Facts and ideas from anywhere

William C. Roberts, MD.

LIPID LEVELS IN PATIENTS WITH CORONARY HEART DISEASE

Sachdeva and colleagues (1) from 6 US medical centers described admission lipid levels in 136,905 patients hospitalized with coronary artery disease from 2000 to 2006. The mean lipid levels were as follows: low-density lipoprotein (LDL) cholesterol, 105 ± 40; high-density lipoprotein (HDL) cholesterol, 40 ± 13; and triglycerides, 161 ± 128 mg/dL. LDL cholesterol <70 mg/dL was observed in 18% of the patients, and ideal levels (LDL <70 with HDL ≥60 mg/dL) in only 1% of patients. HDL cholesterol was <40 mg/dL in 55% of the patients. Before admission, 28,944 (21%) of the patients were receiving lipid-lowering medications. Thus, almost half of patients hospitalized with coronary artery disease had admission LDL cholesterol levels <100 mg/dL; more than half had admission HDL levels <40 mg/dL; and <10% had HDL levels >60 mg/dL. To prevent coronary disease, it is likely that the serum LDL cholesterol will need to be <50 mg/dL.

HYDROCODONE

The most prescribed drugs in the USA are painkillers containing addictive opioids, and they are also driving the deadliest drug problem in the USA (2). On average, 46 people a day die from painkiller overdoses, and 1150 enter emergency rooms each day. Deaths from illegal drugs do not even come close to this number. In 2013 alone, physicians wrote about 180 million prescriptions for hydrocodone and oxycodone, nearly one for every adult in the USA. After underplaying the problem for years, the US Food and Drug Administration (FDA) recommended restrictions on access to drugs containing hydrocodone, which is highly addictive. The changes, which limit refills and mandate more frequent visits to physicians to obtain prescriptions, went into effect in October 2014.

Just one day later, the FDA approved Zohydro ER (hydrocodone bitartrate), a new drug that is pure hydrocodone (3). Unlike other hydrocodone drugs, Zohydro contains no acetaminophen, which in high does can cause liver damage. Zohydro comes without the abuse-resistant measures now common in most narcotic painkillers, such as hardened shells which make them difficult to crush. In capsule form, Zohydro can be easily crushed to be snorted or injected. In the Zohydro case, the FDA flouted the recommendation of its own expert panel, which had voted 11-2 against approval. Overriding a panel is not unheard of but is infrequently done. The FDA's safety mission ought to be broad enough to preclude placing an easily abused painkiller on the market amid an abuse epidemic. An unsigned editorial in USA Today (September 30, 2014) opined that the FDA should reconsider Zohydro and should encourage other approaches to curbing painkiller abuse as well. It advised state monitoring systems that can prevent doctor shopping by patients seeking multiple prescriptions.

The FDA commissioner, Dr. Margaret A. Hamburg, emphasized that the FDA reviews drugs using a scientific approach within our legal framework and considers not only those who abuse opioids, but also those who use them responsibly. She continued, “While we appreciate the concerns surrounding our recent approval of Zohydro, it should be recognized that Zohydro is a time-released analgesic that, without the added risk of acetaminophen, fills a need for pain patients who respond best to hydrocodone.” She indicated that the problem of opioid overdose is largely driven by inappropriate prescribing, use, and diversion of these drugs. FDA is part of a broader administration-wide strategy to combat overdose. She concluded: “Opioid abuse in this country can only be brought under control by concerted effort from many prescribers, pharmacists, scientists, public health officials, law enforcement, patients and their families. FDA will continue to do its part to overcome this public health crisis.”

OBESITY AND CANCER

The American Society of Clinical Oncology recently indicated that obesity is now implicated in as many as 1 in 5 cancer deaths—about the same rate as cancers linked to smoking (4). Yet, most people aren't aware of this link. A poll released in 2013 found that only 7% of Americans realized there was a link between obesity and cancer. Obesity-related cancers have contributed to increased health care spending. The price per patient of cancer treatments has gone up about 35% since 1996, and the number of people with cancer has risen from 9.2 to 16.1 million. Together, price and incidence have pushed cancer spending from $38 to $89 billion. In Texas, about 18% of adults smoke, a significant drop from smoking rates 40 years ago. Since 1990, however, the incidence of obesity (body mass index >30 kg/m²) has climbed to more than 30%. The nationwide obesity rate now is 35%. Obesity also appears to cause more aggressive breast cancer in postmenopausal women and prostate cancer in older men than in the nonobese victims of these cancers. Obesity also has been implicated in several other cancers. Texas Oncology, a major cancer treatment group, opined that obesity and lack of exercise are factors in cancer of the colon, uterus, gallbladder, pancreas, thyroid gland, and esophagus. The prevention: lose some pounds.

