1.17 to 1.35). Factors associated with ADL disability were being female, being older, minimal education, no alcohol intake in the previous year, falls, fractured hip, feeling depressed and being obese. Factors associated with IADL disabilities were being female, being older, minimal education and feeling depressed. CONCLUSIONS: Chinese health agencies should consider the growing need for sufficient community services infrastructure to maximise independence, particularly in the context of ageing populations.

Protocol for evaluation of enhanced models of primary care in the management of stroke and other chronic disease (PRECISE): A data linkage healthcare evaluation study.

INTRODUCTION: The growing burden of chronic diseases means some governments have been providing financial incentives for multidisciplinary care and self-management support delivered within primary care. Currently, population-based evaluations of the effectiveness of these policies are lacking. AIM: To outline the methodological approach for our study that is designed to evaluate the effectiveness (including cost) of primary care policies for chronic diseases in Australia using stroke as a case study. METHODS: Person-level linkages will be undertaken between registrants from the Australian Stroke Clinical Registry (AuSCR) and (i) Government-held Medicare Australia claims data, to identify receipt or not of chronic disease management and care coordination primary care items; (ii) state government-held hospital data, to define outcomes; and (iii) government-held pharmaceutical and aged care claims data, to define covariates. N=1500 randomly selected AuSCR registrants will be sent surveys to obtain patient experience information. In Australia, unique identifiers are unavailable. Therefore, personal-identifiers will be submitted to government data linkage units. Researchers will merge the de-identified datasets for analysis using a project identifier. An economic evaluation will also be undertaken. ANALYSIS: The index event will be the first stroke recorded in the AuSCR. Multivariable competing risks Poisson regression for multiple events, adjusted by a propensity score, will be used to test for differences in the rates of hospital presentations and medication adherence for different care (policy) types. Our estimated sample size of 25,000 patients will provide 80% estimated power (ɑ>0.05) to detect a 6-8% difference in rates. The incremental costs per Quality-adjusted life years gained of community-based care following the acute event will be estimated from a health sector perspective. CONCLUSION: Completion of this study will provide a novel and comprehensive evaluation of the effectiveness and cost-effectiveness of Australian primary care policies. Its success will enable us to highlight the value of data-linkage for this type of research.

Is health-related quality of life between 90 and 180 days following stroke associated with long-term unmet needs?

PURPOSE: Understanding the relationship between health-related quality of life (HRQoL) and long-term unmet needs is important for guiding services to optimise life following stroke. We investigated whether HRQoL between 90 and 180 days following stroke was associated with long-term unmet needs. METHODS: Data from Australian Stroke Clinical Registry (AuSCR) registrants who participated in the Australian Stroke Survivor Needs Survey were used. Outcome data, including the EQ-5D, are routinely collected in AuSCR between 90 and 180 days post-stroke. Unmet needs were assessed at a median of 2 years and categorised into: health; everyday living; work/leisure; and support domains. Multivariable regression was used to determine associations between the EQ-5D dimensions and the likelihood of experiencing unmet needs and the visual analogue scale (VAS) (rating 0-100) and number of reported unmet needs. RESULTS: In total, 173 AuSCR registrants completed the Needs Survey (median age 69 years, 67 % male; 77 % ischaemic stroke). VAS scores were negatively associated with the number of reported long-term unmet needs [irr 0.98, (95 % CI 0.97, 0 99) p < 0.001]. Having EQ-5D activity limitations was associated with unmet living needs (aOR 4.5, 95 % CI 1.1, 18.8). Requiring living supports at 90-180 days was associated with unmet health needs (aOR 4.9, 95 % CI 1.5, 16.1). Those with pain at 90-180 days were less likely to report unmet health (aOR 0.09, 95 % CI 0.02, 0.4) and support needs (aOR 0.2, 95 % CI 0.06, 0.6). CONCLUSION: Routinely collected HRQoL data can identify survivors at risk of experiencing long-term unmet needs. This information is important for targeting service delivery to optimise outcomes following stroke.

Victorian Stroke Telemedicine Project: implementation of a new model of translational stroke care for Australia.

