Commentary

While you might not typically put chopped or blended, unsalted, boiled canned oysters on your usual list of recommended infant and toddler foods, maybe you should.

The American Academy of Pediatrics just published a new policy statement on advocacy to improve child nutrition in the first 1,000 days (from conception to age 2). The statement emphasizes the importance of nutrition to optimal brain development. Pediatricians are encouraged to be familiar with community services to support optimal nutrition such as the Special Supplemental Nutrition Program for Women, Infants, and Children, the Supplemental Nutrition Assistance Program, the Child and Adult Care Food Program, and food pantries and soup kitchens, but also to get beyond recommending a “good diet” to something more specific that is high in key nutrients important for brain development such as protein; zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and polyunsaturated fatty acids. That’s where the boiled oysters, a decent source of the listed nutrients and especially loaded with zinc, iron, and vitamin B12, come in. While not everyone is going to rush out to buy their babies such an unexpected (and for many, unfamiliar) food, the statement reminds pediatricians to recommend foods that are good sources of the nutrients that babies and toddlers need most. Other foods that fit the bill include oatmeal, meat and poultry, fish like salmon and tuna, eggs, tofu and soybeans, and other legumes and beans like chickpeas and lentils.

—Natalie D. Muth, MD
Pediatrician
Children's Primary Care Medical Group
Carlsbad, California

While you might not typically put chopped or blended, unsalted, boiled canned oysters on your usual list of recommended infant and toddler foods, maybe you should.

The American Academy of Pediatrics just published a new policy statement on advocacy to improve child nutrition in the first 1,000 days (from conception to age 2). The statement emphasizes the importance of nutrition to optimal brain development. Pediatricians are encouraged to be familiar with community services to support optimal nutrition such as the Special Supplemental Nutrition Program for Women, Infants, and Children, the Supplemental Nutrition Assistance Program, the Child and Adult Care Food Program, and food pantries and soup kitchens, but also to get beyond recommending a “good diet” to something more specific that is high in key nutrients important for brain development such as protein; zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and polyunsaturated fatty acids. That’s where the boiled oysters, a decent source of the listed nutrients and especially loaded with zinc, iron, and vitamin B12, come in. While not everyone is going to rush out to buy their babies such an unexpected (and for many, unfamiliar) food, the statement reminds pediatricians to recommend foods that are good sources of the nutrients that babies and toddlers need most. Other foods that fit the bill include oatmeal, meat and poultry, fish like salmon and tuna, eggs, tofu and soybeans, and other legumes and beans like chickpeas and lentils.

—Natalie D. Muth, MD
Pediatrician
Children's Primary Care Medical Group
Carlsbad, California

While you might not typically put chopped or blended, unsalted, boiled canned oysters on your usual list of recommended infant and toddler foods, maybe you should.

The American Academy of Pediatrics just published a new policy statement on advocacy to improve child nutrition in the first 1,000 days (from conception to age 2). The statement emphasizes the importance of nutrition to optimal brain development. Pediatricians are encouraged to be familiar with community services to support optimal nutrition such as the Special Supplemental Nutrition Program for Women, Infants, and Children, the Supplemental Nutrition Assistance Program, the Child and Adult Care Food Program, and food pantries and soup kitchens, but also to get beyond recommending a “good diet” to something more specific that is high in key nutrients important for brain development such as protein; zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and polyunsaturated fatty acids. That’s where the boiled oysters, a decent source of the listed nutrients and especially loaded with zinc, iron, and vitamin B12, come in. While not everyone is going to rush out to buy their babies such an unexpected (and for many, unfamiliar) food, the statement reminds pediatricians to recommend foods that are good sources of the nutrients that babies and toddlers need most. Other foods that fit the bill include oatmeal, meat and poultry, fish like salmon and tuna, eggs, tofu and soybeans, and other legumes and beans like chickpeas and lentils.

—Natalie D. Muth, MD
Pediatrician
Children's Primary Care Medical Group
Carlsbad, California

Serotonin syndrome.

What do those words make you think of? A rare neurological condition? The differential diagnosis you got at 2:00 a.m. from an overly enthusiastic resident? Or a fax from a pharmacy that you get a few times a week?

I’ll say the last.

megaflopp/Thinkstock

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Serotonin syndrome.

What do those words make you think of? A rare neurological condition? The differential diagnosis you got at 2:00 a.m. from an overly enthusiastic resident? Or a fax from a pharmacy that you get a few times a week?

I’ll say the last.

megaflopp/Thinkstock

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Serotonin syndrome.

What do those words make you think of? A rare neurological condition? The differential diagnosis you got at 2:00 a.m. from an overly enthusiastic resident? Or a fax from a pharmacy that you get a few times a week?

I’ll say the last.

megaflopp/Thinkstock

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The patient was diagnosed with pityriasis rosea (PR) on the basis of the clinical findings; a biopsy was not performed. The patient’s pruritus was treated with oral hydroxyzine and topical 1% triamcinolone ointment. She experienced itch relief with these treatments. On follow-up at 3 months, the patient’s lesions had mostly resolved with some postinflammatory hyperpigmentation.

Courtesy Dr. Catalina Matiz

Mimics

The herald patch of pityriasis rosea can resemble tinea corporis, and if there is any doubt as to the diagnosis, potassium hydroxide examination (also known as a KOH test) and/or fungal culture should be done to rule out a fungal etiology. However, certain features of this case, particularly the subsequent development of satellite lesions, are more consistent with pityriasis rosea.

Secondary syphilis should be considered in patients who are sexually active. The lesions of secondary syphilis are not typically pruritic, and involvement of the palms and soles is common (whereas such involvement is rare in pityriasis rosea).

Like pityriasis rosea, pityriasis lichenoides et varioliformis acuta (PLEVA) is characterized by papular lesions that resolve spontaneously; the lesions of PLEVA usually evolve to vesicular, necrotic, and purpuric papules that take longer to resolve than PR lesions. The lesions of PLEVA are more erythematous, pustular, and crusting than the lesions of pityriasis rosea.

Guttate psoriasis, which occurs following streptococcal pharyngitis in over 50% of patients, does not present with a herald lesion or distribution along Langer’s lines.¹⁰ If guttate psoriasis is suspected, rapid streptococcal testing of the throat or perianal area may be considered.

Nummular eczema presents as papules that enlarge to form erythematous, lichenified plaques that measure 1-2 cm in diameter. A relatively sudden eruption, such as this patient’s, would be unusual for nummular eczema. Also, nummular eczema typically occurs on xerotic skin, more often on the extremities than the trunk.
 

Diagnostic tests, treatment

Mr. Kusari is with the division of pediatric and adolescent dermatology at Rady Children’s Hospital, San Diego, and the departments of dermatology and pediatrics, University of California, San Diego. Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. They have no relevant financial disclosures. Email them at [email protected].

References

1. Dermatology. 2015;231(1):9-14.

2. World J Clin Cases. 2017 Jun 16;5(6):203-11.

3. Pediatr Dermatol. 2011 May-Jun;28(3):341-2.

4. J Eur Acad Dermatol Venereol. 2006 Jul;20(6):667-71.

5. Dermatology. 1997;195(4):374-8.

6. J Invest Dermatol. 2005 Jun;124(6):1234-40.

7. Arch Dermatol. 1999 Sep;135(9):1070-2.

8. J Am Acad Dermatol. 1982 Jul;7(1):80-9.

9. Iran J Pediatr. 2010 Jun;20(2):237-41.

10. J Pediatr. 1988 Dec;113(6):1037-9.

11. J Am Acad Dermatol. 2008 May;58(5 Suppl 1):S78-83.

12. J Am Acad Dermatol. 1995 Dec;33(6):996-9.

13. Indian Dermatol Online J. 2015 May-Jun;6(3):181-4.

The patient was diagnosed with pityriasis rosea (PR) on the basis of the clinical findings; a biopsy was not performed. The patient’s pruritus was treated with oral hydroxyzine and topical 1% triamcinolone ointment. She experienced itch relief with these treatments. On follow-up at 3 months, the patient’s lesions had mostly resolved with some postinflammatory hyperpigmentation.

