Alarm Over India’s Dengue Fever Epidemic

Enrico Fabian for The New York Times

Filthy standing water abound in New Delhi has contributed to an epidemic of dengue fever in India. More Photos »

NEW DELHI — An epidemic of dengue fever in India is fostering a growing sense of alarm even as government officials here have publicly refused to acknowledge the scope of a problem that experts say is threatening hundreds of millions of people, not just in India but around the world.

India has become the focal point for a mosquito-borne plague that is sweeping the globe. Reported in just a handful of countries in the 1950s, dengue (pronounced DEN-gay) is now endemic in half the world’s nations.

“The global dengue problem is far worse than most people know, and it keeps getting worse,” said Dr. Raman Velayudhan, the World Health Organization’s lead dengue coordinator.

The tropical disease, though life-threatening for a tiny fraction of those infected, can be extremely painful. Growing numbers of Western tourists are returning from warm-weather vacations with the disease, which has reached the shores of the United States and Europe. Last month, health officials in Miami announced a case of locally acquired dengue infection.

Here in India’s capital, where areas of standing water contribute to the epidemic’s growth, hospitals are overrun and feverish patients are sharing beds and languishing in hallways. At Kalawati Saran Hospital, a pediatric facility, a large crowd of relatives lay on mats and blankets under the shade of a huge banyan tree outside the hospital entrance recently.

Among them was Neelam, who said her two grandchildren were deathly ill inside. Eight-year-old Sneha got the disease first, followed by Tanya, 7, she said. The girls’ parents treated them at home but then Sneha’s temperature rose to 104 degrees, a rash spread across her legs and shoulders, and her pain grew unbearable.

“Sneha has been given five liters of blood,” said Neelam, who has one name. “It is terrible.”

Officials say that 30,002 people in India had been sickened with dengue fever through October, a 59 percent jump from the 18,860 recorded for all of 2011. But the real number of Indians who get dengue fever annually is in the millions, several experts said.

“I’d conservatively estimate that there are 37 million dengue infections occurring every year in India, and maybe 227,500 hospitalizations,” said Dr. Scott Halstead, a tropical disease expert focused on dengue research.

A senior Indian government health official, who agreed to speak about the matter only on the condition of anonymity, acknowledged that official figures represent a mere sliver of dengue’s actual toll. The government only counts cases of dengue that come from public hospitals and that have been confirmed by laboratories, the official said. Such a census, “which was deliberated at the highest levels,” is a small subset that is nonetheless informative and comparable from one year to the next, he said.

“There is no denying that the actual number of cases would be much, much higher,” the official said. “Our interest has not been to arrive at an exact figure.”

The problem with that policy, said Dr. Manish Kakkar, a specialist at the Public Health Foundation of India, is that India’s “massive underreporting of cases” has contributed to the disease’s spread. Experts from around the world said that India’s failure to construct an adequate dengue surveillance system has impeded awareness of the illness’s vast reach, discouraged efforts to clean up the sources of the disease and slowed the search for a vaccine.

“When you look at the number of reported cases India has, it’s a joke,” said Dr. Harold S. Margolis, chief of the dengue branch at the Centers for Disease Control and Prevention in Atlanta.

Neighboring Sri Lanka, for instance, reported nearly three times as many dengue cases as India through August, according to the World Health Organization, even though India’s population is 60 times larger.

Hari Kumar contributed reporting.

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Exclusive - Amazon to win EU e-book pricing tussle with Apple

BRUSSELS (Reuters) - European Union regulators are to end an antitrust probe into e-book prices by accepting an offer by Apple and four publishers to ease price restrictions on Amazon, two sources said on Tuesday.

That decision would hand online retailer Amazon a victory in its attempt to sell e-books cheaper than rivals in the fast-growing market publishers hope will boost revenue and increase customer numbers.

"Faced with years of court battles and uncertainty I can understand why some of these guys decided to fold their cards and take the whipping," said Mark Coker, founder of Smashwords, an ebook publisher and distributor that works with Apple.

"It's certainly another win for Amazon," he added. "I have not seen the terms of the final settlement, but my initial reaction is that it places restrictions on what publishers can do, slowing them down just when they need to be more nimble."

A spokesman at the EU Commission said its investigation was not yet finished. Amazon and Apple declined to comment.

