Rena Ramani is a young woman from north London who has battled with the disease since her early teens. Now, at what she describes as the lowest physical and emotional point of her life, Rena shares with us her journey to better understand this illness. She hears the moving stories of fellow sufferers from around the country, and gets the chance to talk to the healthcare community directly – even challenging one GP to spend some time in her shoes. In this groundbreaking film by acclaimed director James Routh, we are given access to the intimate thoughts and feelings of a young woman whose life has been turned upside down by psoriasis. And, as Rena Ramani’s journey draws to an end, we watch as this brave woman is left to face one of her greatest fears.

Pharmaceutical company Pfizer is to invest €145m at its site in Clondalkin in Dublin. The company said it would expand its production and product testing facilities at the plant.

It is thought up to 400 construction jobs will be created during peak construction periods.

The site currently employs approximately 1,100 full time staff. It is one of the largest biotech manufacturing sites in the world and produces two of Pfizer's main drugs, Enbrel and Prevenar 13.

The news has been welcomed by the Taoiseach and the IDA. Taoiseach Enda Kenny said the investment is a further demonstration of the company's continuous commitment to Ireland.

''This investment gives a substantial boost to Ireland's Life Sciences sector and is a vote of confidence in Ireland's attractiveness as a location for bio-pharmaceutical manufacturing,'' commented IDA Ireland's chief executive Barry O'Leary.

Pfizer has about 4,300 workers across eight locations in Cork, Dublin, Kildare and Limerick.

Source: rte.ie

New report on Archives Of Dermatology suggest that There is a discrepancy in treatment of children with psoriasis between specialties, children of different ages, and adults.

"There were an estimated 3.8 million visits for psoriasis over the study interval with a median of 123 420 visits per year. Dermatologists saw 63% of patients, pediatricians saw 17%, and internists, 14%. The numbers of visits were equal between sexes but ranged by age group: patients ages 13 to 18 years accounted for 47% of visits, those ages 8 to 12 years for 35%, and those ages 0 to 7 for 18%. Ninety-three percent of patients were white. Topical corticosteroids were the most commonly prescribed medications. Children 0 to 9 years old received equally potent corticosteroids as children 10 to 18 years old. Among all patients, the most prescribed medication was topical betamethasone; among those ages 0 to 9 years, tacrolimus; and among those ages 10 to 18 years, betamethasone. By physician specialty, the most prescribed medications were high-potency steroids for dermatologists and internists, and topical tacrolimus for pediatricians. Topical calcineurin inhibitors were not among the top 20 most prescribed medications by dermatologists, and systemic antipsoriatic agents were not among the top 20 most prescribed medications in any age group.


Treatment: The most common medications prescribed overall were topical corticosteroids, which accounted for 7 of the top 10 most prescribed medications. Betamethasone diproprionate, a high-potency topical corticosteroid, was the most listed medication for all children in the study, followed by fluocinonide (high potency) and fluocinolone acetonide (low to medium potency). The most common noncorticosteroid topical medications included a keratolytic (salicylic acid), vitamin D analog (calcipotriene), and coal tar. Topical calcineurin inhibitors occupied the fifth position of most listed medication by class in the nonsteroidal group, the second position by age in the 0- to 8-year-old group, and the first (tacrolimus), and third (pimecrolimus) position by specialty among pediatricians. Systemic antipsoriatic agents were not observed among the top 20 most listed medications by any physician group.


Conclusions: There is a discrepancy in treatment of children with psoriasis between specialties, children of different ages, and adults. Although these data may be biased toward milder or localized disease, the results suggest that pediatric patients with psoriasis, compared with adults, may be undertreated. The documented impairment of quality of life in children with psoriasis, together with recent data suggesting a potential increased risk of comorbid conditions, creates a compelling argument for adequately addressing all aspects of psoriasis management in children. Although treatment guidelines specific to pediatric psoriasis would be useful, formal evidence on which to base such guidelines is not yet available. The current state-of-the-art care for pediatric psoriasis is based primarily on experience and expert consensus. Some differences in approach to management between dermatologists and nondermatologists seem due in part to the "art" of dermatology (choice of vehicle, potency, combination, and rotational therapy) and thus may not be reasonably anticipated to change, even with standardized treatment guidelines. As such, education of our dermatology and nondermatology colleagues about unique clinical and treatment aspects of pediatric psoriasis, rather than guidelines alone, may decrease the treatment gap by creating more comfortable, safe, and effective use of topical and systemic regimens for children with psoriasis.

