Climate change and the principle of leaving well enough alone.

The previous administrations of both then President George W Bush and Prime Minister John Howard took some considerable flak over their positions on climate change, particularly their refusal to support the Kyoto Protocol, and it can be argued that these positions may have contributed to subsequent political "regime changes"

Former senior White House economic advisor to President George W Bush, Keith Hennessy , has now set out the reasons why they did not support Kyoto and the current administration should consider these points carefully.

At the outset Hennessy does not dispute either the science or the evidence of climate change but asks that for a policy response to be effective the risks need to be quantified;

I treat this like any other policy question: Given tremendous quantitative uncertainty, what are the marginal costs and benefits of our current emissions path, compared with various recommended policy options?

For a counterpoint he went to Nobel prize winner and outspoken President Bush critic Paul Krugman who is hopeful that the US policy will be more conciliatory to climate change activists

President Obama has spoken forcefully about the need to take action on climate change; the people I talk to are increasingly optimistic that Congress will soon establish a cap-and-trade system that limits emissions of greenhouse gases, with the limits growing steadily tighter over time. And once America acts, we can expect much of the world to follow our lead.

And as always there is the big BUT

China announced that it plans to continue its reliance on coal as its main energy source and that to feed its economic growth it will increase coal production 30 percent by 2015. That’s a decision that, all by itself, will swamp any emission reductions elsewhere.

What is Paul Krugmans' response to China? He suggests that those who sign emission reduction agreements

will also be morally empowered to confront those nations that refuse to act. Sooner than most people think, countries that refuse to limit their greenhouse gas emissions will face sanctions, probably in the form of taxes on their exports. They will complain bitterly that this is protectionism, but so what?

Keith Hennessy considers the Krugman scenario and responds

I believe there are cures that are worse than the disease. An import tariff would be protectionist (Dr. Krugman concedes this point). In the context of a global climate change negotiation in which different countries are establishing different domestic carbon prices, and in which two of the world’s largest economies (China and India) refuse to do the same, it is easy to see how a carbon import tariff by the U.S. could set off a global trade war, with potentially devastating effects on the world economy. It appears that Dr. Krugman is willing to bear the increased risk of a global trade war for the benefit of an increased probability that China (and India?) will slow their greenhouse gas emissions. I am not.

Whichever way it turns out one thing that is now clear is that Paul Krugman is finding it less easy to sustain the allegation that his opposite number lacks principle. As former Presidential economic advisor Greg Mankiw concurs;

Their failure to act, while disappointing to me, was nonetheless principled and thoughtful.

TB goes to the Movies

The film On the Lake opened early January 2009 and earned the following reviews;

-- "Spell-binding," "heart-wrenching," "unforgettable," says WJAR-TV, NBC-10. NBC-10 gives it five stars.

-- "An intelligent, well-researched and heartfelt film that's consistently entertaining." The Providence Journal. Projo gives it four stars.

-- "An emotionally powerful true-life tale of friendship and love in tragic circumstances." WPRI-TV, CBS-12.

-- "David Bettencourt and G. Wayne Miller have achieved what every filmmaker wants: raising enough money to produce and complete a film, having people see it, moving them by it, and hopefully, inspiring a change in the lives of others." NewEnglandFilm.com

-- "Tugs gently on the heart strings." Motif Magazine.

-- "Absorbing," University of Rhode Island news office.

-- An authoritative feature story, with clips from the movie, in Harvard Magazine.

-- A complimentary piece in the Providence Phoenix.


So what's it all about? from their website;

A century ago, tuberculosis was the number-one killer in America. Today, it's the world's second most deadly infectious disease, after HIV/AIDS. And now, acclaimed filmmakers David Bettencourt and G. Wayne Miller bring this story to life in a one-hour documentary featuring never-before-seen images and interviews.

This is a medical story, a chronicle of loss and despair -- but also an emotionally powerful true-life tale of friendship and love in tragic circumstances, a triumph of the human spirit for those who survived.

On The Lake will also be shown at the June 18 2009 National TB Conference in Atlanta. Sponsored by the National Tuberculosis Controllers Association and the National Tuberculosis Nurse Coalition,
the conference draws TB specialist from state, federal, university and private organizations, including the CDC's Division of Tuberculosis Control (DTBC).

Quest labs - update ∞

To assist in previous attempts to identify the current lab status Doc G-T advises me of the following;

1. Tempe (Arizona) No
2. Sacramento (California) Yes
3. San Jose (California) Yes
4. San Juan Capistrano (California) Yes
5. West Hills (California) No
6. Denver (Colorado) Yes
7. Wallingford (Connecticut) Yes
8. Miramar (Florida) No
9. Tampa (Florida) No
10. Tucker (Georgia) Yes
11. Wood Dale (Illinois) Yes
12. Indianapolis (Indiana) Yes
13. Lenexa (Kansas) Yes
14. Cambridge (Massachusetts) Yes
15. Baltimore (Maryland) No
16. Auburn Hills (Minnesota) No
17. Maryland Heights (Missouri) Yes
18. Teterboro (New Jersey) No
19. Las Vegas (Nevada) No
20. Syosset (New York) No
21. Cincinnati (Ohio) Yes
22. Dayton (Ohio) No
23. Oklahoma City (Oklahoma) No
24. Portland (Oregon) Yes
25. Erie (Pennsylvania) Yes
26. Horsham (Pennsylvania) Yes
27. Pittsburgh (Pennsylvania) Yes
28. Nashville (Tennessee) Yes
29. Houston (Texas) Yes
30. Irving (Texas) Yes
31. Chantilly (Virginia) Yes
32. Seattle (Washington) Yes

Out of 32 locations 21 currently run QFT - the ayes have it.

.

Our fearless leader

Whilst the Rudd government continues to proclaim the success of their stimulus package the reality is not so pretty;

Official figures show business spending on buildings and equipment fell by almost 9 per cent in the March quarter to $23 billion.

That is worse than the 6 per cent fall economists had been expecting.

The outcome has heightened expectations that next week's GDP data will show that the economy has now gone backwards for two consecutive quarters, which is the technical definition of a recession.

The Australian dollar fell slightly just after the news.

A 50% anomaly indicates a dismal failure of Treasury modeling particularly after Secretary Ken Henry had recently defended the Rudd Government's robust growth projections included in the 2009 budget.

..Mr Henry was responding to critics who dismissed as "heroic'' the government's budget projections showing the Australian economy, after shrinking 0.5 per cent in 2009-10, would jump to 4.5 per cent in 2011-12 and 2012-13.

..This budget is telling a big story,'' he said today during a speech on the 2009/10 federal budget, which was released a week ago.

Unfortunately the story tellers don't believe that cutting payroll taxes is in the best interest of their constituents, the taxpayer

An analysis of the Tasmanian Chamber of Commerce and Industry study suggests a federal takeover and suspension of payroll tax would be a cheaper, quicker and more efficient method of saving jobs than components of the Rudd stimulus packages.

"The two stimulus packages worth a combined $52 billion will save 200,000 jobs, leading to an average cost of $260,000 for each job saved," TCCI chief economist Richard Dowling told The Australian. "The total cost of payroll tax nationally is $14 billion. Based on our data, the payroll tax stimulus would cost $150,000 per job saved."

..."An extrapolation of this sample indicates that a temporary suspension of payroll tax in Tasmania would save 1393 (vulnerable) jobs," the study concludes

The ALP Government in Tasmania has again found itself on the back foot with Treasury leaking documents like the proverbial sieve

The document indicates departmental fees and recoveries such as driver licences, land title and vehicle registration charges, will almost double next financial year.

The Premier, David Bartlett, has told Parliament he stands by previous statements that there will not be any new taxes, other than increases in line with inflation.

He is also defended a potential increase in funding for his own agency.

"The Department of Premier and Cabinet is in fact the conductor of the orchestra of the public sector," he said.

Over to you, maestro

.

