Cost effectiveness - the de Perio model

de Perio et al (University of Cincinnati College of Medicine) drilled down into the Pai et al Meta-analysis and rejected indeterminate results, studies of children and those that did not use culture confirmed tuberculosis cases as the gold standard.

Their conclusions are based on more correct data and they ran their models firstly be excluding indeterminates and then secondly also excluding children and unconfirmed culture TB;

"We reran our decision analysis using these updated pooled test characteristics and obtained similar findings as before: IGRA testing is both less costly and more effective than TST test"

"QFT-G and QFT-GIT are clinically and economically worthwhile alternatives to TST and should be considered in screening non-BCG and BCG-vaccinated HCWs for LTBI"

______________________________________________________________________

Cost-effectiveness of interferon gamma release assays vs tuberculin skin tests in health care workers

ABSTRACT

BACKGROUND: The new interferon-γ release assays (IGRAs) offer alternatives to the traditional tuberculin skin test (TST) for diagnosing latent tuberculosis infection (LTBI). Advantages include the fact that they require only one patient visit, do not boost responses in second tests, and are not affected by prior BCG vaccination, thus providing greater specificity. We compared the cost effectiveness of 3 strategies for detecting LTBI in new VA healthcare workers (HCWs): QuantiFERON®-TB Gold (QFT-G), QuantiFERON-TB® Gold In Tube (QFT-GIT), and TST.

METHODS: We constructed a Markov state transition decision analytic model, using the societal perspective and lifetime horizon, to compare the 3 strategies for hypothetical 35-year-old HCWs with or without prior BCG vaccination. Direct costs, costs of missed work time, and probabilities were based on manufacturers’ data, national VA data, and the published literature. We calculated the incremental costs per quality-adjusted life year (QALY) gained for the three strategies, discounting future costs and QALYs at 3% per year. We performed sensitivity analyses, varying all of the input parameters over wide ranges.

RESULTS: The 2 IGRA strategies were both more effective and less costly than the TST strategy whether or not the HCW had been previously BCG vaccinated. For non-BCG-vaccinated HCWs, the incremental cost-effectiveness of QFT-G compared with QFT-GIT was $14,092/QALY. For BCG-vaccinated HCWs, the incremental cost-effectiveness of QFT-G was $103,047/QALY. There was no prevalence of LTBI at which TST became the most effective or least costly strategy for either cohort. Additional sensitivity analyses showed that if the sensitivity of QFT-GIT exceeded that of QFT-G, then QFT-GIT would be the most effective and least costly strategy.

CONCLUSIONS: QFT-G and QFT-GIT are clinically and economically worthwhile alternatives to TST and should be considered in screening non-BCG and BCG-vaccinated HCWs for LTBI. Although both IGRA strategies have similar costs and benefits in non-BCG-vaccinated HCWs, QFT-GIT may be preferred in BCG-vaccinated HCWs.

Another happy customer - *updated

As they say,

Word-of-mouth advertising is important for every business, as each happy customer can steer dozens of new ones your way

Here is one happy camper

Positive Mantoux Test - update
I just realized that I never posted the update for my son who tested positive for TB (but negative chest xray). His pediatrician was ready to put him on 9 months of meds, but then his endocrinologist contacted an infectious disease Dr. at Children's Hospital Los Angeles, where she works, and he informed us that there is a fairly new blood test that we could do which would tell us if he really was exposed to tb. So, we went to the hospital, did the blood test (quantiferon r - tb gold) and it was NEGATIVE!!! We were so happy because that means he was not exposed to tb, and he doesn't have to take any meds. It definitely pays to ask around and find doctors who have the most updated info.

Thought I would pass this along in case it helps someone else along the way.

and here is a not-so-pleased camper

Wow! I wish we had heard of this earlier this summer. Alex has been taking tb meds most of the summer b/c his tb test came back positive (xray normal). Do you know if this test can be done at this point? The meds he is taking sound pretty powerful. He hasn't had any side effects but he has to take B vitamins and get liver panels done to make sure the meds aren't doing harm.

The response..

Hmmmm, I don't know if it would work at this point, but maybe you can find an infectious disease Dr. to check with?? Our local hospital didn't know about it, but the Dr. at Children's had all of the info. Guess it would be worth making a few calls to see if you can find out? I will send you a pm with the info.

It would work at this point, it's a shame that doctors are being misled by dubious statistics.

.

Health care reform - the KISS principle

Back in April 2008 Terje Petersen wrote that Medicare should be like HECS

Medicare should be reformed so it is more like HECS. When you front up to the doctor or hospital for medical services then in order to pay the medical bill you should have the option of whipping out some cash, whipping out the MASTERCARD or whipping out the Medicare card. Medicare should be a credit fascility much like MASTERCARD or VISA. The only difference should be that the Medicare debt should be repaid via the tax system in the same way that HECS debts are repaid. In fact the debt could be administered by the same bureaucracy.