Source: archderm

To check for new posts since you last logged in click "View New Posts" in the green bar just below the menu. you can also check "View Today's Posts".

Another way of knowing if there are any new posts is the Icons beside each board.
= New Posts.
= No New Posts.

If you click it will mark all post as read in that board.

Seen a thread that you would like to Rate ? Wondering what the stars are on a thread ? It's the rating system.

There are five stars, and each member is allowed one choice to rate a thread. You can rate as many threads as you like but only once per thread.

Just click your choice of 1-5 stars and you vote will be counted. your choice may not change the star rating, as it depends how many members have voted. the software collects all the votes and shows an average.

So get rating now!

Trident Pharmaceuticals Inc., a biotechnology company developing therapies for autoimmune diseases and allergic conditions, today announced the initiation of a Phase 1a study for HF1020, a first in class recombinant protein with immunomodulatory activity. HF1020 is believed to offer a novel approach for treating the underlying inflammatory pathology of autoimmune disease and allergic asthma, without causing systemic immunosuppression.

HF1020 is an oral biopharmaceutical product which acts by inducing naturally occurring T-regulatory cells as a mechanism for selectively down regulating the inflammatory response associated with allergic asthma, as well as autoimmune disorders, including rheumatoid arthritis, inflammatory bowel disease and psoriasis.
HF1020 is a stable protein and is administered orally by capsule. In extensive pre-clinical animal safety and efficacy testing, HF1020 was safe and well tolerated, demonstrating positive effects on multiple disease parameters and efficacy endpoints in animal models of asthma, rheumatoid arthritis, inflammatory bowel disease and diabetes.

“Entering the clinic with HF1020 is an important milestone for Trident,” said Dr. Robin Brown, Chief Scientific Officer of Trident Pharmaceuticals Inc. “Based on extensive published research and data from preclinical studies, we believe this drug has true disease modifying potential offering long term control of underlying inflammation to allergic asthma patients as well as broad applicability across a range of patients
suffering from autoimmune disease."

The Phase 1a randomized, placebo-controlled, blinded, single-ascending dose escalation study is being conducted in the UK by Dr. David Singh, Medical Director at the Medicines Evaluation Unit in Manchester, UK and Professor of Respiratory Medicine and Clinical Pharmacology, University Hospital of South Manchester. The trial will involve 32 subjects, and is designed to investigate the safety and tolerability of HF1020 in healthy volunteers and to identify a dose that can be used in further Phase 1b and Phase IIa studies planned in mild-to-moderate allergic asthma patients.

Professor David Singh, Principal Investigator for the HF1020 study, said: “We are delighted that the clinical phase of this exciting new compound has begun. We anticipate that new compounds such as HF1020, when fully researched, will provide new therapeutic options to patients with asthma and autoimmune diseases.”

Source: tridentpharma.com

Do you want to help Psoriasis Club ?

#1 It's better for all of us to have a good mix of friendly people on the forum to help each other. so please take a moment to check for new posts occasionally especially on the Health Boards.

#2 Please tell others about Psoriasis Club via Email, Twitter, Facebook, Etc.

#3 To help get Psoriasis Club noticed by Search Engines, try a search for Psoriasis find us and follow the link to psoriasisclub.org

#4 It's all about spreading the word, making posts, and keeping the forum active. so please help, it only takes a few minutes to make a difference.

#5 Important: Please do not go posting spam on other sites this is not the way to do it. it helps no one in the end and will only give you a bad name not us.

Any other ideas please post here.

Thanks.

Please take a moment to tell us how you found Psoriasis Club. We are self funded and it helps to know where our new members are coming from.

Please choose an option on the Pole Above. Members can tell us more on this thread if they wish, Guests can also vote but why not come and join us you will find a friendly bunch of people here.

Thank You.

Objective:
To determine the demographics, usage patterns, attitudes, and experiences of online support site users.

Design:  
Online survey.

Patients:  
A total of 260 subjects recruited from 5 online psoriasis support groups.

Main Outcome Measures:  
An exploratory analysis was performed to determine demographic and disease characteristics of online support site users. Perceived benefits were also documented.