California OSH update

"This is the most comprehensive standard I have ever worked with," DOSH Chief Len Welsh said about the ATD standard. Board occupational health representative Dr. Jonathan Frisch, an epidemiologist, called the standard "a remarkable piece of work. This is a groundbreaking regulation in many ways." After the standards were adopted, the audience applauded, a rarity after a board vote.

California has just ratified the Aerosol Transmissible Diseases standards, these standards cover workers who are employed in the areas of Homeless Shelters and Drug Treatment Programs, Emergency Medical Services Hospitals, Corrections and Law Enforcement, Primary Care Physicians and Clinics and Laboratories.

With regards to tuberculosis in essence all are instructed to;

Establish procedures for providing employees covered by this standard with annual testing for latent tuberculosis infection, and follow-up for employees who have been exposed at work to a confirmed case of a reportable ATD

Laboratories need only do so if handling TB samples and Homeless Shelter workers require a more intensive evaluation.

#######

CalOSHA Reporter - May 21, 2009

Cal/OSHA Adopts Landmark Communicable Disease Protections

SAN DIEGO -- In a move universally supported by stakeholders in a packed meeting this morning, the Cal/OSHA Standards Board adopted two first-in-the-nation standards to protect workers in health care and an array of other workplace settings from diseases that can be spread by coughing and sneezing, and from animals.

The board voted 6-0 to approve the aerosol transmissible and zoonotic disease standards. They add two new regulations -- General Industry Safety Orders 5199 and 5199.1, which require employers to devise control methods appropriate to the workplace to protect workers from diseases such as tuberculosis and novel influenza strains. Covered workplaces for ﾧ5199 include health care settings, such as hospitals, clinics, doctor's offices and home health care operations, homeless shelters, correctional facilities, emergency response operations and laboratories. The zoonotics standard covers operations involved in animal handling and was crafted following the bird flu threat several years ago.

Stakeholders from industries as diverse as health care and telecommunications urged the board to adopt the protections. They were exemplified by a registered nurse, who told the board that during the ongoing H1N1 flu outbreak, while patients were handed respirators for their protection, nurses were not provided with them, and in fact were instructed by the employers not to wear them so as not to scare the public. The ATD standard will change that, she said. Other speakers predicted that the standards would pave the way for the rest of the nation.

Board members lauded Division of Occupational Safety and Health senior industrial hygienists Deborah Gold and Robert Nakamura for their work on the regulations. "This is the most comprehensive standard I have ever worked with," DOSH Chief Len Welsh said about the ATD standard. Board occupational health representative Dr. Jonathan Frisch, an epidemiologist, called the standard "a remarkable piece of work. This is a groundbreaking regulation in many ways." After the standards were adopted, the audience applauded, a rarity after a board vote.

Japan - labs handling QFT update

I am starting to lose count of the number of Japanese labs that are offering QFT-G, previously it was thought to be 165 but without fluency in the lingo it is difficult to know whether the latest addition makes it 169 or some other figure.

• Gunma prefecture Maebashi city
• Kyoto prefecture Kyoto city
• Kanagawa prefecture Yokohama city
• Saitama prefecture Konosu city

Whatever the specific quantity there is plenty of activity.

Proving Medical Negligence Across Australia

It would appear from this opinion that the onus of proof substantially lies with the plaintiff and that the health professional has to only act "in a manner widely accepted by his or her peers" to avoid a charge of negligence.

####

08 May 2009
Article by Mark Williams

The emerging differences in proving medical negligence across Australia.

Some differences across the states may soon start to appear in relation to how the courts determine whether a health professional has been negligent and what injured patients need to prove to obtain such a finding. This is because of subtle differences in tort reform legislation across the states.

The differences arise from the varying legislation that was enacted after the September 2002 Review of Law of Negligence, Final Report 1. The report recommended the law be changed so that:

A medical practitioner is not negligent if the treatment provided was in accordance with an opinion widely held by a significant number of respected practitioners in the field.2

The explanation for the recommendation was:

The recommended rule recognises, first, that there might be more than one opinion widely held by a significant number of medical practitioners in the field. It provides a defence for any medical practitioner whose treatment is supported by any such an opinion, provided the court does not consider it irrational. It would not be for the court to adjudicate between the opinions.

With the exception of the Australian Capital Territory and Northern Territory, all Australian jurisdictions enacted legislation purporting to give effect to the recommendation.

However, subtle differences in the Acts in each state may mean that there will be a major distinction in the way medical negligence cases are tried and determined around the country.

The first superior court decision in the post-reform period3 considered the law in New South Wales. The court did not consider there had been a radical change in the standard of care to be applied in medical negligence cases in NSW, and that the Civil Liability Act 2002 (NSW) merely provided a defence to the health professional if he or she could prove that he acted in a manner that was widely accepted by peer professional opinion as competent processional practice. In other words, a health professional could technically breach his or her duty of care, but not actually be liable to the injured patient. As a result, in NSW, a case will be run by considering the following sequential issues:

1. Did the defendant act in accordance with the standard of care imposed by the common law? This standard is determined by the court with guidance from expert evidence of acceptable medical practice.

2. If the defendant did not act in accordance with the court determined standard of care, did he or she nonetheless still act in a manner that was widely accepted by peer professional opinion as competent professional practice? The defendant carries the burden of proof on this issue.

3. Is the widely accepted peer professional opinion, relied on by the defendant, 'irrational' and therefore not able to form a defence?

The significance of this for plaintiffs in NSW is that they do not have to adduce expert evidence that the defendant acted in a way that was not widely accepted by peer professional opinion as competent professional practice. This is because, in NSW, the defendant has to prove the 'peer professional opinion' issue by way of a defence. As a result, plaintiffs in NSW do not have to change the questions they ask their expert witnesses in order to obtain an opinion to make out a case of negligence on its face.

South Australia's Civil Liability Act 1936 has a similar provision to NSW. However, the other Australian states have a subtle but significant difference in the way they attempted to enact the Review's recommendation. Rather than using the NSW language of:

...[a health professional] does not incur a liability in negligence ... if ... [he or she] acted in a manner that ... was widely accepted ... by peer professional opinion as competent professional practice',

the Civil Liability Acts in the remaining states provide that the health professional 'is not negligent' or 'does not breach' his or her duty of care if he or she acted in a manner widely accepted by his or her peers. This may be interpreted by the courts in those states as actually changing the standard of care owed by a health professional to a patient (unlike in NSW), and therefore requiring a plaintiff to prove that the defendant did not act in a way that was widely accepted by peer professional opinion as competent professional practice.

The prospect of the courts in Western Australia taking this view is particularly strong, given the Civil Liability Act 2002 (WA) specifically states:

The plaintiff always bears the onus of proving ... that the applicable standard of care (whether under this section or any other law) was breached by the defendant. [emphasis added]

In view of this, lawyers and professional indemnity insurers need to consider carefully the differences between each state's law reforms and not rush to assume that, just because each state purported to adopt the Review's recommendation, that the position in each state is substantially the same. While the ultimate outcome of the case may be the same regardless of the state in which the case is run, the burden of proof and (and, particularly, the content of the plaintiff's expert evidence) may well vary substantially from jurisdiction to jurisdiction. Health care providers with multi-jurisdictional operations should particularly bear this in mind.

Footnotes

1. See http://revofneg.treasury.gov.au/content.review2.asp

2. Recommendation 3.

3. Dobler v Halverson [2007] NSWCA 335

Phillips Fox has changed its name to DLA Phillips Fox because the firm entered into an exclusive alliance with DLA Piper, one of the largest legal services organisations in the world. We will retain our offices in every major commercial centre in Australia and New Zealand, with no operational change to your relationship with the firm. DLA Phillips Fox can now take your business one step further − by connecting you to a global network of legal experience, talent and knowledge.

This publication is intended as a first point of reference and should not be relied on as a substitute for professional advice. Specialist legal advice should always be sought in relation to any particular circumstances and no liability will be accepted for any losses incurred by those relying solely on this publication.

