Traditions Checklist - from the A.A. Grapevine Service Material from the General Service Office These questions were originally published in the AA Grapevine in conjunction with a series on the Twelve Traditions that began in November 1969 and ran through September 1971. While they were originally intended primarily for individual use, many AA groups have since used them as a basi
Advantag of ingestion administration way is its easiness even when applied at home. But with their help necessary treatment concentration in blood cannot be always quickly achieve amoxil online transaction is carried out on anonymity and mutual profit principles, and in addition customers will be positively surprised with quality and speed of service.
Ncfh.orgThis article was downloaded by: [Texas A&M University-Commerce]On: 4 June 2010Access details: Access Details: [subscription number 915581151]Publisher Taylor & FrancisInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Publication details, including instructions for authors and subscription information: Common Skin Disorders Seen in the Migrant Farmworker Health CareClinic Setting Michael Hinckleya; Steven R. Feldmanb; Alan B. Fleischer Jr.a; Quirina M. Vallejosc; Lara E. Whalleyc;Sara A. Quandtd; Judy Hecke; Gonzalo Cabralf; Thanh Brooksf; Mark R. Schulzg; Thomas A. Arcuryca Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NorthCarolina, USA b Department of Dermatology, Department of Pathology, Division of Public HealthSciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA cDepartment of Family and Community Medicine, Wake Forest University School of Medicine,Winston-Salem, North Carolina, USA d Division of Public Health Sciences and Department of Familyand Community Medicine, Wake Forest University School of Medicine, Winston-Salem, NorthCarolina, USA e Walstonburg Clinic, Greene County Healthcare, Inc, Walstonburg, North Carolina,USA f Harvest Family Clinic, Carolina Family Health Centers, Inc, Wilson, North Carolina, USA gDepartment of Public Health Education, University of North Carolina at Greensboro, Greensboro,North Carolina, USA To cite this Article Hinckley, Michael , Feldman, Steven R. , Fleischer Jr., Alan B. , Vallejos, Quirina M. , Whalley, Lara E. , Quandt, Sara A. , Heck, Judy , Cabral, Gonzalo , Brooks, Thanh , Schulz, Mark R. and Arcury, Thomas A.(2008) 'Common Skin Disorders Seen in the Migrant Farmworker Health Care Clinic Setting', Journal of Agromedicine, 12: 4, 71 — 79To link to this Article: DOI: 10.1080/10599240801986272URL: This article may be used for research, teaching and private study purposes. Any substantial orsystematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply ordistribution in any form to anyone is expressly forbidden.
The publisher does not give any warranty express or implied or make any representation that the contentswill be complete or accurate or up to date. The accuracy of any instructions, formulae and drug dosesshould be independently verified with primary sources. The publisher shall not be liable for any loss,actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directlyor indirectly in connection with or arising out of the use of this material.
Common Skin Disorders Seen in the Migrant Michael Hinckley is affiliated with the Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
Steven R. Feldman is affiliated with the Department of Dermatology, Department of Pathology, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
Alan B. Fleischer, Jr, is affiliated with the Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
Quirina M. Vallejos is affiliated with the Department of Family and Community Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
Lara E. Whalley is affiliated with the Department of Family and Community Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
Sara A. Quandt is affiliated with the Division of Public Health Sciences and Department of Family and Community Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
Thomas A. Arcury is affiliated with the Department of Family and Community Medicine, Wake Forest Downloaded By: [Texas A&M University-Commerce] At: 16:15 4 June 2010 University School of Medicine, Winston-Salem, North Carolina, USA.
Judy Heck is affiliated with Walstonburg Clinic, Greene County Healthcare, Inc, Walstonburg, North Gonzalo Cabral is affiliated with Harvest Family Clinic, Carolina Family Health Centers, Inc, Wilson, Thanh Brooks is affiliated with Harvest Family Clinic, Carolina Family Health Centers, Inc., Wilson, Mark R. Schulz is affiliated with the Department of Public Health Education, University of North Carolina at Greensboro, Greensboro, North Carolina, USA.
Funding for this research was provided by grant R01-ES012358 from the National Institute of Environ- Address correspondence to: Steven R. Feldman, MD, PhD, Department of Dermatology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1071(E-mail: [email protected]).
Available online at http://ja.haworthpress.com 2007 by The Haworth Press. All rights reserved.
JOURNAL OF AGROMEDICINE
ABSTRACT. Background: Skin diseases are common occupational illnesses for farmworkers.