Results:  
The mean (SD) age of respondents was 40.1 (11.5) years (range, 18-75 years), most (75.7%) were white, female (60.4%), and college educated (84.3%). Key factors associated with use of online support sites included availability of resources (95.3%), convenience (94.0%), access to good advice (91.0%), and the lack of embarrassment when dealing with personal issues (90.8%). The most common activities were posting messages (65.0%) and searching for information (63.1%). Nearly half of all respondents perceived improvements in their quality of life (49.5%) and psoriasis severity (41.0%) since joining the site. Intensity of participation in online support activities was associated with improved quality of life (P = .002), but not with improvements in psoriasis severity.

Conclusions:  
Our data demonstrate that psoriasis virtual communities offer users both a valuable educational resource and a source of psychological and social support. Such benefits could be further enhanced by physician engagement within these communities.

Quote:

---

Psoriasis currently affects approximately 0.6% to 4.8% of the world's population. In addition to the well-recognized skin and joint manifestations, psoriasis impairs many aspects of individual well-being, including emotional, physical, sexual, and financial status. An estimated 10% of individuals affected by psoriasis have had suicidal ideations, a prevalence surpassing many other medical conditions. As a result, it is a necessity to provide patients with access to psychological support.

Patient support groups are one source of such assistance. They are designed to develop and reinforce positive coping styles known to be associated with improvements in both medical and social outcomes. In the United States, approximately 3% to 4% of the population annually engages in support group activity, and around 25 million Americans are estimated to have participated at some point in their lifetime. There are, however, a number of challenges with traditional face-to-face groups, including geographic barriers, embarrassment, limited space, and time constraints.

The worldwide rise in Internet usage has offered new ways for patients to interact. Despite initial concerns that online activity might lead people to withdraw from social interaction, a number of recent reports have noted that use of the Internet can empower people, thus improving social support and self-esteem. There has been a dramatic rise in the number of user-generated health care–related Web sites and online support sites. People with chronic disease are believed to relate best to Web-based information produced by other patients. Internet support groups share common objectives with their face-to-face counterparts but have strengths and weaknesses unique to the online setting. Although online support may lack the immediacy and intensity of a group meeting, it allows members to access information at a time and place of their choice. In addition, it offers individuals the advantage of anonymity and perceived lack of judgment. The benefits of structured, moderated online support programs have been demonstrated for patients with back pain, heart disease, lung disease, and type 2 diabetes mellitus. However, no structured programs have been developed for patients living with chronic skin disease. Indeed, little is currently known about the online user population living with certain dermatologic conditions, their drive to participate in online support groups, and their experiences within these virtual communities.

We conducted a Web-based cross-sectional survey study of people with psoriasis involved in online support groups. To our knowledge, this is the first survey study to describe user characteristics and the perceived benefits of online support groups in the field of dermatology. This study offers a richer insight into the demographics, usage patterns, attitudes, and experiences of participants involved with these virtual communities.

The fissured tongue is the most common oral finding in patients with psoriasis. Other names applied to the fissured tongue are scrotal or plicated tongue. Erythema migrans (geographic tongue) is often associated with fissured tongue as well.



A chief complaint is that of malodor and discoloration associated with deep fissuring of the tongue due to the bacteria and food particles that become embedded in the grooves and cracks. The trapped particles may lead to inflammation and often cause discomfort/burning in the patient.

The fissured tongue is relatively common. In fact, it's so common that it is not noted in many clinical exams. Both aging and local environmental factors may also contribute to the small and deep grooves that become noticeable. As we age, other factors may come into play, such as the way that we process foods, vitamins, and minerals, and our T-cell functions decrease or may become faulty.

The deeper the crack, the more chronic the condition of the tongue. The body is experiencing dehydration and long-term adrenal stress. Typically, the tongue is swollen in this state and the pressure causes cracking. Once the underlying issues have been addressed, the fissuring should begin to diminish.

The most common items missing in the body are minerals, proper fats such as essential fatty acids (EFAs) and greens. The diet is extremely important, and the patient needs to increase fresh foods and water. Even though the fissured tongue is considered a benign condition with no treatment needed, the body is perhaps telling us something that needs to be addressed.

I do believe there are lots of natural things that can help with psoriasis. but please be careful of all the Scams out there that will only make you bank balance shrink!