Cellestis appoints Indomedix as new Commercial Partner for distribution of QFT in Egypt and Sudan

Source

Darmstadt, Germany; May 26, 2009 – Cellestis is pleased to introduce Indomedix (Cairo, Egypt) as its newly appointed commercial partner for distribution of the tuberculosis test, QuantiFERON®-TB Gold In-Tube (QFT™), in Egypt and Sudan. A diagnostics distribution company with a strong focus on infectious diseases, Indomedix has already undertaken joint marketing and sales activities with Cellestis to assess market acceptance of QFT. Cellestis' appointment of Indomedix, an experienced local distributor, will help serve the growing QFT demand of our Egyptian and Sudanese customers.

With tuberculosis (TB) infection widespread, both Egypt and Sudan have a clear need for improved TB infection screening. The tuberculin skin test, despite its limitations, has traditionally been the only diagnostic test available in this region for tuberculosis screening. Of concern for Egypt and Sudan, where BCG vaccination is required at birth, is that the skin test is highly confounded by BCG vaccination and prevents accurate TB diagnosis. To improve this, public health and occupational TB programs in the region are now looking to QFT because it is not influenced by BCG vaccination and has been proven to be a more accurate and cost-effective means of detecting TB infection. In particular, Egyptian health services, universities and schools will face important challenges in future because of the influx of individuals from high-endemic TB areas.


For interested customers, please contact Indomedix at:
Indomedix Egypt
4 Ebn Abd Elzaher St.
Manschiet Al-Bakry Heliopolis
Cairo, Egypt
T: +20 2245 17339
F +20 2245 17296
E: Indomedix@gmail.com
Contact: Dr. Ibrahim Ismail

About QuantiFERON®-TB Gold In-tube (QFT™):
QFT™ is the first major advancement in TB diagnosis since the introduction of the Mantoux or tuberculin skin test (TST) over 100 years ago. The QFT test is based on measurement of a cell mediated immune response in TB-infected individuals. The T cells of these individuals are sensitized to TB, and respond to stimulation with peptides simulating those expressed by the TB causing bacteria, secreting a cytokine called interferon-γ. QFT accurately measures the interferon-γ response in a sensitive enzyme assay. Unlike the TST, QFT is unaffected by previous BCG vaccination and most other mycobacteria. QFT requires only one patient visit, is a controlled laboratory test, and provides an objective, reproducible result that is not subject to interpretation based on a patient’s relative risk factors for TB exposure. The test has received regulatory and policy approvals in the USA, Japan, Europe, Canada and elsewhere.

About Indomedix:
Indomedix is a leading distributor specializing in medical diagnostics in the Egyptian market. Established in 1998, Indomedix represents the highest-quality European and U.S. manufacturers of diagnostic products and has a long-established clinical and research customer base for products including QuantiFERON, ELISA kits, and fertility and IVF units. Indomedix is located in Cairo, Egypt with distribution offices in Alexandria, Mansoura, Assuite, and Aswan.

The market in humanity

In her book The Travels of a T-Shirt in the Global Economy: An Economist Examines the Markets, Power, and Politics of World Trade economist Pietra Rivoli examines the effects of globalisation and then warns of the dangers inherent to central planning;

From the Inside Flap

In The Travels of a T-Shirt in the Global Economy, business professor Pietra Rivoli takes the reader on a fascinating around-the-world adventure to reveal the life story of her six-dollar T-shirt. Traveling from a West Texas cotton field to a Chinese factory, and from trade negotiations in Washington to a used clothing market in Africa, Rivoli examines international trade through the life story of this simple product. Combining a compelling story with substantive scholarship, Rivoli shows that both globalization's critics and its cheerleaders have oversimplified the world of international trade.

As Rivoli spoke with businesspeople around the world who played a part in her T-shirt's life, she was forced to confront her own assumptions about the political, economic, and ethical effects of globalization. Trained as a classical economist, Rivoli expected the story of her T-shirt to reveal the undeniable benefits of global free trade and the misguided ideas of the anti-globalization movement. Instead, she found that "free markets" usually aren't free; that even the staunchest allies of free trade regularly benefit from its restriction; and that the alleged "victims" of globalization are often its greatest beneficiaries. While the globalization debate remains centered on the perils versus the promise of competitive economic markets, Rivoli finds that the life story of her T-shirt turns as much on power and politics as it does on markets.

The Travels of a T-Shirt in the Global Economy uses a simple T-shirt to reveal the politics and the human side of the globalization debate. Within the fabric of every product are fascinating businesses, good and bad politics, revealing histories, and especially the hopes and dreams of real people. These people's stories—and the story of the T-shirt that ties them together—present the most nuanced look yet at the economics and politics of globalization.

From the book;

Americans, and now Russians and Slovaks and Chinese, disdain such central planning for its inefficiencies. A system that ignores market signals, that provides no incentives, that subsidizes losers cannot be efficient in producing goods and services. Central planners will produce the wrong goods, use the wrong inputs, set the wrong prices, hire the wrong people, and ultimately produce shoddy products, and not enough of them, anyway. But to meet [Chinese textile-mill manager] Tao [Yong Fang] in the Number 36 factory is to realize that the real tragedy of central planning lies not in its inefficiency but in its crushing of the intellect, of 20 years of Tao's energy and intelligence laid to waste. For 35 years the spindles in the Number 36 mill clattered, and no one working in the mill had to decide anything. So today there is determination but bewilderment as Tao faces the basic questions of running a business rather than turning a cog: what to produce, where to sell, whom to hire, what to pay?

BCG gets a makeover

The once efficacious BCG vaccine has now become a shadow of its former self and researchers set out to find why. In doing so they found that by stripping BCG of its ability to produce antioxidants its preventative powers were restored.

This is good news, not only for TB but for other diseases that BCG can influence, such as HIV and malaria.

######

Source

TB vaccine gets its groove back

May 19th, 2009

A team of Vanderbilt University Medical Center investigators has cracked one of clinical medicine's enduring mysteries - what happened to the tuberculosis vaccine. The once-effective vaccine no longer prevents the bacterial lung infection that kills more than 1.7 million people worldwide each year.

Their solution, reported in the journal PLoS ONE, could lead to an improved TB vaccine and also may offer a novel platform for vaccines against other pathogens.

"Our findings represent nearly a 180-degree reversal from the dogma of the last 60 years - that the TB vaccine stopped working because it became over-attenuated and was too 'wimpy' to be effective," said Douglas Kernodle, M.D., associate professor of Medicine.

Instead, Kernodle and colleagues found that the TB vaccine has acquired some traits that make it less effective in evoking a sustained immune response. When they take away these traits, the TB vaccine induces stronger immune responses in mice.

The current TB vaccine, known as BCG (bacille Calmette-Guérin), has been around since the 1920s. It was made by weakening (attenuating) a strain of bacteria that causes tuberculosis in cows and that genetically is 98 percent identical to the human TB germ.

During the early years of its use, BCG was 80 percent effective against pulmonary TB. But because there were no long-term storage options for bacterial strains until the 1960s, BCG was grown continuously in culture, with "sub-cultures" of the original BCG maintained in laboratories around the world. Over time, BCG changed - the original vaccine ceased to exist and the daughter sub-cultures lost effectiveness against pulmonary TB.

Today, although BCG no longer protects against lung disease, it is still 80 percent effective against "disseminated TB" (TB infection in many parts of the body) in early childhood. Because of this protection, BCG is given annually to 100 million newborns worldwide - not in the United States and a few other countries - and is estimated to prevent about 40,000 cases each year of TB meningitis and other disseminated TB, Kernodle said.

But the question of why BCG lost its effectiveness against pulmonary TB has not been fully investigated. Researchers accepted the notion that as BCG was grown in culture, it changed genetically and became too weak to evoke the kind of immune response needed for protection.

Kernodle and colleagues came to the problem of BCG's poor activity against pulmonary TB from a different angle. They had reported in 2001 that one way TB itself evades the immune system is by producing antioxidants. Since BCG also produces antioxidants, they suggested that removing BCG's antioxidant-producing capacity might improve the vaccine.

