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 UNITED STATES HEALTH CARE REFORMPROGRESS TO DATE AND NEXT STEPS

•IMPORTANCE  THE AFFORDABLE CARE ACT IS THE MOST IMPORTANT HEALTH CARE LEGISLATION ENACTED IN THE UNITED
STATES SINCE THE CREATION OF MEDICARE AND MEDICAID IN 1965. THE LAW IMPLEMENTED COMPREHENSIVE REFORMS
DESIGNED TO IMPROVE THE ACCESSIBILITY, AFFORDABILITY, AND QUALITY OF HEALTH CARE.

•OBJECTIVES  TO REVIEW THE FACTORS INFLUENCING THE DECISION TO PURSUE HEALTH REFORM, SUMMARIZE EVIDENCE
ON THE EFFECTS OF THE LAW TO DATE, RECOMMEND ACTIONS THAT COULD IMPROVE THE HEALTH CARE SYSTEM, AND
IDENTIFY GENERAL LESSONS FOR PUBLIC POLICY FROM THE AFFORDABLE CARE ACT.

•CONCLUSION POLICY MAKERS SHOULD BUILD ON PROGRESS MADE BY THE AFFORDABLE CARE ACT BY CONTINUING TO
IMPLEMENT THE HEALTH INSURANCE MARKETPLACES AND DELIVERY SYSTEM REFORM, INCREASING FEDERAL FINANCIAL
ASSISTANCE FOR MARKETPLACE ENROLLEES, INTRODUCING A PUBLIC PLAN OPTION IN AREAS LACKING INDIVIDUAL
MARKET COMPETITION, AND TAKING ACTIONS TO REDUCE PRESCRIPTION DRUG COSTS. ALTHOUGH PARTISANSHIP AND
SPECIAL INTEREST OPPOSITION REMAIN, EXPERIENCE WITH THE AFFORDABLE CARE ACT DEMONSTRATES THAT POSITIVE
CHANGE IS ACHIEVABLE ON SOME OF THE NATION’S MOST COMPLEX CHALLENGES.
 MEDICAL ERROR—THE THIRD LEADING CAUSE OF DEATH IN THE US

•MEDICAL ERROR IS NOT INCLUDED ON DEATH CERTIFICATES OR IN RANKINGS OF CAUSE OF DEATH. MARTIN

MAKARY AND MICHAEL DANIEL ASSESS ITS CONTRIBUTION TO MORTALITY AND CALL FOR BETTER REPORTING

•THE ANNUAL LIST OF THE MOST COMMON CAUSES OF DEATH IN THE UNITED STATES, COMPILED BY THE CENTERS FOR
DISEASE CONTROL AND PREVENTION (CDC), INFORMS PUBLIC AWARENESS AND NATIONAL RESEARCH PRIORITIES EACH
YEAR. THE LIST IS CREATED USING DEATH CERTIFICATES FILLED OUT BY PHYSICIANS, FUNERAL DIRECTORS, MEDICAL
EXAMINERS, AND CORONERS. HOWEVER, A MAJOR LIMITATION OF THE DEATH CERTIFICATE IS THAT IT RELIES ON ASSIGNING
AN INTERNATIONAL CLASSIFICATION OF DISEASE (ICD) CODE TO THE CAUSE OF DEATH.1 AS A RESULT, CAUSES OF DEATH NOT
ASSOCIATED WITH AN ICD CODE, SUCH AS HUMAN AND SYSTEM FACTORS, ARE NOT CAPTURED. THE SCIENCE OF SAFETY
HAS MATURED TO DESCRIBE HOW COMMUNICATION BREAKDOWNS, DIAGNOSTIC ERRORS, POOR JUDGMENT, AND
INADEQUATE SKILL CAN DIRECTLY RESULT IN PATIENT HARM AND DEATH. WE ANALYZED THE SCIENTIFIC LITERATURE ON
MEDICAL ERROR TO IDENTIFY ITS CONTRIBUTION TO US DEATHS IN RELATION TO CAUSES LISTED BY THE CDC.2
 OBSERVATION OF GRAVITATIONAL WAVES FROM A BINARY BLACK HOLE MERGER