I'm not saying the natural approach doesn't work and I wouldn't. I just cant keep to a regime, so it wouldn't be fair of me to comment. I just want to warn people to be careful.

I have done some research about the natural approach and came to the conclusion it's all about Positive Attitude, Sun, and Diet. I don't do to bad on the positive attitude or the sunshine but the diet! I have to admit I just can't do it.

During my research I found out the following foods are supposed to be bad for Psoriasis.

Saturated Fats: Beef, Pork, Veal, Sausage, Salami, Burgers, Margarine, Etc.
Nightshades: Tomatoes, Tobacco, Peppers, Potatoes, Chilli, Etc.
Shellfish: Lobster,Shrimp, Prawn, Crab, Etc.
And: Coffee, Gluten, Yeast, Fried Food, Pizza, Vinegar, Pickles, Spices, Strawberries, Peanut Butter, And Alcohol.

And the ideal diet for Psoriasis would be.
7 Glasses of water.
80% of the following:
Fruit, But no strawberry's or citrus.
Vegetables: 3 that grow above ground and one that grows below ground.
Juices: some people swear by Juices. I'm sure if you do a google search you will find some.
20% of the following:
Grain, Rice, Pasta.
Oily Fish, White Fish.
Poultry, But no skin.
Lamb.
Skimmed Milk, Yoghurt,
Others include Olive Oil, Light Tea, 2 Eggs per week.

I wish you all well on your search for the natural approach and have a huge respect for those of you that do manage to achieve it. Please share with others your natural approach as I'm sure there are lots of people who would rather take this route.

But please be careful of the scams! You will find lots of so called cures for psoriasis on the Internet. Don't Fall For It you will be wasting your money on nothing more than a diet and life style approach. Do a Google search for "psoriasis affiliate programs" instead and see how much people are making with claims like: I cured psoriasis find out how / Cure for psoriasis / Dr X reveals the secrets on curing psoriasis / Professors Predicted I Would Die With Psoriasis.

This thread is intended to give you information on the most common prescribed biological treatments for psoriasis & psoriatic arthritis. You should always check the information with your GP or Dermatologist.

I will lock this thread to save any confusion, if you want to comment on the thread please start a new topic or send me a PM.

What Are Biologics ?
Biologic drugs are made from living human or animal proteins. They are designed to treat psoriasis and psoriatic arthritis by targeting overactive cells in the body. Some biologics target a type of immune cell called T cells while others target the chemical messengers released by activated T cells.

Tests: Patients should be checked for tuberculosis (TB) before taking Biologicals and you should have regular blood tests. You may also be given X Rays.

Storage:
Always keep Biologicals in the fridge (Not Freezer) Take them out about 15 minutes before using this will make them sting less. Please follow the relevant link to the manufacturers web site for detailed storage instructions.

Using:
Always wash your hands well before use and make sure you have a clean area to work on, wipe the area of skin well with the alcohol swab provided with the medication. Pinch an inch of skin on your chosen site usually the stomach, and stab the needle in "don't push it in" the slower you go the more it will sting. Slowly push the syringe till all the medication has gone, remove the needle, let go of your skin and give a final wipe with an alcohol swab. Don't worry about injecting yourself it's a simple process and not painful, and your adviser will make sure you are comfortable with it before letting you go it alone. But once you do, you will wonder what all the fuss is about.
For detailed instructions please follow the relevant link to the manufacturers web site found in each post.

Side Effects: Please read each section for side effects and follow the link to the manufacturers web site.

Please click a biologic from the list or scroll down to view all.

Humira (adalimumab) Targets TNF-a

Enbrel (etanercept) Targets TNF-a

Remicade (infliximab) Targets TNF-a

Stelara (ustekinumab) Targets interleukin 12 and interleukin 23

Simponi (golimumab) Targets TNF-a

Cimzia (certolizumab pegol) Targets TNF-a

Cosentyx (secukinumab) Targets interleukin 17

Taltz (ixekizumab) Targets interleukin 17

Kyntheum / Siliq (brodalumab) Targets interleukin 17

Tremfya (guselkumab) Targets interleukin 23

Orencia (abatacept) Targets TNF *Only used for psoriatic arthritis.