"Our idea to take something away from BCG - and therefore theoretically attenuate it even further - was met with a lot of skepticism," Kernodle said. "But we believed our data that we could make BCG more immunogenic and safer."

Two years ago, after the Kernodle group had modified BCG and was beginning to test it for immune responses, researchers at the Institut Pasteur in Paris published a paper describing the genomic evolution of BCG. They found that in addition to containing gene deletions consistent with attenuation of the vaccine, the BCG genome also had regions of gene duplication and increased gene expression. Some of the duplicated and over-expressed genes were for antioxidants already being targeted by the Kernodle group.

It was suddenly obvious what had happened to BCG, Kernodle said.

"It had not become too weak - instead, by making more antioxidants it had become better at suppressing immune responses."

In the current studies, first author Lakshmi Sadagopal, Ph.D., research instructor of Medicine, vaccinated mice with a modified BCG (genetically changed in three ways to reduce or eliminate the production of several antioxidants) and examined the immune response in the days following vaccination and later with a "challenge" dose of BCG.

She found that, compared to BCG, the modified BCG induced greater cytokine (immune regulatory factor) production during the early phase of the immune response, more CD8 cell-killing T cells at the peak of the primary response, and more CD4 helper T cells during the memory phase. Modified BCG also produced greater recall immune responses and was eliminated better by the vaccinated host animal than the parent BCG vaccine, which might correlate with improved safety in humans.

"At each time point of the immune response, the modified BCG vaccine worked better than the parent BCG vaccine," Kernodle said. "By targeting antioxidants that had increased in expression during decades of cultivation, we ended up making BCG more like it was back in the 1920s when it was 80 percent effective against pulmonary TB. We fixed it."

Using modern molecular techniques to reduce the activity of antioxidants below levels in naturally occurring strains, "it should be possible to make it even better than the original BCG," he added.

The Aeras Global TB Vaccine Foundation, supported by the Bill & Melinda Gates Foundation, has already licensed the modification technology developed by Kernodle and colleagues. Aeras is working to make the best possible modified BCG vaccine, and it has built the infrastructure to conduct clinical trials in South Africa, Kenya and India - countries with a high incidence of TB.

Kernodle and colleagues say the results are also encouraging for other vaccine development. Because the modified BCG produces a better immune response profile than existing vaccine technologies, it could be a useful vector for vaccines directed against other pathogens, including HIV and the parasites that cause malaria.

Source: Vanderbilt University Medical Center (news : web)

University of Illinois

A purchase order for 3 years of QFT-GIT for $1.2M plus and additional $140K to top up FY09 (which ends September 30 2009)

The reason for the top up?;

increase in testing due to the facilities accommodations for large batch testing

So can it be assumed that the sum involved is a minimum with the ability for further "top ups" as conditions arise? The evidence would support this hypothesis.

Quest labs - update #7

Previous updates here; add Nashville, Cincinatti and Erie (Pennsylvania) to the growing list.

Could London have a NYC style TB epidemic?

Its worth looking back at a time before QFT, the HPA are now using Quantiferon as a first line diagnostic

###

From 1978 through 1992, the number of patients with tuberculosis in New York City nearly tripled, and the proportion of such patients who had drug-resistant isolates of Mycobacterium tuberculosis more than doubled.(1)

The response to the city’s tuberculosis epidemic has cost well over $1bn (£625m) and the human cost has been immeasurable (2)

If TB control in London is not improved, the city could experience an epidemic of similar proportions to that in New York. (3)



(1) TB in New York City--turning the tide.

(2) Lessons from New York’s TB epidemic

(3) Could a TB Epidemic Occur in London as It Did in New York?

Tuberculosis Control in the 21st Century

It is instructive to look back at the startling observations made by Dr. Sepkowitz

An active surveillance program must rely on the time honored tuberculin PPD test..

...The strongest argument for maintaining the current 6- to 12- month skin testing programs is the need to continue to minimize the booster phenomenon, rather than the need for heightened surveillance to detect TB transmission.

The TB skin test is about as time honoured as the horse drawn plough and just about as effective - if the $250M skin testing program was replaced with IGRA there would be no boosting

Dr. Sepkowitz, head of the clinical infectious disease section at Memorial Sloan-Kettering Cancer Center, is despairing of the then current (2001) detection programs

..21st century TB control efforts continue to rely on the 19th-century PPD test and the insensitive sputum AFB smear. It is hard to be optimistic about great gains in TB control in the years ahead..

Dr. Sepkowitz now has more reason to be optimistic; IGRAs are proving to be more precise, easier to use and cost effective than the TB skin test

Study suggests TB screening needs to be targeted for maximum public health benefit

Public release date: 19-May-2009
[ Print | E-mail | Share ] [ Close Window ]

Contact: Keely Savoie
ksavoie@thoracic.org
212-315-8620
American Thoracic Society

ATS 2009, San Diego—New estimates of the likelihood that a latent case of tuberculosis (TB) will become active have resulted in a roughly 50 percent increase over previous estimates of the number of people needed to be screened (NNS) to prevent an active infection, limiting the cost effectiveness of screening in many Center for Disease Control and Prevention (CDC)-defined risk groups, according to an analysis conducted by experts in the epidemiology of the disease.

The research will be presented at the American Thoracic Society's 105th International Conference on Tuesday, May 19.

"Screening for LTBI [latent tuberculosis infection] is an important method for eliminating the diseases," says lead researcher Benjamin Linas, M.D., M.P.H., of Massachusetts General Hospital. "This analysis, does not suggest we reduce screening. Indeed, if we did that, we'd likely take a step backward in TB control. The study does suggest, though, that we redirect and focus our screening efforts on those most at risk."

Among patients with chronic medical conditions, the NNS to prevent an active case of TB ranged from 1,150 for those who are underweight to 2,778 for patients with end-stage renal disease. Previous estimates of the NNS ranged from 806 to 1,923. Screening was not cost-effective for many patients who are currently recommended for screening, including those who are underweight, have had a gastrectomy, or have silicosis, diabetes or end stage renal disease. Screening was a cost-effective strategy under previous estimates of the rate of reactivation TB, but the new, lower estimates of reactivation limited the case finding rate and decreased the cost effectiveness of screening.

The NNS was lower in populations with a high prevalence of latent TB infection, including foreign-born residents, recent immigrants, the homeless and injection drug users. It was also lower in patients with a high risk of reactivation TB, including those with HIV infection and those taking immunosuppressive medications. As a result, screening remained cost effective for these groups.

Dr. Linas and his colleagues, from MGH and Boston University School of Public Health, based their analysis on several new estimates of TB reactivation rates gathered from 1998-2005. According to Dr. Linas, current guidelines for screening are based on rates indicated from studies conducted in the 1950s and 1960s.

To arrive at new estimates of NNS and cost effectiveness, the Boston-based researchers constructed a Markov computer model that simulates the clinical progression of a cohort of patients, can integrate a wide array of parameters and allows the analysts to plug in different estimates to determine which are most important in determining outcomes.

In addition to the old and new estimates of reactivation rates, the group included in their model estimates based on published reports of TB mortality, percent of diagnosed patients who complete isoniazid (INH), the standard therapy for LTBI (for U.S.-born residents, 50 percent; for foreign-born, 48 percent) and the effectiveness of the therapy among those who complete it.

"The take home message of this research," Dr. Linas said, "is not that we should reduce funding for LTBI screening, but that we can use current funding to make greater strides toward eliminating TB by targeting those at highest risk for latent infection becoming active."

###

Speaking in mandarin

In a speech to friendly canucks RBA Governor Glenn Stevens was upbeat on the economy claiming that China would pull Australia out of the mire;

THE RBA says Australia is on track to emerge from recession and take part in a renewed global economic upswing by the end of 2009.