Migrant farmworkers commonly access rural health clinics for diagnosis and treatment of skin
Purpose: To assess common skin conditions of migrant farmworkers treated in rural clinics and to describe effective and economic management of these conditions.
farmworkers with a skin condition were seen as patients at 4 clinics in eastern North Carolina. A list ofthe most common conditions encountered was compiled and treatment methods were found in theliterature.
Results: Twenty-three common conditions were identified. The most common conditions were contact dermatitis, melasma, tinea, seborrheic keratoses, and impetigo. A table of treatment rec-ommendations was composed that can be used by clinicians in this setting.
the most common skin conditions seen in the migrant farmworker population in eastern North Caro-lina are similar to conditions found in the general population.
KEYWORDS. Skin disease, primary care, rural, underserved, treatment
medically diagnosed occupational skin diseases,their severity, and skin-related quality of life.
Skin disease among migrant farmworkers is a common health problem, as with the general Sample
population.1,2 However, other factors compli- Recruitment was conducted in 4 community/ cate the dermatologic situation for these farm- migrant clinics in eastern North Carolina. To be workers. Migrant farmworkers have exposures recruited in the study, the participant had to be to chemicals, wild plants, organic and inorganic (1) currently employed as a hired laborer in dust, and fungi with which most of the general farm work (this season), (2) 18 years of age or population will not be in contact.3 Such addi- older, and (3) presenting at the clinic with a pri- tional exposures can result in diverse skin prob- mary or secondary diagnosis of a skin disease lems. Furthermore, language barriers may present (the skin disease did not need to be the patient’s an obstacle to accessing health services.
primary complaint). The total sample included Migrant farmworkers also live in unhygienic 79 farmworkers (53 men and 26 women).
conditions and have limited access to healthservices resulting from low income and lack ofhealth insurance.4–6 Finally, few specialty phy- Data Collection
sicians serve this population, making access to Patient data included a questionnaire, patient specialized dermatologic expertise problematic.
information form, photographs of the affected In light of the factors complicating the health Downloaded By: [Texas A&M University-Commerce] At: 16:15 4 June 2010 area(s), and a dermatologist consult. After the care situation of these workers, the purpose was to patient information form and photographs were assess the most common skin conditions of posted to a secure server by clinic staff, 1 of 2 patients treated in the migrant worker health care board-certified dermatologists reviewed the clinic setting and to provide basic information on information and then posted his consult to the the management of these conditions. These treat- same secure server. The providers reviewed the ment suggestions can provide practitioners and consults and tried to contact participants if patients with simple and cost-effective measures changes to the diagnoses and/or treatments to aid in treatment of these skin conditions.
were necessary. Participants received a cashincentive of $20. Data collection procedureswere approved by the Wake Forest University METHODS
School of Medicine Institutional Review Board.
Treatment options were collected using the The project employed teledermatology meth- PubMed and Google search engines and der- ods among a sample of migrant clinic patients matology textbooks. In 2 cases, the treat- during the 2006 agricultural season to focus on ment for the condition was so basic a personal Case Reports
recommendation was made by one of the authors family physicians in the United States, the most (MRH). In another case, the condition was nonspe- commonly diagnosed dermatologic conditions cific and again a personal recommendation was were quite similar and included dermatitis, pyo- made. Cost of medications was determined using derma, wart, tinea infection, and epidermoid Wal-Mart, Target, and drugstore.com web sites.
cyst.7 Some diagnoses in this study likelyshowed overlap with diagnostic terms used by Data Interpretation
the family physicians in the referenced report.
One would expect that the dermatologic con- compiled. Diagnoses that were considered similar by a board-certified dermatologist were grouped present would tend to be acute disorders, such together, and the appropriateness of the groupings as those causing pain or pruritus, limiting the was reviewed by a second dermatologist. Group- patient’s ability to work. However, the data ings included dermatitis (contact dermatitis, indicate that this is not necessarily the case.
eczema, and dermatitis), tinea (tinea pedis and other tinea), seborrheic keratosis (skin tags and relatively banal, chronic conditions, seen in benign keratoses), and impetigo (bullous impetigo patients who presented for other reasons.
and nonbullous impetigo). Treatment suggestions were also compiled and reference to cost of medi- farmworkers are self-limiting if the patient does cations was noted if possible. Costs were deter- not exacerbate the condition. In an effort to mined using drugstore.com and Wal-Mart’s and self-treat, sometimes the patient can make the condition more severe.8 Latino farmworkershave been reported to self-treat with bleach,alcohol, garlic, lemon juice, salt water, and RESULTS
scratching the lesion and then applying amedicine such as cornstarch.9 These may cause superimposed irritant reactions that may com- were then condensed into 23 diagnostic catego- plicate the presentation and treatment of the ries. One hundred thirty-three treatments were given, including treatments that were repeated.