Courtesy Dr. Catalina Matiz

Mimics

The herald patch of pityriasis rosea can resemble tinea corporis, and if there is any doubt as to the diagnosis, potassium hydroxide examination (also known as a KOH test) and/or fungal culture should be done to rule out a fungal etiology. However, certain features of this case, particularly the subsequent development of satellite lesions, are more consistent with pityriasis rosea.

Secondary syphilis should be considered in patients who are sexually active. The lesions of secondary syphilis are not typically pruritic, and involvement of the palms and soles is common (whereas such involvement is rare in pityriasis rosea).

Like pityriasis rosea, pityriasis lichenoides et varioliformis acuta (PLEVA) is characterized by papular lesions that resolve spontaneously; the lesions of PLEVA usually evolve to vesicular, necrotic, and purpuric papules that take longer to resolve than PR lesions. The lesions of PLEVA are more erythematous, pustular, and crusting than the lesions of pityriasis rosea.

Guttate psoriasis, which occurs following streptococcal pharyngitis in over 50% of patients, does not present with a herald lesion or distribution along Langer’s lines.¹⁰ If guttate psoriasis is suspected, rapid streptococcal testing of the throat or perianal area may be considered.

Nummular eczema presents as papules that enlarge to form erythematous, lichenified plaques that measure 1-2 cm in diameter. A relatively sudden eruption, such as this patient’s, would be unusual for nummular eczema. Also, nummular eczema typically occurs on xerotic skin, more often on the extremities than the trunk.
 

Diagnostic tests, treatment

Mr. Kusari is with the division of pediatric and adolescent dermatology at Rady Children’s Hospital, San Diego, and the departments of dermatology and pediatrics, University of California, San Diego. Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. They have no relevant financial disclosures. Email them at [email protected].

References

1. Dermatology. 2015;231(1):9-14.

2. World J Clin Cases. 2017 Jun 16;5(6):203-11.

3. Pediatr Dermatol. 2011 May-Jun;28(3):341-2.

4. J Eur Acad Dermatol Venereol. 2006 Jul;20(6):667-71.

5. Dermatology. 1997;195(4):374-8.

6. J Invest Dermatol. 2005 Jun;124(6):1234-40.

7. Arch Dermatol. 1999 Sep;135(9):1070-2.

8. J Am Acad Dermatol. 1982 Jul;7(1):80-9.

9. Iran J Pediatr. 2010 Jun;20(2):237-41.

10. J Pediatr. 1988 Dec;113(6):1037-9.

11. J Am Acad Dermatol. 2008 May;58(5 Suppl 1):S78-83.

12. J Am Acad Dermatol. 1995 Dec;33(6):996-9.

13. Indian Dermatol Online J. 2015 May-Jun;6(3):181-4.

The patient was diagnosed with pityriasis rosea (PR) on the basis of the clinical findings; a biopsy was not performed. The patient’s pruritus was treated with oral hydroxyzine and topical 1% triamcinolone ointment. She experienced itch relief with these treatments. On follow-up at 3 months, the patient’s lesions had mostly resolved with some postinflammatory hyperpigmentation.

Courtesy Dr. Catalina Matiz

Mimics

The herald patch of pityriasis rosea can resemble tinea corporis, and if there is any doubt as to the diagnosis, potassium hydroxide examination (also known as a KOH test) and/or fungal culture should be done to rule out a fungal etiology. However, certain features of this case, particularly the subsequent development of satellite lesions, are more consistent with pityriasis rosea.

Secondary syphilis should be considered in patients who are sexually active. The lesions of secondary syphilis are not typically pruritic, and involvement of the palms and soles is common (whereas such involvement is rare in pityriasis rosea).

Like pityriasis rosea, pityriasis lichenoides et varioliformis acuta (PLEVA) is characterized by papular lesions that resolve spontaneously; the lesions of PLEVA usually evolve to vesicular, necrotic, and purpuric papules that take longer to resolve than PR lesions. The lesions of PLEVA are more erythematous, pustular, and crusting than the lesions of pityriasis rosea.

Guttate psoriasis, which occurs following streptococcal pharyngitis in over 50% of patients, does not present with a herald lesion or distribution along Langer’s lines.¹⁰ If guttate psoriasis is suspected, rapid streptococcal testing of the throat or perianal area may be considered.

Nummular eczema presents as papules that enlarge to form erythematous, lichenified plaques that measure 1-2 cm in diameter. A relatively sudden eruption, such as this patient’s, would be unusual for nummular eczema. Also, nummular eczema typically occurs on xerotic skin, more often on the extremities than the trunk.
 

Diagnostic tests, treatment

Mr. Kusari is with the division of pediatric and adolescent dermatology at Rady Children’s Hospital, San Diego, and the departments of dermatology and pediatrics, University of California, San Diego. Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. They have no relevant financial disclosures. Email them at [email protected].

References

1. Dermatology. 2015;231(1):9-14.

2. World J Clin Cases. 2017 Jun 16;5(6):203-11.

3. Pediatr Dermatol. 2011 May-Jun;28(3):341-2.

4. J Eur Acad Dermatol Venereol. 2006 Jul;20(6):667-71.

5. Dermatology. 1997;195(4):374-8.

6. J Invest Dermatol. 2005 Jun;124(6):1234-40.

7. Arch Dermatol. 1999 Sep;135(9):1070-2.

8. J Am Acad Dermatol. 1982 Jul;7(1):80-9.

9. Iran J Pediatr. 2010 Jun;20(2):237-41.

10. J Pediatr. 1988 Dec;113(6):1037-9.

11. J Am Acad Dermatol. 2008 May;58(5 Suppl 1):S78-83.

12. J Am Acad Dermatol. 1995 Dec;33(6):996-9.

13. Indian Dermatol Online J. 2015 May-Jun;6(3):181-4.

Peter A. LeWitt, MD

Dr. LeWitt is the Director of the Parkinson Disease and Movement Disorder Program at Henry Ford Hospital, West Bloomfield, Michigan.

For most neurology subspecialties, the past quarter-century was only the latest chapter of a productive history extending through the mid-19th century, but for movement disorders, these years were formative. Before then, movement disorder specialists were few in number, and their medical literature was far more scanty than it is now, with multiple journals and texts now devoted to this topic. Twenty-five years ago, the international society devoted to Parkinson disease and other movement disorders was only a recent arrival. Fortunately, two charismatic and brilliant leaders—the American neurologist Stanley Fahn, MD, and the British neurologist C. David Marsden, MBBS—came forward to inspire a generation of trainees with their broad interests in bridging clinical neurology, experimental neuroscience, and patient advocacy. Today, the impact of these pioneers is still felt by a growing community of movement disorder clinicians and researchers who have transformed movement disorders from an earlier realm of descriptive neurology into a vibrant field exploring disease mechanisms and therapeutics, as well as an expanding array of clinical insights.

When Neurology Reviews was founded in 1993, the majority of significant developments in movement disorders concerned Parkinson’s disease. Strategies to improve upon dopaminergic therapy were being tested in clinical trials, along with ventures into pallidotomy as a neurosurgical treatment. Animal models of parkinsonism and neurochemical analysis of brain and putative biomarkers provided scientific guidance for trials of disease modification. Another milestone from the 1990s was discovery of the first gene leading to autosomal-dominant parkinsonism. This rare mutation in the structural protein alpha-synuclein had a much broader impact on Parkinson’s disease research in that it provided important information about the sporadic disorder’s final common pathway of pathogenesis. Today, alpha-synuclein is the focus of therapeutic intervention utilizing immunologic therapies to halt disease progression. Over the past quarter-century, more than two dozen additional gene mutations associated with parkinsonism have been discovered. These mutations provide additional insight into disease mechanisms. Beyond the science and clinical insights that have propelled advances in understanding Parkinson’s disease and its related disorders, the growth of the patient advocacy and caregiver movement has also been remarkable in expanding what is needed to improve daily life with this disorder.

