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Minn. police shooting reignites debate over Second Amendment …

Posted: July 12, 2016 at 6:19 am

President Obama responded to the recent police shootings in Louisiana and Minnesota by recognizing the need to root out bias in law enforcement and encouraging communities to trust their local police department.

A memorial left for Philando Castile following the police shooting death of the black man on July 7, 2016, in St. Paul, Minn. 8(Photo: Stephen Maturen, Getty Images)

A black Minnesota man fatally shot by police Wednesday during a stop for a broken tail light was a licensed gun owner, prompting some observers to suggest that the debate over gun control and the Second Amendment has racial undertones.

When police in Falcon Heights, Minn.,stopped the car in which Philando Castile, 37, was riding on Wednesday night, Castile attempted to give them his license and registration, as requested. He also told them he was a licensed weapon owner, according to the Facebook Live video posted by Diamond “Lavish” Reynolds, who identified herself as Castile’s fiance.

As Castile put his hands up, police fired into his arm four times, according to the video. He was pronounced dead later at a hospital.

“I’m waiting to hear the human outcry from Second Amendment defenders over (this incident),” NAACP president and CEO Cornell William Brooks told USA TODAY Thursday.

Brookswas preparing to travel to Minnesota to get up to speed on the Castile case after a trip to Baton Rouge, La., to get details on the police-involved shooting of another black man earlier this week.

“When it comes to an African American with a license to carry a firearm, it appears that his pigmentation, his degree of pigmentation, is more important than the permit or license to carry a firearm,” Brooks said. “One would hope and pray that’s not true.”

Tweeted author and TV commentator Keith Boykin: “Does the Second Amendment only apply to White People?”

Amanda Zantal-Wiener, tweeted aboutthe National Rifle Association, perhaps the most powerful of the national organizations supporting the Second Amendment, saying: “Hey, NRA, I’m sure you’re just moments away from defending Philando Castile’s second amendment rights. Right? Any minute now, right?”

The NRA did not immediatelyrespond to a request for an interview. The organization has been publicly silent regarding the Minnesota shooting.

But at least two organizations, the Second Amendment Foundation and the Citizens Committee for the Right to Keep and Bear Arms, both based in Bellevue, Wash., expressed concern over the case and called for an investigation by state-level entities, perhaps even from a state outside of Minnesota.

“Wednesday nights shooting of Philando Castile is very troubling, especially to the firearms community, because he was a legally-armed private citizen who may have done nothing more than reach for his identification and carry permit,” Allan Gottleib, founder and executive vice president of the foundation, and chair of the Citizens Committee, said in a statement Thursday.

“We are cognizant of the racial overtones arising from Mr. Castiles death,”Gottlieb said. “The concerns of our members, and honest gun owners everywhere, go even deeper. Exercising our right to bear arms should not translate to a death sentence over something so trivial as a traffic stop for a broken tail light, and we are going to watch this case with a magnifying glass.”

Survey data show that white Americans and black Americans appear to have two different and distinct relationships with firearms.

Data released in 2014 by the Pew Research Center showed that blacks are less likely than whites to have a firearm at home.According to the study, 41% of whites said they had a gun at home compared to 19% of blacks.

But there has been much research to show that black Americans are more likely than white Americans to be gun homicide victims.

In 2010, blacks were 55% of shooting homicide victims but 13% of the U.S. population, according to a Pew review of data from the Centers for Disease Control and Prevention. By contrast, in the same year, whites were 25% of gun homicide victims but 65% of the population, according to the same data.

In the early days of the Second Amendment, blacks were prohibited from possessing firearms, according to the National Constitution Center, a nonprofit organization in Philadelphia. The measure was intended to protect Americans’ right to bear arms, and designated states as the entities who would manage this.

Gerald Horne, an historian at the University of Houston, said during a recent interview with the Real News Network that there was a race and class bias inherent in the amendment’s provisions.

“The Second Amendment certainly did not apply to enslaved Africans,” Horne said. “All measures were taken to keep arms out of their hands. The Second Amendment did not apply to indigenous people because the European settlers were at war with the indigenous people to take their land. And providing arms to them was considered somewhat akin to a capital offense. So the Second Amendment was mostly applicable to the settler class.”

Horne says that many of the battles during reconstruction were about keeping arms out of the hands of black Americans hesays one of the key reasons the Ku Klux Klan was formed in the post-Civil War era was to keep arms out of the hands of blacks.

Said Brooks, “I would just simply note that in a state like Texas, where we have thousands upon thousands of people with concealed weapons permits, a permit is sufficient proof to vote while a college ID is not. Think about that.”

Follow Melanie Eversley on Twitter:@MelanieEversley

USA TODAY

Obama, angered by police shootings, calls for elimination of racial bias

USA TODAY

Minn. governor: Castile would be alive if he had been white

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Second Amendment Basics | Law Center to Prevent Gun Violence

Posted: July 3, 2016 at 6:25 pm

A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed. The Second Amendment to the US Constitution

Does the Second Amendment prevent effective gun regulations? What is the right to bear arms? Second Amendment litigation has become a critical battleground since the U.S. Supreme Court held, in District of Columbia v. Heller, that the Amendment guarantees an individual right to possess a firearm in the home for self-defense. This decision created a radical shift in the meaning of the Second Amendment, but it doesnt prevent smart gun regulations. In fact, since Heller, courts nationwide have found a wide variety of firearms laws constitutional because they can help prevent gun deaths, injuries, and crimes in communities across the country.