TEXAS'S OBESITY

In 1990, just 24 years ago, only 1 in 10 Texas adults were obese; by 2013, nearly 1 in 3 were obese (5). American adults today on average weigh 24 more pounds than they did in 1960. In 2010, 1.26 million Texans had heart disease; it is projected that 5.7 million will have heart disease by 2030. The national obesity rate for Latinos is 42.5%. The report estimated that Texas cases of adult-onset diabetes mellitus could rise from about 2 million in 2010 to nearly 3 million by 2030. Cases of obesity-related cancer in the state could climb from approximately 330,000 to just over 800,000 by 2030. Six states had increases in obesity in 2013, and none of the 52 states or territories had a decrease in the frequency of obesity! In Texas, in 2011, 16% of high school students were obese. If all American adults lost 10 pounds, our health would skyrocket.

GERMS IN THE WORKPLACE

Sumathi Reddy (6) described a study performed by some University of Arizona researchers at an office building with 80 employees. The researchers contaminated a push-plate door at the building's entrance with a virus called bacteriophage MS-2. (The virus does not infect people yet it is similar in shape, size, and survivability to common cold and stomach flu viruses.) Within 2 hours the virus had contaminated the break room—coffee pot, microwave button, fridge door handle—and then spread to restrooms, individual offices, and cubicles. There the virus had heavily contaminated phones, desks, and computers. By 4 hours they found the virus on more than 50% of the commonly touched surfaces and on the hands of about half of the employees in the offices. Most of the people did not know each other. The studies were funded by Kimberly-Clark, the Irving, Texas, maker of consumer brands including Kleenex and Huggies.

In an intervention, the Arizona researchers then gave about half of the employees hand sanitizer and disinfectant wipes to use. After the intervention, detection of the virus on people's hands went from about 30% to 10%. The results were similar to an experiment in which the researchers infected a single employee with a droplet containing an artificial virus that did not cause illness. Within 4 hours, half of the commonly touched surfaces and the hands of half of the employees were infected with at least one virus.

Studies indicate that average adults bring their hands to their nose, mouth, or eyes about 16 times an hour! For children aged 2 to 5, the number can be up to 50 times an hour. The researchers calculated that employees would have had a 30% chance of infection if the organism experimented with affected humans. Just because we are exposed to a virus or bacterium does not mean we will get sick. Much depends on the dose or number of virus particles that we are exposed to, whether we have been exposed to the germ before, and our overall susceptibility and health. Many people have devised low-tech methods of avoiding germs. One can use his or her elbow or knuckle in the elevator rather than the fingertips. The use of a paper towel in one's hand to open the door in any public restroom is helpful.

Different viruses, of course, have different lifespans, and they also are dependent on factors such as temperature and the material where they are harboring. Some viruses are more infectious than others. Our bodies harbor viruses all the time. The average person harbors trillions of bacteria and dozens of virus species. The norovirus, the most common cause of infectious diarrhea, is super infectious, while others may be less infectious or more difficult to catch. Studies conducted at day care centers have found that 30% to 40% of children without symptoms have respiratory viruses on them. Pathogens have survival rates ranging from seconds to months. Most respiratory viruses can survive a minimum of 2 to 4 days. Some viruses die at high temperatures. Microbes survive differently on different materials. Microbes on porous surfaces, such as carpeting and upholstery, have better survival rates on synthetic fibers like polyester than on cotton. Pathogens are readily transferred on stainless steel surfaces although certain metals such as copper tend to have an antimicrobial effect, and germs will not be able to survive on them more than a few hours. Microbes have comparatively good survival on plastic or Formica. Anything with textured grooves or connection points, like a keyboard or a child's toy, will have a tendency to collect dirt, which can help survival.

While the University of Arizona researchers believe the use of hand sanitizers and disinfecting wipes can sharply reduce the spread of viruses, not all experts agree. Dr. Martin J. Blaser, director of the Human Microbiome Program at New York University's Langone Medical Center, says he generally does not recommend hand sanitizers and disinfectant wipes because they kill good bacteria, which can help protect against bad bacteria. Exceptions, he says, are in hospitals and during the flu season. Of course, a handshake can transfer from 10 to 20 times the bacteria as a fist bump.

The University of Arizona researchers have also conducted experiments in hotels, schools, and health care facilities. They found that infecting one hotel room with the virus led to the infection of nearby rooms. They speculated that cleaning tools, like mops and towels, spread the germs. The virus also spread to the conference room. Their next study will involve restrooms.