Such a reform would ensure that medical consumers seek value for money. However it would still provide access for those with financial difficulties. Medicare should be regarded as a payment system not an insurance system. Insurance should be entirely optional.

Now Ross Gittins is running with the idea

..the Federal Government issue all consumers with a "health credit card" to be used to pay in full for all approved health goods and services.

The Government would then pay the providers in full and, after making allowance for the applicable government subsidies and private health insurance rebates, send the consumer a monthly consolidated bill for the outstanding gap amounts.

As with an ordinary credit card, the customer could either pay the bill in full or pay in instalments.

But, as with the Higher Education Contribution Scheme, the size of repayments would be determined by the consumer's ability to pay, not the size of the debt. Presumably, debts would be indexed to the inflation rate as a form of interest charge.

This might be too simple a solution for our Prime Minister, who is busy painting himself as a Crusader exemplar

Meta analysis - the analysis of analyses or much ado about nothing?

Whilst meta analysis is widely used in epidemiology and evidence-based medicine it is not without its faults, in particular it is probe to bias and paradox.

A good meta-analysis of badly designed studies will still result in bad statistics.

The update of the Pai Zwerling Menzies meta analysis gave pooled sensitivities and specificities for the various diagnostics and these pooled results are now being used elsewhere as a reference. Unfortunately they are in significant error, as Pai et al admit

Most studies were small and had limitations, including no gold standard for diagnosing latent tuberculosis and variable TST methods and cutoff values

In fact Pai et al also say that sensitivity and specificity for latent TB diagnosis cannot be directly estimated.

Although sensitivity and specificity are useful and easily measured test characteristics, they have limitations. Given the lack of a gold standard, sensitivity and specificity for active tuberculosis may not translate to accuracy for latent tuberculosis (which cannot be directly estimated).

The pooled figures are subject to bias, paradox and error and should be viewed with caution.

USA - new home sales up 11%

Bloomberg

Purchases of new homes in the U.S. climbed 11 percent in June, the biggest gain in eight years, underscoring evidence that the deepest housing slump since the Great Depression is starting to stabilize.

Sales increased to a 384,000 annual pace, higher than every forecast in a Bloomberg News survey and the most since November, figures from the Commerce Department showed today in Washington. The number of houses on the market dropped to the lowest level in more than a decade.

How citation distortions create unfounded authority: analysis of a citation network

A study by Steven Greenburg from Harvard Medical School and published in the BMJ into herd behaviour amongst the scientific community. Principally it sets out to prove that citation alone can convert hypothesis to fact and citation bias or invention was present in eight of nine proposals for funding by the National Institutes of Health

Full article here

ABSTRACT

Objective To understand belief in a specific scientific claim by studying the pattern of citations among papers stating it.

Design A complete citation network was constructed from all PubMed indexed English literature papers addressing the belief that β amyloid, a protein accumulated in the brain in Alzheimer’s disease, is produced by and injures skeletal muscle of patients with inclusion body myositis. Social network theory and graph theory were used to analyse this network.

Main outcome measures Citation bias, amplification, and invention, and their effects on determining authority. Results The network contained 242 papers and 675 citations addressing the belief, with 220 553 citation paths supporting it. Unfounded authority was established by citation bias against papers that refuted or weakened the belief; amplification, the marked expansion of the belief system by papers presenting no data addressing it; and forms of invention such as the conversion of hypothesis into fact through citation alone. Extension of this network into text within grants funded by the National Institutes of Health and obtained through the Freedom of Information Act showed the same phenomena present and sometimes used to justify requests for funding.

Conclusion Citation is both an impartial scholarly method and a powerful form of social communication. Through distortions in its social use that include bias, amplification, and invention, citation can be used to generate information cascades resulting in unfounded authority of claims. Construction and analysis of a claim specific citation network may clarify the nature of a published belief system and expose distorted methods of social citation.

_______________________________________

Vocabulary of citation distortions
_______________________________________

Citation
- Both scholarly and social forms: the scholarly form connects statements to the broader medical literature, the social form (social citation) includes self serving and persuasive subtypes

Citation distortions
- Self serving citation is always a distortion
- Persuasive citation may be necessary to communicate new, sound claims to the scientific community; it may, however, have distorted uses—citation bias, amplification, and invention

Citation bias
- Systematic ignoring of papers that contain content conflicting with a claim
- Bolster claim; justifying animal models to provide opportunities to amplify claim

Amplification
- Expansion of a belief system without data
- Citation made to papers that don’t contain primary data, increasing the number of citations supporting the claim without presenting data addressing it

Invention

Citation diversion—citing content but claiming it has a different meaning, thereby diverting
its implications

Citation transmutation—the conversion of hypothesis into fact through the act of citation alone

Back door invention—repeated misrepresentation of abstracts as peer reviewed papers to fool readers into believing that claims are based on peer reviewed publishedmethods and data

Dead end citation—support of a claim with citation to papers that do not contain content addressing the claim

Title invention—reporting of “experimental results” in a paper’s title, even though the paper does not report the performance or results of any such experiments

Tipping point passe'?

