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Frontline Forum Part 1: Challenges and Opportunities to Enhance Psoriasis Management – Dermatology Times

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As the understanding of psoriasis continues to evolve, the imperative of personalized care has gained prominence, reshaping the traditional paradigms of treatment. In the recentDermatology Timescustom video series Advancements in Psoriasis Care: Navigating Emerging Therapies and Guidelines, experts in the management of skin conditions discussed the latest developments in plaque psoriasis management. The panel discussion included Linda Stein Gold, MD, of Henry Ford Health in Detroit, Michigan; Mona Shahriari, MD, of Yale University School of Medicine in New Haven, Connecticut; Michael Cameron, MD, of Cameron Dermatology in New York, New York; Leon Kircik, MD, of Derm Research, PLLC, in Louisville, Kentucky; and George Han, MD, of Hofstra University in Hempstead, New York. The conversation shed light on the evolving paradigms, evidence-based approaches, and need for individualized care in managing thiscondition (Table).

Stein Gold emphasized the challenges posed by complex treatment regimens and said, The use of complex regimens with multiple topical agents can lead to lower adherence and less effective treatment. This sentiment underscores the critical need to streamline treatment approaches to enhance patient adherence and optimize treatment outcomes.

The panelists also highlighted the impact of treatment complexity on patient adherence, with Cameron noting, The more complex the regimen is, the lower the adherence, which means were less effectively [managing] the disease. This insight underscores the direct correlation between treatment complexity and patient adherence, emphasizing the need for streamlined andpatient-friendly regimens.

Furthermore, Shahriari said, Its really a matter of simplifying the treatment regimen. This sentiment underscores the need to reevaluate treatment approaches and streamline regimens to enhance patient adherence andtreatment efficacy.

In the realm of psoriasis management, the emergence of steroid phobia and evolving patient preferences has sparked critical discussions among health care professionals. Kircik highlighted the growing trend of steroid phobia among patients, stating, There is now this trend that nobody wants to be on steroids. This observation underscores the shifting attitudes toward steroid-based treatments and the impact on patient-provider discussions regarding treatment options.

The panelists also addressed the concerns surrounding patient preferences for nonsteroidal treatment options, with Stein Gold emphasizing the need to consider alternative therapies, stating, I think of steroids as a short-term solution to a long-term problem. Its really a Band-Aid. This sentiment underscores the evolving perspectives on steroid-based treatments and the need to explore nonsteroidal alternatives to address patient preferences and concerns. Additionally, Cameron provided insights into the prevalence of steroid phobia, saying, I find that [for] most of my patients, whether they [have] mild, moderate, or severe [disease], I dont want them using steroidslong term.

Psoriasis management guidelines serve as a critical resource, providing evidence-based recommendations for the management of psoriasis. Stein Gold addressed the limitations of current treatment guidelines and said, The problem is the guidelines are not for psoriasis. Theyre being done for atopic dermatitis right now. This observation sparked a conversation about the need for updated and comprehensive guidelines that align with the evolving landscape ofpsoriasis management.

The panelists also addressed the implications of treatment guidelines on patient care, with Kircik emphasizing the need for individualized treatment approaches, stating, We are looking for new topicals that are steroid freeor nonsteroidal.

Shahriari expressed the importance of defining disease severity in treatment guidelines and noted, I think we need to talk more about the definitions of mild, moderate, [and] severe psoriasis. This perspective highlights the need for clear and comprehensive definitions of disease severity to guide treatment approaches and optimize patient outcomes.

The panel noted that guidelines are often used against providers by attorneys and insurance companies and can be prescriptive rather than informative. The entire panel agreed that guidelines should be based on a review of the literature and provide a comprehensive overview of available treatments rather thanspecific recommendations.