The Law Center not only tracks the extensive Second Amendment litigation currently happening nationwide, but also analyzes the trends, to bring you the latest developments in the courts.

Learn more about the 2008 DC vs Heller decision.

Learn more about the 2010McDonald v. City of Chicago decision.

In 2008, the U.S. Supreme Court singlehandedly inserted the judicial system into the ongoing national debate over gun laws in America. In a 5-4 decision inDistrict of Columbia v. Heller, the Court invalidated the District of Columbias handgun ban and firearm storage law, stating for the first time that the Second Amendment protects a responsible, law-abiding citizens right to possess an operable handgun in the home for self-defense.

Heller was unquestionably a radical decision, overturning the Courts previous ruling that the Second Amendment was tied to state militia service. For almost seventy years, lower federal and state courts nationwide had relied on that pronouncement to reject hundreds of Second Amendment challenges.

The Heller decision immediately drew strong criticism from a wide array of legal scholars, historians, advocates and legislators, including a particularly scathing rebuke from respected conservative judge Richard Posner, who noted that, The only certain effect of the Heller decision will be to increase litigation over gun ownership.

In fact, new litigation started almost immediately. The day that Heller was announced, plaintiffs filed a lawsuit challenging the City of Chicagos handgun ban, with a second suit filed the next day. Other suits emerged soon after, escalating once the Supreme Court confirmed that the Second Amendment also applied to state and local laws in 2010s McDonald v. City of Chicago decision. After that case, the number of lawsuits challenging gun laws nationwide skyrocketed.

Thankfully, despite the explosion of litigation, courts across the country have rejected the overwhelming majority of Second Amendment challenges initiated since Heller. Gun rights advocates and criminal defendants across the country have sought to expand the Second Amendment to invalidate almost every gun law on the books today. In siding with us and the majority of Americans who support sensible gun laws, courts are finding that smart laws arent just constitutionaltheyre also critical to keeping our communities safe from gun violence.

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Why It's Time to Repeal the Second Amendment

Posted: June 17, 2016 at 4:48 am

I teach the Constitution for a living. I revere the document when it is used to further social justice and make our country a more inclusive one. I admire the Founders for establishing a representative democracy that has survived for over two centuries.

But sometimes we just have to acknowledge that the Founders and the Constitution are wrong. This is one of those times. We need to say loud and clear: The Second Amendment must be repealed.

As much as we have a culture of reverence for the founding generation, it’s important to understand that they got it wrong and got it wrong often. Unfortunately, in many instances, they enshrined those faults in the Constitution. For instance, most people don’t know it now, but under the original document, Mitt Romney would be serving as President Obama’s vice president right now because he was the runner-up in the last presidential election. That part of the Constitution was fixed by the Twelfth Amendment, which set up the system we currently have of the president and vice president running for office together.

Much more profoundly, the Framers and the Constitution were wildly wrong on race. They enshrined slavery into the Constitution in multiple ways, including taking the extreme step of prohibiting the Constitution from being amended to stop the slave trade in the country’s first 20years. They also blatantly wrote racism into the Constitution by counting slaves as only 3/5 of a person for purposes of Congressional representation. It took a bloody civil war to fix these constitutional flaws (and then another 150 years, and counting, to try to fix the societal consequences of them).

There are others flaws that have been fixed (such as about voting and Presidential succession), and still other flaws that have not yet been fixed (such as about equal rights for women and land-based representation in the Senate), but the point is the same there is absolutely nothing permanently sacrosanct about the Founders and the Constitution. They were deeply flawed people, it was and is a flawed document, and when we think about how to make our country a more perfect union, we must operate with those principles in mind.

In the face of yet another mass shooting, now is the time to acknowledge a profound but obvious truth the Second Amendment is wrong for this country and needs to be jettisoned. We can do that through a Constitutional amendment. It’s been done before (when the Twenty-First Amendment repealed prohibition in the Eighteenth), and it must be done now.

The Second Amendment needs to be repealed because it is outdated, a threat to liberty and a suicide pact. When the Second Amendment was adopted in 1791, there were no weapons remotely like the AR-15assault rifle and many of the advances of modern weaponry were long from being invented or popularized.

Sure, the Founders knew that the world evolved and that technology changed, but the weapons of today that are easily accessible are vastly different than anything that existed in 1791. When the Second Amendment was written, the Founders didn’t have to weigh the risks of one man killing 49and injuring 53 all by himself. Now we do, and the risk-benefit analysis of 1791 is flatly irrelevant to the risk-benefit analysis of today.

Gun-rights advocates like to make this all about liberty, insisting that their freedom to bear arms is of utmost importance and that restricting their freedom would be a violation of basic rights.

But liberty is not a one way street. It also includes the liberty to enjoy a night out with friends, loving who you want to love, dancing how you want to dance, in a club that has historically provided a refuge from the hate and fear that surrounds you. It also includes the liberty to go to and send your kids to kindergarten and first grade so that they can begin to be infused with a love of learning. It includes the liberty to go to a movie, to your religious house of worship, to college, to work, to an abortion clinic, go to a hair salon, to a community center, to the supermarket, to go anywhere and feel that you are free to do to so without having to weigh the risk of being gunned downby someone wielding a weapon that can easily kill you and countless others.