tious and inflammatory diseases, such as con- disorders seen in the rural health care clinic tact dermatitis (including eczema, dermatitis, for these skin conditions were found in jour- (12.7%), tinea (defined as any dermatophytosis Downloaded By: [Texas A&M University-Commerce] At: 16:15 4 June 2010 conditions did not seem to lend themselves to keratoses (6.3%), and impetigo (including both specific regimens that would be readily found bullous and nonbullous impetigo, 5%). Treat- in the literature and were thus designated.
ment recommendations based on the literature (when readily available) as well as cost of generic and some can be purchased at spe- individual medications are presented for the cific pharmacies which offer a discounted rate on select prescriptions. Where inexpen-sive alternatives are not available, theexpected cost was listed, which will allow the DISCUSSION
provider to better counsel the patient.
One limitation of this study is the relatively small number of participants. While the number encountered in the migrant farmworker clinics is likely not sufficient to define the entire range that were sampled include contact dermatitis, of skin problems seen, it is adequate for identi- melasma, tinea, seborrheic keratoses, and impe- fying the common presenting cutaneous condi- tigo. In a representative sampling of visits to tions. Another limitation is that treatment Downloaded By: [Texas A&M University-Commerce] At: 16:15 4 June 2010 74
e prednisone 40 mg to 80 mg daily for 1 to 2 wee Downloaded By: [Texas A&M University-Commerce] At: 16:15 4 June 2010 75
from the chin down and wash off after 8 to 12 Downloaded By: [Texas A&M University-Commerce] At: 16:15 4 June 2010 76
infected and not responding to topical antibiotic, may Downloaded By: [Texas A&M University-Commerce] At: 16:15 4 June 2010 77
JOURNAL OF AGROMEDICINE
11. Strauss JS, Krowchuk DP, Leyden JJ, et al, and the providers and the suggestions reported herein American Academy of Dermatology/American Academy are not the only way to treat the conditions.
of Dermatology Association. Guidelines of care foracne vulgaris management. J Am Acad Dermatol. Moreover, using only 3 sources to list costs does not provide the complete range of what 12. Batra RS. Acne. In: Arndt KA, Hsu JHS, eds. Man- ual of Dermatologic Therapeutics. 7th ed. Philadelphia, This study provided insight into the common Pa: Lippincott Williams & Wilkins; 2007.
dermatologic conditions found in migrant farm- 13. Wenner KA. Atypical mole. Available at: http:// workers. Despite the different exposures such www.emedicine.com/derm/topic42.htm. Accessed December workers may experience compared to much of the general population, it was noted that many 14. Stevens DL, Bisno AL, Chambers HF, et al, and the Infectious Diseases Society of America. Practice of the same types of conditions were encoun- guidelines for the diagnosis and management of skin tered in a medical clinic. However, the econom- and soft-tissue infections. Clin Infect Dis. 2005; ics of practicing in such a setting differ as some patients may lack insurance. A table has been 15. Curtis DL. Cellulitis. Available at: http://www.
included of treatment regimens and prices of emedicine.com/EMERG/topic88.htm. Accessed December 6, medications that will hopefully benefit the prac- titioners and the farmworkers in this setting.
16. Hogan D. Contact dermatitis, allergic. Available at: http://www.emedicine.com/derm/topic84.htm#section.
Accessed December 6, 2007.
17. Cohen DE, Bassiri-Tehrani S. Irritant contact dermatitis. In: Bolognia JL, Jorizzo JL, Rapini RP, eds. Der- REFERENCES
matology. Vol 1. New York, NY: Mosby; 2003: 241–250.
18. Lamoreux MR, Sternbach MR, Hsu WT. Erythema 1. Krejci-Manwaring J, Schulz MR, Feldman SR, et multiforme. Am Fam Physician. 2006;74:1883–1888.
al. Skin disease among Latino farmworkers in North 19. Al-Johani KA, Fedele S, Porter SR. Erythema Carolina. J Agric Safety Health. 2006;12:155–163.
multiforme and related disorders. Oral Surg Oral Med 2. Villarejo D, Baron SL. The occupational health Oral Pathol Oral Radiol Endod. 2007;103:642–654.
status of hired farm workers. Occup Med. 1999;14:613– 20. Kelly P. Folliculitis and the follicular occlusion tetrad. In: Bolognia JL, Jorizzo JL, Rapini RP, eds.
3. Villarejo D. The health of US hired farm workers.
Dermatology. Vol 1. Edinburgh: Mosby; 2003:553v556.
Annu Rev Public Health. 2003;24:175–193.