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Frontline Forum Part 1: Challenges and Opportunities to Enhance Psoriasis Management - Dermatology Times

Cloud-Computing in the Post-Serverless Era: Current Trends and Beyond – InfoQ.com

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Key Takeaways

[Note: The opinions and predictions in this article are those of the author and not of InfoQ.]

As AWS Lambda approaches its 10th anniversary this year, serverless computing expands beyond just Function as a Service (FaaS). Today, serverless describes cloud services that require no manual provisioning, offer on-demand auto-scaling, and use consumption-based pricing. This shift is part of a broader evolution in cloud computing, with serverless technology continuously transforming. This article focuses on the future beyond serverless, exploring how the cloud landscape will evolve beyond current hyperscaler models and its impact on developers and operations teams. I will examine the top three trends shaping this evolution.

In software development, a "module" or "component" typically refers to a self-contained unit of software that performs a cohesive set of actions. This concept corresponds elegantly to the microservice architecture that typically runs on long-running compute services such as Virtual Machines (VMs) or a container service. AWS EC2, one of the first widely accessible cloud computing services, offered scalable VMs. Introducing such scalable, accessible cloud resources provided the infrastructure necessary for microservices architecture to become practical and widespread. This shift led to decomposing monolithic applications into independently deployable microservice units.

Lets continue with this analogy of software units. A function is a block of code that encapsulates a sequence of statements performing a single task with defined input and output. This unit of code nicely corresponds to the FaaS execution model. The concept of FaaS executing code in response to events without the need to manage infrastructure existed before AWS Lambda but lacked broad implementation and recognition.

The concept of FaaS, which involves executing code in response to events without the need for managing infrastructure, was already suggested by services like Google App Engine, Azure WebJobs, IronWorker, and AWS Elastic Beanstalk before AWS Lambda brought it into the mainstream. Lambda, emerging as the first major commercial implementation of FaaS, acted as a catalyst for its popularity by easing the deployment process for developers. This advancement led to the transformation of microservices into smaller, individually scalable, event-driven operations.

In the evolution toward smaller software units offered as a service, one might wonder if we will see basic programming elements like expressions or statements as a service (such as int x = a + b;). The progression, however, steers away from this path. Instead, we are witnessing the minimization and eventual replacement of functions by configurable cloud constructs. Constructs in software development, encompassing elements like conditionals (if-else, switch statements), loops (for, while), exception handling (try-catch-finally), or user-defined data structures, are instrumental in controlling program flow or managing complex data types. In cloud services, constructs align with capabilities that enable the composition of distributed applications, interlinking software modules such as microservices and functions, and managing data flow between them.

Cloud construct replacing functions, replacing microservices, replacing monolithic applications

While you might have previously used a function to filter, route, batch, split events, or call another cloud service or function, now these operations and more can be done with less code in your functions, or in many cases with no function code at all. They can be replaced by configurable cloud constructs that are part of the cloud services. Lets look at a few concrete examples from AWS to demonstrate this transition from Lambda function code to cloud constructs:

These are just a few examples of application code constructs becoming serverless cloud constructs. Rather than validating input values in a function with if-else logic, you can validate the inputs through configuration. Rather than routing events with a case or switch statement to invoke other code from within a function, you can define routing logic declaratively outside the function. Events can be triggered from data sources on data change, batched, or split without a repetition construct, such as a for or while loop.

Events can be validated, transformed, batched, routed, filtered, and enriched without a function. Failures were handled and directed to DLQs and back without a try-catch code, and successful completion was directed to other functions and service endpoints. Moving these constructs from application code into construct configuration reduces application code size or removes it, eliminating the need for security patching and any maintenance.

A primitive and a construct in programming have distinct meanings and roles. A primitive is a basic data type inherently part of a programming language. It embodies a basic value, such as an integer, float, boolean, or character, and does not comprise other types. Mirroring this concept, the cloud - just like a giant programming runtime - is evolving from infrastructure primitives like network load balancers, virtual machines, file storage, and databases to more refined and configurable cloud constructs.