The liberty of some to own guns cannot take precedence over the liberty of everyone to live their lives free from the risk of being easily murdered. It has for too long, and we must now say no more.

Finally, if we take the gun-rights lobby at their word, the Second Amendment is a suicide pact. As they say over and over, the only way to stop a bad guy with a gun is a good guy with a gun. In other words, please the gun manufacturers by arming even the vast majority of Americans who do not own a gun.

Just think of what would have happened in the Orlando night-club Saturday night if there had been many others armed. In a crowded, dark, loud dance club, after the shooter began firing, imagine if others took out their guns and started firing back. Yes, maybe they would have killed the shooter, but how would anyone else have known what exactly was going on? How would it not have devolved into mass confusion and fear followed by a large-scale shootout without anyone knowing who was the good guy with a gun, who was the bad guy with a gun, and who was just caught in the middle? The death toll could have been much higher if more people were armed.

The gun-rights lobby’s mantra that more people need guns will lead to an obvious result more people will be killed. We’d be walking down a road in which blood baths are a common occurrence, all because the Second Amendment allows them to be.

At this point, bickering about the niceties of textual interpretation, whether the history of the amendment supports this view or that, and how legislators can solve this problem within the confines of the constitution is useless drivel that will lead to more of the same. We need a mass movement of those who are fed up with the long-dead Founders’ view of the world ruling current day politics. A mass movement of those who will stand up and say that our founding document was wrong and needs to be changed. A mass movement of those who will thumb their nose at the NRA, an organization that is nothing more than the political wing of the country’s gun manufacturers, and say enough is enough.

The Second Amendment must be repealed, and it is the essence of American democracy to say so.

Watch four pro-gun arguments we’re sick of hearing.

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Don’t Bank On The Supreme Court To Clarify The Second …

Posted: June 16, 2016 at 5:41 pm

If you think the Supreme Court is poised to expand or restrict gun rights sometime soon, don’t hold your breath.

As handwringing continues over what might have prevented the Orlando massacre– an old-time filibuster sparked by it even broke outin the Senate on Wednesday — the justices are about to consider a state gun control law enacted in the aftermath of the Sandy Hook school massacre in Newtown, Connecticut.

According to its docket, the court on Thursday will weigh whether to take up Shew v. Malloy, a case with all the elements that could make it emblematic for the battle over the Second Amendment’s meaning.

It’s a dispute between a host of gun rights groups, businesses and individual gun owners against Connecticut over the constitutionality of a sweeping regulatory regime that bans so-called “assault weapons” — semiautomatic firearms and large-capacity magazines of the very sort used in Newtown and Orlando.

Back in October, an appeals court in Manhattan said the Connecticut law and a similarly restrictive law in New Yorkwere constitutional –and the plaintiffs vowed to take the battle to the Supreme Court.

Tom King, the head of New York’s biggest gun rights group, even said he was “happy” to have lost the case because that meant his organization could now ask the highest court of the land to decide the issue once and for all.

Brendan McDermid / Reuters

But then Justice Antonin Scalia died. And suddenly,the gun lobby’s calculations changed — including King’s, who told the New York Daily News weeks after Scalia’s death that it was “just the wrong time” to continue the fight in the absence of a reliable conservative vote at the Supreme Court.

That might explain why Senate Majority Leader Mitch McConnell (R-Ky.) glowingly pointed to the National Rifle Association’s opposition to Merrick Garland, the president’s high court nominee, to rationalize his own refusal to hold a vote and a hearing for Garland.

None of this matters, and yet it matters a great deal.

Because despite the pleas from gun rights advocates who still want the Supreme Court to take up the challenge to the weapons ban, the justices could wield all kinds of reasons not to touch the case with a 10-foot pole.

It’s not that they aren’t interested in clarifying the scope of the Second Amendment in the wake of Scalia’s magnum opus in District of Columbia v. Heller, which for the first time recognized a fundamental right to gun ownership in the home. But to echo King, it’s just not the right time — not with a short-staffed Supreme Court, a volatile political environment, and a nomination fight that may very well continue after President Barack Obama’s successor takes office.

As things stand now, all signs point to an extremely quiet and uncontroversial Supreme Court term beginning next October — a dry season that will stand in stark contrast to the current term’s constitutional blockbusters on affirmative action, abortion and immigration, to name only a few.The court just isn’t taking many new cases.

This paucity of potential big decisions aside, the courthassent some signals that the Second Amendment is safe, even as it has rejected dozens of cases challenging gun control measures across the country, leaving lower courts as the final decision-makers.

Over the protest of Scalia and Justice Clarence Thomas, the Supreme Court refused in December to review an appeals court decision that effectively upheld an assault weapons ban in a small Illinois town. Thomas said that decision treated the Second Amendment as a second-class right.

But in March, a month after Scalia’s death, the justices tipped their hand the other way, ruling that a Massachusetts ban on stun guns may violate the right to bear arms, quietly but forcefully endorsing the late justice’s Heller decision.