In September, Apple and the publishers offered to let retailers set prices or discounts for a period of two years, and also to suspend "most-favored nation" contracts for five years.

Such clauses bar Simon & Schuster, News Corp. unit HarperCollins, Lagardere SCA's Hachette Livre and Verlagsgruppe Georg von Holtzbrinck, the owner of German company Macmillan, from making deals with rival retailers to sell e-books more cheaply than Apple.

The agreements, which critics say prevent Amazon and other retailers from undercutting Apple's charges, sparked an investigation by the European Commission in December last year.

Pearson Plc's Penguin group, which is also under investigation, did not take part in the offer.

The EU antitrust authority, which in September asked for feedback from rivals and consumers about the proposal, has not asked for more concessions, said one of sources.

"The Commission is likely to accept the offer and announce its decision next month," the source said on Tuesday.

Antoine Colombani, spokesman for competition policy at the European Commission, said: "We have launched a market test in September and our investigation is still ongoing."

Amazon declined to comment, while Apple did not respond to an email seeking comment.

Companies found guilty of breaching EU rules could be fined up to 10 percent of their global sales, which in Apple's case could reach $15.6 billion, based on its 2012 fiscal year.

AGGREGATE PRICING

UBS analysts estimate that e-books account for about 30 percent of the U.S. book market and 20 percent of sales in Britain but are minuscule elsewhere. When Amazon launched its Kindle e-reader, it charged $9.99 per book.

Apple's agency model let publishers set prices in return for a 30 percent cut to the maker of iPhone and iPad.

The U.S. Department of Justice is investigating e-book prices. HarperCollins, Simon & Schuster and Hachette have settled, but Apple, Pengin Group and Macmillan have not.

The DOJ settlement required that retailers must at least break even selling all ebooks from a publisher's available list, according to Coker and Joe Wikert, general manager and publisher at O'Reilly Media Inc.

It was not clear if EU regulators will include a similar requirement, which would prohibit Amazon from pricing all ebooks at a loss, said Wikert, a former publishing executive.

In the United States, Amazon will likely price popular titles at a loss and try to make up the difference on a publisher's other ebooks, he said.

Coker said any such rule could be dangerous in Europe, which still has distinct markets.

"It could allow a single retailer to charge full price in a large market like the U.K., and then sell below cost or for free in multiple smaller markets as a strategy to kill regional ebook retailing upstarts before they take root," Coker said.

FROWNING ON ONLINE TRADE CURBS

Antitrust regulators tend to frown on restrictions on online trade and the case is a good example, said Mark Tricker, a partner at Brussels-based law firm Norton Rose.

"This case shows the online world continues to be a major focus for the Commission," he said.

"These markets change very quickly and if you don't stamp down on potential infringements of competition rules, you can have significant consequences."

(Additional reporting by Alistair Barr in San Francisco; Editing by Rex Merrifield, David Goodman and David Gregorio)

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Pick 6 of enticing NFL homecoming ideas

DeAngelo Williams was not pleased when he learned that the Carolina Panthers were deemed the Washington Redskins' "homecoming" opponent.

He riled up his teammates by talking about it in a pregame speech, stashed a copy of the game program in his locker, then took to Twitter to rub it in after the Panthers' 21-13 victory. His conversation with reporters on the topic was one of the best locker room moments ever at the Redskins' stadium.

"You don't say you're going to have a 'homecoming' in the National Football League," Williams said. "You do it in college. It's one of those teams that's just terrible. You don't book, like, a good team for homecoming."

So does he think the Panthers spoiled the homecoming dance?

"I don't know if they had a dance or anything," he said. "I just know you don't give a team extra motivation by putting that on your program. Even just blatantly coming out and saying: 'You're our homecoming game.'"

But if the Panthers, 1-6 entering the game, weren't the ideal homecoming opponent, then who is? The NFL has more than enough prime candidates to serve up for King and Queen festivities between now and the end of the season.

— Buffalo at New England (Nov. 11) — May be chilly, but knowing a W is on the way should be warming all you Patriots. And by the way, if you have an ID showing your name is Bill, you'll get a ticket to the concert after the game, where all the music will be played in a dull monotone by musicians who squirm and smirk. The worst part: Imagining your date really does look good in that hooded sweat shirt.

— Jacksonville at Houston (Nov. 18) — Every day leading up the game has a dress-up theme. The Jaguars, for example, can put on their uniforms and pretend they're actually relevant.