•ON SEPTEMBER 14, 2015 AT 09:50:45 UTC THE TWO DETECTORS OF THE LASER INTERFEROMETER GRAVITATIONAL-WAVE
OBSERVATORY SIMULTANEOUSLY OBSERVED A TRANSIENT GRAVITATIONAL-WAVE SIGNAL. THE SIGNAL SWEEPS UPWARDS IN
FREQUENCY FROM 35 TO 250 HZ WITH A PEAK GRAVITATIONAL-WAVE STRAIN OF 1.0×10−21. IT MATCHES THE WAVEFORM
PREDICTED BY GENERAL RELATIVITY FOR THE INSPIRAL AND MERGER OF A PAIR OF BLACK HOLES AND THE RINGDOWN OF THE
RESULTING SINGLE BLACK HOLE. THE SIGNAL WAS OBSERVED WITH A MATCHED-FILTER SIGNAL-TO-NOISE RATIO OF 24 AND A FALSE
ALARM RATE ESTIMATED TO BE LESS THAN 1 EVENT PER 203 000 YEARS, EQUIVALENT TO A SIGNIFICANCE GREATER THAN 5.1Σ. THE
SOURCE LIES AT A LUMINOSITY DISTANCE OF 410+160−180  MPCCORRESPONDING TO A REDSHIFT Z=0.09+0.03−0.04. IN THE
SOURCE FRAME, THE INITIAL BLACK HOLE MASSES ARE 36+5−4M⊙ AND 29+4−4M⊙, AND THE FINAL BLACK HOLE MASS
IS 62+4−4M⊙, WITH 3.0+0.5−0.5M⊙C2 RADIATED IN GRAVITATIONAL WAVES. ALL UNCERTAINTIES DEFINE 90% CREDIBLE
INTERVALS. THESE OBSERVATIONS DEMONSTRATE THE EXISTENCE OF BINARY STELLAR-MASS BLACK HOLE SYSTEMS. THIS IS THE
FIRST DIRECT DETECTION OF GRAVITATIONAL WAVES AND THE FIRST OBSERVATION OF A BINARY BLACK HOLE MERGER.
 EVIDENCE FOR A DISTANT GIANT PLANET IN THE SOLAR SYSTEM