The Second Amendment extends … to all instruments that constitute bearable arms, even those that were not in existence at the time of the founding,” the court said in a very brief rulingthat no justice signed his or her name to.

But writing separately, Thomas and Justice Samuel Alito said they would have gone further, asserting that indeed, gun ownership for self-defense is a “fundamental right” while making clear that Americans’ safety shouldn’t be “left to the mercy of state authorities who may be more concerned about disarming the people than about keeping them safe.”

Fighting words, as well as fodder for debate about where the court may go next on guns.

It is precisely this seeming tension within the Supreme Court — plus the political fallout from Scalia’s vacancy and all the work that other courts are doing to make some sense of the Second Amendment — that indicates why the justices probably won’t pull the trigger on the next big gun rights case soon.

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Hillary Clinton wavers on Second Amendment right to bear arms …

Posted: June 7, 2016 at 7:42 pm

Hillary Clinton declined to say Sunday whether she believes in a constitutional right to bear arms, possibly opening the door to a fresh round of attacks from Donald Trump, who has already accused the likely Democratic presidential nominee of wanting to “abolish” the Second Amendment.

In an interview on ABC’s “This Week,” Clinton deflected twice when she was asked whether she agrees with the Supreme Court’s interpretation of the Second Amendment. The court ruled in 2008 that the Constitution affords private citizens the right to keep firearms in their homes and that such possession need not be connected to military service.

The wording of the Second Amendment has long made the extent of gun-ownership rights a point of contention.

“A well regulated militia, being necessary to the security of a free state, the right of the people to keep and bear arms, shall not be infringed.”

Questioned by George Stephanopoulos about her view of the amendment, Clinton talked about a “nuanced reading” and emphasized her belief in the rights of local, state and federal governments to regulate gun ownership. Stephanopoulos, formerly a top aide to President Bill Clinton, wasn’t satisfied by the response.

“That’s not what I asked,” he replied.

Clinton then discussed the right to own a gun as a hypothetical. “If it is a constitutional right,” she began her next answer, “then it like every other constitutional right is subject to reasonable regulations.”

Here’s the full exchange:

STEPHANOPOULOS: Let’s talk about the Second Amendment. As you know, Donald Trump has also been out on the stump talking about the Second Amendment and saying you want to abolish the Second Amendment. I know you reject that. But I want to ask you a specific question: Do you believe that an individual’s right to bear arms is a constitutional right that it’s not linked to service in a militia?

CLINTON: I think that for most of our history there was a nuanced reading of the Second Amendment until the decision by the late Justice [Antonin] Scalia. And there was no argument until then that localities and states and the federal government had a right as we do with every amendment to impose reasonable regulations. So I believe we can have common-sense gun-safety measures consistent with the Second Amendment. And, in fact, what I have proposed is supported by 90 percent of the American people and more than 75 percent of responsible gun owners. So that is exactly what I think is constitutionally permissible and, once again, you have Donald Trump just making outright fabrications, accusing me of something that is absolutely untrue. But I’m going to continue to speak out for comprehensive background checks; closing the gun-show loophole; closing the online loophole; closing the so-called Charleston loophole;reversing the bill that Senator[Bernie] Sanders voted for and I voted against, giving immunity from liability to gun makers and sellers. I think all of that can and should be done, and it is, in my view, consistent with the Constitution.

STEPHANOPOULOS: And, and the Heller decision also says there can be some restrictions. But that’s not what I asked. I said, “Do you believe their conclusion that the right to bear arms is a constitutional right?”

CLINTON: If it is a constitutional right, then it like every other constitutional right is subject to reasonable regulations. And what people have done with that decision is to take it as far as they possibly can and reject what has been our history from the very beginning of the republic, where some of the earliest laws that were passed were about firearms. So I think it’s important to recognize that reasonable people can say, as I do, responsible gun owners have a right. I have no objection to that. But the rest of the American public has a right to require certain kinds of regulatory, responsible actions to protect everyone else.

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The Patriot Post Shop – 2A – Second Amendment

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Defending the Second Amendment – Kasich for America

Posted: April 9, 2016 at 12:40 am

Experience and Results Like No Other

Gov. John R. Kasich continues to be a strong supporter of the right to bear arms and, as governor, has signed every pro-2nd amendment bill that has crossed his desk to defend this basic, constitutional right. John Kasich is a gun-owner himself, and in his 2014 reelection was endorsed by the National Rifle Association for his support of the Second Amendment as an inviolate part of our Constitution.

Removing Burdensome Restrictions for Law-Abiding Concealed Carry Licensees: John Kasich enacted legislation protecting Ohios concealed carry laws, including protecting the privacy of permit holdersandallowing for reciprocity licenses with other stateswhere permit holders can carry their firearms.

Opposing Barack Obamas Gun Control Efforts: John Kasich opposes President Obamas gun control executive orders. The Second Amendment is too important and Obamas hostility to it is too well known for him to be allowed to go around Congress and undermine the Second Amendment. His efforts to expand the federal governments interference with Americans Right to Keep and Bear Arms are wrong and the governor opposes them.

Upholding Ohios Outdoors Traditions: In addition to having a $3.6 billion annual economic impact in Ohio, hunting and fishing are parts of Ohios long tradition of enjoying our natural places. John Kasich upheld this heritage by enacting legislation that removes restrictions on licensing requirements for hunters and by creating new policies to expand hunting rights in Ohio.