MYTHS ABOUT GERMS ON AIRCRAFTS

Everett Potter described 5 myths about germs on aircrafts (7):

• 1)The most dangerous health hazard in the air is the cabin air itself. No. The real problems lie on the chair upholstery, the tray table, the arm rest, and the toilet handle, where bacteria such as methicillin-resistant Staphylococcus aureus and Escherichia coli can live for up to a week on airplanes that aren't properly cleaned. Tray tables have the highest levels of bacteria, and seatbelts and arm rests also are places where bacteria like to survive.
• 2)Bagged pillows and blankets are okay to use. Blankets sealed in plastic are okay, but only for the lower legs. Pillows should be avoided because the pillowcases are not changed.
• 3)The aircraft is cleaned between flights. How often and well an aircraft is “cleaned” is something of a secret. Removing trash and magazines is routine, but most industry watchers say a proper cleaning occurs infrequently. The Federal Aviation Administration does not regulate cleaning, so the frequency and thoroughness of cleaning are left to the airlines. An aircraft is supposed to be completely wiped down every 30 days of service or at 100 flying-hour intervals, but that means an aircraft can be used for dozens of flights between deep cleanings.
• 4)Airlines have taken steps to ensure that passengers can't contract diseases like the Ebola virus in the aircraft. There have not been any reported cases of the Ebola virus spreading within the confines of an aircraft cabin so far. Ebola, of course, is not an airborne virus but is spread through bodily fluids. Still, passengers should adhere to rigorous hygiene practices.
• 5)There is not much we can do to protect ourselves when trapped in an aircraft cabin. Not true. There are multiple steps that every passenger can take to prevent the spread of bacteria when flying. First, travel with and use an alcohol-based hand sanitizer. Also travel with a pack of disinfectant wipes. Wipe the armrest and the table tray. Stay hydrated. Use a tissue or paper towel to open bathroom doorknobs and touch toilet handles. The most vulnerable area may be the eyes. Keep your hands away from your eyes, as tear ducts are a fast route for germs to the nose and throat.

SIMPLE STEPS TO LIVE LONGER

Leslie Barker (8), writing in The Dallas Morning News, provided 10 simple steps to add time and quality to our lives:

• 1)Floss. Flossing removes plaque, the bacterial film that forms along our gum line. It might even lessen our chances of heart disease, Alzheimer's disease, and some forms of cancer.
• 2)Get a colonoscopy. Nine out of 10 people whose colon cancer is discovered early will still be alive in 10 years.
• 3)Stop eating before you are full. Being 100 pounds overweight can subtract at least a decade from your life.
• 4)Use sunscreen. In 2014, 3.5 million people in the US will get skin cancer, and 76,000 more will develop melanoma. Only about one-third of adults in the US use sunscreen.
• 5)Stop smoking. If you quit at age 30, you can increase your life by 10 years; at age 40, 9 years; at age 50, 6 years; and at age 60, 3 years.
• 6)Get enough sleep. Not getting enough sleep has been linked to memory problems, hearing problems, anger, high blood pressure, stroke, depression, vehicle accidents, and obesity.
• 7)Exercise. People who exercise 15 minutes a day add 3 years to their life. Every minute we exercise adds 7 minutes to our lives!
• 8)Eat produce. Eating 5 or more servings per day reduces our risk of stroke by about 25%. Seventh-day Adventists who typically follow a vegetarian diet outlive those who do not by 3 to 7 years.
• 9)Cultivate healthy relationships. People with friends and people in healthy relationships tend to live longer.
• 10)Be grateful. Be positive and complimentary. Those actions may not lengthen life, but they make it more enjoyable.

HOW LONG IS ENOUGH?

Ezekiel J. Emanuel, who helped write the Affordable Care Act and who is a brother to Chicago's mayor, says that 75 years is enough (9). That is how long he wants to live. He indicated that by the time he reaches 75, he will have lived a complete life:

I will have loved and been loved. My children will be grown and in the midst of their own rich lives. I will have seen my grandchildren born and beginning their lives. I will have pursued my life's projects and made whatever contributions, important or not, I am going to make. And, hopefully I will not have too many mental and physical limitations.

