Two considerations for patients with psoriasis and their clinicians: what defines mild, moderate, and severe psoriasis? What constitutes a clinically significant improvement when treating psoriasis?

The definitions of psoriasis severity and clinically significant improvement in psoriasis are used to classify treatments, obtain Food and Drug Administration approval, and determine product labeling and reimbursement. The Medical Advisory Board of the National Psoriasis Foundation has addressed these issues because of their importance in the clinical trials that are conducted to gain FDA approval of indications. Narrow indications, which are without a sound rational basis, will-in this era of constant oversight by third party payers-affect physicians' ability to manage patients with psoriasis. Body surface area (BSA) is usually used to define severity for clinical trials. It is not optimal for defining psoriasis severity because there are some patients with low BSA involvement who have very severe psoriasis and some patients with high BSA involvement who have mild psoriasis. We conclude that a quality of life (QOL) standard is better than BSA measurement for identifying patients with severe psoriasis. The second issue is what defines clinically significant improvement for patients with psoriasis. Setting an arbitrarily high criterion of clinical efficacy for new psoriasis treatments will likely limit the development and approval of useful treatments. To maximize the availability of useful psoriasis treatments, it is our thesis that psoriasis treatments should be approved when they have been shown to produce a statistically significant level of improvement in well-designed clinical trials.

Value measurement in health care: a new perspective.

Vital to the success of any healthcare organization is the ability to obtain useful information and feedback about its performance. In particular, healthcare organizations need to begin to understand how non-value-adding work activities detract from their bottom lines. Additionally, financial managers and information systems need to provide data and reports throughout the continuum of care. Overall, healthcare organizations must align the management information and control systems with the planning and decision-making processes. The horizontal information system is a tool to manage three common problems facing today's healthcare managers: (1) the use of existing information to focus on control rather than improve business, (2) failure to focus on satisfying the customer, and (3) failure to combine their efforts with those of the employees by developing trust and a common focus.

Relevance of water quality to broiler and turkey performance.

Water was tested from 300 broiler farms in Arkansas in cooperation with three integrated poultry companies, each having at least two locations in the state. The turkey study was conducted in cooperation with three integrated turkey companies with samples from 100 turkey farms, although the numbers were not equal among companies. Performance criteria collected were body weight, feed conversion, livability, and condemnation. In the overall analysis in the broiler study, nitrate had a detrimental effect on performance. Calcium was negatively correlated with adjusted conversion; i.e., conversion improved as calcium increased. Magnesium was positively correlated with adjusted conversion, or had an adverse effect on conversion. Dissolved oxygen, bicarbonate, hardness, calcium, and magnesium were all positively correlated with adjusted weight but nitrate was negatively correlated with adjusted weight. Calcium and potassium were negatively correlated with livability and calcium and nitrate were positively correlated with condemnation. The bacterial results showed no significant difference between top and bottom producers for either Pseudomonas or Escherichia coli. In the turkey study, calcium, magnesium, bicarbonate, hardness, and aggressive index were beneficial to feed conversion. Phosphate and ammonia were detrimental to feed conversion. Calcium, magnesium, dissolved oxygen, zinc, hardness, and aggressive index were all positively correlated with adjusted body weight. Magnesium was negatively correlated with livability. Magnesium and aggressive index were positively correlated with condemnation and potassium, zinc, nitrate, and phosphate were negatively correlated with condemnation. Although fewer farms were involved in the turkey study, the results generally support the results of the broiler study.

Feed and water consumption, growth, and mortality of male broilers.

Daily feed use, water use, body weight, and mortality of Cobb x Cobb male broilers over 8-wk growout periods were measured for 10 consecutive growouts in four commercial-scale broiler houses (121.0 x 12.1 m each). Polynomial equations were developed to relate bird age to body weight, daily feed and water use, cumulative weekly feed and water use, and cumulative mortality. Weekly feed conversion was derived from growth and feed use data and was depicted by a third-order polynomial equation. Dead bird weight was calculated using mortality and body weight of the broilers and related to bird age with three polynomial equations over the growth period. Total dead bird weight averaged 76 kg per 1,000 birds placed, of which 10 kg or 13% occurred during the first 5 wk and the remaining 66 kg or 87% occurred during the last 3 wk of the growout periods. Results of this study provide a realistic data base for mathematical modeling of production responses and a guideline for management planning in commercial male broiler operation.

Nonsteroidal anti-inflammatory drugs.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most widely used medications today. Although their exact mechanism of action is unclear, inhibition of prostaglandin synthesis contributes significantly to their analgesic, anti-inflammatory, antipyretic, and antiplatelet effects. In recent years, additional mechanisms of action have been proposed for NSAIDs, and these may explain the variability commonly noted in patient response and tolerability to individual NSAIDs. NSAID therapy is not without risk, and serious adverse effects involving the gastrointestinal tract, kidneys, blood, and liver have been reported.

Seizures associated with ganciclovir therapy.

A 32-year-old man diagnosed with acquired immunodeficiency syndrome and a disseminated cytomegalovirus infection experienced seizures associated with the administration of ganciclovir. Seizures began 1 month after initiation of therapy and worsened with increasing dosages. Despite phenytoin administration, the seizure-like activity subsided only after discontinuing ganciclovir. After rechallenge with ganciclovir the seizures recurred. Although this case was confounded by numerous patient and disease factors, the Naranjo algorithm produced a score of 7, indicating a probable association between ganciclovir and seizure activity.