— Washington at Dallas (Nov. 22) — Turnabout is fair play, Redskins. Having "homecominged" the Panthers, the same gets done to you on Thanksgiving Day. Clint Longley gets the prime seat on the featured float. And just imagine all the confetti they could tie to the bottom of that whopper of a scoreboard.

— New Orleans at Atlanta (Nov. 29) — The Falcons certainly deserve a homecoming game if they remain the league's only unbeaten team, so why not make it a Mardi Gras theme? Of course, the Saints make for a bit of an unpredictable opponent, one more than capable of ruining the day, so maybe Atlanta shouldn't go overboard and fly those Super Bowl championship banners too prominently during the fun. Oh, wait a minute ...

— Cleveland at Oakland (Dec. 2) — Homecoming in the Black Hole. Need we say more?

— Kansas City at Denver (Dec. 30) — Peyton Manning can supply the pizza for the final Homecoming party of 2012. (We understand he has some connections.) One catch: If Kansas City's players stay for the dance, it'll have to be girl ask boy because the Chiefs don't know how to take the lead.

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Global Update: Polio Eradication Efforts in Pakistan Focus on Pashtuns

Michael Kamber for The New York Times

Polio will never be eradicated in Pakistan until a way is found to persuade poor Pashtuns to embrace the vaccine, according to a study released by the World Health Organization.

A survey of 1,017 parents of young children found that 41 percent had never heard of polio and 11 percent refused to vaccinate their children against it. The survey was done in Karachi, Pakistan’s largest city and the only big city in the world where polio persists; it was published in the agency’s November bulletin.

Parents from poor families “cited lack of permission from family elders,” said Dr. Anita Zaidi, who teaches pediatrics at the Aga Khan University in Karachi. Some rich parents also disdained the vaccine, saying it was “harmful or unnecessary,” she added.

Pashtuns account for 75 percent of Pakistan’s polio cases even though they are only 15 percent of the population. Wealthy children are safer because the virus travels in sewage, and their neighborhoods may have covered sewers and be less flood-prone.

Pashtuns are the largest ethnic group in next-door Afghanistan, where polio has also never been wiped out. Most Taliban fighters are Pashtun, and some Taliban threatened to kill vaccinators earlier this year. Two W.H.O. vaccinators were shot in Karachi in July.

Rumors persist that the vaccine is a plot to sterilize Muslims. But the eradication drive is recruiting Pashtuns as vaccinators and asking prominent religious leaders from various sects to make videos endorsing the vaccine.

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Square Feet: Geothermal Energy Advocates Hope Systems Get a Second Look

Advocates for geothermal energy say that the path of destruction cut by Hurricane Sandy, which unearthed fuel tanks, ravaged cooling towers and battered air-conditioners, has already persuaded some building owners to switch to geothermal systems that use underground pipes to harness the earth’s energy for heating and cooling buildings.

Andrea Mohin/The New York Times

The geothermal energy system at the Brooklyn Children’s Museum, installed in 2007 at a cost of $675,000.

“We’re seeing dozens of these half-empty and empty oil tanks just popping up all over the place in the flooded areas,” said David E. Reardon, the manager of geothermal drilling for the Miller Environmental Group, an environmental response, remediation and restoration services company based in Calverton on Long Island that has been involved in poststorm environmental cleanup throughout the region.

“Those tanks become buoyant in all that water,” he said. But since geothermal systems don’t use fossil fuels or mechanical systems that are exposed to the elements, Mr. Reardon said, he started fielding calls from people asking for estimates on geothermal systems just days after the storm. “Often it’s a case where they were considering doing it, but were waiting for something to finally no longer be able to be repaired,” he said, and the storm has ended that wait.

Geothermal energy systems, common in countries like Iceland and China, use the constant temperature of the earth to heat and cool buildings.

Geothermal wells are dug to a depth where the earth regulates the temperature of water or a liquid circulating through the system. Geothermal systems may require one well or dozens to regulate a building’s temperature, depending on the size of a building and type of system installed. While the systems are called wells, they are actually an underground network of pipes connected to heat pumps to circulate water or some other liquid.