Transplants and TB

From the May issue of Clinical Infectious Diseases; Tuberculosis and Transplantation: Battling the Opportunist

The editorial discusses the findings of a review of a large Spanish database of information on solid organ transplant recipients.

* Post transplant TB was 480 cases per 100,000 per year
* approximately 2/3 of cases occur during the first year after transplantation
* Mortality of TB cases was 9.5%
* greatest incidence of TB was from lung transplants (due to higher immunosuppression)
* Post lung transplant TB was 2,072 cases per 100,000 per year
* donor derived TB about 4% of TB cases
* this figure probably under estimated because donors (deceased) do not undergo screening for latent infection
* not possible to screen deceased donors by skin test
* practical issues of donor screening may be overcome by QuantiFERON-TB Gold

Determining between active and latent TB

From ARUP Labs (May 2009);

QuantiFERON®-TB Gold In-Tube and Mycobacterium tuberculosis Antibody, IgG by ELISA

For use in the diagnosis of latent or active Mycobacterium tuberculosis infection

Test Highlights
• New panel combines the QuantiFERON®-TB Gold in-tube test (QFT- GIT) with the Mtb IgG ELISA.
• Requires only a single patient visit to draw blood sample.
• The nil tube required for the QuantiFERON®-TB Gold in-tube test provides plasma for use in the IgG ELISA, so no extra draw is required.
• Panel increases the ability to differentiate active and latent cases of TB.


Update, whilst InBios TB IgG is covered by CPT code 86609 its status is "For Research Only"

QFT and HIV

From the latest Cellestis Newsletter;

"The WHO guidelines recommend that all people with HIV be regularly screened for TB.."

..we can make at least two major conclusions based on the available data. Firstly, QFT is more specific than the TST in all populations, including those HIV infected. Secondly, QFT has at least (and probably significantly greater) sensitivity as the TST in immunosuppressed populations.

Taking all into account, there are clear performance benefits in using QFT in place of TST when screening HIV-infected for M.tuberculosis infection. Indeed, using the TST may now be negligent.

Negligence to not regularly screen HIV for TB and negligence in using the TST.

.

Two up at Arup

University of Utah's Arup laboratories originally offered to process QFT-G (code: 0051231) and then QFT-GIT (code: 0051729) and now they will run both QFT-GIT and TB antibody IgG from the one sample (code: 2001627)


Click on image for FULL SIZE

Multicentred health care

On June 2 2008 MultiCare Health System announced that they would be switching over from TST to Quantiferon and that all tests were to be processed " in the Laboratories Northwest Immunology Lab at Tacoma General."

MultiCare also advised that they are making QFT available from "Allenmore Hospital Lab, Tacoma General Lab front desk, the phlebotomy team in-house at Tacoma General and Mary Bridge, Covington Lab, Gig Harbor Medical Park Lab, Jackson Hall Lab, and Good Samaritan inpatient phlebotomy."

Get Quantiferon has listed Laboratories Northwest at Tacoma General Hospital as one of the "institutions (that) have agreed to provide QFT testing services to outside physicians and laboratories."

One listing in Get-QFT gets to cover a multitude of health and medical centres.

Stanford sets the pace

Further evidence that Stanford School of Medicine are to replace the TST with QFT; their OHS department is now making QFT TB testing mandatory;

Mandatory TB screening is performed at Stanford Hospital & Clinics and Lucile Packard Children's Hospital with the QuantiFERON Gold blood test.

Managing Indeterminate Quantiferon

From abstracts being presented at the NTCA conference;

Banach and Harris from the New York City Department of Health and Mental Hygiene found that whilst reasons for indeterminates was not clear

The rate of indeterminate results was within acceptable limits.

Jennifer Grinsdale and Masae Kawamura from the San Francisco Dept. of Public Health found that

high indeterminate QFT-G and QFT-GIT nil occurred when new clinics began using the test and when batches of faulty tubes were identified.

Regardless of the reason they found that

Retesting with QFT after an indeterminate result appears to be a valid strategy.

Desperately seeking Quantiferon

From the latest NTCA conference comes this narrative from Rachel Birk, TB Coordinator/HIV Surveillance Coordinator North Dakota DOH.

As North Dakota has a relatively low TB rate QFT was unavailable which meant Ms Birk had to travel long distances for the procedure. After a number of missed opportunities Ms Birk is now

Actively promoting large hospital laboratories to provide QFT-Gold testing

QFT used to differentiate active -vs- latent TB

Once again Gold proves to be the most precious metal


######

Host markers in Quantiferon supernatants differentiate active TB from latent TB infection : preliminary report

Novel N Chegou , Gillian F Black , Martin Kidd , Paul D van Helden and Gerhard Walzl

BMC Pulmonary Medicine 2009, 9:21doi:10.1186/1471-2466-9-21

Published: 16 May 2009

Abstract (provisional)

Background
Interferon gamma release assays, including the QuantiFERON(R) TB Gold In Tube (QFT) have been shown to be accurate in diagnosing Mycobacterium tuberculosis infection. These assays however, do not discriminate between latent TB infection (LTBI) and active TB disease.

Methods
We recruited twenty-three pulmonary TB patients and 34 household contacts from Cape Town, South Africa and performed the QFT test. To investigate the ability of new host markers to differentiate between LTBI and active TB, levels of 29 biomarkers in QFT supernatants were evaluated using a Luminex multiplex cytokine assay.

Results
Eight out of 29 biomarkers distinguished active TB from LTBI in a pilot study. Baseline levels of epidermal growth factor (EGF) soluble CD40 ligand (sCD40L), antigen stimulated levels of EGF, and the background corrected antigen stimulated levels of EGF and macrophage inflammatory protein (MIP)-1beta were the most informative single markers for differentiation between TB disease and LTBI, with AUCs of 0.88, 0.84, 0.87, 0.90 and 0.79 respectively. The combination of EGF and MIP-1beta predicted 96% of active TB cases and 92% of LTBIs. Combinations between EGF, sCD40L, VEGF, TGF-alpha and IL-1alpha also showed potential to differentiate between TB infection states. EGF, VEGF, TGF-alpha and sCD40L levels were higher in TB patients.

Conclusions
These preliminary data suggest that active TB may be accurately differentiated from LTBI utilizing adaptations of the commercial QFT test that includes measurement of EGF, sCD40L, MIP-1beta, VEGF, TGF-alpha or IL-1alpha in supernatants from QFT assays. This approach holds promise for development as a rapid diagnostic test for active TB.

Yesterdays platinum todays tinfoil

Bernie's Credit Card Statements

Publish at Scribd or explore others: Finance Business & Law money credit

Wind change

A report of a TB scare at a junior school in the UK contained this item "Those identified as having had close prolonged contact with the individual will be offered screening in the form of a simple skin and/or blood test."

This is a departure from the original NICE guidelines, which advocate TST first and confirmation of positives with an IGRA. In their interim guidance (August 2008) the HPA state that "there are a number of disadvantages to this strategy" and further advise that whilst "TST (Mantoux) should generally be used as the first line test for LTBI in contacts"... "in certain circumstances IGRA testing, if available, can be considered as the sole test for LTBI."

Curiously those "certain circumstances" include "screening large numbers of individuals as part of a public health
investigation"

In October 2008 the HPA advised that TB contact testing at a nursery in Westminster be by either IGRA or Xray; the TST had been excluded.

These all point to a change in official opinion on IGRA and that through cautious usage confidence in IGRA is slowly building.

Isoniazid Tablets User Reviews

A selection of comments by those undergoing INH therapy, not exactly a happy bunch of campers...link


lidmarjon, 25-34 Female on Treatment for less than 1 month (Patient)
When i strated taking the medication i was fine. i was taking my diuretic in the evening and isoniazid at 11:25am. i noticed that just about 1 hour or so before my next dosage i would become dizzy and weak. about an hour or so after taking it i would be myself again. but i didn't felt comfortable i felt to tired and weak. i went to my doctor and took me off the medication. in 2 wks im supposed to go back and get another medicine and im praying to GOD that everything goes well the 2nd time around. i really dont know if this is ok but i guess the doctors didnt want to take a risk. the doctor even told me that it was not a common symptom but that i had to get off the medication. i hope all goes well.