Since 1993, other movement disorders have also profited from the tremendous growth of molecular neuroscience and its applications. Novel neuroimaging techniques like functional MRI, computation of neural pathways, and scanning using PET and SPECT have helped work out the brain mechanisms of several disorders. Genetic probing of familial disorders like dystonia and myoclonus have helped to unravel the neurochemistry of what has gone wrong to cause certain movement disorders. In turn, transgenic animal models using these human genetic mutations have allowed exploration of what might be done to fix the problems. These developments could have huge implications for making progress in the therapies of the future, since the most common categories of movement disorders—dystonia, myoclonus, ataxia, tremor, restless legs syndrome, Tourette syndrome, choreic disorders, and paroxysmal movement disorders—all can have hereditary patterns. Genetic testing can be valuable for choosing at-risk individuals for participation in trials of disease-modifying drugs for Huntington’s disease, for example, and this strategy may be the way of the future for other late-life emergent disorders. In the past decade, several gene therapy studies have been carried out in patients with Parkinson’s disease. The promise of this approach and the recent gene editing and RNA interference approaches, all part of the molecular biology revolution of the past 25 years, may further change the landscape of movement disorder therapeutics ahead.

Today, movement disorder specialists routinely use therapeutic approaches that were in their infancy in 1993. Botulinum toxin selective denervation has had a major impact by improving quality of life for patients affected with a wide range of movement disorders: dystonic necks, hands, and feet; involuntary facial movements and voice aberrations; tics; spasticity; and drooling. Deep brain stimulation is a routine option for many patients with tremor, Parkinson’s disease, and dystonia. Developments in this field have refined the choice of targets for stimulation and the possibility of treating other disorders with these techniques, like Tourette syndrome. A nonsurgical approach to abolishing tremor, MRI-guided focused ultrasound, recently was approved. In the background of these advances is the increasing knowledge of movement disorders that practitioners have to offer many patients with disorders that in the past were merely neurologic curiosities. Through clinical trial research and serendipity (the major treatment options for essential tremor arose this way), there is an expanding search for repurposing older medications and harnessing new biotechnology to target the mechanisms leading to various movement disorders.

It is impressive how much the neurologic discipline of movement disorders has changed in response to the new era of electronic communications and other technologies. In the past quarter-century, medical students, residents, and practicing neurologists have had instant access to a curriculum that includes resources such as video-recorded movement disorders. Clinical trials are being revolutionized by electronic technologies that record information in ways that improve upon human ratings. A patient with Parkinson’s disease, essential tremor, or restless legs syndrome can now have symptoms monitored remotely by wearable devices that offer a real-world view on how a new therapy is performing. But perhaps the greatest revolution in the recent past has been increasing confidence that progressive disabilities caused by movement disorders might be halted by emerging insights into disease mechanisms. There has been tremendous growth of interest among the basic neuroscience community in human diseases affecting motor control. More than half of research presentations at recent international Parkinson’s disease and movement disorder conferences reflect this trend. These efforts support an optimistic view that, over the next quarter-century, the most challenging movement disorder problems of today will experience as much progress as in the past 25 years.

Peter A. LeWitt, MD

Dr. LeWitt is the Director of the Parkinson Disease and Movement Disorder Program at Henry Ford Hospital, West Bloomfield, Michigan.

For most neurology subspecialties, the past quarter-century was only the latest chapter of a productive history extending through the mid-19th century, but for movement disorders, these years were formative. Before then, movement disorder specialists were few in number, and their medical literature was far more scanty than it is now, with multiple journals and texts now devoted to this topic. Twenty-five years ago, the international society devoted to Parkinson disease and other movement disorders was only a recent arrival. Fortunately, two charismatic and brilliant leaders—the American neurologist Stanley Fahn, MD, and the British neurologist C. David Marsden, MBBS—came forward to inspire a generation of trainees with their broad interests in bridging clinical neurology, experimental neuroscience, and patient advocacy. Today, the impact of these pioneers is still felt by a growing community of movement disorder clinicians and researchers who have transformed movement disorders from an earlier realm of descriptive neurology into a vibrant field exploring disease mechanisms and therapeutics, as well as an expanding array of clinical insights.

When Neurology Reviews was founded in 1993, the majority of significant developments in movement disorders concerned Parkinson’s disease. Strategies to improve upon dopaminergic therapy were being tested in clinical trials, along with ventures into pallidotomy as a neurosurgical treatment. Animal models of parkinsonism and neurochemical analysis of brain and putative biomarkers provided scientific guidance for trials of disease modification. Another milestone from the 1990s was discovery of the first gene leading to autosomal-dominant parkinsonism. This rare mutation in the structural protein alpha-synuclein had a much broader impact on Parkinson’s disease research in that it provided important information about the sporadic disorder’s final common pathway of pathogenesis. Today, alpha-synuclein is the focus of therapeutic intervention utilizing immunologic therapies to halt disease progression. Over the past quarter-century, more than two dozen additional gene mutations associated with parkinsonism have been discovered. These mutations provide additional insight into disease mechanisms. Beyond the science and clinical insights that have propelled advances in understanding Parkinson’s disease and its related disorders, the growth of the patient advocacy and caregiver movement has also been remarkable in expanding what is needed to improve daily life with this disorder.

Since 1993, other movement disorders have also profited from the tremendous growth of molecular neuroscience and its applications. Novel neuroimaging techniques like functional MRI, computation of neural pathways, and scanning using PET and SPECT have helped work out the brain mechanisms of several disorders. Genetic probing of familial disorders like dystonia and myoclonus have helped to unravel the neurochemistry of what has gone wrong to cause certain movement disorders. In turn, transgenic animal models using these human genetic mutations have allowed exploration of what might be done to fix the problems. These developments could have huge implications for making progress in the therapies of the future, since the most common categories of movement disorders—dystonia, myoclonus, ataxia, tremor, restless legs syndrome, Tourette syndrome, choreic disorders, and paroxysmal movement disorders—all can have hereditary patterns. Genetic testing can be valuable for choosing at-risk individuals for participation in trials of disease-modifying drugs for Huntington’s disease, for example, and this strategy may be the way of the future for other late-life emergent disorders. In the past decade, several gene therapy studies have been carried out in patients with Parkinson’s disease. The promise of this approach and the recent gene editing and RNA interference approaches, all part of the molecular biology revolution of the past 25 years, may further change the landscape of movement disorder therapeutics ahead.

Today, movement disorder specialists routinely use therapeutic approaches that were in their infancy in 1993. Botulinum toxin selective denervation has had a major impact by improving quality of life for patients affected with a wide range of movement disorders: dystonic necks, hands, and feet; involuntary facial movements and voice aberrations; tics; spasticity; and drooling. Deep brain stimulation is a routine option for many patients with tremor, Parkinson’s disease, and dystonia. Developments in this field have refined the choice of targets for stimulation and the possibility of treating other disorders with these techniques, like Tourette syndrome. A nonsurgical approach to abolishing tremor, MRI-guided focused ultrasound, recently was approved. In the background of these advances is the increasing knowledge of movement disorders that practitioners have to offer many patients with disorders that in the past were merely neurologic curiosities. Through clinical trial research and serendipity (the major treatment options for essential tremor arose this way), there is an expanding search for repurposing older medications and harnessing new biotechnology to target the mechanisms leading to various movement disorders.

It is impressive how much the neurologic discipline of movement disorders has changed in response to the new era of electronic communications and other technologies. In the past quarter-century, medical students, residents, and practicing neurologists have had instant access to a curriculum that includes resources such as video-recorded movement disorders. Clinical trials are being revolutionized by electronic technologies that record information in ways that improve upon human ratings. A patient with Parkinson’s disease, essential tremor, or restless legs syndrome can now have symptoms monitored remotely by wearable devices that offer a real-world view on how a new therapy is performing. But perhaps the greatest revolution in the recent past has been increasing confidence that progressive disabilities caused by movement disorders might be halted by emerging insights into disease mechanisms. There has been tremendous growth of interest among the basic neuroscience community in human diseases affecting motor control. More than half of research presentations at recent international Parkinson’s disease and movement disorder conferences reflect this trend. These efforts support an optimistic view that, over the next quarter-century, the most challenging movement disorder problems of today will experience as much progress as in the past 25 years.

Peter A. LeWitt, MD

Dr. LeWitt is the Director of the Parkinson Disease and Movement Disorder Program at Henry Ford Hospital, West Bloomfield, Michigan.