He is now 18 years short of 75. He will have plenty of time to change his mind. He explained:

I am talking about how long I want to live and the kind and amount of health care I will consent to after 75. Americans seem to be obsessed with exercising, doing mental puzzles, consuming various juice and protein concoctions, sticking to strict diets and popping vitamins and supplements, all in a valiant effort to cheat death and prolong life as long as possible. This has become so persuasive that it now defines a cultural type: what I call the American Immortal. I reject this aspiration. I think this maniac desperation to endlessly extend life is misguided and potentially destructive. For many reasons, 75 is a pretty good age to stop. Americans may live longer than their parents, but they are likely to be more incapacitated. Does that sound very desirable? Not to me. What are those reasons? Let's begin with demography. We are growing old, and our older years are not of high quality. Since the mid-19th century Americans have been living longer. In 1900 the life expectancy of an average American at birth was approximately 47 years. Today, a newborn can expect to live about 79 years.

Ezekiel Emanuel indicated that his view has practical implications. He stated that once he has lived to 75, he will not actively end his life but he will not try to prolong it. He indicated that at age 75 and beyond, he will need a good reason to even visit a physician and take any medical tests or treatment, no matter how routine and painless. And that good reason is not “it will prolong your life.” He will stipulate a do-not-resuscitate order and a complete advance directive indicating no ventilators, dialysis, surgery, antibiotics, or any other medication—nothing except palliative care. He went on:

Again, let me be clear: I am not saying that those who want to live as long as possible are unethical or wrong. I am certainly not scorning or dismissing people who want to live on despite their physical and mental limitations. I'm not even trying to convince anyone I'm right. Indeed, I often advise people in this age group on how to get the best medical care available in the United States for their ailments. That is their choice and I want to support them. And I am not abdicating 75 as the official statistic of a complete, good life in order to save resources, ration health care or address public-policy issues arising from the increases in life expectancy. What I am trying to do is delineate my views for a good life and make my friends and others think about how they want to live as they grow older. I want them to think of an alternative to succumbing to that slow constriction of activities and aspirations perceptively imposed by aging.

I hope that I am around in 2032, the year Ezekiel Emanuel reaches age 75, to see whether he still believes his ideas generated 18 years earlier.

TRAFFIC FATALITIES

In 2002, highway deaths totaled 38,491; in 2012, they totaled 30,800 (10). During those 12 years, a number of cars were added to the road, so in proportion to the increased number, the decrease is rather remarkable. Wearing a seatbelt is another way to lengthen survival and increase life's quality.

FOOTBALL INJURIES, CHRONIC TRAUMATIC ENCEPHALOPATHY, AND THE NATIONAL FOOTBALL LEAGUE

Each week, The Dallas Morning News publishes the Dallas Cowboys' injury toll. In 2013, 15 of the 40 team players missed one or more games, and one missed all 16 season games. So far in 2014, 8 players have missed one or more games, including 1 who has missed all 8 so far. And Tony Romo with 2 back operations was recently injured again (as of October 2014).

Steve Almond has published Against Football: One Fan's Reluctant Manifesto (11). Professional football has displaced baseball as America's number 1 fan sport. Almond, who used to be a major National Football League (NFL) fan, has now turned his back on the game. He asks fans to consider their own complicity in ignoring and even encouraging the darker side of the sport. He indicated that “the reason ferocious hits get broadcast over and over, often in slow motion, is because fans love to see them.” The TV people, of course, know the fans' appetite.

Almond reported on the effects of head injuries and on a form of dementia called chronic traumatic encephalopathy (CTE), common in former football players. The NFL has not just been slow to react to these findings; it has employed junk science to muddy the debate. Even more chilling is how little we know about the effects of football on brains that are still developing. Almond cited a Purdue University study that showed that high school football players experience diminished brain function even in the absence of concussions.

A chapter on NFL's business practices could make the most ardent pigskin fan bristle. The NFL has created what amounts to a risk-free business environment where taxpayers get bilked. Almond provided plenty of blood-boiling examples, like the NFL's tax-exempt status—unique among major sports leagues—and the now commonplace arrangement that sees taxpayers fund NFL stadiums while team owners reap the economic rewards. The New Orleans Saints even receive an “inducement payment” of up to $6 million a year just to keep the franchise in the city. That's on top of the $200 million that taxpayers forked over for renovating the Mercedes-Benz Superdome. They will see none of the $50 to $60 million the team received in naming rights from the carmaker. NFL Commissioner Roger Goodall's salary in 2013 was $35 million. Between the recent domestic violence scandals and the stream of medical research revealing that football is more dangerous than previously thought, the sport that Goodall oversees has garnered plenty of negative headlines. But will the bad press ever cause fans to stop enriching America's most popular pastime?