TJ, 35-44 Female on Treatment for 1-6 months (Patient)
It's been a few years since taking INH for latent TB. I recall severe joint pain/swelling and various other ailments. I still can't get rings over my knuckles. My life/health is still "not right" I also fear lupus, as my recent bloodwork seems to indicate. I've also done some research on ganglion cysts I now have & there may be a link to the INH!?! Thankfully, no other friends/family members have ever had a positive PPD (I still question the when/where I could have picked it up). My xrays were clear & I have no other signs of TB. Because the side-effects were making life pretty miserable and my liver enzymes were beginnig to become affected, my public health nurse gave her "blessing" for me to quit after 4-1/2 months...I'm thinking not soon enough!

TB boy, 25-34 Male on Treatment for less than 1 month (Patient)
I was about to start taking this medication for inactive TB, but I read all the side effects and the comments of many people that had taken this medication and I refused to do it. I believed the medication should be take if become active only. If we take the medication, whatever, we are not 100% immune to develope active TB and the health risks fot taking it are very high. I will suggest anyone with inactive TB and normal to strong immune system to avoid to take it until becomes active. That might never happen. Some patients live with inactive TB all their lives and never notice it. My personal opinion.

45-54 Female on Treatment for 6 months - 1 year (Caregiver)
I have been taking this for 8mo's now I have experienced head aches body aches fatigue moodiness & cough now I am noticing hair loss & breakage, anytime I have said this to my doctor she says it's not a side affect so I quit telling her this was an on the job exposure & they haven't done a thing except supply the meds I haven't had blood tests done I have asked to see a specialist & as of yet have not received a reply, don't know if meds have worked, easy to take because it's a pill difficult because of why I take, satisfied?? how?? why?? satisfied because I get to take a med that is so serious nobody monitors & it was negligence that caused me to be exposed..nope not satisfied.

Female on Treatment for 6 months - 1 year (Patient)
i only comment with stars because it requires it i have taken this treatment for only one week and from the begginning to now i suffer severe headaches, continued loss of appetite, extreme tiredness/fatigue is there anything to counter act this it sure isn't worth going through for a preventitive. at this rate i'd rather treat if it ever became active

may, 25-34 Female on Treatment for 6 months - 1 year (Patient)
after taking this medication for 9 mos. i've developed an allergy or sensitivity to sun! I immediately breakout in sun-blisters after 5 minutes of exposure to the sunlight.

55-64 Female on Treatment for less than 1 month (Patient)
I have been taking Isoniazid for two weeks now. My joints are painful and I am worried about lupus, it is one of the side effects of this drug. My sister has lupus now that she got from one of her heart medications. I am going to press my Dr for a QuantiFERON-TB Gold blood test before I will continue with this treatment. My sister has undergone two hip replacements and is always off of work because of the lupus. I had the BCG vaccine as a child and am wondering if that is the cause of my positive skin test. My chest xray is clear.

Jerehda, 13-18 Male on Treatment for 6 months - 1 year (Patient)
It makes me feel like crap after I take it. I get blured vision that come with headaches.

cdbene, 25-34 Female on Treatment for 1-6 months (Caregiver)
My 12 yr old son is taking this medicine 2x a week. He takes 3 tablets on Monday and then 3 on Friday. The bad part is I have to take him to town to take it. They will not let me give it to him at home. He had a positive skin test but "does not have TB" (thier words not mine)and this is suppose to be a "preventive measure." Its nothing but a pain in the butt.

45-54 Female on Treatment for 6 months - 1 year (Patient)
I have latent TB and decided to take the meds as I have niece with leukemia and has recently had a transplant. I did not want to inadvertently infect her so I have been taking this for almost 6 months. After experiencing fatigue and itching when taking every night, my doc had me take it every other night. That helped the fatigue and the itching went away after a few weeks. The one thing that I found out from my pharmacist is to avoid pineapple and raisins. they contain a certain ingredient that counter-acts the meds. Also to avoid ibuprofens and tylenol to reduce the risk of liver problems

(Patient)
I am having some of these side effects and will call my doctor today. Thanks for your info. I thought I was going crazy.

Budget '09 in a global context

Journalist Guy Rundle and Professor John Quiggin give the leftish interpretation.

QFT - the movie

Follow this LINK for the video, care of Reuters Health

Interferon release assays may be "gold standard" for latent TB detection

NEW YORK (Reuters Health) - The two commercially available Mycobacterium tuberculosis-specific interferon-gamma release assays show excellent agreement with each other. As far more accurate indicators of latent TB infection than the tuberculin skin test, German physicians suggest the two tests may be considered the "gold standard" for this purpose.

The primary target for the interferon release assays is latent rather than active infection, the researchers note in the April issue of Chest. Unlike the tuberculin test, interferon release assays are unaffected by previous BCG vaccination and most nontuberculous mycobacteria.

To compare the two interferon release assays -- QuantiFERON-TB Gold In Tube assay (QFT) and the T-Spot.TB (T-spot) -- with the tuberculin skin test, Dr. Roland Diel at the University of Dusseldorf and associates conducted a prospective study of 812 close contacts of 123 culture-confirmed pulmonary TB source cases reported to the Hamburg Public Health Department between 2006 and 2008.

Agreement between the two interferon release assays was 93.9%, with the majority of contacts with discordant results having responses close the manufacturers' cutoffs of both tests. Positive results from both assays were strongly associated with measures of exposure and infection risk.

"If a positive result for both IGRAs were to be assumed as representative of true infection," Dr. Diel's team states, "the sensitivity of the TST would be only moderate at a 10-mm cutoff (71.5%) and very low at a 15-mm cutoff (31.3%)."

Use of either the QFT or the T-spot test as a replacement for the tuberculin skin test would decrease the number of latent TB infection suspects to be investigated by approximately 70%, the investigators note. "Both QFT and T-Spot appear to be valuable public health tools," they conclude.

Reference:
Chest 2009;135:1010-1018

Job numbers in the US - the canary in the coalmine?

Statistician James Hamilton takes the latest US job claim figures and runs them through his composter;

The above graph also plots 70% confidence intervals calculated from this dynamic simulation. The model implies that there is a 15% chance of seeing the new claims numbers go back up above their peak of 4 weeks ago. In other words, there's an 85% chance that the worst numbers for this particular series are now behind us.

Sounds good to me.

Professor Robert Gordon (Professor in the Social Sciences and Professor of Economics at Northwestern University) agrees

Bottomline – The US turn-around will come in May or June 2009
My reasoning leads me to conclude that the ultimate NBER trough of the current business cycle is likely to occur in May or June 2009, substantially earlier than is currently predicted by many professional forecasters.

DOUBT IS BETTER THAN CERTAINTY (I think).

Designer Milton Glasser has produced a 10 point credo on things I have learned; this is #8

Everyone always talks about confidence in believing what you do. I remember once going to a class in yoga where the teacher said that, spirituality speaking, if you believed that you had achieved enlightenment you have merely arrived at your limitation. I think that is also true in a practical sense. Deeply held beliefs of any kind prevent you from being open to experience, which is why I find all firmly held ideological positions questionable. It makes me nervous when someone believes too deeply or too much. I think that being sceptical and questioning all deeply held beliefs is essential.

Of course we must know the difference between scepticism and cynicism because cynicism is as much a restriction of one’s openness to the world as passionate belief is. They are sort of twins. And then in a very real way, solving any problem is more important than being right. There is a significant sense of self-righteousness in both the art and design world. Perhaps it begins at school. Art school often begins with the Ayn Rand model of the single personality resisting the ideas of the surrounding culture. The theory of the avant garde is that as an individual you can transform the world, which is true up to a point. One of the signs of a damaged ego is absolute certainty.