BACKGROUND: Stroke telemedicine is widely used to treat patients with acute stroke in Europe and North America but is seldom used in Australia. The Victorian Stroke Telemedicine (VST) programme aims to enhance acute stroke care in regional Australia. METHODS: Twelve-month pilot prospective, historical-controlled, implementation cohort study. Emergency Department (ED) at a large regional hospital in Victoria. Patients ≥ 18 years of age arriving < 4.5 h in the ED with a possible diagnosis of acute stroke. Telemedicine consultation by a Melbourne-based stroke specialist. Stroke thrombolysis rate, timelines for clinical processes, discharge outcomes. RESULTS: In the initial 12 month VST implementation, 62 patients arrived < 4.5 h of stroke onset (60% male; median age 75 years). Compared to pre-VST data (n = 58; 52% male; median age 77 years), stroke thrombolysis use increased from 17% to 26% (P = 0.26). Clinical process timelines improved including door to computed tomography time (reduced by 29 min, P = 0.006), and door to needle time (reduced by 21 min, P = 0.21). There was no significant increase in deaths (pre-VST 7% vs VST 10%), or symptomatic intracerebral haemorrhage (n = 1 tPA patient). More patients who received tPA were discharged to home or rehabilitation (pre-VST 33% vs VST 80%, P = 0.02), with significantly fewer transfers to other acute care services. CONCLUSIONS: The VST pilot implementation provides evidence that telemedicine can enhance the quality of acute stroke care in a regional hospital. Expanding VST to 16 regional hospitals, Australia's largest telestroke programme, will allow for a more comprehensive clinical and economic analysis.

Metropolitan-rural divide for stroke outcomes: do stroke units make a difference?

BACKGROUND: Stroke care across Australian hospitals is variable. The impact on health outcomes, in particular levels of disability for patients in rural areas, is unclear. The aim of this study was to determine whether geographic location and access to stroke units are associated with differences in health outcomes in patients with acute stroke. METHODS: Retrospective cohort study of consecutive eligible admissions from 32 hospitals (12 rural) in New South Wales between 2003 and 2007. Health status measured at discharge included level of independence (modified Rankin score: mRS) and frequency of severe complications during hospitalization. Multivariable analyses included adjustment for patient casemix and clustering. RESULTS: Among 2254 eligible patients, 55% were treated in metropolitan hospitals. Stroke unit treatment varied significantly (rural 3%; metropolitan 77%). Age, gender and stroke type did not differ by location (mean age 74, 50% female). After adjusting for age, gender, ethnicity, important risk factors and validated stroke prognostic variables, patients treated in rural hospitals had a greater odds of dying during hospitalization compared with those treated in metropolitan hospitals (adjusted odds ratio (aOR) 1.46, 95% confidence interval (CI) 1.03-2.05). There were no differences in mortality or frequency of severe complications between patients treated in rural and metropolitan hospitals when we adjusted for access to stroke units (aOR 1.00, 95% CI 0.62-1.61). Nevertheless, patients treated in rural hospitals were more dependent (mRS 3-5) at discharge (aOR 1.82, 95% CI 1.23-2.70) despite adjusting for stroke unit status. CONCLUSION: Patients with stroke treated in rural hospitals have poorer health outcomes, especially if not managed in stroke units.

Structural insights into the evolution of the pantothenate-biosynthesis pathway.

Pantothenate is synthesized in bacteria, fungi and plants, and as vitamin B5 is a dietary requirement in animals. The three-dimensional structures of the four Escherichia coli enzymes involved in the production of pantothenate have been determined. We describe the use of comparative analyses of the sequences and structures to identify distant homologues of the four enzymes in an attempt to understand the evolution of the pathway. We conclude that it is likely to have evolved via a patchwork mechanism, whereby the individual enzymes were recruited separately.

The prevalence of common skin conditions in Australian school students: 4 Tinea pedis.

Tinea pedis is a condition that is common, often undiagnosed and frequently inadequately treated. It is reported as being rare in young children, but there are relatively few population-based reports of prevalence. A randomized sample of 2491 students from schools throughout the State of Victoria, Australia, were examined by dermatologists and dermatology registrars, who recorded clinical signs suggestive of tinea pedis, which were then confirmed by fungal culture. The age- and sex-adjusted prevalence of culture-proven tinea pedis was 5.2% [95% confidence interval (CI) 3.58-6.82] increasing with age from 2.1% (95% CI 0.95-3.28) in 4-6 year olds to 9.7% (95% CI 5.21-14.26) in 16-18 year olds. A higher proportion of males (6.0%) had tinea pedis than females (4.3%). Trichophyton mentagrophytes and T. rubrum were the most common dermatophytes isolated on culture. Less than 40% of those with a positive diagnosis had reported on the questionnaire that they had tinea. Of those who reported correctly that they had tinea, 75% had used one or more products to treat their condition, of which more than 40% were classified as unlikely to have any therapeutic effect on tinea pedis. These data confirm that tinea pedis, a potentially transmissible disease, is common in Australian schoolchildren, including those in primary school. There is a need for education programmes in schools on the nature of tinea pedis, the treatment available, and the public health approach to infection control within the school and home environment.