For most neurology subspecialties, the past quarter-century was only the latest chapter of a productive history extending through the mid-19th century, but for movement disorders, these years were formative. Before then, movement disorder specialists were few in number, and their medical literature was far more scanty than it is now, with multiple journals and texts now devoted to this topic. Twenty-five years ago, the international society devoted to Parkinson disease and other movement disorders was only a recent arrival. Fortunately, two charismatic and brilliant leaders—the American neurologist Stanley Fahn, MD, and the British neurologist C. David Marsden, MBBS—came forward to inspire a generation of trainees with their broad interests in bridging clinical neurology, experimental neuroscience, and patient advocacy. Today, the impact of these pioneers is still felt by a growing community of movement disorder clinicians and researchers who have transformed movement disorders from an earlier realm of descriptive neurology into a vibrant field exploring disease mechanisms and therapeutics, as well as an expanding array of clinical insights.

When Neurology Reviews was founded in 1993, the majority of significant developments in movement disorders concerned Parkinson’s disease. Strategies to improve upon dopaminergic therapy were being tested in clinical trials, along with ventures into pallidotomy as a neurosurgical treatment. Animal models of parkinsonism and neurochemical analysis of brain and putative biomarkers provided scientific guidance for trials of disease modification. Another milestone from the 1990s was discovery of the first gene leading to autosomal-dominant parkinsonism. This rare mutation in the structural protein alpha-synuclein had a much broader impact on Parkinson’s disease research in that it provided important information about the sporadic disorder’s final common pathway of pathogenesis. Today, alpha-synuclein is the focus of therapeutic intervention utilizing immunologic therapies to halt disease progression. Over the past quarter-century, more than two dozen additional gene mutations associated with parkinsonism have been discovered. These mutations provide additional insight into disease mechanisms. Beyond the science and clinical insights that have propelled advances in understanding Parkinson’s disease and its related disorders, the growth of the patient advocacy and caregiver movement has also been remarkable in expanding what is needed to improve daily life with this disorder.

Since 1993, other movement disorders have also profited from the tremendous growth of molecular neuroscience and its applications. Novel neuroimaging techniques like functional MRI, computation of neural pathways, and scanning using PET and SPECT have helped work out the brain mechanisms of several disorders. Genetic probing of familial disorders like dystonia and myoclonus have helped to unravel the neurochemistry of what has gone wrong to cause certain movement disorders. In turn, transgenic animal models using these human genetic mutations have allowed exploration of what might be done to fix the problems. These developments could have huge implications for making progress in the therapies of the future, since the most common categories of movement disorders—dystonia, myoclonus, ataxia, tremor, restless legs syndrome, Tourette syndrome, choreic disorders, and paroxysmal movement disorders—all can have hereditary patterns. Genetic testing can be valuable for choosing at-risk individuals for participation in trials of disease-modifying drugs for Huntington’s disease, for example, and this strategy may be the way of the future for other late-life emergent disorders. In the past decade, several gene therapy studies have been carried out in patients with Parkinson’s disease. The promise of this approach and the recent gene editing and RNA interference approaches, all part of the molecular biology revolution of the past 25 years, may further change the landscape of movement disorder therapeutics ahead.

Today, movement disorder specialists routinely use therapeutic approaches that were in their infancy in 1993. Botulinum toxin selective denervation has had a major impact by improving quality of life for patients affected with a wide range of movement disorders: dystonic necks, hands, and feet; involuntary facial movements and voice aberrations; tics; spasticity; and drooling. Deep brain stimulation is a routine option for many patients with tremor, Parkinson’s disease, and dystonia. Developments in this field have refined the choice of targets for stimulation and the possibility of treating other disorders with these techniques, like Tourette syndrome. A nonsurgical approach to abolishing tremor, MRI-guided focused ultrasound, recently was approved. In the background of these advances is the increasing knowledge of movement disorders that practitioners have to offer many patients with disorders that in the past were merely neurologic curiosities. Through clinical trial research and serendipity (the major treatment options for essential tremor arose this way), there is an expanding search for repurposing older medications and harnessing new biotechnology to target the mechanisms leading to various movement disorders.

It is impressive how much the neurologic discipline of movement disorders has changed in response to the new era of electronic communications and other technologies. In the past quarter-century, medical students, residents, and practicing neurologists have had instant access to a curriculum that includes resources such as video-recorded movement disorders. Clinical trials are being revolutionized by electronic technologies that record information in ways that improve upon human ratings. A patient with Parkinson’s disease, essential tremor, or restless legs syndrome can now have symptoms monitored remotely by wearable devices that offer a real-world view on how a new therapy is performing. But perhaps the greatest revolution in the recent past has been increasing confidence that progressive disabilities caused by movement disorders might be halted by emerging insights into disease mechanisms. There has been tremendous growth of interest among the basic neuroscience community in human diseases affecting motor control. More than half of research presentations at recent international Parkinson’s disease and movement disorder conferences reflect this trend. These efforts support an optimistic view that, over the next quarter-century, the most challenging movement disorder problems of today will experience as much progress as in the past 25 years.

It was a “never event.” At the very end of the 2017 Academy Awards presentation, the winner for Best Picture was announced. It was wrong. Two and a half minutes later it was corrected. The true winner was “Moonlight,” not “La La Land.” But by then much damage had been done.

What can a safety engineer learn from this 2017 Oscar fiasco?

I watched it happen live on TV and reviewed it again on YouTube. Several news agencies investigated and reported on what happened. I don’t have any inside information beyond that, but my engineering perspective can illuminate how to reduce mistakes.

Ivan Bandura/Wikimedia Commons/CC BY 2.0

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

It was a “never event.” At the very end of the 2017 Academy Awards presentation, the winner for Best Picture was announced. It was wrong. Two and a half minutes later it was corrected. The true winner was “Moonlight,” not “La La Land.” But by then much damage had been done.

What can a safety engineer learn from this 2017 Oscar fiasco?

I watched it happen live on TV and reviewed it again on YouTube. Several news agencies investigated and reported on what happened. I don’t have any inside information beyond that, but my engineering perspective can illuminate how to reduce mistakes.

Ivan Bandura/Wikimedia Commons/CC BY 2.0

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

It was a “never event.” At the very end of the 2017 Academy Awards presentation, the winner for Best Picture was announced. It was wrong. Two and a half minutes later it was corrected. The true winner was “Moonlight,” not “La La Land.” But by then much damage had been done.

What can a safety engineer learn from this 2017 Oscar fiasco?

I watched it happen live on TV and reviewed it again on YouTube. Several news agencies investigated and reported on what happened. I don’t have any inside information beyond that, but my engineering perspective can illuminate how to reduce mistakes.

Ivan Bandura/Wikimedia Commons/CC BY 2.0

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

Responsive neurostimulation (RNS) appears to reduce the risk of sudden unexpected death in epilepsy (SUDEP), according to research published online ahead of print January 16 in Epilepsia. The results provide evidence that treatments that reduce seizures decrease the risk of SUDEP, according to the authors. The data also indicate that not every SUDEP follows a seizure.

Orrin Devinsky, MD, Director of the Comprehensive Epilepsy Center at New York University Langone Medical Center, and colleagues examined data for all deaths in patients with epilepsy who received RNS in clinical trials or following FDA approval through May 5, 2016, and adjudicated them for SUDEP. In all, 256 patients received treatment during trials, and 451 received treatment after FDA approval.

—Erik Greb

Suggested Reading

Devinsky O, Friedman D, Duckrow RB, et al. Sudden unexpected death in epilepsy in patients treated with brain-responsive neurostimulation. Epilepsia. 2018 Jan 16 [Epub ahead of print].

Responsive neurostimulation (RNS) appears to reduce the risk of sudden unexpected death in epilepsy (SUDEP), according to research published online ahead of print January 16 in Epilepsia. The results provide evidence that treatments that reduce seizures decrease the risk of SUDEP, according to the authors. The data also indicate that not every SUDEP follows a seizure.

Orrin Devinsky, MD, Director of the Comprehensive Epilepsy Center at New York University Langone Medical Center, and colleagues examined data for all deaths in patients with epilepsy who received RNS in clinical trials or following FDA approval through May 5, 2016, and adjudicated them for SUDEP. In all, 256 patients received treatment during trials, and 451 received treatment after FDA approval.

—Erik Greb

Suggested Reading

Devinsky O, Friedman D, Duckrow RB, et al. Sudden unexpected death in epilepsy in patients treated with brain-responsive neurostimulation. Epilepsia. 2018 Jan 16 [Epub ahead of print].

