Light Pollution

Cities and towns are shifting their outdoor lighting to LED bulbs (Light Emitting Diodes) because they use less energy and fuel to burn and are more environmentally friendly.  They last longer and ultimately will be cheaper. The cities of New York and Seattle have replaced, or are in the process of replacing, all their street lights with white LED bulbs at a color temperature of 4000 – 5000k.  Why then did this environmentally friendly and economically sound decision result in the American Medical Association (AMA) issuing a statement condemning this practice?

It seems that the older less efficient street lamps or incandescent bulbs had a color temperature of 2400 K or less Candle light is actually a bit less than 1800 CT. At the higher color temperature the light contains more of the blue spectrum of light which has a shorter wavelength than the former incandescent bulbs which had more yellow and red. The result is that the new bulbs produce significant glare resulting in pupillary constriction and reduced vision. In addition, blue light scatters more on the retina and at sufficient levels can damage the retina in addition to making driving and night walking more difficult.

The American Medical Association believes the white LED light suppresses natural production of melatonin by the brain more than five times what the former bulbs were capable of. This has a major effect on human’s circadian rhythm and ability to fall asleep. For the animal kingdom it can adversely affect the migratory pattern of animals and can adversely affect aquatic animals such as turtles and their nesting and reproductive habits.

The AMA statement called for using the lowest level of blue wavelength light possible to reduce glare. They encourage the use of 3000k or less CT for outdoor lightings and roadway lighting to reduce glare and improve safety.  They additionally asked for dimming of these lights for off peak periods. They did not condemn or call for a ban on LED lights just for municipalities to be aware of the dangers of using the products with a high color temperature (CT) above 3000k and blue wave length predominant light.

Generics and Therapeutic Substitution – Safety and Efficacy?

Excuse me for being a “doubting Thomas,” but when I saw articles in JAMA Internal Medicine and commentaries supporting use of generics instead of brand name drugs I asked myself “Where is the proof of equivalent results and safety?”.  Generic substitution implies that the original product is no longer patented and exclusive and another firm is now producing an identical chemical version which produces the same beneficial effects on the patient.  Therapeutic substitution means your pharmaceutical insurance company or pharmacy changes the drug you are prescribed to one in the same drug class. Think of drinking Coca Cola and having the supermarket substitute a comparable brand instead.

The reason for this is simply to spend less money. Many pharmaceutical insurance companies realize if they put an obstacle in your path of obtaining your medication you likely will pay for it independently saving them money.  The authors of the JAMA articles estimate between 2010 and 2012 therapeutic substitution would have saved $73 billion. The out-of-pocket savings to the patient would have amounted to $25 billion.

I’m for saving money and spending less with certain guidelines. However; I want to know that a generic medicine is produced in a factory inspected by the Food and Drug Administration (FDA) at least as frequently as the drugs produced in North American factories. I like to know where the drug was made including country of origin, city, location and the plant’s track record for health and safety. I also want to know the generic medication produces the same drug levels and positive effects as the brand name medication and is made with no more contaminants than the original branded product.

I need reassurance that my patient isn’t receiving a counterfeit product with stolen original labeling, which has been a scam fooling pharmacists and Customs agents for years.   I would additionally like to know that the generic product, or therapeutically substituted product, works as well as the original. We know for example that Levothyroxine generics and substitutions are problematic.  We additionally know that the beta blocker carvidilol (Coreg) has certain unique properties that other beta blockers do not provide making therapeutic substitution for less expensive medications in the beta blocker class problematic.

Once this information is available it should be distributed in package inserts, online and taught in pharmaceutical, nursing and medical school courses as well as CME courses for health care professionals.

There is an abnormally perverse concern that if a pharmaceutical representative takes a health care provider out for a meal and a drink while explaining their product, we will prescribe it even if it is more expensive or doesn’t work as well.  I doubt sincerely that most physicians would do that but do believe if the cost is comparable, or less, and the efficacy is as good, they might choose the product as a viable alternative.

Zika Virus: Updates and Need for Congressional Action

As we move from spring to summer we will be facing warmer temperatures, higher humidity and more rain.  This creates a perfect environment for standing water mosquito breeding grounds, and an increase in the mosquito population especially the Aedes aegypti which carries the Zika Virus, Dengue Fever and Chikengunya Viruses.  President Obama and the Center for Disease Control have asked the United States Congress to allocate 1.9 billion dollars to fight Zika virus but conservative Republican elected officials have failed to address the issue. As a short term stop gap measure the CDC has suspended its work on Ebola and other hemorrhagic diseases and begun using those funds for Zika Virus research.  They are in the process of developing a Zika Virus Vaccine for prevention in humans but are several years away from achieving this.  Zika virus is currently widespread in South America, Central America and the Caribbean Basin.  While the infection produces an extremely mild clinical pattern in most humans, it causes severe birth defects in pregnant women including microcephaly or small skull or cranial cavity for an enlarging growing brain. Infected fetuses result in spontaneous abortion, death of the child or lifelong neurologic deficits. At this point researchers are not sure exactly at what point in a pregnancy, exposure to the Zika virus causes birth defects.  In adults the disease is mild but the body’s antibody response against the virus can result in progressive ascending paralysis with a disease known as Guillan Barre. Many of these patients eventually have their diaphragm and respiratory muscles involved and require intubation and respirators to survive. If they survive the adult illness they are often left with painful neurologic issues post paralysis.  To date most Zika infections occurred in travelers returning from areas of the world overrun with Zika. There has been documented sexual transmission of the virus between an infected and uninfected partner.  The disease symptoms are so mild in some they do not even realize they are infected.

The fear is that with the warm wet weather our local mosquito population will become infected with the Zika virus by sampling the blood of infected individuals and start a local epidemic.  NASA has created a model which predicts an epidemic in South Florida, Houston and southern Texas and parts of Louisiana. Mosquito control is one means of fighting the vector of transmission. Most local spraying programs hope to reduce the mosquito population by 50% to be considered successful but this rate of success will not prevent transmission of these three viruses.  Officials in the Florida Keys have begun releasing sterile male Aedes aegypti mosquitoes into the population in the hopes of reducing the overall mosquito population.  In a recent article in the journal Cell Symposia, researchers presented data suggesting that infecting the male Aedes aegypti mosquito with parasitic bacteria known as Wolbachia may inhibit viral replication of the virus and transmission by mosquito bites.  They have already shown that infecting mosquitoes with this parasitic bacterium reduces the spread of Dengue fever and Chikengunya.  To move forward with a project like this requires Federal funding and Congress is delaying addressing the issue as part of the politics of NO in an election year.

To protect yourself this spring and summer please make sure there is no free standing water on your property which can be used as a breeding ground by mosquitoes. Make sure your screens are intact at your home.   Wear long sleeves and use insect repellant. Consumer Reports still recommends repellant with 8 – 30% DEET, 20% Picardin or 30% Oil of Lemon Eucalyptus. They specifically suggest Sawyer Fishermans Formula Picardin or 2 Repel Lemon Eucalyptus or Deep Woods Off with 25% DEET.  Above all contact your Congresspersons and Senators and encourage them to fund the fight against Zika.