The thought of any large-scale exodus of fans is unlikely. TV ratings are up again this season from already astronomical levels. The continued popularity, as Almond pointed out, is due in part to the way the sports media promote rather than cover the games. “Sports represent one of the few growth sectors for the corporate media,” he observed. “It's far more profitable to cover football as a glorious diversion than as a sobering news story.”

The decline of boxing from one of America's popular sports might have seemed equally impossible. The steady supply of future gridiron warriors is already starting to thin. High school football participation has fallen 2% since 2008, and the drop is more pronounced for younger players. While falling participation might bring about football's decline, Almond dared fans to consider how long they could continue to ignore football's obvious flaws to preserve their weekend ritual. The average age of death of former NFL players is 55 years!

A proposed $765 million settlement of concussion lawsuits against the NFL is presently on the table (12). There are approximately 19,500 retired NFL players, and 6000 (28%) are expected to develop Alzheimer's disease or at least moderate dementia. Dozens more will be diagnosed with amyotrophic lateral sclerosis (Lou Gehrig's disease) or Parkinson's disease during their lives. That is nearly 3 in 10 former players who will develop these debilitating brain conditions earlier than and at least twice as often as the general population. The NFL's calculations show that players <50 years had a 0.8% chance of developing Alzheimer's and dementia, compared with <0.1% for the general population. For players 50 to 54, the rate was 14% compared with <0.1% for the general population. The gap between the players and the general population grows wider with increasing age. The proposed settlement includes $765 million for player awards, $75 million for baseline assessments, $10 million for research, and $5 million for public notice. The settlement would not cover current players.

Some have argued that the NFL's offering is a pittance given its $10 billion in annual revenue. Critics also lament that the settlement plan offers no awards to anyone diagnosed with CTE in the future and that the Alzheimer's and dementia awards are cut by 75% for players who also suffered strokes. The plan would pay up to $5 million for players with amyotrophic lateral sclerosis, $4 million for deaths involving CTE, $3.5 million for Alzheimer's disease, and $3 million for moderate dementia and other neurologic problems. Only men under 45 who spent at least 5 years in the league would get these maximum payouts. The awards are reduced on a sliding scale if the men played fewer years or were diagnosed later in life. The players' data, therefore, predicts the average payout in today's dollars to be $2.1 million for ALS, $1.4 million for death involving CTE, and $190,000 for Alzheimer's disease or moderate dementia. Only 60% of those eligible for awards are expected to enter the program. My daughter does not allow her 2 boys to play football. It's understandable.

A NONMEDICAL EBOLA CZAR

Thomas G. Donlan (13), writing in Barron's, said that “the mere use of the word czar ought to be considered a sign of approaching futility.” He indicated that “the services of at least 149 czars have been appointed in the USA since 1918, including for example AIDS czar, Asian carp czar, bank czar, bioethics czar, bird flu czar, car czar, climate czar, copyright czar, cyber securities czar, democracy czar, drug czar, economic czar, energy czar, food czar, green jobs czar, health czar, homeland security czar, homelessness czar, inflation czar, information czar, intelligence czar, and on through the alphabet to the weatherization czar.” The Ebola czar Ron Klain is the latest in the long dynastic succession, but Donlan indicated that these czars are essentially unable to perform miraculous feats of organizational efficiency. The American czars have responsibility without power.

Donlan indicated that scientists and drug companies have neglected the development, testing, and marketing of vaccines, including the Ebola vaccines, because there is no money for them in doing so. Sixty years ago, Dr. Jonas Salk devised his own trial for his vaccine to protect against polio. Salk simply asked parents to sign consent forms for the kids to participate in a double-blind study in which neither the children nor the parents nor the people administering the injections would know if a hypodermic needle contained a vaccine or a placebo. About 2 million children participated. Today, a drug company would not be allowed to do that in Africa or in the USA. An Ebola vaccine that is 100% effective at preventing the disease in monkeys was developed 10 years ago but never tested in humans according to Donlan. But we commonly hear the drug companies blamed for the supposed lack of a vaccine. Drug companies have resisted spending the enormous sums needed to develop products useful mostly in countries with little ability to pay. As Donlan said, “This produces two choices: either drug companies must be allowed to raise prices on their other drugs to create a surplus for charity work or the government must raise taxes and borrowing to pay for vaccines and orphan drugs.”

Donlan indicated that the real problem could be the enormous expense created by a safety and regulatory system imposed on the world by the FDA and its counterparts in Western Europe and also by a small corps of professional ethicists who have excessive concern for informed consent in drug trials and insufficient concern for scientific progress to aid victims of dreaded diseases.