Responsive neurostimulation (RNS) appears to reduce the risk of sudden unexpected death in epilepsy (SUDEP), according to research published online ahead of print January 16 in Epilepsia. The results provide evidence that treatments that reduce seizures decrease the risk of SUDEP, according to the authors. The data also indicate that not every SUDEP follows a seizure.

Orrin Devinsky, MD, Director of the Comprehensive Epilepsy Center at New York University Langone Medical Center, and colleagues examined data for all deaths in patients with epilepsy who received RNS in clinical trials or following FDA approval through May 5, 2016, and adjudicated them for SUDEP. In all, 256 patients received treatment during trials, and 451 received treatment after FDA approval.

—Erik Greb

Suggested Reading

Devinsky O, Friedman D, Duckrow RB, et al. Sudden unexpected death in epilepsy in patients treated with brain-responsive neurostimulation. Epilepsia. 2018 Jan 16 [Epub ahead of print].

There was a time, not so long ago, when in the popular imagination, a drug deal involved an aging hippie in a tie-dyed shirt and love beads, copping a joint at a Dead concert. Today, however, in the age of the Internet and smartphones, a teenager in his bedroom can select, order, and have delivered to his door illicit drugs via the marketplaces on the “dark web.”

As the name implies, the dark web is a subterranean layer of the Internet that is mysterious, ominous, and sometimes lawless. It lies “beneath” the surface web – the layer where grandmothers post on Facebook and purchase on Amazon.

The dark web largely was the brainchild of three mathematicians at the Naval Research Laboratory as a means of encrypting messages exchanged by the intelligence community. They dubbed their project “Tor,” for “The Onion Router,” as the system consists of layer after layer of random relays, permitting anonymity on the Internet with little risk of tracking or surveillance.

This online underworld first came to my attention several years ago. The father of a teen who was being treated for disruptive mood dysregulation, attention-deficit disorder, and alcohol and cannabis use disorder called to inform me that his son had been arrested at Lollapalooza with hundreds of Adderall tablets and Xanax bars. Several weeks later, in session, the young man disclosed to me that he had found simple instructions online about installing Tor, creating a VPN (a virtual private network), accessing the dark web, transacting with bitcoin, and identifying drug marketplaces. He also demonstrated a detailed knowledge of chemical manufacturing in China, pill pressing in Canada, and money laundering in Switzerland.

With the air of an insider sharing “trade secrets,” this young man described how dealers on the dark web avoid detection and ensure secure delivery of the goods: latex gloves, vacuum sealing, and bleach dipping to obviate fingerprints – human and chemical. He said that dealers will send “dummy” packages to throw off the authorities and that buyers often will use the address of a clueless or absent neighbor. In his case, however, the parcels were delivered to his doorstep.

To a generation raised on the Internet and virtual reality, buying drugs on the dark web can appear appealing and have many advantages. For one thing, acquiring drugs in this way can seem less risky, as there is no chance of being robbed at gunpoint in a sketchy neighborhood or being busted for possession during a routine traffic stop.

Crossing over to the world of the dark web also can give an adolescent a sense of being clever and rebellious and of pulling a “fast one” on the parents – and on us, the clinicians who are treating them. And a teen who is interested in using illicit substances and plays “Call of Duty” from the comfort of his family’s basement without actual injury or death might assume that he can attain illicit drugs that are safe and inexpensive.

There are counterarguments to misinformation about the dark web. For example, contrary to the notion that buying drugs on the dark web minimizes interdiction or arrest, clinicians should point out that since international law enforcement shut down Silk Road and incarcerated its founder, Ross Ulbricht (also known as “Dread Pirate Roberts”) in 2013, hundreds of other dark web marketplaces such as AlphaBay and Hansa have been silenced and their operators prosecuted.

Moreover, the U.S. Department of Justice recently launched the Joint Criminal Opioid Darknet Enforcement (J-CODE) group, and the U.S. Postal Service Inspection Service reportedly has been hiring cybercrime and dark web specialists to combat drug trafficking. It might come as a surprise to a teen that, in a state where recreational marijuana is legal, transport and delivery of cannabis by the postal service elevates purchase and possession to the level of a violation of federal law. Informing even the most oblivious or oppositional adolescent that a drug felony can disqualify him for college grants and loans, impede his search for gainful employment, or prohibit him from obtaining a professional license, might give him a moment’s pause.

Adolescents seeking to buy drugs on the dark web should brace themselves for another shock. Whether lulled by custom after years of shopping on Amazon or using PayPal, or simply dulled by addiction, they might have a blind trust that bitcoin tumblers and “dark” escrow accounts will secure their payments. It will be rude awakening when they learn that the transfer and holding of currency on the dark web is vulnerable to hackers and to operators of the marketplaces – who are known to simply abscond with funds.

Currently, the drug marketplaces on the dark web represent a thin slice of the total illicit drug trade. These marketplaces, however, are growing quickly and offer buyers a virtual smorgasbord: the leading prescription drugs bought are Xanax and OxyContin, whereas 3,4-methylenedioxymethamphetamine (MDMA)/ecstasy and cannabis are the most commonly purchased controlled Schedule I substances, according to an article in The Economist. The estimated annual sales for 2016 ranged from $100 million to $200 million, but even more alarming is the percentage of substance abusers who have purchased drugs on the dark web: A recent article in The Independent reported that 13.2% of U.S. respondents self-reported making at least one purchase online, whereas in the United Kingdom, the self-reported percentage was 25.3 %, and in Finland, it was 41.4%.

Evidence abounds that drugs purchased on the dark web often are counterfeit and sometimes “dirty.” There is a report of “Viagra” containing cement dust, of “Ambien” containing haloperidol, and “Xanax” laced with fentanyl, the latter having been linked to several deaths and hospital admissions in the Bay Area in 2016. (Big Pharma, in fact, is engaged in surveillance and investigation of the sale of knockoffs online, The Telegraph reported in article about the proliferation of fake drugs available on the surface web).Unfortunately, attempting to reduce teen substance abuse using law enforcement measures directed at dark web marketplaces might be a game of whack-a-mole: As soon as one supply source is staunched, another surfaces. Indeed, addiction should be viewed not simply in terms of the biopsychosocial model, but also as an economic activity. Thus, it might be more beneficial for clinicians to concentrate our resources and efforts on curtailing the demand through education and treatment.

Dr. Marseille is a psychiatrist who works on the staff at a clinic in Winfield, Ill. His special interests include adolescent and addiction medicine, eating disorders, trauma, bipolar disorder, and the psychiatric manifestations of acute and chronic medical conditions.

There was a time, not so long ago, when in the popular imagination, a drug deal involved an aging hippie in a tie-dyed shirt and love beads, copping a joint at a Dead concert. Today, however, in the age of the Internet and smartphones, a teenager in his bedroom can select, order, and have delivered to his door illicit drugs via the marketplaces on the “dark web.”

As the name implies, the dark web is a subterranean layer of the Internet that is mysterious, ominous, and sometimes lawless. It lies “beneath” the surface web – the layer where grandmothers post on Facebook and purchase on Amazon.

The dark web largely was the brainchild of three mathematicians at the Naval Research Laboratory as a means of encrypting messages exchanged by the intelligence community. They dubbed their project “Tor,” for “The Onion Router,” as the system consists of layer after layer of random relays, permitting anonymity on the Internet with little risk of tracking or surveillance.

This online underworld first came to my attention several years ago. The father of a teen who was being treated for disruptive mood dysregulation, attention-deficit disorder, and alcohol and cannabis use disorder called to inform me that his son had been arrested at Lollapalooza with hundreds of Adderall tablets and Xanax bars. Several weeks later, in session, the young man disclosed to me that he had found simple instructions online about installing Tor, creating a VPN (a virtual private network), accessing the dark web, transacting with bitcoin, and identifying drug marketplaces. He also demonstrated a detailed knowledge of chemical manufacturing in China, pill pressing in Canada, and money laundering in Switzerland.

With the air of an insider sharing “trade secrets,” this young man described how dealers on the dark web avoid detection and ensure secure delivery of the goods: latex gloves, vacuum sealing, and bleach dipping to obviate fingerprints – human and chemical. He said that dealers will send “dummy” packages to throw off the authorities and that buyers often will use the address of a clueless or absent neighbor. In his case, however, the parcels were delivered to his doorstep.