•RECENT ANALYSES HAVE SHOWN THAT DISTANT ORBITS WITHIN THE SCATTERED DISK POPULATION OF THE KUIPER BELT EXHIBIT AN
UNEXPECTED CLUSTERING IN THEIR RESPECTIVE ARGUMENTS OF PERIHELION. WHILE SEVERAL HYPOTHESES HAVE BEEN PUT FORWARD TO
EXPLAIN THIS ALIGNMENT, TO DATE, A THEORETICAL MODEL THAT CAN SUCCESSFULLY ACCOUNT FOR THE OBSERVATIONS REMAINS ELUSIVE. IN
THIS WORK WE SHOW THAT THE ORBITS OF DISTANT KUIPER BELT OBJECTS CLUSTER NOT ONLY IN ARGUMENT OF PERIHELION, BUT ALSO IN
PHYSICAL SPACE. WE DEMONSTRATE THAT THE PERIHELION POSITIONS AND ORBITAL PLANES OF THE OBJECTS ARE TIGHTLY CONFINED AND
THAT SUCH A CLUSTERING HAS ONLY A PROBABILITY OF 0.007% TO BE DUE TO CHANCE, THUS REQUIRING A DYNAMICAL ORIGIN. WE FIND THAT
THE OBSERVED ORBITAL ALIGNMENT CAN BE MAINTAINED BY A DISTANT ECCENTRIC PLANET WITH MASS GREATER THAN ~10 EARTH MASSES,
WHOSE ORBIT LIES IN APPROXIMATELY THE SAME PLANE AS THOSE OF THE DISTANT KUIPER BELT OBJECTS, BUT WHOSE PERIHELION IS 180
DEGREES AWAY FROM THE PERIHELIA OF THE MINOR BODIES. IN ADDITION TO ACCOUNTING FOR THE OBSERVED ORBITAL ALIGNMENT, THE
EXISTENCE OF SUCH A PLANET NATURALLY EXPLAINS THE PRESENCE OF HIGH PERIHELION SEDNA-LIKE OBJECTS, AS WELL AS THE KNOWN
COLLECTION OF HIGH SEMIMAJOR AXIS OBJECTS WITH INCLINATIONS BETWEEN 60 AND 150 DEGREES WHOSE ORIGIN WAS PREVIOUSLY
UNCLEAR. CONTINUED ANALYSIS OF BOTH DISTANT AND HIGHLY INCLINED OUTER SOLAR SYSTEM OBJECTS PROVIDES THE OPPORTUNITY FOR
TESTING OUR HYPOTHESIS AS WELL AS FURTHER CONSTRAINING THE ORBITAL ELEMENTS AND MASS OF THE DISTANT PLANET.
 SUGAR INDUSTRY AND CORONARY HEART DISEASE
RESEARCHA HISTORICAL ANALYSIS OF INTERNAL
INDUSTRY DOCUMENTS
• EARLY WARNING SIGNALS OF THE CORONARY HEART DISEASE (CHD) RISK OF SUGAR (SUCROSE) EMERGED IN THE 1950S. WE
EXAMINED SUGAR RESEARCH FOUNDATION (SRF) INTERNAL DOCUMENTS, HISTORICAL REPORTS, AND STATEMENTS RELEVANT
TO EARLY DEBATES ABOUT THE DIETARY CAUSES OF CHD AND ASSEMBLED FINDINGS CHRONOLOGICALLY INTO A NARRATIVE
CASE STUDY. THE SRF SPONSORED ITS FIRST CHD RESEARCH PROJECT IN 1965, A LITERATURE REVIEW PUBLISHED IN THE NEW
ENGLAND JOURNAL OF MEDICINE, WHICH SINGLED OUT FAT AND CHOLESTEROL AS THE DIETARY CAUSES OF CHD AND
DOWNPLAYED EVIDENCE THAT SUCROSE CONSUMPTION WAS ALSO A RISK FACTOR. THE SRF SET THE REVIEW’S OBJECTIVE,
CONTRIBUTED ARTICLES FOR INCLUSION, AND RECEIVED DRAFTS. THE SRF’S FUNDING AND ROLE WAS NOT DISCLOSED.
TOGETHER WITH OTHER RECENT ANALYSES OF SUGAR INDUSTRY DOCUMENTS, OUR FINDINGS SUGGEST THE INDUSTRY
SPONSORED A RESEARCH PROGRAM IN THE 1960S AND 1970S THAT SUCCESSFULLY CAST DOUBT ABOUT THE HAZARDS OF
SUCROSE WHILE PROMOTING FAT AS THE DIETARY CULPRIT IN CHD. POLICYMAKING COMMITTEES SHOULD CONSIDER GIVING
LESS WEIGHT TO FOOD INDUSTRY–FUNDED STUDIES AND INCLUDE MECHANISTIC AND ANIMAL STUDIES AS WELL AS STUDIES
APPRAISING THE EFFECT OF ADDED SUGARS ON MULTIPLE CHD BIOMARKERS AND DISEASE DEVELOPMENT.
 ZIKA VIRUS AND BIRTH DEFECTS — REVIEWING THE
EVIDENCE FOR CAUSALITY
• MOVING FROM A HYPOTHESIS THAT ZIKA VIRUS IS LINKED TO CERTAIN ADVERSE OUTCOMES TO A STATEMENT THAT ZIKA VIRUS IS A CAUSE OF
CERTAIN ADVERSE OUTCOMES ALLOWS FOR DIRECT COMMUNICATIONS REGARDING RISK, BOTH IN CLINICAL CARE SETTINGS AND IN PUBLIC
HEALTH GUIDANCE, AND AN INTENSIFIED FOCUS ON PREVENTION EFFORTS, SUCH AS THE IMPLEMENTATION OF VECTOR CONTROL, THE
IDENTIFICATION OF IMPROVED DIAGNOSTIC METHODS, AND THE DEVELOPMENT OF A ZIKA VIRUS VACCINE.44 IN ADDITION, AFTER
RECOGNIZING A CAUSAL RELATIONSHIP BETWEEN ZIKA VIRUS INFECTION AND ADVERSE PREGNANCY AND BIRTH OUTCOMES, WE CAN FOCUS
RESEARCH EFFORTS ON OTHER CRITICAL ISSUES: FIRST, UNDERSTANDING THE FULL SPECTRUM OF DEFECTS CAUSED BY CONGENITAL ZIKA
VIRUS INFECTION; IF ZIKA VIRUS IS SIMILAR TO OTHER TERATOGENS, AN EXPANSION OF THE PHENOTYPE WOULD BE EXPECTED (E.G., WITH THE
CONGENITAL RUBELLA SYNDROME, THE PHENOTYPE WAS EXPANDED FROM CATARACTS TO INCLUDE OTHER FINDINGS SUCH AS HEARING LOSS,
CONGENITAL HEART DEFECTS, AND MICROCEPHALY).11 SECOND, QUANTIFYING THE RELATIVE AND ABSOLUTE RISKS AMONG INFANTS WHO ARE
BORN TO WOMEN WHO WERE INFECTED AT DIFFERENT TIMES DURING PREGNANCY. THIRD, IDENTIFYING FACTORS THAT MODIFY THE RISK OF
AN ADVERSE PREGNANCY OR BIRTH OUTCOME (E.G., COINFECTION WITH ANOTHER VIRUS, PREEXISTING IMMUNE RESPONSE TO ANOTHER
FLAVIVIRUS, GENETIC BACKGROUND OF THE MOTHER OR FETUS, AND SEVERITY OF INFECTION). ADDRESSING THESE ISSUES WILL IMPROVE
OUR EFFORTS TO MINIMIZE THE BURDEN OF THE EFFECTS OF ZIKA VIRUS INFECTION DURING PREGNANCY.
 THE ASSOCIATION BETWEEN INCOME AND LIFE EXPECTANCY IN THE UNITED STATES,
2001-2014.
• IMPORTANCE:
• THE RELATIONSHIP BETWEEN INCOME AND LIFE EXPECTANCY IS WELL ESTABLISHED BUT REMAINS POORLY
UNDERSTOOD.