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Parsing the Second Amendment – CBS News

Posted: March 19, 2016 at 8:41 pm

Any discussion of the right to bear arms has to take note of the Second Amendment. Here’s Anthony Mason:

At the heart of the debate over guns in America is a single, inscrutable sentence: The Second Amendment of the Bill of Rights, whose wording is unusual.

Simon & Schuster

“The Second Amendment says, ‘A well-regulated militia, being necessary to the security of a free state, the right of the people to keep and bear arms, shall not be infringed.’ What does that mean?”

The most-disputed clause in the Constitution is the phrase about militias, which were a great concern when the Bill of Rights was written in 1792.

“At the Constitutional Convention in Philadelphia, there was a very big controversy about how to allocate military power,” said Nelson Lund, professor of constitutional law at George Mason University. He says the states feared the new government would try to disarm the 13 state militias, which required every white male over 16 to own a musket.

“The anti-Federalists were very worried that the states would be deprived of their power to resist federal tyranny,” Lund said.

“The militia, sir, is our ultimate safety,” Patrick Henry argued. “We can have no security without it.”

While guns were commonplace then, so were gun regulations. New York and Boston prohibited the firing of guns within city limits.

And in the notes for the Constitutional Convention, Waldman says, “There’s literally not a word about it protecting an individual right for gun ownership for self-protection, hunting, or any of the other things we think about now.”

“There’s one side that believes that this amendment refers specifically and only to militias,” said Mason.

“Well, I know people say that, but it just can’t be true,” replied Lund. “If you look at what the words say, it says ‘The right of the people to keep and bear arms.’ It does not say, ‘The right of the states’ or ‘The right of the militias.’ It says ‘the right of the people.'”

The debate over the Second Amendment came to a head at the Supreme Court in 2008, in a case filed over the Capital’s gun laws, called District of Columbia v. Heller. In a 5-4 vote, the court affirmed an individual’s right to keep and bear arms, striking down D.C.’s ban on handguns in the home.

‘The inherent right of self-defense,” Justice Antonin Scalia wrote in the majority opinion, “has been central to the Second Amendment right.”

But, Scalia added, “The right … is not unlimited,” also leaving room for gun regulation.

Lund said, “It is absolutely a continuing grey area.”

Another grey area is how the court might rule on future Second Amendment issues after the sudden death of Justice Scalia in February.

“So, you know, a lot depends on who replaces Justice Scalia,” said Lund.

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Psoriasis – Cleveland Clinic Center for Continuing Education

Posted: January 14, 2016 at 6:42 pm

Definition and Etiology

Psoriasis is a common; typically chronic papulosquamous skin disease that may be associated with a seronegative spondyloarthropathy. The etiology of psoriasis is unknown.

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Psoriasis affects 2% of the U.S. population, and about 11% of these patients have psoriatic arthritis (PsA). Psoriasis may begin at any age however generally there are two peaks of onset, the first at 20-30 years and the second at 50-60 years. Men and women are equally affected.

U.S. primary care physicians initially see 58% of the estimated 150,000 new cases of psoriasis per year, however dermatologists manage 80% of the 3 million office and hospital visits for psoriasis each year.

The type and clinical manifestations of psoriasis in a patient depend on a combination of genetic influences, environmental factors (i.e. trauma and climate) and associated diseases (particularly bacterial infections). Additionally, certain medications, notably lithium, antimalarials, beta blockers, interferon, and ethanol (if abused) have been reported to induce psoriasis or exacerbate preexisting disease in some patients. Emotional stress may also lead to psoriasis flares.

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Psoriasis is associated with the metabolic syndrome and cardiovascular (CV) disease. Psoriasis patients are not only more likely to have CV risk factors but severe psoriasis may serve as an independent risk factor for CV mortality.

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Psoriatic skin lesions are the result of inflammation in the dermis and hyperproliferation with abnormal differentiation of the epidermis. The primary pathologic process is most likely dysregulation of activated T cell interactions with antigen-presenting cells and overproduction of pro-inflammatory cytokines such as interferon- and tumor necrosis factor- (TNF- ). Evidence for this theory derives from the dramatic improvement of severe psoriasis in patients treated with immunosuppressive therapies such as cyclosporine (a potent T cell inhibitor used to prevent transplant rejection) or with TNF- inhibitors (used in other inflammatory diseases such as inflammatory bowel disease, rheumatoid arthritis and ankylosing spondylitis).

Recently, additional cytokine mediators, IL-12 and IL-23, have been linked to psoriasis as they promote differentiation of nave CD4+ lymphocytes into Th1 and Th17 cells respectively. The U.S Food and Drug Administration (FDA) has recently approved a novel therapy for psoriasis targeting Il-12 and IL-23, which will be discussed in the therapy section.

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Although considered a single disease, psoriasis has several morphologic expressions and a full range of severity.

Plaque-type psoriasis, or psoriasis vulgaris, is the most common form, occurring in about 80% of all psoriasis patients. A typical lesion is a well-demarcated, red-violet plaque with adherent white silvery scales (Fig. 1).

