Editorial.
The cosmopolitan nature of current travel practices, as well as significant immigration from endemic areas, has led to increases in the incidence of leprosy. The classic presentation of leprosy usually appears as the indeterminate form, demonstrates hypopigmented macules with a loss of sensation. However, the manifestations can sometimes be quite protean. Sadeghi et al. review the rheumatic manifestations of leprosy with an illustrating case presenting with arthritis. Rheumatic symptoms are common in leprosy patients and may be the presenting manifestations and should be considered in patients with persistent rash and unusual arthritis who have a history of exposure to endemic areas. Significant interest has developed over the past decade in inhibiting cutaneous carcinogenesis with retinoic acid. This has been used as an effective therapy in certain genetically predisposed individuals, including individuals with a DNA repair defect in xeroderma pigmentosa. The molecular mechanisms of retinoids ability to inhibit ultraviolet light induced carcinogenesis have not been determined. Li and co-workers have examined the effect of retinoic acid on ultraviolet light induced programmed cell death (apotosis) as well as expression of the tumour suppressor gene P53. Their studies suggest that retinoic acid does not work on the initiation stages of the cancer development, but may work in the promotion and progression stage. Of more immediate clinical importance, in the Point-Counterpoint section, we have two insightful articles on how physician reimbursement affects patient care. As North American health care continues to evolve, there is constant debate on what model system works best for the ultimate benefit of our patients. Physicians, politicians, and administrators are constantly comparing the United States health care delivery to that of Canada. While no one can accurately predict the future developments in these areas, I think Dr. McElgunn sums the concerns that indeed are applicable on both sides of the border: ".socialized medical system has been of great benefit to patients but the ability of its physicians to continue to carry the system is at or near the breaking point. The ramifications of the issues of access and quality of care are harbingers of a system in turmoil." While these concerns must be dealt with, strong physician input is vital to continuing the effective evolution of our health care system. A vital part of our health care delivery is the increasing use of diagnostic tests. Key treatment decisions and interventions are based on the interpretation of these tests. However, most tests are "imperfect instruments." The article by Binder and Dreiseitl concisely reviews sensitivity, specificity, prevalence, predictive values, and likelihood ratios in a highly informative manner with significant examples. This paper provides a reference with which all physicians should be familiar. Traditionally, Western medicine has focused on a model of disease whereby pathology was regarded as well defined alteration in normal physiology that should respond to appropriate pharmaceutical or surgical interventions. However, in recent years patient focused medicine has become an important aspect of our practices. The concept of health related quality of life has represented an important advance in dealing with these concerns in our treatment of disease. Drs. Price and Harding examine the concept of health related quality of life using the example of a diabetic foot ulcer complications. These types of measures are important to understand, not only in the context of this disease but in the context of any chronic dermatologic condition.
Sauder
DN
Editor-in-Chief, Division of Dermatology, University of Toronto.