Schools encourage the idea of not compromising and defending your work at all costs. Well, the issue at work is usually all about the nature of compromise. You just have to know what to compromise. Blind pursuit of your own ends which excludes the possibility that others may be right does not allow for the fact that in design we are always dealing with a triad – the client, the audience and you.

Ideally, making everyone win through acts of accommodation is desirable. But self-righteousness is often the enemy. Self-righteousness and narcissism generally come out of some sort of childhood trauma, which we do not have to go into. It is a consistently difficult thing in human affairs. Some years ago I read a most remarkable thing about love, that also applies to the nature of co-existing with others. It was a quotation from Iris Murdoch in her obituary. It read ‘ Love is the extremely difficult realisation that something other than oneself is real.’ Isn’t that fantastic! The best insight on the subject of love that one can imagine.

Having been born in 1929 gives him some insight into ageing

"rule number one is that ‘it doesn’t matter.’

Unemployment is the secret for longevity

‘Never have a job, because if you have a job someday someone will take it away from you and then you will be unprepared for your old age. For me, it has always been the same every since the age of 12. I wake up in the morning and I try to figure out how am I going to put bread on the table today? It is the same at 75, I wake up every morning and I think how am I going to put bread on the table today? I am exceedingly well prepared for my old age’ he said.

Property hot spot - not

Any thoughts of investing in Venezuelan realty should be tempered by Venezuelan reality;

...A new round of expropriations by the Venezuelan government has touched not only oil producers, but the agriculture business as well. Troops were mobilized on May 9-10 to assist the state-owned petroleum company, PDVSA, to seize the assets of approximately 60 oil services companies.

On his “Hello, President” TV program, President Chávez opined

“if the property titles of those who consider themselves owners of the land are closely examined, one will come to the conclusion that there is no private land...There is no private property, that’s what I say.”

Property investors are being advised that while President Chavez continues to draw breath Venezuela does not present good prospects. This also applies to those Venezuelans who voted against Chavez, a recent study found that those who did so were punished for doing so;

In 2004, the Chávez regime in Venezuela distributed the list of several million voters whom had attempted to remove him from office throughout the government bureaucracy, allegedly to identify and punish these voters. We match the list of petition signers distributed by the government to household survey respondents to measure the economic effects of being identified as a Chavez political opponent. We find that voters who were identified as Chavez opponents experienced a 5 percent drop in earnings and a 1.5 percentage point drop in employment rates after the voter list was released. A back-of-the-envelope calculation suggests that the loss aggregate TFP from the misallocation of workers across jobs was substantial, on the order of 3 percent of GDP.

So much for secret ballots and freedom of expression, next step; reeducation camps

Spot muddying the waters

The abstract of "Interferon- release assays for detection of tuberculosis infection in immune-compromised children in a low prevalence country" says

Commercial interferon- release assays (IGRAs), T.SPOT.TB and QuantiFERON TB Gold "In tube", were compared with tuberculin skin test for detection of tuberculosis (TB) infection in immune-compromised children in a low prevalence country. IGRAs are of limited usefulness in this study setting due to high rates of discordant and indeterminate results.

however the full version says

...Eighty consecutive Italian HIV-negative immune-compromised children were enrolled

...Due to poor TST reliabilaty (sic), performance of two commercial IGRAs was evaluated for TB infection screening purposes in children receiving immune-suppressive therapies, including TNF-α blockers.

...Unlike TST and QFT-IT, TS-TB (T.SPOT.TB ) yielded a surprisingly high proportion of positive results,
approaching a worrying 10% of patients.

...The rate of TS-TB positive results was higher in patients affected by rheumatic diseases compared with liver-transplanted cases [5/19 vs 2/54]; and in patients treated with TNF-α blockers compared with those receiving other medications

...Are they true-positive or false-positive results?

...Our position was a “wait and see” approach until further evidence of TB infection became available. As until now we detected no cases of active TB, it should be speculated that TS-TB yielded false positive results.

Testing patients with dysfunctional immune systems must be difficult at the best of times however what is surprising is the high number of indeterminate and possible false positive results by T Spot TB. When supported by their own testing this has always been T Spot's best argument ie

The T-SPOT.TB test results are not affected by a weakened immune system.

A quick look at their FDA approved Package Insert showed some departure from their previous claims;

Invalid results are uncommon and may be related to the immune status of the individual being tested

As always it pays to read the fine print.

.

Still grannying about

These characters are still unsure as why they should not continue to use the 100 year old unreliable skin test...the killer quote below the fold...to be published in the next edition of Infection Control and Hospital Epidemiology

Rate of Latent Tuberculosis Infection Detected by Occupational Health Screening of Nurses New to a London Teaching Hospital

_________________________________________________

The prevalence of latent tuberculosis infection in a cohort of nurses new to a London hospital was 7.6% (13 of 171), using an interferon g (IFN-g) release assay, and 16.2% (24 of 148), using the tuberculin skin test.On multivariate analysis, birth in a country with tuberculosis prevalence of more than 40 cases per 100,000 population was associated with positive results of both the IFN-g release assay and the tuberculin skin test.

Infect Control Hosp Epidemiol 2009; 30:000-000

_________________________________________________

...We found that the rate of IGRA positivity increased as the TST induration increased, as reported previously. A larger TST induration is associated with a greater probability of developing active tuberculosis, and although the risk of developing active tuberculosis among persons with positive IGRA results has not been established, it seems reasonable to suppose that greater IGRA values will represent a greater risk of developing tuberculosis.

We recommend using TST and IGRA to screen new entrant healthcare workers for LTBI in our population (chemoprophylaxis should be administered to persons with positive results of both tests); if staff resources are limited, IGRA alone would be a reasonable option. For serial or subsequent testing of healthcare workers, the IGRA is a more appropriate test because it eliminates the need for a second visit and is not affected by interreader variability and previous bacille Calmette-Gue´rin vaccination.

Awesome odds

Strange people these odds, when the numbers 5, 7, and 9 fell on 7 May 2009 they got all excited;

As Odd as it is, the day will be fine,
You see, it's the numbers 5,7, and 9.
Three odds in a row to tell you the date,
We've only three more, then a 90-year wait.

Odd as it may seem these odd days do serve a vital function;

Odd Days are the unsung numerical peace-keepers---if it wasn't for odd numbers, all the even numbers would bump into each other!

Click on image for FULL SIZE

Reducing QFT indeterminates in Ohio

Not sure if this has been seen before but its worth seeing again;

We implemented the QuantiFERON‐TB Gold (QFT‐G) In‐Tube test to identify latent tuberculosis infection among potential employees prior to employment. The rates of indeterminate QFT‐G In‐Tube test results were higher than expected and prompted an investigation that led to successful interventions (eg, manual vortexing before incubation and the use of a modified in‐tube method). The tracking of indeterminate results is suggested as an important quality control measure.

QFT for a true diagnosis

Becca, who is in her last year of speech pathology, writes

So an update on the TB issue....the health department still hasn't called me. I guess it's not too much of an emergency then? I'm going to have to call them if they don't soon. I'm going to ask for a blood test called the Quantiferon TB-Gold test that will show if I really do have latent TB or if the PPD skin test happened to be a false-positive. Apparently, false-positives are very common. All it takes is for the nurse to push the needle in too deep and voila, you get a false-positive every time. Let's pray it's that because I really do not want to take antiobiotics that can damage my liver for 9 months. I wouldn't be able to drink any alcohol (not at weddings, not at dinner, not on my birthday, not on my sister's 21st birthday, not on New Year's..you get the idea), I can't take acetominophen (aka tylenol), and I might not be able to wear my contacts. How fun does that sound? Oh, and I might have to go in to get my liver enzymes checked every month.

Ok, I'll quit complaining until I have a true diagnosis.