To a generation raised on the Internet and virtual reality, buying drugs on the dark web can appear appealing and have many advantages. For one thing, acquiring drugs in this way can seem less risky, as there is no chance of being robbed at gunpoint in a sketchy neighborhood or being busted for possession during a routine traffic stop.

Crossing over to the world of the dark web also can give an adolescent a sense of being clever and rebellious and of pulling a “fast one” on the parents – and on us, the clinicians who are treating them. And a teen who is interested in using illicit substances and plays “Call of Duty” from the comfort of his family’s basement without actual injury or death might assume that he can attain illicit drugs that are safe and inexpensive.

There are counterarguments to misinformation about the dark web. For example, contrary to the notion that buying drugs on the dark web minimizes interdiction or arrest, clinicians should point out that since international law enforcement shut down Silk Road and incarcerated its founder, Ross Ulbricht (also known as “Dread Pirate Roberts”) in 2013, hundreds of other dark web marketplaces such as AlphaBay and Hansa have been silenced and their operators prosecuted.

Moreover, the U.S. Department of Justice recently launched the Joint Criminal Opioid Darknet Enforcement (J-CODE) group, and the U.S. Postal Service Inspection Service reportedly has been hiring cybercrime and dark web specialists to combat drug trafficking. It might come as a surprise to a teen that, in a state where recreational marijuana is legal, transport and delivery of cannabis by the postal service elevates purchase and possession to the level of a violation of federal law. Informing even the most oblivious or oppositional adolescent that a drug felony can disqualify him for college grants and loans, impede his search for gainful employment, or prohibit him from obtaining a professional license, might give him a moment’s pause.

Adolescents seeking to buy drugs on the dark web should brace themselves for another shock. Whether lulled by custom after years of shopping on Amazon or using PayPal, or simply dulled by addiction, they might have a blind trust that bitcoin tumblers and “dark” escrow accounts will secure their payments. It will be rude awakening when they learn that the transfer and holding of currency on the dark web is vulnerable to hackers and to operators of the marketplaces – who are known to simply abscond with funds.

Currently, the drug marketplaces on the dark web represent a thin slice of the total illicit drug trade. These marketplaces, however, are growing quickly and offer buyers a virtual smorgasbord: the leading prescription drugs bought are Xanax and OxyContin, whereas 3,4-methylenedioxymethamphetamine (MDMA)/ecstasy and cannabis are the most commonly purchased controlled Schedule I substances, according to an article in The Economist. The estimated annual sales for 2016 ranged from $100 million to $200 million, but even more alarming is the percentage of substance abusers who have purchased drugs on the dark web: A recent article in The Independent reported that 13.2% of U.S. respondents self-reported making at least one purchase online, whereas in the United Kingdom, the self-reported percentage was 25.3 %, and in Finland, it was 41.4%.

Evidence abounds that drugs purchased on the dark web often are counterfeit and sometimes “dirty.” There is a report of “Viagra” containing cement dust, of “Ambien” containing haloperidol, and “Xanax” laced with fentanyl, the latter having been linked to several deaths and hospital admissions in the Bay Area in 2016. (Big Pharma, in fact, is engaged in surveillance and investigation of the sale of knockoffs online, The Telegraph reported in article about the proliferation of fake drugs available on the surface web).Unfortunately, attempting to reduce teen substance abuse using law enforcement measures directed at dark web marketplaces might be a game of whack-a-mole: As soon as one supply source is staunched, another surfaces. Indeed, addiction should be viewed not simply in terms of the biopsychosocial model, but also as an economic activity. Thus, it might be more beneficial for clinicians to concentrate our resources and efforts on curtailing the demand through education and treatment.

Dr. Marseille is a psychiatrist who works on the staff at a clinic in Winfield, Ill. His special interests include adolescent and addiction medicine, eating disorders, trauma, bipolar disorder, and the psychiatric manifestations of acute and chronic medical conditions.

There was a time, not so long ago, when in the popular imagination, a drug deal involved an aging hippie in a tie-dyed shirt and love beads, copping a joint at a Dead concert. Today, however, in the age of the Internet and smartphones, a teenager in his bedroom can select, order, and have delivered to his door illicit drugs via the marketplaces on the “dark web.”

As the name implies, the dark web is a subterranean layer of the Internet that is mysterious, ominous, and sometimes lawless. It lies “beneath” the surface web – the layer where grandmothers post on Facebook and purchase on Amazon.

The dark web largely was the brainchild of three mathematicians at the Naval Research Laboratory as a means of encrypting messages exchanged by the intelligence community. They dubbed their project “Tor,” for “The Onion Router,” as the system consists of layer after layer of random relays, permitting anonymity on the Internet with little risk of tracking or surveillance.

This online underworld first came to my attention several years ago. The father of a teen who was being treated for disruptive mood dysregulation, attention-deficit disorder, and alcohol and cannabis use disorder called to inform me that his son had been arrested at Lollapalooza with hundreds of Adderall tablets and Xanax bars. Several weeks later, in session, the young man disclosed to me that he had found simple instructions online about installing Tor, creating a VPN (a virtual private network), accessing the dark web, transacting with bitcoin, and identifying drug marketplaces. He also demonstrated a detailed knowledge of chemical manufacturing in China, pill pressing in Canada, and money laundering in Switzerland.

With the air of an insider sharing “trade secrets,” this young man described how dealers on the dark web avoid detection and ensure secure delivery of the goods: latex gloves, vacuum sealing, and bleach dipping to obviate fingerprints – human and chemical. He said that dealers will send “dummy” packages to throw off the authorities and that buyers often will use the address of a clueless or absent neighbor. In his case, however, the parcels were delivered to his doorstep.

To a generation raised on the Internet and virtual reality, buying drugs on the dark web can appear appealing and have many advantages. For one thing, acquiring drugs in this way can seem less risky, as there is no chance of being robbed at gunpoint in a sketchy neighborhood or being busted for possession during a routine traffic stop.

Crossing over to the world of the dark web also can give an adolescent a sense of being clever and rebellious and of pulling a “fast one” on the parents – and on us, the clinicians who are treating them. And a teen who is interested in using illicit substances and plays “Call of Duty” from the comfort of his family’s basement without actual injury or death might assume that he can attain illicit drugs that are safe and inexpensive.

There are counterarguments to misinformation about the dark web. For example, contrary to the notion that buying drugs on the dark web minimizes interdiction or arrest, clinicians should point out that since international law enforcement shut down Silk Road and incarcerated its founder, Ross Ulbricht (also known as “Dread Pirate Roberts”) in 2013, hundreds of other dark web marketplaces such as AlphaBay and Hansa have been silenced and their operators prosecuted.

Moreover, the U.S. Department of Justice recently launched the Joint Criminal Opioid Darknet Enforcement (J-CODE) group, and the U.S. Postal Service Inspection Service reportedly has been hiring cybercrime and dark web specialists to combat drug trafficking. It might come as a surprise to a teen that, in a state where recreational marijuana is legal, transport and delivery of cannabis by the postal service elevates purchase and possession to the level of a violation of federal law. Informing even the most oblivious or oppositional adolescent that a drug felony can disqualify him for college grants and loans, impede his search for gainful employment, or prohibit him from obtaining a professional license, might give him a moment’s pause.

Adolescents seeking to buy drugs on the dark web should brace themselves for another shock. Whether lulled by custom after years of shopping on Amazon or using PayPal, or simply dulled by addiction, they might have a blind trust that bitcoin tumblers and “dark” escrow accounts will secure their payments. It will be rude awakening when they learn that the transfer and holding of currency on the dark web is vulnerable to hackers and to operators of the marketplaces – who are known to simply abscond with funds.

Currently, the drug marketplaces on the dark web represent a thin slice of the total illicit drug trade. These marketplaces, however, are growing quickly and offer buyers a virtual smorgasbord: the leading prescription drugs bought are Xanax and OxyContin, whereas 3,4-methylenedioxymethamphetamine (MDMA)/ecstasy and cannabis are the most commonly purchased controlled Schedule I substances, according to an article in The Economist. The estimated annual sales for 2016 ranged from $100 million to $200 million, but even more alarming is the percentage of substance abusers who have purchased drugs on the dark web: A recent article in The Independent reported that 13.2% of U.S. respondents self-reported making at least one purchase online, whereas in the United Kingdom, the self-reported percentage was 25.3 %, and in Finland, it was 41.4%.