Because digging geothermal wells can be expensive and logistically difficult, the systems have been slow to catch on in New York City. Yet, according to the Rockefeller Foundation and DB Climate Change Advisors, “buildings consume approximately 40 percent of the world’s primary energy and are responsible for 40 percent of global carbon emissions,” said Jack DiEnna, the executive director of the Geothermal Heat Pump National and International Initiative, based in Washington.

Installing a geothermal system can significantly reduce a building’s carbon footprint, and over the last decade, the number of geothermal heat pump systems in the city has grown steadily. More geothermal systems are installed in New York, New Jersey and Pennsylvania than anywhere else in the United States.

Most systems are being installed in institutional buildings, multifamily residential buildings and relatively small commercial buildings. There have been systems installed by several prominent organizations and sites in the city, including the American Institute of Architects, the Times Square TKTS Booth, the Brooklyn Children’s Museum, the Queens Botanical Garden and the Bronx Zoo Lion House. In some of the outer boroughs and the suburbs, geothermal systems for single-family homes are also becoming more popular.

In all, more than 100 geothermal projects are in operation in the five boroughs, and about 90 percent of those projects are what are known as closed loop vertical bore systems, Mr. DiEnna said. A closed loop system is sealed from the ground and liquids are reused within the system, while an open loop system has discharge water it releases into a ground well or surface water.

Because building sites in the city, particularly Manhattan, tend to be small, the wells tend to be vertical, just like the buildings. Manhattan is not an ideal location for geothermal heat pump systems, because the wells must go so deep — to depths of roughly 1,500 feet — to reach the volume of land necessary to provide a constant temperature. In other areas with more available land, a geothermal heat pump system can be more spread out and much shallower, making it less costly to dig.

Elsewhere, larger scale geothermal projects known as enhanced geothermal systems have raised serious concerns because these larger power-production projects involve drilling wells down to tens of thousands of feet and fracturing the bedrock so water can be injected to create steam.

A few years ago, a project in Switzerland was shut down after it caused small earthquakes, and another project in Northern California was also stopped because of similar concerns. But the static, small-scale geothermal heat pump systems installed in the New York area bear little relation to these projects, said Daniel P. Schrag, a professor of geology and director of the Center for the Environment at Harvard.

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Doctor: Colts coach Pagano's leukemia in remission

INDIANAPOLIS (AP) — Colts head coach Chuck Pagano is winning his battle with leukemia.

On Monday, Dr. Larry Cripe, Pagano's physician, told The Associated Press that the illness which has sidelined Indy's head coach for more than a month was in "complete remission." Cripe said a morning exam showed Pagano's white blood cell count and bone marrow tests were normal as he prepares to start a second round of chemotherapy.

The doctor explained patients typically undergo three rounds of treatment to wipe out any potentially lingering cancer cells. The second round of chemo is scheduled to start later this week and will last four to six weeks, Cripe said.

"His (blood cell) count was great," interim coach Bruce Arians told reporters after Pagano visited the team complex Monday. "He knows that this next one (round) is going to be really tough and we're praying for him, and he's going to be fine."

The latest medical update came less than 24 hours after Pagano returned to Lucas Oil Stadium for the first time since he was diagnosed with a form of leukemia on Sept. 26. Pagano spent most of the next month in an Indianapolis hospital, watching two Colts games from his room. On Oct. 21, he returned home where he watched the next two Indy games. Doctors wanted to keep him in primarily sterile environments to avoid any risk of infection.

On Sunday, Pagano cleared yet another hurdle when doctors allowed him to attend the Miami game in person. He watched the Colts win their third straight, 23-20, from the coaches' box and provided inspirational messages to players before and after the game.

"I've got circumstances. You guys understand it, I understand it. It's already beat. It's already beat," Pagano said during Sunday's postgame speech, hesitating to catch his breath a couple of times. "My vision that I'm living is to see two more daughters get married, dance at their weddings and then lift the Lombardi Trophy several times. I'm dancing at two more weddings and we're hoisting that trophy together, men. Congratulations, I love all of you."

Pagano's appearance Sunday was a clear indication things were going well. Cripe confirmed that in his comments Monday.

On the field, things have gone well for the Colts, too. Indy (5-3) is 4-1 since Arians, also a cancer survivor, was made interim coach and the sudden spate of success has put Indy back in the playoff discussion.

But as the Colts continue to shock the NFL world, Pagano's health status continues to loom large.