Christina Romer's testimony in the front of the Joint Economic Committee

Source

We currently expect that the pace of the overall decline in the economy to moderate sharply over the next several months. This is consistent with the Blue Chip consensus forecast, which shows a rate of decline of GDP of 2.1% in the second quarter.37 We expect the economy to level out in the second half of the year and then begin to recover. Whether the recovery begins later this year, as most private forecasters predict, or takes a bit longer is hard to know. Because labor market indicators tend to lag changes in output, most likely we will see positive GDP growth before we see increases in employment and declines in the unemployment rate.

The President’s economic team is keeping a watchful eye on all aspects of the economic situation, and we will not rest until we are assured of a long-term and lasting recovery with robust employment growth. Because the downturn has been so long and so severe, the recovery will almost surely take a long time. But, as I have stressed, our intent, and our expectation, is for the economy not just to recover, but to emerge even stronger and more resilient than before.

Update on TB testing Swiss migrants

Previously we only had the abstract, now there is the full text

On acceptance rate for screening;

compared to tuberculosis skin tests, the introduction of interferon-γ assays has largely improved the specificity of LTBI detection; thus, the number of patients that would receive preventive treatment without needing it can be reduced. This knowledge might raise the motivation of healthcare workers in their efforts to follow patients and help them adhere to the proposed treatment.

On cost effectiveness;

The high prevalence of LTBI suggests that screening with an interferon-γ assay could be cost-effective under conditions that promoted adherence to the end of therapy for most patients

A new kid in town

For those frustrated with the lack of discrimination by Google or Yahoo a new search engine is about to be launched, Wolfram Alpha. Created by British physicist Stephen Wolfram Wolfram Alpha is intuitive and computes the answer to a question and, according to some, could change the internet forever;

Wolfram Alpha will not only give a straight answer to questions such as "how high is Mount Everest?", but it will also produce a neat page of related information – all properly sourced – such as geographical location and nearby towns, and other mountains, complete with graphs and charts.

The real innovation, however, is in its ability to work things out "on the fly", according to its British inventor, Dr Stephen Wolfram. If you ask it to compare the height of Mount Everest to the length of the Golden Gate Bridge, it will tell you. Or ask what the weather was like in London on the day John F Kennedy was assassinated, it will cross-check and provide the answer. Ask it about D sharp major, it will play the scale. Type in "10 flips for four heads" and it will guess that you need to know the probability of coin-tossing. If you want to know when the next solar eclipse over Chicago is, or the exact current location of the International Space Station, it can work it out.

Worldwide network: A brief history of the internet

1969 The internet is created by the US Department of Defense with the networking of computers at UCLA and the Stanford Research Institute.

1979 The British Post Office uses the technology to create the first international computer networks.

1980 Bill Gates's deal to put a Microsoft Operating System on IBM's computers paves the way for almost universal computer ownership.

1984 Apple launches the first successful 'modern' computer interface using graphics to represent files and folders, drop-down menus and, crucially, mouse control.

1989 Tim Berners-Lee creates the world wide web – using browsers, pages and links to make communication on the internet simple.

1996 Google begins as a research project at Stanford University. The company is formally founded two years later by Sergey Brin and Larry Page.

2009 Dr Stephen Wolfram launches Wolfram Alpha.

Interferon-gamma Release Assay Improves the Diagnosis of Tuberculosis in Children.

From the land of La Dolce Vita;

The good agreement between positive IGRA and active TB disease suggests a good sensitivity of IGRA. Discrepancies between IGRA and TST can be a result of higher specificity of IGRA that is not influenced by previous BCG vaccination. IGRA may be more sensitive in children younger than 48 months.

Buffett bullish on banks

Source

Warren Buffett Tells Shareholders Earnings Will Be Down, But He's Up On Banks

Published: Saturday, 2 May 2009 | 5:23 PM ET Text Size
By: Alex Crippen
Executive Producer


Warren Buffett told a record 35,000 Berkshire Hathaway shareholders gathered today in Omaha the company will report a decline of almost 11 percent in first quarter earnings, due in part to losses on credit default swaps.

Saying the condition of some of Berkshire's swaps has gotten worse over the past few months, he also predicted they may wind up losing money over the long term.

"We have run into far more bankruptcies in the last year than is normal."

But Buffett defended Berkshire's much larger derivative contracts that provide their buyers insurance against long-term losses for major stock indexes around the world.

"I personally think the odds are extremely good that on the equity put options, we will make money."

Some critics have accused Buffett of not following his own advice on derivatives, recounting that he once famously called them "financial weapons of mass destruction."

BULLISH ON BANKS

Buffett continued to publicly praise Wells Fargo, calling it a "fabulous" bank that is well prepared to ride out the financial crisis.

In an on-camera interview with CNBC's Becky Quick before the Q&A session, he told her he did not know how Wells had done in the government's stress test but that he had done his own test and the bank had passed "with flying colors."

Berkshire owns over 290 million shares of Wells, a 6.9 percent stake in the company. The holding was worth about $5.7 billion at Friday's close. Berkshire also has a $1.2 billion stake in US Bancorp.

Buffett told the audience today, "I would love to buy all of US Bancorp or I would love to buy all of Wells Fargo." Berkshire can't do that, he said, because it would have to become a bank holding company.

Also making headlines during the roughly 5-hour long question-and-answer session:

* Buffett sees signs of stabilization in housing markets. Citing information from Berkshire's real estate brokerage business, Buffett said, "In the last few months you've seen a real pickup in activity although at much lower prices."

* The four candidates to potentially succeed Buffett as chief investment officer did not "cover themselves in glory" last year, failing to outperform the benchmark S&P 500 stock index. But Buffett remains confident in their long-term track records.

* The three CEO candidates previously identified, but not revealed publicly, are all Berkshire insiders.

* There are no plans for a Berkshire stock buyback now, because its price (around $92,500) is not "demonstrably below" a conservative estimate of its intrinsic value.

* Berkshire won't be spinning off any subsidiaries, in part because companies that are bought by Berkshire need to be able to trust they'll continue to be owned by Berkshire.

* Buffett says he wouldn't buy most U.S. newspapers now "at any price" because they "have the possibility of unending losses" with "nothing on the horizon that causes that erosion to end."

* Berkshire did buy some "cheap" corporate bonds a few months ago. Some are up 20 to 25 percent.

* Berkshire is "still AAA in my mind," says Buffett, despite downgrades by two of the credit rating agencies. He admits to being "irritated" at losing the top rating, but doesn't see any material impact.

Even though Berkshire's stock price is down about 30 percent over the past 12 months, many of those attending the weekend event appeared to be enthusiastic, excited, and especially interested in what Buffett and Charlie Munger had to say.

J P Morgan shareholder letter

From CEO Jamie Dimon, a comprehensive yet easy to read overview of the current economic and financial environment

On causes

The combination of no-money-down mortgages, speculation on home prices, and some dishonest brokers and consumers who out-and-out lied will cause damage for years to come. This, in no way, absolves the poor underwriting judgments made by us and other institutions, and it certainly doesn’t absolve anyone who mis-sold loans to consumers

On regulation

With great hesitation, I would like to point out that mistakes also were made by the regulatory system.
That said, I do not blame the regulators for what happened. In each and every circumstance, the responsibility for a company’s actions rests with us, the CEO and the company’s management. Just because regulators let you do something, it does not mean you should do it. But regulators have a responsibility, too. And if we are ever to get this right, it is important to examine what the regulators could have done better. In many instances, good regulation could have prevented some of the problems. And had some of these problems not happened, perhaps things would not have gotten this bad.

On risk management

We regularly do stress tests for our company, always projecting forward our capital and liquidity. We think our capital ratios will maintain their extremely strong levels throughout the government’s “adverse economic environment.”

You also should know that your company will be prepared for an environment even worse than the one just described.

On dividends

Out of an abundance of caution to be prepared for the future during this uncertain environment, we believed it was prudent to reduce our quarterly dividend..

..We maintain a long-term commitment to the dividend and still view a 30%-40% payout ratio of normalized earnings as ultimately reasonable

On the future

We see that the largest global economic downturn is being met with massive global government actions – and while the specific outcome is uncertain, there is good reason to think that the governments will eventually win.