21. Satter E, Cyr PR. Folliculitis. Available at: 4. Housing Assistance Council. No Refuge From the http://www.emedicine.com/derm/topic159.htm. Accessed Fields: Findings From a Survey of Farmworker Housing Conditions in the United States. Washington, DC: Housing 22. Patel MJ. Hyperpigmentation and hypopigmenta- tion. In: Arndt KA, Hsu JTS, eds. Manual of Dermato- 5. Gentry AL, Grzywacz JG, Quandt SA, Davis SW, logic Therapeutics. 7th ed. Philadelphia, Pa: Lippincott Downloaded By: [Texas A&M University-Commerce] At: 16:15 4 June 2010 Arcury TA. Housing quality among North Carolina farm- Williams & Wilkins; 2007:111–117.
worker families. J Agric Safety Health. 2007;13:323–337.
23. Crowe MA, Escobar SJ. Keratosis pilaris. Avail- 6. Arcury TA, Quandt SA. Delivery of health ser- able at: http://www.emedicine.com/ped/topic1246.htm.
vices to migrant and seasonal farmworkers. Annu Rev Public Health. 2007;28:345–363.
24. Gupta AK, Gover MD, Nouri K, Taylor S. The 7. Fleischer AB Jr, Feldman SR, McConnell RC. The treatment of melasma: a review of clinical trials. J Am most common dermatologic problems identified by family Acad Dermatol. 2006;55:1048–1065.
physicians, 1990–1994. Fam Med. 1997;29:648–652.
25. McCalmont T. Nevi, melanocytic. Available at: 8. Cathcart S, Feldman SR, Vallejos Q, et al. Self- http://www.emedicine.com/derm/topic289.htm. Accessed treatment of contact dermatitis with bleach in a Latino farmworker. Dermatitis. In press.
26. Crawford F, Young P, Godfrey C, et al. Oral treat- 9. Arcury TA, Vallejos QM, Feldman SR, Quandt ments for toenail onychomycosis: a systematic review.
SA. Treating skin disease: self-management behaviors Arch Dermatol. 2002;138:811–816.
of Latino farmworkers. J Agromedicine. 2006; 27. Choi S. Fungal infections. In: Arndt KA, Hsu JTS, eds. Manual of Dermatologic Therapeutics. 7th 10. LaFleur L, Wernli B, Allen PS, Wild RA. Acanthosis ed. Philadelphia, Pa: Lippincott Williams & Wilkins; Nigricans. Skin Aging. 2006;14(11):50–57.
28. Scheinfeld NS, Shirin S. Polymorphous light 32. Bogle MA. Keratoses. In: Arndt KA, Hsu JTS, eds.
eruption. Available at: http://www.emedicine.com/derm/ Manual of Dermatologic Therapeutics. 7th ed. Philadel- topic342.htm. Accessed December 6, 2007.
phia, Pa: Lippincott Williams & Wilkins; 2007:143–147.
29. Sobell JM, Geist DE. Psoriasis. In: Arndt KA, Hsu 33. Naradzay JF, Rubeiz N. Tinea. Available at: http:// JTS, eds. Manual of Dermatologic Therapeutics. 7th ed. Phil- www.emedicine.com/EMERG/topic592.htm. Accessed adelphia, Pa: Lippincott Williams & Wilkins; 2007:164–173.
30. Bogle MA. Infestations: pediculosis, scabies, and 34. Yelverton CB. Warts. In: Arndt KA, Hsu JTS, ticks. In: Arndt KA, Hsu JTS, eds. Manual of Dermato- eds. Manual of Dermatologic Therapeutics. 7th ed.
logic Therapeutics. 7th ed. Philadelphia, Pa: Lippincott Philadelphia, Pa: Lippincott Williams & Wilkins; Williams & Wilkins; 2007:128–136.
31. Klaus MV, Wehr RF, Rogers RS III, Russell TJ, Krochmal L. Evaluation of ammonium lactate in the treat- ment of seborrheic keratoses. J Am Acad Dermatol. Downloaded By: [Texas A&M University-Commerce] At: 16:15 4 June 2010 Downloaded By: [Texas A&M University-Commerce] At: 16:15 4 June 2010
Research Report European Addiction Anxiety Disorders: Treatable regardless of the Severity of Comorbid Alcohol Dependence Annemiek Schadé a Loes A. Marquenie a Anton J.L.M. van Balkom a Maarten W.J. Koeter b Edwin de Beurs c Richard van Dyck a Wim van den Brink b a Department of Psychiatry and Institute for Extramural Medicine, VU University Medical Centre, GGZ-Buitenamstel,