Lesions are typically symmetrical and the face is usually spared. The most commonly involved areas are the elbows and knees, scalp, sacrum, umbilicus, intergluteal cleft, and genitalia. In addition to physical trauma (Koebner phenomenon), other causes of cutaneous injury such as viral exanthems or sunburn may elicit the formation of any type of psoriatic lesion. About 70% of patients complain of pruritus, skin pain, or burning, especially when the scalp is involved. A characteristic finding, coined Auspitz sign, is pinpoint bleeding when psoriatic scale is lifted and correlates with histologic elongation of dermal papillae vessels in combination with suprapapillary epidermal thinning.

Guttate psoriasis (Fig. 2), named for its small droplet-shaped lesions, accounts for about 18% of all cases. This type is more common among children and young adults and is more likely to involve the face. Patients frequently have a history of a preceding upper respiratory tract infection or pharyngitis, particularly Group A Streptococcus. Some cases of acute guttate flares following streptococcal infection are precipitated by its superantigen exotoxin.

Pustular psoriasis (Fig. 3 and B) accounts for approximately 1.7% of cases. It is characterized by sterile pustules, which may be generalized or localized to the palms and soles. There is a female predominance in localized pustular psoriasis, however the incidence is equal in men and women in the generalized type. The average age at onset for pustular psoriasis is 50 years. Pregnancy and rapid tapering of systemic corticosteroids are known triggers. Generalized pustular psoriasis in pregnancy is also known as impetigo herpetiformis. Impetigo herpetiformis and generalized pustular psoriasis must be treated more aggressively because untreated, may lead to serious complications such as sepsis and bacterial superinfection.

Inverse psoriasis involves intertriginous areas (i.e skin folds of axilla, inguinal, intergluteal and inframammary regions). Plaques are typically pink to red and minimally scaly. Lesions may mimic cutaneous candidiasis however satellite lesions (if present) distinguish candidiasis from inverse psoriasis. Consider inverse psoriasis if candidiasis is recalcitrant to appropriate therapies.

The least common form of psoriasis is exfoliative dermatitis or psoriatic erythroderma, which accounts for 1% to 2% of all cases. Erythroderma is defined as a scaling pruritic, erythematous inflammatory skin eruption that involves over 90% of the body surface. Erythrodermic psoriasis may develop gradually or acutely during the course of chronic plaque-type psoriasis, but it may be the first manifestation of psoriasis, even in children. Psoriasis is the most common cause of erythroderma in adults and the second (following drug eruptions) in children. The mean age at onset is approximately 50 years. Men with the condition outnumber women, and concomitant psoriatic arthropathy is common. The most common precipitating factor is the withdrawal of potent topical, oral, and intramuscular corticosteroids. Although psoriasis patients are typically thought to be at decreased risk of cutaneous infection, those with erythrodermic psoriasis may be at risk for Staphylococcus aureus septicemia as a result of their compromised skin barrier therefore it is important for emergent evaluation by a dermatologist. Additionally, erythroderma may result in temperature dysregulation, hypoalbuminemia, and high output cardiac failure.

The nails (Fig. 4) are involved in up to 50% of psoriasis patients; in patients with psoriatic arthritis (PsA), the prevalence exceeds 80%. Pitting of the nail plate is the most common manifestation and is the result of damage to the proximal nail matrix. The pits tend to be large, deep, and randomly dispersed on the nail plate. Distal onycholysis, or lifting of the nail plate, is a common finding in psoriatic nail disease. Yellow-brown dyschromia (oil droplet sign) of the nail bed corresponds to psoriasis in that location and is the result of abnormal keratinization of the nail bed.

PsA affects up to one third of patients with psoriasis and is a destructive arthropathy and enthesopathy. Although PsA may share clinical features with rheumatoid arthritis (involving small and medium sized joints), it most commonly presents as inflammation of the proximal and distal interphalangeal joints in the hands and feet. Arthritis occurs after the onset of skin involvement in two thirds of cases however in 10-15% of patients, it occurs prior to the development of skin lesions. The severity of skin and nail involvement does not correlate with the severity of joint disease in patients with PsA. Early recognition and intervention is important as PsA may lead to loss of function. For this reason, patients with joint involvement are typically treated with more aggressive therapies such as a TNF inhibitor.

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A clinical diagnosis is usually sufficient for classic skin and nail lesions. The differential diagnosis is expansive however with several dermatologic conditions, which may present similarly including: atopic dermatitis, pityriasis rubra pilaris, drug reactions, tinea corporis, secondary syphilis, and cutaneous T cell lymphoma (mycosis fungoides variant). Therefore, it may be necessary to perform skin biopsy, potassium hydroxide (KOH) examination of scales, and serologic evaluations such as RPR and CBC with differential, blood smear and immunophenotyping (CD 4 to CD 8 ratio).

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The choice of treatment depends on the severity of disease and response in the individual patient.

Betamethasone dipropionate 0.05% (Diprolene)

Fluocinonide 0.05% (Lidex)

Desoximetasone 0.25% (Topicort)

PUVA*

Cyclosporine (Gengraf, Neoral, Sandimmune)

Acitretin (Soriatane)

Ustekinumab (Stelara)

Calcipotriol (Dovonex)

calcipotriene (Dovonex)

Calcitriol (Vectical)

Etanercept (Enbrel)

Adalimumab (Humira)

* *(PUVA) Psoralen combined with ultraviolet A.