Ilumetri / Ilumya (tildrakizumab) Targets interleukin 23

Skyrizi (risankizumab) Targets interleukin 23

Bimzelx (bimekizumab) Targets interluken 17F & 17A

Spevigo (spesolimab) Targets interleukin 36 *Only used for Generalized Pustular Psoriasis.

A question often asked by psoriasis sufferers is "what is the difference between Dovobet and Dovonex"

Both products are made by Leo Pharma and are Cream/Ointment/Solution/Gel treatments for psoriasis. there is a big difference between the two products, and this thread is intended to give you some answers. so please take time to familiarize yourself with the two products.

Dovonex also called Daivonex in some countries comes in Blue & White tubes and is Calcipotriol based. (Calcipotriol is a vitamin D derivative)

Dovobet also called Daivobet in some counties comes in Red & White tubes and is Betamethasone & Calcipotriol based. (Betamethasone is a potent glucocorticoid steroid)

Please scroll down or click your choice below.

Dovonex Cream

Dovonex Ointment

Dovonex Scalp Solution

Dovobet Ointment

Dovobet Gel

This thread on the old forum has had a lot of hits. and it gives an insight into how Psoriasis can affect ones mental health.

I have copy and pasted the posts and mentioned the author of each post. It's a good read and I would recommend you give it a look.

We have decided not to allow signatures on the forum for two reasons.

#1 Some people go a bit overboard with photos / links / and statements / etc. and it can start to look messy and distracting on threads.

#2 We have found out that a lot of spammers join just to make one post with a link in their signatures. obviously we are not here to promote other websites.

However at Psoriasis Club we are not all spoil sports, and members with 10 posts will have the option to change their User Title and can also request a link in the Links Page.

To change your "User Title" go to User CP / Edit Profile.
To request a link in the Links Page send me a PM.

OK know you have joined Psoriasis Club as a member we recommend you set your preferences, and set a profile that makes you different from other members.

In the green bar just below the menu click "User CP" you should now see your own user control panel. here you can make changes to prefernces and profile.

Scroll down to "Your Profile" you will see 5 options: Edit Profile / Change Password / Change Email / Change Avatar / & Edit Options.

Edit Profile: This is where you can change what is seen in your posts or member profile and share with others. Want others to know your birthday ? Want to share your psoriasis score ? Want to tell others what treatment you are using ? Want to tell others where you live ? How about a little bio about yourself ? *Note once you have made 10 posts you can choose a custom title.

Change password: Here you can change your password.

Change Email: Here you can change your Email address.

Change Avatar: This is where you can have your own picture for your profile and in your posts. We have decided not to have Avatars in the Default Gallery as it takes up space on the server.
To add your own Avatar: #1 Click Browse to download from your computer. #2 Add the URL of an Avatar.
#1 is the best option as the URL may change or disappear unless you are in control of it.

Edit Options: Here you can choose your options for using the forum.

Go on be different from other members and give yourself a profile. Any problems just ask.

Hello I'm Mrs Fred
Having been with Fred about 30 years I have come to know many of the good and bad sides of living with someone with Psoriasis. Over the years I have learnt when to talk or if he gets so down about it just be there. In the early years I remember when I was changing the bed and said "We know which side of the bed you sleep on" and he was very angry, I did not realize what a stupid remark it was.
Not so many years ago Fred had a very bad time and I phoned the hospital. They said to bring him in and they would look at him but he may have to stay. I told him they needed to see the problem but we will take an overnight bag just in case. His skin by then was very sore and bad so I know they would keep him in. When we got there and he know he had to stay he was very angry and being the person nearest I got full force. He told me to go home and I left in tears, I had a good cry in the car park. I know he did not mean to be nasty and if you had seen his skin you would understand.
It would be nice if you would like to share some of your experiences and to know someone understands.

Here is a list of the most common types of Psoriasis, If anyone has more input please let me know so I can make changes. the information is taken from various sources and this thread is only intended to give you an idea. "You should always seek medical advice if you think you have Psoriasis"

Please scroll down to find an explanation of the different types and some members photos. (or click a link below)

What Is Psoriasis ?

Plaque Psoriasis (psoriasis vulgaris)

Guttate Psoriasis also known as Eruptive / Raindrop Psoriasis / Paintbrush Psoriasis

Inverse (flexural) Psoriasis

Pustular Psoriasis

Erythrodermic Psoriasis

Nail Psoriasis

Napkin Psoriasis

Scalp Psoriasis

Psoriatic Arthritis

And Finally

Psoriasis is an auto-immune reaction where your body is attacking your skin. If it was this easy to treat auto-immune problems, then Multiple Sclerosis, Rheumatoid Arthritis, and other auto-immune disease would already be cured.

