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The industry is taking advantage of this momentum by extending the scope of standardization. From simple SOAP-based messaging, we now have gone to standard vendor-neutral ways of providing security, transaction, and guaranteed delivery. In the end, these additional standards are not a luxury but a necessity for a robust IT environment. The success of SOA will depend on them.

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Psoriasis vulgaris Typical plaque psoriasis affects 2% of the population and presents as erythematous, silvery scaling plaques on the elbows, knees, scalp, trunk, and buttocks (Fig. 9.2). The soles and the palms may also be affected; nails may become brittle and discolored. The type of therapy primarily relates to the body surface area of involvement. Limited disease (less than 10 15% of involved body surface area) necessitates topical therapy with solo or combination use of topical steroids, calcipotriene, and tazarotene. Potent topical steroids such as clobetasol or diprolene must be used carefully and for only brief periods of time (less than 1 month). Chronic use of these potent steroids can cause tachyphylaxis, wherein the athlete s psoriasis no longer responds to the previously effective, high strength steroid. More severe disease, as represented by surface area greater than 15%, requires systemic therapy. These therapies include oral retinoids, phototherapy, cyclosporine, methotrexate, and the more recent so-called biologics. The risks and bene ts as they speci cally relate to the athlete must be ascertained; referral to a dermatologist with an appreciation of the level of sporting activity is important. Psoriasis vulgaris is a chronic lifelong disease punctuated by periodic ares; debilitating arthritis can rarely occur.

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A third type of thinking error that may interfere with changing a drug problem is called discounting the positive. When clients engage in this type of thinking error, they generally ignore or refute evidence that supports the idea that positive events or changes are happening to them. Frequently this type of thinking error can be detected in a client s language. You as a therapist may point out something positive to your client in session, but a client engaging in this thinking error may respond by saying, Yes, but. . . . At other times the client may have problems accepting a compliment or may express suspicion when one is given, or may verbally diminish the impact or importance of a positive event. This behavior may cause the client to discount positive or reinforcing experiences related to drug behavior change, which can adversely influence motivation and commitment to continue making changes over time.

for 1 week. A single dose of two 200-mg tablets ketoconazole also clears tinea versicolor; ketoconazole concentrates in sweat so the athlete should exercise after ingestion to increase ef cacy. Repeating this regimen 1 week later further maximize ef cacy. Athletes must acknowledge that while the treatment clears the athlete of the dermatophyte s overgrowth, the light or dark areas on the skin may take months to normalize in color. Athletes can prevent tinea versicolor by wearing synthetic moisture wicking clothing and by using selenium sul de 2.5% once weekly for 10 min before rinsing. Bacterial infections impetigo Multiple sports teams (wrestling, soccer, sea water swimming, rugby and American football) have experienced epidemics of impetigo. Both Staphylococcus aureus and Streptococcus (including nephrogenic Streptococcus [M-type 2]) species can cause impetigo. The clinical presentation depends primarily on the age of the lesion. Very young lesions demonstrate well-de ned, erythematous papules and can be confused with acne vulgaris, atopic dermatitis, folliculitis, herpes gladiatorum, and tinea corporis gladiatorum. Mature lesions demonstrate honey-colored, crusted, erythematous plaques with or without obvious pustules; tense, clear, uid- lled bullae may occur. The lesions occur as a result of skin-to-skin contamination and appear typically on the face and extremities. Lymphadenopathy, pharyngitis, and post-streptococcal glomerulonephritis may also result. Urinalysis and serum complement levels (C3) are indicated if a Streptococcus species is cultured; post-streptococcal nephritis may occur up to 3 weeks after skin infection. The diagnosis of mature lesions is often quite straightforward but in indeterminate lesions and when methicillin-resistant Staphylococcus aureus is suspected cultures should be performed. Cultures of the perianal region and nares may identify Staphylococcus aureus carriage. Clinicians should consider throat cultures to identify chronic streptococcal carriage. Initial therapy is directed at repairing the perturbed stratum corneum; this therapy

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