The prevalence of common skin conditions in Australian school students: 2. Atopic dermatitis.

The prevalence of atopic dermatitis (AD) was recorded following examination by dermatologists and dermatology registrars of a random sample of 2491 school students throughout the State of Victoria, Australia. The overall prevalence, based on clinical examination, was 16.3% (95% confidence interval, CI 14.1-18.5), being higher in girls (17.7%; 95% CI 15.0-20.4) than boys (14.8%; 95% CI 11.8-17.8). Using the U.K. Working Party Diagnostic Criteria for AD reduced the prevalence to 10.8% (95% CI 9.3-12.3) with the prevalence in girls 12.3% (95% CI 10.1-14.4) and in boys 9.2% (95% CI 7.1-11.4). The prevalence was highest in 4-6 year olds (18.7% on clinical examination, 11.5% using the U.K. Working Party Criteria), decreasing with increasing age to 11.6% on clinical examination (8. 6% on U.K. Working Party Criteria) among 16-18 year olds. Most of those with AD were classified as having mild disease (54.1%), with 32.1% classified as having minimal and 13.8% as having moderate to severe disease. Over 80% of those who reported on the questionnaire that they had dermatitis that was then confirmed on examination had been using one or more products to treat it. Nearly 90% of these products were classified as efficacious, with medical practitioners being the major source of advice for their use (77%). Pharmacists (8%), family/friends (6%) and others (9%), including beauticians and naturopaths, made up the remainder of the persons from whom those affected had sought advice about their treatment. These data, the first community-based prevalence data on AD published from Australia, confirm that the condition is common among those of school age. There is a need for AD to be included among those conditions that are discussed in health education lessons in schools.

Maryborough skin health survey: prevalence and sources of advice for skin conditions.

A computer-assisted telephone interview survey was carried out in the City of Maryborough to determine the prevalence and sources of advice for self-reported skin conditions. Of the 443 adults contacted, 416 (94%) agreed to participate in the study. One hundred and fourteen people (27%) reported having one or more skin conditions over the past 2 weeks, which included eczema/dermatitis 25.5% (range, 18.1-32.8%; 95% CI), warts 16.1% (9.8-22.4%), acne 16.2% (9.6-22.7%), cold sores 13.1% (7.3-18.9%) and tinea 11.2% (5.9-16.5%). Medical practitioners were the most common source of advice for 49% of skin conditions, followed by family and friends or self-prescribed (25%). Advice from a pharmacist was sought for 19% of skin conditions. Logistic regression analysis showed that those people who reported a moderate to severe inflammatory skin condition, such as dermatitis, urticaria or psoriasis, were most likely to seek advice from their medical practitioner. The type and severity of skin condition were factors which determined where a person sought advice on diagnosis and management.

The prevalence of common skin conditions in Australian school students: 1. Common, plane and plantar viral warts.

Although viral warts are common, their exact frequency in the community is often underestimated and not well recorded. A random sample of 2491 students from schools throughout the State of Victoria, Australia were examined by dermatologists and dermatology registrars to record the prevalence of common, plantar and plane warts. The overall prevalence of warts adjusted for the age and sex of Victorian school children was 22% (95% confidence interval (CI) 20.1-20.7) varying from 12% (95% CI 9.4-15.7) in 4-6 year olds to 24% (95% CI 18.3-30.4) in 16-18 year olds. Common warts were the most frequent (16%) compared with plantar warts (6%) and plane warts (2%). There was no difference in the overall frequency of warts between males and females and there was no difference in frequency between those who had eczema and those who did not. Almost 40% of those found to have warts on examination had indicated on the survey questionnaire that they did not have any of these lesions. Of those who knew that they had warts, only 38% had used any treatment for them. These data, the first community-based prevalence data on warts ever published from Australia, confirm that warts are indeed common. They suggest the need for education programmes in schools on the nature of these lesions and the treatment available.

The prevalence of common skin conditions in Australian school students: 3. acne vulgaris.