Donlan concluded as follows: “Given a choice between the regulatory protection of 2014 and the mass vaccine testing of 1954, we'll take the system that worked to fight disease. And we would like to take the one that doesn't crown a czar.” Donlan also indicated that “too often we forget that the real czar—of all the Russians—was deposed, imprisoned, and executed. Nicholas II is an inappropriate symbol of power or wisdom, and remains so.”

DRUGSTORE CEASES SELLING CIGARETTES

CVS Caremark stopped selling cigarettes in September 2014 (14). It has 7700 retail locations and is the second largest drug-store chain in the US behind Walgreens. It manages the pharmacy benefits for 65 million Americans and has 900 walk-in medical clinics. Its tobacco sales total about $2 billion a year. Good for CVS!

UNDERAGE ALCOHOLISM

In 2012 the National Institute on Alcohol Abuse and Alcoholism reported that 855,000 people between ages 12 and 17 years struggled with alcohol dependence or abused alcohol (15). And 5.9 million people aged 12 to 20 consider themselves binge drinkers. According to a piece by Stephanie Embree in The Dallas Morning News, 6 times as many young adults die from alcohol abuse than from any other substance. No one knows whether that first drink is the beginning of alcoholism or not.

MARKETING DRUGS

The system is changing (16). When physicians were mainly in private practice, pharmaceutical representatives visited them frequently urging use of drugs manufactured by their company. Today, 42% of physicians practice as salaried employees of hospital systems, up from 24% in 2004. As a result, the pharmaceutical industry is shifting its sales efforts from physicians to the institutions they work for. In 2005, drug companies employed about 102,000 US sales representatives, who mostly pitched to physicians. By mid-2014, their numbers were down to about 63,000. Stepping in are so-called “key-account managers” who build relationships with hospital administrators. The 20 biggest drug companies employ roughly 600 key-account managers, 3 times the number 5 years ago. The trend is in early stages. Sales representatives still account for the bulk of drug sales, but companies are increasingly deploying key-account managers in regions where hospitals have moved more quickly to buy practices.

Eli Lilly & Company, for example, last year scrapped its old sales-rep approach in 6 metropolitan areas including Boston and Salt Lake City in favor of key-account teams. The pharmaceutical companies are asking how they can get health system adoption. Getting a drug on the hospital system's formulary can mean potentially millions of dollars in sales from thousands of physicians' prescriptions. Drug companies used to send armies of sales reps to woo individual physicians after introducing new drugs. The reps would sometimes take physicians to sports events or cater lunches for their offices, and they usually left samples. Physicians were often more interested in a drug's clinical trial results than costs. Reps could generate hundreds of millions of dollars over the few months after a drug's introduction.

But physicians are losing influence. Hospital systems are growing more powerful as they bulk up by buying physician practices, nursing homes, urgent care centers, and other hospitals. Insurers and the federal health care overhaul are squeezing hospitals and physician payments and shifting reimbursements from how much care is given to how effective it is. To manage costs, hospital systems are taking control of what drugs their physicians can prescribe. Many limit physician contact with sales people. The gatekeepers are committees and administrators. Today's key-account managers can spend many months trying to persuade administrators to put a drug on the formulary. And big systems have more negotiating power over price than small systems. At health systems, the sales emphasis has shifted to not just how the medicine works but also how it lowers the total cost of managing disease. Formulary committees in the hospital systems decide what drugs to recommend based on evidence of effectiveness, toxicity, and cost. A committee in one hospital recently standardized treatment of certain colorectal cancer patients around the use of the drug Vectibix, which costs about $38,000 for a 16-week course, removing a drug from its list that was found to be similar but cost about 15% more. It says that physicians working in its 21 hospitals follow the cancer drug-prescribing protocols about 80% of the time.

For drug companies, health systems' expanding control not only can slow new drug acceptance but may also hurt profits by limiting a drug's peak sales and by driving down prices as systems use their increasing control over what physicians prescribe to press for discounts. For patients, the trend can be a mixed blessing. They are more likely to get drugs that evidence shows will keep them healthy and out of the hospital, but patients may face more restrictions on their choice of drugs. Physicians are finding the trend mixed. Physicians are losing their ability to negotiate with insurers. Some systems bar physicians from meeting drug sales reps during office hours and the systems are crafting formularies that will direct what their physicians can prescribe. The good side from the physician standpoint is that more time is available to spend on patient care. But, it is harder to learn about new drugs.

