Topical treatment of psoriasis: questionnaire results on topical therapy as long-term continuous treatment and use on specific body sites.

BACKGROUND: Currently, no formalized international consensus guidelines exist to direct optimal topical treatment including long-term treatment. OBJECTIVE: In this survey, we aim to examine if and which topicals are used in clinical practice in long-term continuous treatment of psoriasis and how topicals are used in treating specific sites of the body. METHODS: A questionnaire was distributed electronically to dermatologists from the International Psoriasis Council (IPC) representing 26 countries. RESULTS: The top three topicals used across all severities of disease were topical corticosteroids, vitamin D analogs, and potent topical corticosteroids in combination with vitamin D analogs. On locations where the skin is thin, flexural and genital psoriasis, lower potency topical corticosteroids were used, whereas on other sites, in particular in palmoplantar psoriasis, superpotent topical corticosteroids and combination vitamin D analogs/corticosteroids were used. CONCLUSIONS: It is relevant to optimize localized therapy for all severities of psoriasis reconciling disease activity (stable vs. unstable disease), localization of the lesions and the individual patient and his/her perspectives on disease control. Topical therapies are valuable treatments for classical mild disease and may have a position in some patients with more severe manifestations.

Topical treatment of psoriasis: questionnaire results on topical therapy accessibility and influence of body surface area on usage.

BACKGROUND: Topical treatment of mild to moderate psoriasis is first-line treatment and exhibits varying degrees of success across patient groups. Key factors influencing treatment success are physician topical treatment choice (high efficacy, low adverse events) and strict patient adherence. Currently, no formalized, international consensus guidelines exist to direct optimal topical treatment, although many countries have national guidelines. OBJECTIVE: To describe and analyse cross-regional variations in the use and access of psoriasis topical therapies. METHODS: The study was conducted as an observational cross-sectional study. A survey was distributed to dermatologists from the International Psoriasis Council (IPC) to assess topical therapy accessibility in 26 countries and to understand how body surface area (BSA) categories guide clinical decisions on topical use. RESULTS: Variation in the availability of tars, topical retinoids, dithranol and balneotherapy was reported. The vast majority of respondents (100% and 88.4%) used topical therapy as first-line monotherapy in situations with BSA < 3% and BSA between 3% and 10%, respectively. However, with disease severity increasing to BSA > 10%, the number of respondents who prescribe topical therapy decreased considerably. In addition, combination therapy of a topical drug and a systemic drug was frequently reported when BSA measured >10%. CONCLUSION: This physician survey provides new evidence on topical access and the influence of disease severity on topical usage in an effort to improve treatment strategies on a global level.

A data-generated basis for medical ethics education: categorizing issues experienced by students during clinical training.

PURPOSE: To use issues identified by students in order to establish an experience- and evidence-based approach to medical ethics education. METHOD: A total of 628 sophomore and senior students at the State University of New York at Buffalo School of Medicine and Biomedical Sciences were asked to identify incidents during their clinical training that had raised ethical concerns. The sophomores were surveyed during two time periods: 1979-80, and 1991-92 and 1992-93; the seniors were surveyed in 1991-92 and 1992-93. Responses were analyzed and categorized through content analysis. RESULTS: In all, 249 students (45% of the sophomores and 20% of the seniors) responded. The categories of issues identified were professional norms, limits of intervention, defensive shielding of professional colleagues, respect toward patients, communication, and student boundaries (situations where the student feels uncomfortable). The most frequently reported incidents reflected the students' perceptions of lapses in level of care (under- or over-treatment), communication, respect toward patients, and maintenance of professional norms. The seniors and the 1979-80 sophomores reported respect toward patients as an issue less often than did the 1991-92 and 1992-93 sophomores. The seniors most often identified concerns raised over limits of intervention and resource allocation. CONCLUSION: The differences between the responses of the sophomores and seniors tend to support other research suggesting a retardation of moral sensitivity in the course of medical education. It may be that clinical teaching and faculty behavior model values at odds with what is taught in the classroom. Ethics education should focus on issues relevant to students' experience.

The educational effect of clinical rotations in nonindustrialized countries.

BACKGROUND: Rotations by American medical students in foreign countries have been common in US medical schools for nearly half a century. Although anecdotal literature makes claims for the significant educational value of these foreign rotations, neither the nature and educational consequences of these experiences, nor the students' impressions, have been thoroughly documented. METHODS: To document the educational impact of clinical rotations in developing countries, all 30 students at the University of Buffalo who participated in such rotations during a period of 7 years were given a questionnaire to complete. Completed questionnaires (n = 28) were analyzed using content analysis. RESULTS: Students reported increased skill and confidence in the use of knowledge, personal history, and physical as the primary means of diagnosis; students also reported that the rotations contributed to outcomes such as enhanced sensitivity to cost issues, heightened awareness of the importance of public health and preventive medicine, greater appreciation for the role of the family and culture in health and disease, and decreased reliance on technology. CONCLUSIONS: Students who completed clinical rotations in Third World countries reported gaining knowledge and skills in areas which, while important in all medical fields, are of particular concern to the family physician. While no causative relationship can be adduced from this study, the fact that 70% of the students who completed these rotations entered primary care careers suggests at least a reinforcing effect.