The prevalence, severity and disability related to facial acne (comprising acne on the head and neck) was assessed in a randomized sample of 2491 students (aged 4-18 years) from schools throughout the State of Victoria in Australia. Students were diagnosed clinically by a dermatologist or dermatology registrar. The overall prevalence (including 4-7 year olds) was 36.1% (95% confidence intervals, CI 24.7-47.5), ranging from 27.7% (95% CI 20.6-34.8) in 10-12 year olds to 93.3% (95% CI 89.6-96.9) in 16-18 year olds. It was less prevalent among boys aged 10-12 years than girls of the same age; however, between the ages of 16 and 18 years, boys were more likely than girls to have acne. Moderate to severe acne was present in 17% of students (24% boys, 11% girls). Comedones, papules and pustules were the most common manifestations of acne, with one in four students aged 16-18 years having acne scars. Twelve per cent of students reported a high Acne Disability Index score. This tended to correlate with clinical severity, although there was some individual variation in perception of disability. Seventy per cent of those found to have acne on examination had indicated in the questionnaire that they had acne. Of those, 65% had sought treatment, a substantial proportion of which (varying with who gave the advice) was classified as being likely to have no beneficial effect. This is the first population-based prevalence study on clinically confirmed acne published from Australia. The results show that acne is a common problem. They suggest the need for education programmes in schools to ensure that adolescents understand their disease, and know what treatments are available and from whom they should seek advice.

Plasma analysis of alpha-difluoromethylornithine using pre-column derivatization with naphthalene-2,3-dicarboxaldehyde/CN and multidimensional chromatography.

A procedure for the plasma analysis of alpha-difluoromethylornithine (DFMO) has been developed that utilizes pre-column derivatization with naphthalene-2,3-dicarboxaldehyde/cyanide (NDA/CN) in pH 9.2 borate buffer. Selective derivatization of delta-amine of DFMO followed by quenching of the reaction results in the formation of a cyanobenz [f] isoindole (CBI) derivative that is stable for 24 h. Plasma was prepared for derivatization by a single step procedure which resulted in an ultrafiltrate compatible with derivatization and analysis. The DFMO derivative (CBI-DFMO) was separated from plasma interferences by multidimensional chromatography with an analysis time of 28 min. The response for DFMO in plasma was linear over the range of 2.1 x 10(-8) 2.1 x 10(-6) M after derivatization. This procedure encompasses a useful linear range and offers the advantages of minimal sample preparation and production of a stable fluorophor.

Acne in Victorian adolescents: associations with age, gender, puberty and psychiatric symptoms.

OBJECTIVES: This study aimed to examine the associations between the frequency and severity of self-reported acne and age, gender, puberty and psychiatric symptoms in Victorian adolescents. METHODOLOGY: A sample of secondary schoolchildren in Victoria, Australia were surveyed using a computerized questionnaire. Developmental and psycho-social factors associated with acne were recorded and analysed using logistic regression. RESULTS: The Victorian Adolescent Health Survey (1992) recorded the frequency and severity of self-reported acne in 2491 students. Frequency of acne increased with age and pubertal development. For females commencement of menstruation was associated with increased frequency of acne. Asian born male students were less likely to report acne than Australian born males. Acne severity was coded into mild (students reporting acne sometimes on back or face) and moderate (students reporting acne often on face or back). Students reporting moderate acne were more likely to report a high level of psychiatric symptoms and were in the later stages of puberty. CONCLUSIONS: This study confirms an association between the frequency and severity of self-reported acne and stage of pubertal development. It showed also that students reporting moderate acne were more likely to report psychiatric symptoms of depression and anxiety.

Descriptive epidemiology of acne vulgaris in the community.

Acne is a common skin condition. No universally accepted standardized classification system for acne vulgaris exists, although there is a strong need for it. Thus, the clinical definition of acne has been unclear in many studies. The reported prevalence of acne varies from 35 to over 90% of adolescents at some stage. In some studies the prevalence of comedones approaches 100% in both sexes during adolescence. The prevalence of acne varies between sexes and age groups, appearing earlier in females than in males, possibly reflecting the earlier onset of puberty. There is a greater severity of acne in males than in females in the late teens, which is compatible with androgens being a potent stimulus to sebum secretion. The prevalence of acne at a given age has been shown to be highly dependent on the degree of sexual maturity. Acne commonly shows a premenstrual increase in women. Some studies have detected seasonal variability in acne vulgaris, with the colder months associated with exacerbation and the warmer months showing improvement. Other studies have not confirmed these findings. Several studies that have investigated the psychosocial impact of acne have had conflicting results. The prevalence of severe acne has decreased over the past 20 years due to improved treatment. The general prevalence figure for acne may be confounded by treatment and this factor needs to be accounted for when collecting data.

Mycosis fungoides: an Australian experience.