BOVINES AND METHANE

Cows have long been castigated for their methane-belching, manure-producing ways, one of agriculture's top contributors to climate change (17). The Environmental Protection Agency has fingered the methane emissions of “enteric fermentation”—the digestive process of animals with multichambered stomachs—as second only to emissions from natural gas and petroleum systems in greenhouse gas emissions. Our president has proposed cutting methane emissions from the US dairy industry by 25% by 2020. The US dairy industry has pledged the same goal. They call it the “Cow of the Future” project. The aim is a super-cow that produces far less methane and far more milk. A farmer enters data, including the cow's age and size, what kind of barn she is in, whether she's ever in the pasture or mud, and even how hot the weather is. Out pops the optimal feed formulation for the 100 or so pounds of food each cow eats in a day, washed down by 30 gallons of water. Cows in their prime get milked 3 times a day instead of twice. This more closely resembles a natural cycle and results in 10% to 15% higher milk production. Many farmers use bovine hormones to extend the peak of a cow's lactation. One farmer indicated that “we take the feed out of the fields and get two products—milk and manure. Milk goes to the consumer. The manure we store and reapply as fertilizer. We are analyzing all of it” so it stays in balance.

The cows are treated pretty nicely these days. In many farms the cows lounge on beds of soft sand. They are cooled by spritzers of water and breezes generated by fans. They eat a custom-blended diet of gourmet grains that a computer determines will suit them best. Each cow wears a collar with a computer chip that keeps track of her milk production, which is nearly 4 times that of the cows in olden days. Thus, it's not so bad to be a cow in some of the large farms these days—except for the ending.

MEGADROUGHT IN THE WEST

According to bioclimatologist Park Williams, the Western USA has been in a drought during the past 15 years, worse than any other 15-year period since about 1150, or 850 years ago (18). The megadroughts have been called “the great white sharks of climate: powerful, dangerous, and hard to detect before it's too late. They have happened in the past and they are still out there, lurking in what is possible for the future, even without climate change.”

A megadrought is a threat to civilization and is defined more by its duration than its severity. It is an extreme dry spell that can last for a decade or longer. It has parched the West periodically, including present-day California, long before Europeans settled the region in the 1800s. Most of the USA's droughts of the past century, even the infamous 1930s Dust Bowl that forced migration of Oklahomans and others from the Plains, were exceeded in severity and duration multiple times by droughts during the preceding 2000 years. The difference now is the Western US is home to >70 million people who were not here for previous megadroughts. The implications are far more daunting. Droughts are cyclical and these long periods of drought have been commonplace in the past, according to a climatologist at the National Drought Migration Center in Lincoln, Nebraska. “We are simply much more vulnerable today than at any time in the past. People just can't pick up and leave to the degree they did in the past.”

How do scientists know how wet or dry it was centuries ago? Though no weather records exist before the late 1800s, scientists can examine “proxy data” such as tree rings and lake sediment to find out how much or little rain fell hundreds or even thousands of years ago. These rings are wider during wet years and narrower during dry years.

Prolonged droughts, some of which lasted more than a century, brought thriving civilizations to starvation, migration, and finally collapse, wrote Lynn Ingram, a geologist at the University of California Berkeley in her recent book, The West Without Water. Decade-long droughts happen once or twice a century in the Western USA. But much worse droughts, ones that last for a century or more, occur every 500 years or so. Has California reached megadrought status? Not yet: “This one wouldn't stand out as a megadrought.” But this is the state's worst consecutive 3 years for precipitation in 119 years of records.

As of August 28, 2014, 100% of the state of California was considered in a drought, according to the US Drought Monitor. More than 58% is in “exceptional” drought, the worst level. Record warmth has fueled the drought, as the state has seen its hottest year since records began in 1895. Because of the dryness, California Governor Jerry Brown declared a statewide emergency in 2014. Since then, reservoir storage levels have continued to drop, and as of late August 2014, they were down to about 59% of the historical average. Regulations restricting outdoor water use were put in place in July 2014 for the entire state. People are not allowed to hose down driveways and sidewalks, nor are they allowed to water lawns and landscapes. There are also reports of wells running dry in California. About 1000 more wildfires than usual have charred the state. The drought is likely to inflict over $2 billion in losses on the agricultural industry. If California suffered something like a multidecade drought, the best-case scenario would be some combination of conservation, technological improvements (such as desalinization plants), multistate economic-based water transfers from agriculture to urban areas, and other things like that to get humans through the drought. In the worst-case scenario, there might be all-out migration and/or ghost towns. We must learn how to use water more efficiently.