Establishing a rural hospital cooperative: a case study.

Rural hospitals have traditionally been the providers of health services in rural areas. In recent years, however, rural hospitals have come under increasing economic and regulatory stress. Rural hospital cooperatives represent a new level of shared management that addresses mutual problems using a horizontal organizational model. In 1987, the Western New York Rural Health Care Cooperative was established by building on fragments of associations that had existed previously. Triggered by an opportunity for grant funding, a major regional cooperative evolved which has demonstrated effective responses to a variety of problems inherent in providing rural health care. Particularly successful programs have such features as a quality assurance plan that uses cooperative-wide peer review, nursing and allied health education, physician recruitment, and the active involvement of a university medical school. This paper is a case study of the development and success of the Western New York Rural Health Care Cooperative.

American medical students broaden their horizons in the Third World.

Every year for several decades some American medical students have been visiting Third World countries in order to participate in the practices there. These experiences have proved invaluable in helping them to work in the USA among minorities having unorthodox views on health and disease.

A university rural teaching practice: a model for collaboration in rural health care.

After nearly two decades of Federal, State and local incentives, primary medical services in rural areas remain for short of target. Numerous demonstration projects supported by public and private funds have had some success but models with both broad replicability and independence of external start-up and/or maintenance support are rare. The Department of Family Medicine at the State University of New York at Buffalo has established a novel collaborative network of public and private organizations to emplace a four-physician rural group practice concurrently accomplishing three major goals: high quality primary and specialty medical services to two medically underserved populations; enriched training opportunities for students, residents, and fellows; and financial viability. Beyond meeting regional needs, however, the components and nature of the collaborative effort indicate reproducibility in many communities throughout the country. To emphasize exportable features we will focus on: opportunities, operational strategies, financial feasibility, training advantages, and impact.

The role of the clergy in community mental health service: a critical assessment.

Efforts to expand mental health manpower have taken three major directions: (1) increased use of consultation, (2) creating entirely new roles, and (3) offering training to persons engaged in roles or occupations presumably at strategic points of contact between the public and the mental health system (clergy, police, hairdressers, and bartenders). In this paper the role of modern clergy is examined along several dimensions in order to provide a more rational basis for determining their true potential as mental health service extenders or gatekeepers. Role aspects examined are: public acceptance, approachability, community stature, role separation, and professional identity. Clergy seem to be both appropriate and available as mental health resources.

The bartender as a mental health service gatekeeper: a role analysis.

Efforts to expand mental health manpower have taken three major directions: (1) increased use of consultation, (2) creating entirely new roles, and (3) offering training to persons engaged in roles or occupations presumably at strategic points of contact between the public and the mental health system. Among such roles are clergy, police, hairdressers, and bartenders. Little effort has been made to analyze systematically this third approach to assess its true utility for mental health service. In this paper the role of the bartender is analyzed along four dimensions: personality component, functional centrality, role distance, and nonperson status. Functional centrality appears as a clear asset. Role distance and nonperson status have mixed value depending on the activity envisioned. These role attributed will be generally incompatible with relationships requiring sustained intimacy but could facilitate initial opening up and revelation of sensitive personal information. The lack of protracted professional socialization poses some risk with respect to obtrussion of personal idiosyncracies.

The mental health gatekeeper role: a paradigm for conceptual pretest. Proposal for a preliminary test of potential effectiveness.

Two of the major themes in the community psychiatry movement have been the employment of new and different types of persons in service roles and the maintenance of clients in the community, whenever possible, with avoidance of institutionalisation. A logical outcome of the combination of these two themes has been an increasing interest in the role of persons with fixed social roles within the community as gatekeepers for actual direct service or appropriate referrals into the mental health service system. Police, clergy and bartenders are among the social roles that have received serious consideration and, in some cases, actual use as points of entry and actual service. Careful analysis of the likely requirements of the gatekeeper role will show, however, that many existing social roles that appear fertile ground for the mental health gatekeeper function are in fact lacking in certain features necessary to such a role. This paper presents five criteria considered important or essential to any conclusion that a given role should be seriously considered for the gatekeeper function. These criteria may serve for a shortcut prior to the investment of money and time and may thus have false and expensive steps in our enthusiastic but often hasty search for innovation.

Mental health training for the middle manager.

Training in administration for middle managers is an important but much neglected area. While middle mangers such as unit chiefs, supervisors, and team leaders have significant administrative responsibilities along with their clinical work, they are seldom trained in administration. The authors describe a program to train full and part time students for middle management positions.