Analysis was undertaken of 107 patients with mycosis fungoides who presented to St. Vincent's Hospital, Melbourne, during 1977-95. The mean age at diagnosis (55 years) was significantly older than the mean age of onset of symptoms (48 years). The mean duration of follow-up was 7.7 years. Urban residence was over-represented in this group of patients and in those with mycosis fungoides recorded at the State Cancer Registry. Eighty-four per cent were diagnosed at Stage I or II of the disease. Presentation with disease more advanced than Stage I was more likely to be found in males. Disease localized only to the trunk accounted for 45% of all patients. The mean number of biopsies prior to diagnosis was 1.4 but two-thirds were diagnosed at first biopsy. Almost 85% of patients had as their initial treatment either PUVA (44.9%), topical steroids (20.6%) or topical nitrogen mustard (18.7%) and 57% received only one or two treatment modalities during the period of the study. Stage at presentation was not related to the likelihood of clearance following treatment, recurrence, progression to a more advanced stage of disease or survival.

Experiences with ARTEMIS--an Internet-based telemedicine system.

ARTEMIS is one of the first systems to exploit the Internet/Intranet technologies for exchanging patient information among health care providers. The primary project goal was to develop and demonstrate a regional telehealth environment specifically to support real-time consultations among health care providers via a computer network, provide secure access to multi-media patient records and discharge summaries, facilitate authentication/digital sign-off, multi-media mail-based referrals, and network-based dictation/transcription. A prototype is deployed in southern West Virginia in a Community Care Network (CCN). The CCN consists of providers, hospitals, clinics, laboratories, that make up one "Virtual" clinic on the "Intranet". ARTEMIS employs new technologies such as Java and JavaScript for the browser, and CORBA-based "middleware" for interoperability at the server-end. Several experiments were designed for evaluating the impact of ARTEMIS on patient care. In this paper we discuss the challenges we faced and the means by which we plan to meet these challenges. We conclude by outlining new thrust areas in which we are concentrating in our next phase of development of ARTEMIS.

The prevalence of seborrhoeic keratoses in an Australian population: does exposure to sunlight play a part in their frequency?

Although seborrhoeic keratoses (SKs) appear to be very common, there are very few studies reporting details of age-specific prevalence, distribution or possible cause. We report details on the frequency, nature and distribution of SKs in 100 Australian adults in the age groups 15-25, 26-50, 51-75 and those aged more than 75 years. There was an increase in prevalence of SKs from 12% of 15-25 year olds to 100% of those aged more than 50 years. The median number of lesions in those with them also increased with age from six per person in 15-25 year olds to 69 per person in those aged more than 75 years. There was no difference in prevalence or numbers of lesions/person between males and females. SKs on exposed areas were more often flat and more than 3 mm in diameter than those on the non-exposed areas. There was a higher prevalence of SKs on the exposed areas than non-exposed areas when taking into account the surface area. The data in this study demonstrate an increased frequency of SKs compared with those reported from the United Kingdom recently and from Australasia in the past, a phenomenon paralleling the changing frequency of skin cancer in these populations. This fact, plus the finding that SKs were more common as a function of skin surface area on the exposed areas of the body, suggests that sunlight may play a part in their development in those people who are predisposed to develop them.

The descriptive epidemiology of tinea pedis in the community.

Tinea pedis is a common inflammatory skin condition due to infection by dermatophyte fungi. A number of epidemiological studies have been completed on the frequency of tinea pedis in the community, particularly sporting and occupational groups and schools. Most studies have focused on small, high-risk populations. These include occupational groups involving manual labour, sporting groups such as swimmers, and those working or living in confined conditions with shared washing facilities, which favour the opportunity for cross-infection. Most studies show that the frequency of tinea pedis is higher in males than females. Tinea pedis infections appear to be least common among children, but do occur, and are commonly misdiagnosed. The difference between clinical disease and confirmed diagnosis by culture is not always clear when statistics of disease frequency have been presented. Clear diagnosis criteria indicating the level of mycologically confirmed diagnosis should be reported in future studies that include statistics on disease frequency. Future epidemiological studies should also aim to be population-based in order to obtain a more complete picture of disease frequency.

The descriptive epidemiology of warts in the community.

Warts are common skin infections caused by human papillomavirus (HPV) and affect most people sometime in their life. A number of epidemiological studies on the prevalence of warts have been completed in schools, various occupational groups, general practices and hospitals. All studies have relied on a subjective measure for the diagnosis of warts. Cross-sectional studies completed in schools have shown the prevalence in children to vary from 2 to 20%. Occupational handlers of meat, poultry and fish have a higher prevalence than other workers. Children and young adults are the groups most affected. Future studies are needed to investigate the true frequency of warts in the community and the likelihood of an individual developing these lesions during his/her lifetime.