Team officials have hung signs reading (hash)Chuckstrong in each end zone of Lucas Oil Stadium. Reggie Wayne wore orange gloves for two games, the color designated to recognize leukemia, and Arians usually wears a button with an orange ribbon between the two sides of the horseshoe on his hat.

It's unclear whether Pagano will return to full coaching duties this season, though Arians made it clear he hopes that happens.

"Once he comes back from Round 2 and is about to head into Round 3, our goal is for him to be on the sideline Dec. 30," Arians said, referring to Indy's regular-season finale against Houston.

"We know what's coming, the downhill slide is yet to come," Arians added. "To me it's kind of like talking to him about the playoffs this week; one day at a time, one play at a time. There's some down time coming, but it's great to see him here."

___

Online: http://pro32.ap.org/poll and http://twitter.com/AP_NFL

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Unlikely Model for H.I.V. Prevention: Adult Film Industry

Stephanie Diani for The New York Times

INDUSTRY DATABASE Shylar Cobi, right, a film producer, confirmed test results of the actors who perform as James Deen and Stoya.

LOS ANGELES — Before they take off all their clothes, the actors who perform as James Deen and Stoya go through a ritual unique to the heterosexual adult film industry.

First, they show each other their cellphones: Each has an e-mail from a laboratory saying he or she just tested negative for H.I.V., syphilis, chlamydia and gonorrhea.

Then they sit beside the film’s producer, Shylar Cobi, as he checks an industry database with their real names to confirm that those negative tests are less than 15 days old.

Then, out on the pool terrace of the day’s set — a music producer’s hilltop home with a view of the Hollywood sign — they yank down their pants and stand around joking as Mr. Cobi quickly inspects their mouths, hands and genitals for sores.

“I’m not a doctor,” Mr. Cobi, who wears a pleasantly sheepish grin, says. “I’m only qualified to do this because I’ve been shooting porn since 1990 and I know what looks bad.”

Bizarre as the ritual is, it seems to work.

The industry’s medical consultants say that about 350,000 sex scenes have been shot without condoms since 2004, and H.I.V. has not been transmitted on a set once.

Outside the world of pornography, the industry’s testing regimen is not well known, and no serious academic study of it has ever been done. But when it was described to several AIDS experts, they all reacted by saying that there were far fewer infections than they would have expected, given how much high-risk sex takes place.

“I don’t think there’s any question that it works,” said Dr. Allan Ronald, a Canadian AIDS specialist who did landmark studies of the virus in prostitutes in a Nairobi slum. “I’m a little uncomfortable, because it’s giving the wrong message — that you can have multiple sex partners without condoms — but I can’t say it doesn’t work.”

Despite the regimen’s apparent success, California health officials and an advocacy group, the AIDS Healthcare Foundation, are trying to make it illegal to shoot without condoms. They argue that other sexually transmitted diseases are rampant in the industry, though the industry trade group disputes that.

In January, the city of Los Angeles passed a law requiring actors to wear condoms. A measure to do the same for the whole county is on the ballot on Tuesday.

Producers say the condom requirement will drive them out of business since consumers will not buy such films. Local newspapers like The Los Angeles Times oppose the ballot measure, calling it well-intentioned but unenforceable, and warning that it could drive up to 10,000 jobs out of state.

Very frequent testing makes it almost impossible for an actor to stay infected without being caught, said Dr. Jacques Pepin, the author of “The Origins of AIDS” and an expert on transmission rates. “And if you are having sex mostly with people who themselves are tested all the time, this must further reduce the risk.”

When the virus first enters a high-risk group like heroin users, urban prostitutes or habitués of gay bathhouses, it usually infects 30 to 60 percent of the cohort within a few years, studies have shown. The same would be expected in pornography, performers can have more than a dozen partners a month, but the industry says self-policing has prevented it..

“Our talent base has sex exponentially more than other people, but we’re all on the same page about keeping it out,” said Steven Hirsch, the founder of Vivid Entertainment, one of the biggest studios.

Performers have to test negative every 28 days, although some studios recently switched to every 14.

If a test is positive, all the studios across the country that adhere to standards set by the Free Speech Coalition, an industry trade group, are obliged to stop filming until all the on-screen partners of that performer, all their partners, and all their partners’ partners, are found and retested. In 2004, the industry shut down for three months to do that.

It has had briefer shutdowns in each of the last four years.