Evidence abounds that drugs purchased on the dark web often are counterfeit and sometimes “dirty.” There is a report of “Viagra” containing cement dust, of “Ambien” containing haloperidol, and “Xanax” laced with fentanyl, the latter having been linked to several deaths and hospital admissions in the Bay Area in 2016. (Big Pharma, in fact, is engaged in surveillance and investigation of the sale of knockoffs online, The Telegraph reported in article about the proliferation of fake drugs available on the surface web).Unfortunately, attempting to reduce teen substance abuse using law enforcement measures directed at dark web marketplaces might be a game of whack-a-mole: As soon as one supply source is staunched, another surfaces. Indeed, addiction should be viewed not simply in terms of the biopsychosocial model, but also as an economic activity. Thus, it might be more beneficial for clinicians to concentrate our resources and efforts on curtailing the demand through education and treatment.

Dr. Marseille is a psychiatrist who works on the staff at a clinic in Winfield, Ill. His special interests include adolescent and addiction medicine, eating disorders, trauma, bipolar disorder, and the psychiatric manifestations of acute and chronic medical conditions.

When it comes to the portrayal of physicians in popular culture, psychiatrists are second only to surgeons.¹ Far too often, these portrayals of psychiatry have misrepresented our specialty – and stigmatized our patients. Some of the content produced by entertainment giants Netflix and Marvel is a case in point.

That Netflix-Marvel collaboration has proven fruitful, resulting in six television series spanning seven seasons of entertainment to date. Last year alone saw the release of three Netflix-Marvel productions, including Marvel’s “Iron Fist” in March, “The Defenders” in August, and “The Punisher” in November. Given the popularity and ease of streaming Marvel’s Netflix productions, these series have the potential to entertain and inform a wide audience. Unfortunately, however, part of their influence might be to perpetuate stigma and fear surrounding inpatient psychiatric care. Take the inaccurate portrayal of psychiatry in “Iron Fist” compared with the reality of modern psychiatric care, for example.

Dr. Weber is psychiatry department chair at Logan (Utah) Regional Hospital with Intermountain Healthcare.
 

References

1 J Nat Med Assoc. 2002 Jul. 94[7]:635-58.

2 Aggress Violent Behav. 2017;34:139-46.

When it comes to the portrayal of physicians in popular culture, psychiatrists are second only to surgeons.¹ Far too often, these portrayals of psychiatry have misrepresented our specialty – and stigmatized our patients. Some of the content produced by entertainment giants Netflix and Marvel is a case in point.

That Netflix-Marvel collaboration has proven fruitful, resulting in six television series spanning seven seasons of entertainment to date. Last year alone saw the release of three Netflix-Marvel productions, including Marvel’s “Iron Fist” in March, “The Defenders” in August, and “The Punisher” in November. Given the popularity and ease of streaming Marvel’s Netflix productions, these series have the potential to entertain and inform a wide audience. Unfortunately, however, part of their influence might be to perpetuate stigma and fear surrounding inpatient psychiatric care. Take the inaccurate portrayal of psychiatry in “Iron Fist” compared with the reality of modern psychiatric care, for example.

Dr. Weber is psychiatry department chair at Logan (Utah) Regional Hospital with Intermountain Healthcare.
 

References

1 J Nat Med Assoc. 2002 Jul. 94[7]:635-58.

2 Aggress Violent Behav. 2017;34:139-46.

When it comes to the portrayal of physicians in popular culture, psychiatrists are second only to surgeons.¹ Far too often, these portrayals of psychiatry have misrepresented our specialty – and stigmatized our patients. Some of the content produced by entertainment giants Netflix and Marvel is a case in point.

That Netflix-Marvel collaboration has proven fruitful, resulting in six television series spanning seven seasons of entertainment to date. Last year alone saw the release of three Netflix-Marvel productions, including Marvel’s “Iron Fist” in March, “The Defenders” in August, and “The Punisher” in November. Given the popularity and ease of streaming Marvel’s Netflix productions, these series have the potential to entertain and inform a wide audience. Unfortunately, however, part of their influence might be to perpetuate stigma and fear surrounding inpatient psychiatric care. Take the inaccurate portrayal of psychiatry in “Iron Fist” compared with the reality of modern psychiatric care, for example.

Dr. Weber is psychiatry department chair at Logan (Utah) Regional Hospital with Intermountain Healthcare.
 

References

1 J Nat Med Assoc. 2002 Jul. 94[7]:635-58.

2 Aggress Violent Behav. 2017;34:139-46.

On Feb. 14 in Parkland, Florida, 17 students and teachers were murdered in yet another school shooting. Yet another mass killing. More than a dozen others were injured and some are fighting for their lives under the care of physicians and nurses.

The pervasiveness of gun violence and the weapons used in these crimes have changed the way we live. In movie theaters, places of worship, offices, restaurants, night clubs and schools, people today make clear note of escape routes. Schools, including the one attacked yesterday, regularly practice for active shooter situations.

And in emergency departments and trauma centers, we struggle with much more complicated, dangerous injuries inflicted by lethal ammunition fired by military-grade weapons.

At the 2016 AMA Annual Meeting, which began the day after the deadly shooting at the Pulse Nightclub in Orlando, physicians from across the country and at every stage in their career spoke about treating gunshot victims and the scale of violence we are experiencing today. Their stories resonate as much today as they did nearly two years ago.

The shooting at Marjory Stoneman Douglas High School was the 30th mass shooting – a shooting in which four or more people are killed or injured – of 2018. It was also the 17th time a gun has been fired on the grounds of an American school this year. The problem is getting worse – the regularity of, and death from, mass shootings is increasing. With the shooting in Parkland, three of the 10 deadliest mass shootings in modern U.S. history have come in the past five months.


 

Time to act

Gun violence in America today is a public health crisis, one that requires a comprehensive and far-reaching solution. And that is not just my own sentiment; that is the determination of the AMA House of Delegates. With more than 30,000 American men, women and children dying from gun violence and firearm-related accidents each year, the time to act is now.

Today, more than ever before, America’s physicians must lend their voice and their considerable political muscle to force lawmakers to examine this urgent health crisis – through federally funded research – and take appropriate steps to address it. Let me be very clear about this. We are not talking about Second Amendment rights or restricting your ability to own a firearm.

We are talking about a public health crisis that our Congress has failed to address. This must end.

In the wake of the Sandy Hook shooting in 2012 – a massacre that left 20 first-graders and six adults dead – the AMA wrote to President Obama and to the leaders in the House and Senate. We expressed our sense of grief and sadness and offered our expertise and experience in finding workable, commonsense solutions to reduce the epidemic of gun violence – indeed the overall culture of violence – in America.

We noted that the relatively easy access to the increased firepower of assault weapons, semiautomatic firearms, high-capacity magazines, and high-velocity ammunition heightens the risk of multiple gunshot wounds and severe penetrating trauma, resulting in more critical injuries and deaths. Even for those who manage to survive gun violence involving these weapons, the severity and lasting impact of their wounds, disabilities and treatment leads to devastating consequences for the families affected and for society as a whole, contributing to high medical costs for treatment and recovery.

We called for renewing and strengthening the assault weapons ban, including banning high-capacity magazines, as a step in the right direction. We also called for more resources for safety education programs that promote more responsible use and storage of firearms, and noted that part of ensuring firearms safety means that physicians need to be able to have frank discussions with their patients and parents of patients about firearm safety issues and risks to help them safeguard their families from accidents.

We also urged the nation to strengthen its commitment and resources to comprehensive access to mental health services, including screening, prevention and treatment. While the overwhelming majority of patients with mental illness are not violent, physicians and other health professionals must be trained to respond to those who have a mental illness that might make them more prone to commit violence.

On an average day, more than 100 Americans die from gun violence and firearm-related accidents. In communities like yours – regardless of where you live or how safe it feels – people are losing their lives to this scourge.

For many Americans, gun violence used to be a distant idea relegated mostly to the nightly news, movies and faraway places. But today, in communities such as Parkland, it is horrifyingly real. The victims are our friends, neighbors and, unfathomably, our children.