You will find lots of so called cures for psoriasis on the Internet. Don't Fall For It There Is No Cure! you will be wasting your money on nothing more than a diet and life style approach. Do a Google search for "psoriasis affiliate programs" instead and see how much people are making.

They will lead you in with claims like: I cured psoriasis find out how / Cure for psoriasis / Dr X reveals the secrets on curing psoriasis / Professors Predicted I Would Die With Psoriasis. or one of my favorites is a website about a product being a scam and still trying to sell it to you via the links.

*I challenge anyone to give us some free samples of their products or books to send out to our members and let them post the results here.

Like I said save your money. get a positive attitude, keep happy, avoid stress, use loads of moisturiser, then look at your diet.

Foods that are bad for psoriasis include:
Saturated Fats: Beef, Pork, Veal, Sausage, Salami, Burgers, Margarine, Etc.
Nightshades: Tomatoes, Tobacco, Peppers, Potatoes, Chili, Etc.
Shellfish: Lobster,Shrimp, Prawn, Crab, Etc.
And: Coffee, Gluten, Yeast, Fried Food, Pizza, Vinegar, Pickles, Spices, Strawberries, Peanut Butter, Alcohol.

An ideal diet for psoriasis would be:
7 Glasses of water.
80% of the following:
Fruit, But no strawberry's or citrus.
Vegetables: 3 that grow above ground and one that grows below ground.
Juices: some people swear by Juices. I'm sure if you do a google search you will find some.
20% of the following:
Grain, Rice, Pasta.
Oily Fish, White Fish.
Poultry, But no skin.
Lamb.
Skimmed Milk, Yogurt,
Others include Olive Oil, Light Tea, 2 Eggs per week.

Doing it and keeping to it is another thing (I Can't) but you will have saved your money on so called Cures that are nothing more than the above information.

There are lots of Myths about Psoriasis here are some of the most common ones.

1: Psoriasis is a contagious disease.
Fact: Research has shown that psoriasis is not, in fact, contagious at all. You can't catch it from, or pass it on to, another person.

2: Psoriasis is only a skin disease.
Fact: Psoriasis is actually an immune-system disease that causes abnormal growth of skin cells. A normal skin cell matures in 28 to 30 days and is shed from the skin's surface, but a psoriatic skin cell matures and moves to the surface in only three to four days, resulting in an excess of cells, which form raised lesions.

3: Psoriasis is the result of poor hygiene.
Fact: Researchers have found no link between the disease and hygiene. Again, psoriasis is an immune-system disease; it can be triggered by various factors, including weather, stress, infections, skin trauma, and certain medications.

4: Psoriasis is curable.
Fact: Psoriasis is a lifelong condition for which scientists currently have no cure. That said, the condition can be managed through proper treatment.

5: Psoriasis is easy to diagnose.
Fact: Unfortunately, it can be difficult to diagnose psoriasis, and the disease is often mistaken for skin conditions such as eczema. In a survey, 48 percent of respondents stated that their psoriasis had been mistaken by others for a different disease or condition.

6: Psoriasis is easy to cope with.
Fact: Psoriasis can have a profound psychological impact on sufferers. In severe cases, the effects can be debilitating, especially when the symptoms are easily visible. People with psoriasis may experience a range of emotions, from frustration and embarrassment to anger and depression. For this reason it's recommended that patients join a psoriasis support group; it can make a tremendous difference in the lives of those affected by psoriasis.

7: Misinformation about psoriasis is harmless.
Fact: Misconceptions about this condition can have serious consequences. “The perception that psoriasis is contagious leads to discrimination. Many people with psoriasis report discrimination in public places such as gyms, swimming pools. “The perception that psoriasis is not a serious condition leads some patients to not treat their disease. Failure to treat can lead to needless suffering from the disease itself and to an increased risk for other serious health conditions, such as heart attack, diabetes, depression, cancer, and obesity.” People whose psoriasis is undiagnosed or untreated may also be at higher risk of developing psoriatic arthritis — a chronic, painful, and disabling illness that often requires aggressive treatment.