In 2009 and 2010, no other infected performers were found. Coalition representatives said an infected woman in 2009, from Nevada, may have had an infected boyfriend, and offered evidence that a man infected in 2010 in Florida had worked outside the industry as a prostitute. The 2011 test was a false positive.

A shutdown in August came after several actors got syphilis, not H.I.V. All performers were given a choice: Take antibiotics, or pass two back-to-back syphilis tests 14 days apart.

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New Drugs for Lipids Set Off Race

LOS ANGELES — A new class of powerful cholesterol-reducing drugs is showing promising results, potentially offering a new option for people who do not respond to medication now on the market, according to studies presented at a conference of heart specialists here on Monday.

Although the final word on the effectiveness of the drugs is still a few years away, the results so far are so promising that pharmaceutical companies are racing to bring them to market.

In early- and middle-stage trials, use of the experimental drugs reduced so-called bad cholesterol by about 40 to 70 percent in a matter of weeks, equivalent to the reduction achieved by the most effective statins like Lipitor. But it appears that the new drugs can be used along with statins, lowering cholesterol even further.

“With these drugs, together with statins, you can get virtually everyone to the goal,” Dr. Frederick Raal of the University of the Witwatersrand, in Johannesburg, South Africa, who presented one of several studies on these new drugs at the American Heart Association’s scientific meeting here.

The most advanced of the drugs, which as a class are called PCSK9 inhibitors, is only now entering the final stages of clinical trials and is not likely to get to market until 2015 at the earliest.

And there are still some caveats. One is that while the drugs lower cholesterol, it has not yet been shown that they actually reduce the risk of heart attacks, strokes or other cardiovascular problems.

Furthermore, many of the studies so far have lasted no more than 12 weeks and involved fewer than 200 people. Far longer and larger studies are needed to show that the drugs would keep working over a lifetime and would be safe.

So far, however, the studies show “quite good safety,” Dr. Peter Wilson of Emory University said in a presentation here discussing the studies. “This is extremely promising.”

The drugs have to be injected, typically every two to four weeks. That means that the PCSK9 inhibitors are not likely to be widely used for “garden variety high cholesterol,” said Dr. Gordon Tomaselli, chief of cardiology at Johns Hopkins.

Still, millions of Americans cannot lower their cholesterol sufficiently using statins alone, providing a market that could reach billions of dollars in annual sales for a successful drug.

Leading the race so far is the team of Sanofi, the big French drug company, and Regeneron Pharmaceuticals, a biotechnology company in Tarrytown, N.Y.

The companies announced Monday that they were beginning a Phase 3 trial — usually the last step before filing for approval — involving 18,000 patients with a recent heart attack or worsening chest pain who cannot lower their cholesterol with statin therapy alone. The patients will inject themselves once every two weeks with either the drug or a placebo, while continuing to take statins.

The study, which will take at least two years, will determine whether the drug, known by the awkward code name SAR236553/REGN727, can reduce the rate of heart attacks, strokes and other cardiovascular problems.

In a midstage study published recently in The New England Journal of Medicine, patients who took the Sanofi drug plus a high dose of atorvastatin, the generic equivalent of Lipitor, had a mean 73 percent reduction in bad cholesterol compared with a 17 percent reduction for those taking only the high dose of the statin.

Amgen seems to be next in line, saying it plans to begin Phase 3 trials early next year. Pfizer and Roche have drugs in midstage clinical trials. Others in pursuit include Eli Lilly & Company and Alnylam.

Dr. Evan A. Stein of the Metabolic and Atherosclerosis Research Center in Cincinnati, said that about 10 to 20 percent of patients could not tolerate statins at all, or at least could not tolerate doses high enough to lower cholesterol sufficiently. Their main alternative now is Merck’s Zetia, which reduces cholesterol about 18 percent.

Dr. Stein, who is a consultant to Amgen, presented the results on Monday of a trial of Amgen’s drug, AMG 145, in such patients.

Patients receiving AMG 145 experienced an average reduction in LDL cholesterol after 12 weeks of 41 to 51 percent, depending on the dose. Those who received both AMG 145 and Zetia had an even greater average reduction — 63 percent. By contrast, those who received Zetia and a placebo had a drop in bad cholesterol of only 15 percent.

After 12 weeks, only 7 percent of the patients on Zetia alone reduced LDL to 100 milligrams per deciliter, which is the goal for many people. About 61 percent of those on the highest dose of AMG 145 did so, as did 90 percent on both AMG 145 and Zetia. The trial results were also published online by The Journal of the American Medical Association.