• OBJECTIVES:
• TO MEASURE THE LEVEL, TIME TREND, AND GEOGRAPHIC VARIABILITY IN THE ASSOCIATION BETWEEN
INCOME AND LIFE EXPECTANCY AND TO IDENTIFY FACTORS RELATED TO SMALL AREA VARIATION.

• CONCLUSIONS:
• IN THE UNITED STATES BETWEEN 2001 AND 2014, HIGHER INCOME WAS ASSOCIATED WITH GREATER
LONGEVITY, AND DIFFERENCES IN LIFE EXPECTANCY ACROSS INCOME GROUPS INCREASED OVER TIME.
HOWEVER, THE ASSOCIATION BETWEEN LIFE EXPECTANCY AND INCOME VARIED SUBSTANTIALLY ACROSS
AREAS; DIFFERENCES IN LONGEVITY ACROSS INCOME GROUPS DECREASED IN SOME AREAS AND INCREASED
IN OTHERS. THE DIFFERENCES IN LIFE EXPECTANCY WERE CORRELATED WITH HEALTH BEHAVIORS AND
LOCAL AREA CHARACTERISTICS.
 EFFECT OF WEARABLE TECHNOLOGY COMBINED WITH A LIFESTYLE
INTERVENTION ON LONG-TERM WEIGHT LOSS: THE IDEA RANDOMIZED
CLINICAL TRIAL.

• IMPORTANCE:

• EFFECTIVE LONG-TERM TREATMENTS ARE NEEDED TO ADDRESS THE OBESITY EPIDEMIC. NUMEROUS WEARABLE TECHNOLOGIES SPECIFIC
TO PHYSICAL ACTIVITY AND DIET ARE AVAILABLE, BUT IT IS UNCLEAR IF THESE ARE EFFECTIVE AT IMPROVING WEIGHT LOSS.

• OBJECTIVE:

• TO TEST THE HYPOTHESIS THAT, COMPARED WITH A STANDARD BEHAVIORAL WEIGHT LOSS INTERVENTION (STANDARD INTERVENTION), A
TECHNOLOGY-ENHANCED WEIGHT LOSS INTERVENTION (ENHANCED INTERVENTION) WOULD RESULT IN GREATER WEIGHT LOSS.

• CONCLUSIONS:

• AMONG YOUNG ADULTS WITH A BMI BETWEEN 25 AND LESS THAN 40, THE ADDITION OF A WEARABLE TECHNOLOGY DEVICE TO A
STANDARD BEHAVIORAL INTERVENTION RESULTED IN LESS WEIGHT LOSS OVER 24 MONTHS. DEVICES THAT MONITOR AND PROVIDE
FEEDBACK ON PHYSICAL ACTIVITY MAY NOT OFFER AN ADVANTAGE OVER STANDARD BEHAVIORAL WEIGHT LOSS APPROACHES.
MASTERING THE GAME OF GO WITH DEEP NEURAL NETWORKS AND TREE SEARCH