As physicians, we have dedicated our lives to public health. And at the AMA, our mission is improving the health of the nation. That mission today must include determining the root causes of this epidemic and turning the tide on gun violence.

We must do more than pray for families who lost loved ones. It is time to act to prevent future deaths and injuries.
 

Dr. Barbe is president of the American Medical Association. His commentary originally was published on AMA Wire.

On Feb. 14 in Parkland, Florida, 17 students and teachers were murdered in yet another school shooting. Yet another mass killing. More than a dozen others were injured and some are fighting for their lives under the care of physicians and nurses.

The pervasiveness of gun violence and the weapons used in these crimes have changed the way we live. In movie theaters, places of worship, offices, restaurants, night clubs and schools, people today make clear note of escape routes. Schools, including the one attacked yesterday, regularly practice for active shooter situations.

And in emergency departments and trauma centers, we struggle with much more complicated, dangerous injuries inflicted by lethal ammunition fired by military-grade weapons.

At the 2016 AMA Annual Meeting, which began the day after the deadly shooting at the Pulse Nightclub in Orlando, physicians from across the country and at every stage in their career spoke about treating gunshot victims and the scale of violence we are experiencing today. Their stories resonate as much today as they did nearly two years ago.

The shooting at Marjory Stoneman Douglas High School was the 30th mass shooting – a shooting in which four or more people are killed or injured – of 2018. It was also the 17th time a gun has been fired on the grounds of an American school this year. The problem is getting worse – the regularity of, and death from, mass shootings is increasing. With the shooting in Parkland, three of the 10 deadliest mass shootings in modern U.S. history have come in the past five months.


 

Time to act

Gun violence in America today is a public health crisis, one that requires a comprehensive and far-reaching solution. And that is not just my own sentiment; that is the determination of the AMA House of Delegates. With more than 30,000 American men, women and children dying from gun violence and firearm-related accidents each year, the time to act is now.

Today, more than ever before, America’s physicians must lend their voice and their considerable political muscle to force lawmakers to examine this urgent health crisis – through federally funded research – and take appropriate steps to address it. Let me be very clear about this. We are not talking about Second Amendment rights or restricting your ability to own a firearm.

We are talking about a public health crisis that our Congress has failed to address. This must end.

In the wake of the Sandy Hook shooting in 2012 – a massacre that left 20 first-graders and six adults dead – the AMA wrote to President Obama and to the leaders in the House and Senate. We expressed our sense of grief and sadness and offered our expertise and experience in finding workable, commonsense solutions to reduce the epidemic of gun violence – indeed the overall culture of violence – in America.

We noted that the relatively easy access to the increased firepower of assault weapons, semiautomatic firearms, high-capacity magazines, and high-velocity ammunition heightens the risk of multiple gunshot wounds and severe penetrating trauma, resulting in more critical injuries and deaths. Even for those who manage to survive gun violence involving these weapons, the severity and lasting impact of their wounds, disabilities and treatment leads to devastating consequences for the families affected and for society as a whole, contributing to high medical costs for treatment and recovery.

We called for renewing and strengthening the assault weapons ban, including banning high-capacity magazines, as a step in the right direction. We also called for more resources for safety education programs that promote more responsible use and storage of firearms, and noted that part of ensuring firearms safety means that physicians need to be able to have frank discussions with their patients and parents of patients about firearm safety issues and risks to help them safeguard their families from accidents.

We also urged the nation to strengthen its commitment and resources to comprehensive access to mental health services, including screening, prevention and treatment. While the overwhelming majority of patients with mental illness are not violent, physicians and other health professionals must be trained to respond to those who have a mental illness that might make them more prone to commit violence.

On an average day, more than 100 Americans die from gun violence and firearm-related accidents. In communities like yours – regardless of where you live or how safe it feels – people are losing their lives to this scourge.

For many Americans, gun violence used to be a distant idea relegated mostly to the nightly news, movies and faraway places. But today, in communities such as Parkland, it is horrifyingly real. The victims are our friends, neighbors and, unfathomably, our children.

As physicians, we have dedicated our lives to public health. And at the AMA, our mission is improving the health of the nation. That mission today must include determining the root causes of this epidemic and turning the tide on gun violence.

We must do more than pray for families who lost loved ones. It is time to act to prevent future deaths and injuries.
 

Dr. Barbe is president of the American Medical Association. His commentary originally was published on AMA Wire.

On Feb. 14 in Parkland, Florida, 17 students and teachers were murdered in yet another school shooting. Yet another mass killing. More than a dozen others were injured and some are fighting for their lives under the care of physicians and nurses.

The pervasiveness of gun violence and the weapons used in these crimes have changed the way we live. In movie theaters, places of worship, offices, restaurants, night clubs and schools, people today make clear note of escape routes. Schools, including the one attacked yesterday, regularly practice for active shooter situations.

And in emergency departments and trauma centers, we struggle with much more complicated, dangerous injuries inflicted by lethal ammunition fired by military-grade weapons.

At the 2016 AMA Annual Meeting, which began the day after the deadly shooting at the Pulse Nightclub in Orlando, physicians from across the country and at every stage in their career spoke about treating gunshot victims and the scale of violence we are experiencing today. Their stories resonate as much today as they did nearly two years ago.

The shooting at Marjory Stoneman Douglas High School was the 30th mass shooting – a shooting in which four or more people are killed or injured – of 2018. It was also the 17th time a gun has been fired on the grounds of an American school this year. The problem is getting worse – the regularity of, and death from, mass shootings is increasing. With the shooting in Parkland, three of the 10 deadliest mass shootings in modern U.S. history have come in the past five months.


 

Time to act

Gun violence in America today is a public health crisis, one that requires a comprehensive and far-reaching solution. And that is not just my own sentiment; that is the determination of the AMA House of Delegates. With more than 30,000 American men, women and children dying from gun violence and firearm-related accidents each year, the time to act is now.

Today, more than ever before, America’s physicians must lend their voice and their considerable political muscle to force lawmakers to examine this urgent health crisis – through federally funded research – and take appropriate steps to address it. Let me be very clear about this. We are not talking about Second Amendment rights or restricting your ability to own a firearm.

We are talking about a public health crisis that our Congress has failed to address. This must end.

In the wake of the Sandy Hook shooting in 2012 – a massacre that left 20 first-graders and six adults dead – the AMA wrote to President Obama and to the leaders in the House and Senate. We expressed our sense of grief and sadness and offered our expertise and experience in finding workable, commonsense solutions to reduce the epidemic of gun violence – indeed the overall culture of violence – in America.

We noted that the relatively easy access to the increased firepower of assault weapons, semiautomatic firearms, high-capacity magazines, and high-velocity ammunition heightens the risk of multiple gunshot wounds and severe penetrating trauma, resulting in more critical injuries and deaths. Even for those who manage to survive gun violence involving these weapons, the severity and lasting impact of their wounds, disabilities and treatment leads to devastating consequences for the families affected and for society as a whole, contributing to high medical costs for treatment and recovery.

We called for renewing and strengthening the assault weapons ban, including banning high-capacity magazines, as a step in the right direction. We also called for more resources for safety education programs that promote more responsible use and storage of firearms, and noted that part of ensuring firearms safety means that physicians need to be able to have frank discussions with their patients and parents of patients about firearm safety issues and risks to help them safeguard their families from accidents.

We also urged the nation to strengthen its commitment and resources to comprehensive access to mental health services, including screening, prevention and treatment. While the overwhelming majority of patients with mental illness are not violent, physicians and other health professionals must be trained to respond to those who have a mental illness that might make them more prone to commit violence.

On an average day, more than 100 Americans die from gun violence and firearm-related accidents. In communities like yours – regardless of where you live or how safe it feels – people are losing their lives to this scourge.

For many Americans, gun violence used to be a distant idea relegated mostly to the nightly news, movies and faraway places. But today, in communities such as Parkland, it is horrifyingly real. The victims are our friends, neighbors and, unfathomably, our children.

As physicians, we have dedicated our lives to public health. And at the AMA, our mission is improving the health of the nation. That mission today must include determining the root causes of this epidemic and turning the tide on gun violence.

We must do more than pray for families who lost loved ones. It is time to act to prevent future deaths and injuries.
 

Dr. Barbe is president of the American Medical Association. His commentary originally was published on AMA Wire.