Patients with limited disease (affecting less than 5% body surface area), not significantly involving the hands, feet or genitalia are treated primarily with class I or II topical corticosteroids. Steroid sparing agents such as calcipotriene, calcitriol (Vitamin D analogues), pimecrolimus and tacrolimus (calcineurin inhibitors) may also be used as monotherapy or in combination with a topical corticosteroid. Patients may complain of burning with application. The U.S. FDA currently recommends pimecrolimus and tacrolimus as second-line agents given potential cancer risk.

Phototherapy is a first line therapy for moderate to severe psoriasis. It may be used as monotherapy or in combination with topical or systemic therapies. There are several disadvantages to this treatment method as it is costly, requires special equipment and necessitates two or three office visits per week. It is advantageous for patients with additional comorbidities that preclude initiation of systemic therapies. Narrow band UVB therapy is the most commonly utilized form of phototherapy. Although more effective toward long term remission of psoriasis, psoralen plus UVA (PUVA) therapy is less utilized given increased risk of melanoma and non-melanoma skin cancers. Caution must also be taken in patients with fair skin, those who are taking photosensitizing medications, those with a history of skin cancer, and those who are chronically immunosuppressed after organ transplantation (as these patients are already at increased risk of non melanoma skin cancer).

Systemic therapy is effective, in treating severe disease (affecting more than 5% body surface area) and disease significantly involving the hands, feet or genitalia, however they have greater potential for toxicity. Systemic treatments for psoriasis are generally prescribed after consultation with a dermatologist.

Methotrexate (MTX) is the antimetabolite most often prescribed by dermatologists for moderate-to-severe psoriasis. Hepatotoxicity is the primary clinical concern when planning long-term methotrexate therapy. Mild transaminase elevations (less than twice the upper limit of normal) are to be expected during therapy, but these levels do not correlate with hepatic fibrosis. A 2009 consensus conference advocates following the American College of Rheumatology guidelines for patients with no risk factors for liver injury and recommend considering liver biopsy or switching to another treatment after 3.5 to 4 g to total cumulative methotrexate dosage. Folic acid (FA) supplementation at 1 mg daily is recommended to abate the gastrointestinal side effects of methotrexate without reducing efficacy (although many providers hold FA on the day of MTX therapy). It also helps to prevent megaloblastic anemia.

Cyclosporine is particularly useful for erythrodermic psoriasis as it takes effect rather quickly. Nephrotoxicity and hypertension are the two most serious side effects of cyclosporine therapy and should be monitored closely. Hyperlipidemia is also a potential side effect and given an already increased risk of CV disease in patients with severe psoriasis, fasting lipid profiles should be obtained regularly.

The biologic immunomodulators are monoclonal antibodies and fusion proteins that represent a paradigm shift in the treatment of moderate-to-severe psoriasis. These compounds were designed to antagonize cell-cell interactions, memory-effector T cells, or pro inflammatory cytokines.

Alefacept is a fusion protein composed of leukocyte function antigen-3 and human immunoglobulin 1 (IgG1). Alefacept was the first biologic to receive FDA approval for psoriasis in 2003. Although not mandated by the FDA, its pharmaceutical company voluntarily pulled alefacept from manufacturing and distribution in November 2011.

Efalizumab is a humanized monoclonal antibody directed against the CD-11a subunit of leukocyte function antigen-1 (LFA-1) expressed on T cells. By blocking the interaction of LFA-1 and its ligand intercellular adhesion molecule-1, T cell activation and migration into psoriatic plaques are decreased. Efalizumab was approved by the FDA for psoriasis in 2003. After three cases of progressive multifocal leukoencephalopathy caused by the JC virus were reported in association with efalizumab therapy for psoriasis, the manufacturer voluntarily withdrew the drug from the U.S. market in June 2009.

Etanercept is a cloned and engineered fusion protein made of two p75 TNF receptors and the Fc portion of human IgG. It binds and inactivates TNF and prevents its significant proinflammatory effects in the target tissue of skin and joints. Etanercept is FDA approved for RA, PsA, ankylosing spondylitis, and chronic to severe plaque psoriasis in adults. Etanercept is given at a starting dose of 50 mg injected subcutaneously (SQ) twice weekly for 12 weeks followed by 50 mg once weekly for maintenance of moderate to severe chronic plaque psoriasis. For PsA, 50mg is injected SQ weekly.

Infliximab is a chimeric (human-mouse) monoclonal antibody that binds TNF. It is FDA approved for rheumatoid and psoriatic arthritis and Crohn’s disease with and without methotrexate (MTX). For the treatment of severe plaque psoriasis and PsA (with or without MTX), infliximab is delivered by an intravenous infusion over a 2-hour period at weeks 0, 2, and 6 followed by maintenance infusions every 8 weeks. The serious immediate infusion reaction rate is 1%, and about 1% of patients experience delayed hypersensitivity reactions consisting of myalgia, arthralgia, fever, or skin eruption. Neutralizing antibodies are formed in about 20% of patients treated for 1 year, which can result in dose creep, whereby dose escalation or more frequent dosing of infliximab becomes necessary to keep symptoms under control. Concomitant methotrexate administration reduces the development of antichimeric antibodies.