• THE GAME OF GO HAS LONG BEEN VIEWED AS THE MOST CHALLENGING OF CLASSIC GAMES FOR ARTIFICIAL INTELLIGENCE
OWING TO ITS ENORMOUS SEARCH SPACE AND THE DIFFICULTY OF EVALUATING BOARD POSITIONS AND MOVES. HERE WE
INTRODUCE A NEW APPROACH TO COMPUTER GO THAT USES ‘VALUE NETWORKS’ TO EVALUATE BOARD POSITIONS AND
‘POLICY NETWORKS’ TO SELECT MOVES. THESE DEEP NEURAL NETWORKS ARE TRAINED BY A NOVEL COMBINATION OF
SUPERVISED LEARNING FROM HUMAN EXPERT GAMES, AND REINFORCEMENT LEARNING FROM GAMES OF SELF-PLAY.
WITHOUT ANY LOOKAHEAD SEARCH, THE NEURAL NETWORKS PLAY GO AT THE LEVEL OF STATE-OF-THE-ART MONTE CARLO
TREE SEARCH PROGRAMS THAT SIMULATE THOUSANDS OF RANDOM GAMES OF SELF-PLAY. WE ALSO INTRODUCE A NEW
SEARCH ALGORITHM THAT COMBINES MONTE CARLO SIMULATION WITH VALUE AND POLICY NETWORKS. USING THIS
SEARCH ALGORITHM, OUR PROGRAM ALPHAGO ACHIEVED A 99.8% WINNING RATE AGAINST OTHER GO PROGRAMS, AND
DEFEATED THE HUMAN EUROPEAN GO CHAMPION BY 5 GAMES TO 0. THIS IS THE FIRST TIME THAT A COMPUTER PROGRAM
HAS DEFEATED A HUMAN PROFESSIONAL PLAYER IN THE FULL-SIZED GAME OF GO, A FEAT PREVIOUSLY THOUGHT TO BE AT
LEAST A DECADE AWAY.
 THE NEW WORLD ATLAS OF ARTIFICIAL NIGHT SKY
BRIGHTNESS
• ARTIFICIAL LIGHTS RAISE NIGHT SKY LUMINANCE, CREATING THE MOST VISIBLE EFFECT OF LIGHT POLLUTION—
ARTIFICIAL SKYGLOW. DESPITE THE INCREASING INTEREST AMONG SCIENTISTS IN FIELDS SUCH AS ECOLOGY,
ASTRONOMY, HEALTH CARE, AND LAND-USE PLANNING, LIGHT POLLUTION LACKS A CURRENT QUANTIFICATION OF
ITS MAGNITUDE ON A GLOBAL SCALE. TO OVERCOME THIS, WE PRESENT THE WORLD ATLAS OF ARTIFICIAL SKY
LUMINANCE, COMPUTED WITH OUR LIGHT POLLUTION PROPAGATION SOFTWARE USING NEW HIGH-RESOLUTION
SATELLITE DATA AND NEW PRECISION SKY BRIGHTNESS MEASUREMENTS. THIS ATLAS SHOWS THAT MORE
THAN 80% OF THE WORLD AND MORE THAN 99% OF THE U.S. AND EUROPEAN POPULATIONS LIVE UNDER LIGHT-
POLLUTED SKIES. THE MILKY WAY IS HIDDEN FROM MORE THAN ONE-THIRD OF HUMANITY, INCLUDING 60% OF
EUROPEANS AND NEARLY 80% OF NORTH AMERICANS. MOREOVER, 23% OF THE WORLD’S LAND SURFACES
BETWEEN 75°N AND 60°S, 88% OF EUROPE, AND ALMOST HALF OF THE UNITED STATES EXPERIENCE LIGHT-
POLLUTED NIGHTS.
 FO R A LIM IT T O H U M A N LI FESPAN
1. EVIDENCE B A N D’S BRAIN
R IS T IN S ID E M Y H U S R ’S D IS EASE
THE TERRO R E D UCES AΒ PLAQ U ES IN A L ZH EIM E
O D Y A D U C A N U M A B 75 TO 2014
THE ANTIB IN D EX IN 200 CO UN TR IE S FR O M 19
A D U LT B O D Y -M AS S RISE
TRENDS IN T A N D FU TU R E S EA -L EV EL
N TR IBU T IO N O F A N T A R C TICA TO PAS TH E D ET R IM EN TA L A SS O CIATIO
CO U A TE , O R EV EN ELIMINATE,
V IT Y A TT EN
DOES PHYSICAL ACTI ITH MORTALITY?
N OF SITTING TIME W
IM PA IR PAT H O G EN C O LO NIZATION
AL S P R O D UC IN G A N O V EL ANTIBIOTIC
HUMAN COMMENS
E BR AIN A D A P TS TO D IS HONESTY S EP S IS A ND S EP TIC S H OCK (SEP
TH
TIO N AL C O N S EN SU S D E FI NITIONS FOR
THE THIRD INTERNA
SIS-3)
S E A R C H ES IN T ER N A TIO N ALLY
IA T E D W IT H M ICROCEOPTHH ALER TOP RE
Y
ZIKA VIR U S A S S O C