LDL cholesterol is removed from the blood when it binds to LDL receptors on the surface of liver cells, and then is taken inside the cells. PCSK9 — which stands for proprotein convertase subtilisin/kexin type 9 — also binds to the LDL receptor, and when it does so, the receptor is destroyed along with the LDL.

But if PCSK9 does not bind, the receptor can return to the surface of the cell and remove more cholesterol. The drugs, which in general are proteins known as monoclonal antibodies, block PCSK9 from binding to the receptor.

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Benghazi Attack Raises Doubts About U.S. Abilities in Region

Esam Omran Al-Fetori/Reuters

The attack at the American Mission on Sept. 11, seen here, and an annex in Benghazi, Libya, points to a limitation in the capabilities of the American military command responsible for countries swept up in the Arab Spring.

WASHINGTON — About three hours after the American diplomatic mission in Benghazi, Libya, came under attack, the Pentagon issued an urgent call for an array of quick-reaction forces, including an elite Special Forces team that was on a training mission in Croatia.

The team dropped what it was doing and prepared to move to the Sigonella naval air station in Sicily, a short flight from Benghazi and other hot spots in the region. By the time the unit arrived at the base, however, the surviving Americans at the Benghazi mission had been evacuated to Tripoli, and Ambassador J. Christopher Stevens and three other Americans were dead.

The assault, on the anniversary of the Sept. 11, 2001, attacks on the United States, has already exposed shortcomings in the Obama administration’s ability to secure diplomatic missions and act on intelligence warnings. But this previously undisclosed episode, described by several American officials, points to a limitation in the capabilities of the American military command responsible for a large swath of countries swept up in the Arab Spring.

At the heart of the issue is the Africa Command, established in 2007, well before the Arab Spring uprisings and before an affiliate of Al Qaeda became a major regional threat. It did not have on hand what every other regional combatant command has: its own force able to respond rapidly to emergencies — a Commanders’ In-Extremis Force, or C.I.F.

To respond to the Benghazi attack, the Africa Command had to borrow the C.I.F. that belongs to the European Command, because its own force is still in training. It also had no AC-130 gunships or armed drones readily available.

As officials in the White House and Pentagon scrambled to respond to the torrent of reports pouring out from Libya — with Mr. Stevens missing and officials worried that he might have been taken hostage — they took the extraordinary step of sending elite Delta Force commandos, with their own helicopters and ground vehicles, from their base at Fort Bragg, N.C., to Sicily. Those troops also arrived too late.

“The fact of the matter is these forces were not in place until after the attacks were over,” a Pentagon spokesman, George Little, said on Friday, referring to a range of special operations soldiers and other personnel. “We did respond. The secretary ordered forces to move. They simply were not able to arrive in time.”

An examination of these tumultuous events undercuts the criticism leveled by some Republicans that the Obama administration did not try to respond militarily to the crisis. The attack was not a running eight-hour firefight as some critics have contended, questioning how an adequate response could not be mustered in that time, but rather two relatively short, intense assaults separated by a lull of four hours. But the administration’s response also shows that the forces in the region had not been adequately reconfigured.

The Africa Command was spun off from the European Command. At the time it was set up, the Pentagon thought it would be devoted mostly to training African troops and building military ties with African nations. Because of African sensitivities about an overt American military presence in the region, the command’s headquarters was established in Stuttgart, Germany.

While the other regional commands, including the Pacific Command and the Central Command, responsible for the Middle East and South Asia, have their own specialized quick-reaction forces, the Africa Command has had an arrangement to borrow the European Command’s force when needed. The Africa Command has been building its own team from scratch, and its nascent strike force was in the process of being formed in the United States on Sept. 11, a senior military official said.

“The conversation about getting them closer to Africa has new energy,” the military official said.

Some Pentagon officials said that it was unrealistic to think a quick-reaction force could have been sent in time even if the African Command had one ready to act on the base in Sicily when the attack unfolded, and asserted that such a small force might not have even been effective or the best means to protect an embassy. But critics say there has been a gap in the command’s quick-reaction capability, which the force would have helped fill.

A spokesman for the command declined to comment on how its capabilities might be improved.

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Google's Android software in 3 out of 4 smartphones

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