Adalimumab is a human anti-TNF monoclonal antibody that blocks the interaction of TNF with the p55 and p75 cell-surface receptors. It is FDA approved for plaque psoriasis, PsA, ankylosing spondylitis, Crohn’s disease, ulcerative colitis, juvenile idiopathic arthritis, and rheumatoid arthritis. For moderate to severe plaque psoriasis, it is given at a starting dose of 80mg SQ, followed by 40mg SQ every other week beginning one week after the initial dose. For PsA, 40mg of adalimumab is administered every other week as monotherapy or in combination with methotrexate or other nonbiologic disease-modifying antirheumatic drugs (DMARDS).

Ustekinumab utilizes monoclonal antibodies directed against the p40 subunit of cytokines IL-12 and IL-23, which have been recently described as significant mediators of psoriasis. In September 2009, ustekinumab obtained FDA approval for the treatment of moderate to severe plaque psoriasis. It is also used to treat moderate to severe Crohn’s disease that is resistant to TNF inhibitors. For patients weighing 100kg or less, 45mg is injected SQ initially, 4 weeks later, then every 12 weeks thereafter. Patients weighing greater than 100kg may receive 90mg SQ initially, 4 weeks later, followed by every 12 weeks thereafter.

The greatest theoretical risks associated with the biologic immunomodulators are serious infections, particularly granulomatous, and increased rates of malignancy, particularly the lymphoproliferative diseases. To date, controlled trials and postmarketing surveillance studies have not conclusively demonstrated a higher-than-expected frequency of lymphomas in patients who have been treated the longest with anti-TNF agents. Although the risk for reactivating tuberculosis is considered greater for infliximab and adalimumab than with etanercept, a baseline tuberculin skin test (PPD) is recommended for all biologic immunomodulator therapies. Additional laboratory evaluation should include: hepatitis B screening, hepatic function panel and complete blood count with differential.

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Repeal the Second Amendment – Baltimore Sun

Posted: October 4, 2015 at 9:44 pm

In 2008, the Supreme Court of the United States decided in District of Columbia v. Heller that the Second Amendment to the U.S. Constitution protects a civilian’s right to keep a gun in his home. In 2010, the court decided in McDonald v. Chicago that the Due Process Clause of the Fourteenth Amendment limits the power of state and local governments to outlaw the possession of handguns by private citizens. The vote in each case was five-to-four not exactly a ringing endorsement of the court’s reasoning in either case. But for now, the law of the land with regard to easy access to guns is settled.

The Second Amendment is enthroned mistakenly, but as a matter of law as a fundamental dimension of individual freedom. The practical result is that we must live with carnage by firearms as a daily fact of American life.

Surely, the timid voices of reason and humanity whisper, there is some limit to the atrocities that Americans will tolerate. When Adam Lanza, with no prior criminal history nor treatment for mental illness, killed 26 people including 20 first-grade students at the Sandy Hook Elementary School in Newtown, Conn., on December 14, 2012, the nation was riveted and horrified. Something this unspeakable, this ghastly, this straight-out-of-hell, changed exactly nothing in federal law.

Then, in June of this year, a gunman killed nine churchgoers in Charleston, S.C. Two months later, a Virginia TV news crew was slaughtered on air, and the deed posted almost immediately to social media by the killer. And Thursday, a gunman killed at least 9 people and wounded others on the campus of Oregon’s Umpqua Community College.

What will it take to shock us out of our torpor? Another dead president? Not likely half the country will applaud it. How about a dozen people inspired by ISIS slipping simultaneously into the Mall of America and unveiling the assault weapons they have obtained in perfectly legal ways? I cannot imagine what level of gun violence will serve more to horrify than to entertain.

It is certainly a respectable idea to accept the Second Amendment and treat death by firearms as a public health issue. It is doomed to fail, however, because it isn’t the criminal or the psychotic who produces the murder, it’s the easy means to act out one’s fantasies that produces the criminal and the psychotic. Millions of guns, thousands of gun deaths.

Retired Justice John Paul Stevens, the leading dissenter in Heller and McDonald, has published a wise little book, “Six Amendments: How and Why We Should Change the Constitution.” He suggests five words be added to the Second Amendment so that it reads “A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear arms when serving in the Militia shall not be infringed.”

I say, let’s get rid of the Second Amendment altogether. Let the states and Congress regulate firearms as they see fit. Some states, most of them without big-city violence, will retain laws that allow citizens to carry concealed firearms. Gang-ridden Chicago will try again to crack down on guns. Congress will reconsider universal background checks and the prohibition of assault weapons.

As Justice Stevens informs us in his book, “legislatures are in a far better position than judges to assess the wisdom of such rules and to evaluate the costs and benefits that rule changes can be expected to produce. It is those legislators, rather than federal judges, who should make the decisions that will determine what kinds of firearms should be available to private citizens, and when and how they may be used. Constitutional provisions that curtail the legislative power to govern in this area unquestionably do more harm than good.”

And we’ve all already seen enough harm.

Hal Riedl retired from the Maryland Division of Correction in 2010, and from the office of the state’s attorney for Baltimore City in December 2014. His email is halriedl@msn.com.

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