Like programming constructs, these cloud constructs orchestrate distributed application interactions and manage complex data flows. However, these constructs are not isolated cloud services; there isnt a standalone "filtering as a service" or "event emitter as service." There are no "Constructs as a Service," but they are increasingly essential features of core cloud primitives such as gateways, data stores, message brokers, and function runtimes.

This evolution reduces application code complexity and, in many cases, eliminates the need for custom functions. This shift from FaaS to NoFaaS (no fuss, implying simplicity) is just beginning, with insightful talks and code examples on GitHub. Next, I will explore the emergence of construct-rich cloud services within vertical multi-cloud services.

In the post-serverless cloud era, its no longer enough to offer highly scalable cloud primitives like compute for containers and functions, or storage services such as key/value stores, event stores, relational databases, or networking primitives like load balancers. Post-serverless cloud services must be rich in developer constructs and offload much of the application plumbing. This goes beyond hyperscaling a generic cloud service for a broad user base; it involves deep specialization and exposing advanced constructs to more demanding users.

Hyperscalers like AWS, Azure, GCP, and others, with their vast range of services and extensive user bases, are well-positioned to identify new user needs and constructs. However, providing these more granular developer constructs results in increased complexity. Each new construct in every service requires a deep learning curve with its specifics for effective utilization. Thus, in the post-serverless era, we will observe the rise of vertical multi-cloud services that excel in one area. This shift represents a move toward hyperspecialization of cloud services.

Consider Confluent Cloud as an example. While all major hyperscalers (AWS, Azure, GCP, etc.) offer Kafka services, none match the developer experience and constructs provided by Confluent Cloud. With its Kafka brokers, numerous Kafka connectors, integrated schema registry, Flink processing, data governance, tracing, and message browser, Confluent Cloud delivers the most construct-rich and specialized Kafka service, surpassing what hyperscalers offer.

This trend is not isolated; numerous examples include MongoDB Atlas versus DocumentDB, GitLab versus CodeCommit, DataBricks versus EMR, RedisLabs versus ElasticCache, etc. Beyond established cloud companies, a new wave of startups is emerging, focusing on a single multi-cloud primitive (like specialized compute, storage, networking, build-pipeline, monitoring, etc.) and enriching it with developer constructs to offer a unique value proposition. Here are some cloud services hyperspecializing in a single open-source technology, aiming to provide a construct-rich experience and attract users away from hyperscalers:

This list represents a fraction of a growing ecosystem of hyperspecialized vertical multi-cloud services built atop core cloud primitives offered by hyperscalers. They compete by providing a comprehensive set of programmable constructs and an enhanced developer experience.

Serverless cloud services hyperspecializing in one thing with rich developer constructs

Once this transition is completed, bare-bones cloud services without rich constructs, even serverless ones, will seem like outdated on-premise software. A storage service must stream changes like DynamoDB; a message broker should include EventBridge-like constructs for event-driven routing, filtering, and endpoint invocation with retries and DLQs; a pub/sub system should offer message batching, splitting, filtering, transforming, and enriching.

Ultimately, while hyperscalers expand horizontally with an increasing array of services, hyperspecializers grow vertically, offering a single, best-in-class service enriched with constructs, forming an ecosystem of vertical multi-cloud services. The future of cloud service competition will pivot from infrastructure primitives to a duo of core cloud primitives and developer-centric constructs.

Cloud constructs increasingly blur the boundaries between application and infrastructure responsibilities. The next evolution is the "shift left" of cloud automation, integrating application and automation codes in terms of tools and responsibilities. Lets examine how this transition is unfolding.

The first generation of cloud infrastructure management was defined by Infrastructure as Code (IaC), a pattern that emerged to simplify the provisioning and management of infrastructure. This approach is built on the trends set by the commoditization of virtualization in cloud computing.