What role does climate change play in this or future droughts? Scientists apparently say that they don't have the tools to tease out how much of this specific drought might be attributed to climate change. As of now, probably very little of the California drought can be attributed to climate change with any certainty. Overall, past droughts have probably been due to subtle changes in water temperatures in the tropical Pacific Ocean. Colder water temperatures tend to produce drier conditions in the West. According to some computer models, California could actually see more, not less, winter rain and snow because of climate change. Overall, rising temperatures would tend to favor more droughts, however. During the 20th century, California's population increased from 1.5 to almost 40 million, and that increase may well have occurred during an outlier, an unusually wet century. Overall, the 20th century experienced less drought than most of the preceding 4 to 20 centuries, according to a study in Science.

Megadroughts are likely to hit the Southwest USA in this century. Megadroughts, according to an American Geophysical Union conference spokesman in 2014, could possibly be even worse than anything experienced by any humans who have lived in the Western part of the US in the last 1000 years! And we need rain badly here in Texas. If there is not enough water, medicines are hard to swallow.

PERFORMANCE OF HIGH SCHOOL STUDENTS

The highest SAT score available is 800. In math, the 2014 high school students across the nation registered 512 and those in Texas, 495; in reading, the US average was 496 and in Texas, 475; in writing, the US average was 487 and in Texas, 460 (19). Texas education officials have attributed the declining SAT scores in the state to an increase in the number of minority students taking the exams. Minorities generally perform worse than white students on standardized achievement tests, like the SAT and ACT, the nation's two leading college-entrance exams.

California students outperformed Texans by big margins in 2014: by 15 points in math and 22 in reading. Demographics of the student populations in the two states are similar: California is 53% Hispanic and 26% white, while Texas is 51% Hispanic and 30% white. Additionally, >60% of seniors in both states took the SAT.

The drop in SAT math scores in Texas might rekindle debate over the state's recent decision to no longer require all high school students to take algebra II. The College Board reported that just over one-third of the 179,036 Texas students who took the SAT met its college and career readiness benchmark, which requires a score of 1550 out of a possible total of 2400. That was well under the national average of 43% who hit the benchmark. Most minority students fell short of the benchmark: only 19% of Hispanic and 14% of black students in Texas met the college readiness standard. Both percentages trailed the national averages for those groups. We can do better in this great state!

ENDANGERED JOBS

According to a piece in The Dallas Morning News, the following are jobs expected to decline in the next few years: mail carrier, farmer, meter reader, newspaper reporter, travel agent, lumberjack, flight attendant, drill-press operator, printing worker, and tax examiner and collector (20). Technology killed the switchboard operator, the lamplighter, and the ice cutter, and it's now a threat for workers in a variety of other fields. When economics change, it kills opportunities, but it also brings other opportunities.

ADVERBS AND LAWYERS

A piece by Jacob Gershman indicated that no part of speech has had to put up with so much adversity as the adverb (21). It is supposed to be used sparingly, if at all, to modify verbs, adjectives, or other adverbs. Although it is generally believed that the adverb is not the writer's friend, there is one place where the adverb not only flourishes but wields power—the American legal system. Adverbs in recent years have taken on an increasingly important and often contentious role in courthouses. Their influence has spread with the help of lawmakers churning out new laws packed with them. Words such as “knowingly,” “intentionally,” and “recklessly,” which deal with criminal intent, appear frequently in legal writings. Other adverbs like “substantially” or “indiscriminately” have been pivotal in some federal appeals court rulings. The word “quickly” has gotten some attention. Tax law allows the government to immediately freeze the assets of a suspected tax cheat who “appears to be designing quickly” to hide his or her wealth. A legal anthropology professor at the University of Kentucky College of Law recently stated, “Contrary to the ordinary view that adverbs are superfluous, law generally and criminal law especially, emerges through its adverbs.”

The number of adverb-dense disputes over how to properly construe a criminal statute has surged since the 1980s. A US Supreme Court case in 2009 turned on the modifying reach of the word “knowingly,” tucked into a federal statute defining the crime of aggravated identity theft. In 2013, House Republicans clashed with Justice Department attorneys over a Justice Department lawyer's use of fuzzy adverbs, like “traditionally,” “typically,” and “ordinarily” in his statements about the Obama administration's response to an investigation of the Fast and Furious gun-trafficking operation. Even among the most adverbially disinclined, virtually everyone recalls backtracking on promises not to use the adverb. Hemingway used few adverbs. Avoiding adverbs forces one to confront the significance of one's word choice, opined Justice Anthony Kennedy of our Supreme Court. Maybe those of us in medicine can learn something from the lawyers about our use of adverbs.

William Clifford Roberts, MD
November 4, 2014