The initial IaC tools introduced new domain-specific languages (DSL) dedicated to creating, configuring, and managing cloud resources in a repeatable manner. Tools like Chef, Ansible, Puppet, and Terraform led this phase. These tools, leveraging declarative languages, allowed operation teams to define the infrastructures desired state in code, abstracting underlying complexities.

However, as the cloud landscape transitions from low-level coarse-grained infrastructure to more developer-centric programmable finer-grained constructs, a trend toward using existing general-purpose programming languages for defining these constructs is emerging. New entrants like Pulumi and the AWS Cloud Development Kit (CDK) are at the forefront of this wave, supporting languages such as TypeScript, Python, C#, Go, and Java.

The shift to general-purpose languages is driven by the need to overcome the limitations of declarative languages, which lack expressiveness and flexibility for programmatically defining cloud constructs, and by the shift-left of configuring cloud constructs responsibilities from operations to developers. Unlike the static nature of declarative languages suited for low-level static infrastructure, general-purpose languages enable developers to define dynamic, logic-driven cloud constructs, achieving a closer alignment with application code.

Shifting-left of application composition from infrastructure to developer teams

The post-serverless cloud developers need to implement business logic by creating functions and microservices but also compose them together using programmable cloud constructs. This shapes a broader set of developer responsibilities to develop and compose cloud applications. For example, a code with business logic in a Lambda function would also need routing, filtering, and request transformation configurations in API Gateway.

Another Lambda function may need DynamoDB streaming configuration to stream specific data changes, EventBridge routing, filtering, and enrichment configurations.

A third application may have most of its orchestration logic expressed as a StepFunction where the Lambda code is only a small task. A developer, not a platform engineer or Ops member, can compose these units of code together. Tools such as Pulumi, AWS SDK, and others that enable a developer to use the languages of their choice to implement a function and use the same language to compose its interaction with the cloud environment are best suited for this era.

Platform teams still can use declarative languages, such as Terraform, to govern, secure, monitor, and enable teams in the cloud environments, but developer-focused constructs, combined with developer-focused cloud automation languages, will shift left the cloud constructs and make developer self-service in the cloud a reality.

The transition from DSL to general-purpose languages marks a significant milestone in the evolution of IaC. It acknowledges the transition of application code into cloud constructs, which often require a deeper developer control of the resources for application needs. This shift represents a maturation of IaC tools, which now need to cater to a broader spectrum of infrastructure orchestration needs, paving the way for more sophisticated, higher-level abstractions and tools.

The journey of infrastructure management will see a shift from static configurations to a more dynamic, code-driven approach. This evolution hasnt stopped at Infrastructure as Code; it is transcending into a more nuanced realm known as Composition as Code. This paradigm further blurs the lines between application code and infrastructure, leading to more streamlined, efficient, and developer-friendly practices.

In summarizing the trends and their reinforcing effects, were observing an increasing integration of programming constructs into cloud services. Every compute service will integrate CI/CD pipelines; databases will provide HTTP access from the edge and emit change events; message brokers will enhance capabilities with filtering, routing, idempotency, transformations, DLQs, etc.

Infrastructure services are evolving into serverless APIs, infrastructure inferred from code (IfC), framework-defined infrastructure, or explicitly composed by developers (CaC). This evolution leads to smaller functions and sometimes to NoFaaS pattern, paving the way for hyperspecialized, developer-first vertical multi-cloud services. These services will offer infrastructure as programmable APIs, enabling developers to seamlessly merge their applications using their preferred programming language.

The shift-left of application composition using cloud services will increasingly blend with application programming, transforming microservices from an architectural style to an organizational one. A microservice will no longer be just a single deployment unit or process boundary but a composition of functions, containers, and cloud constructs, all implemented and glued together in a single language chosen by the developer. The future is shaping to be hyperspecialized and focused on the developer-first cloud.

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Cloud-Computing in the Post-Serverless Era: Current Trends and Beyond - InfoQ.com