Data from Medicare Australia would indicate that in Australia QFT has just recently overtaken TST as the test of choice. This is a significant market penetration as the TB medical authorities in Australia are demonstrably conservative and, unlike authorities in UK, EU, Japan and US, have expressed reluctance in endorsing IGRA.

Click on image for FULL SIZE

TB in the UK, "rife at the moment"

Hotline hopefuls are tested for TB

Job-seekers applying for work at an NHS swine flu call centre are being tested for tuberculosis.

Applicants had to prove they had been inoculated against the lung disease before they could begin fielding calls from the public. Those who had not received the jab were asked to take a blood test.

A few years ago, TB was virtually extinct in Britain but is now on the increase, partly as a result of mass migration. An estimated 65 per cent of cases involve patients who were not born in the UK.

In some parts of London, one in every 1,000 has the disease, according to recent figures. Although the illness can be treated with antibiotics, public health specialists say a new drug-resistant strain is developing.

The contact centre at Farnborough, Hampshire, is run by NHS Professionals, which provides the health service with temporary and part-time staff. Asked why the tuberculosis checks were needed, an employee said: ‘It’s because TB is rife at the moment.’

A Department of Health spokesman said it was ‘not national policy’ to ask potential staff about TB vaccination.

Read more

Defusing the time bomb

Following on from Cellestis' announcement that they are formally entering the TB testing market in Russia comes this study into MDRTB prevalence in India

India, China and Russia account for more than 62% of multidrug resistant tuberculosis (MDRTB) globally.

..Levels of MDRTB are much higher in both previously untreated and first line treatment-failure cases in the selected wards in Mumbai than those projected by national estimates.

Africa is also feeling the strain

Kenyan health experts have warned that the country is sitting on a tuberculosis time-bomb, and are suggesting that the disease be declared a national emergency like HIV/Aids.

Of most concern, the experts say, is the continued unchecked spread of multi-drug resistant TB (MDR-TB), which is harder and more expensive to treat than conventional tuberculosis.

.."MDR-TB is now a time bomb," said Ms Lucy Chesire, a prominent Kenyan tuberculosis activist last week. "People have been panicking about such scares as swine flu, but this is far worse."

The fear now is that MDR-TB could degenerate into the so-called XDR-TB, or extreme drug resistant TB, a form that cannot be managed by even second-generation medicines. Cases of XDR-TB have previously been reported in South Africa, and virtually all have led to death...

ASX Company announcements and the Law.

The recent decision in ASIC v Macdonald (No 11) has delivered a strong message to company directors that they need to tidy up their act. Justice Gzell found that on the evidence presented the directors of James Hardie were in breach of duty of care and diligence under the Corporations Act.

A director or other officer of a corporation must exercise their powers and discharge their duties with the degree of care and diligence that a reasonable person would exercise

ASIC have produced this table outlining those charges proved and those dismissed, lawyers Lange have also provided a list.

In essence the executive failed to properly advise the board and the board failed to ensure that they had been properly advised.

The legal argument was that by approving a draft ASX announcement which was both misleading and deceptive or was likely to mislead or deceive the directors of Jamie Hardie were in breach of the Corporations Act. Evidence to that argument included the accuracy of the minutes of the board meeting that approved the draft ASX announcement and a failure to comply with Section 251A(1) in that the minutes were not recorded in a minute book within a month of the meeting.

Whilst appearing to be a trivial detail the failure to record minutes properly constitutes a breach of the Corporations Act.

Langes writes

Gzell J observed that "One thing that has emerged clearly in this case is that recollection is fallible. If a minute is to be given evidentiary value, it ought to be a contemporaneous document, for then it is more likely to be an accurate reflection of the proceedings of the meeting rather than a reconstruction of them. "

DLA Phillips Fox have also given their opinion;




James Hardie Civil Penalty Proceedings: New Guidance On Directors’ And Officers’ Duties.
23 July 2009
Article by Adrian Smith and Alastair Macphee

Overview

The recent decision of Gzell J in ASIC v Macdonald (No 11) [2009] NSWSC 287 provides new guidance on directors' and officers' duties under the Corporations Act 2001 (Cth) (Act).

ASIC succeeded in many (but not all) of its civil claims against the former James Hardie Industries Limited (JHIL), James Hardie Industries NV and certain former nonexecutive directors and officers of JHIL for various alleged breaches of the Act. The majority of ASIC's claims related to public disclosures (including ASX announcements in draft and final form) made in respect of the restructure of the James Hardie Group.

There are a number of matters that directors and other company officers should consider in respect of their own governance practices and arrangements in light of this judgment.

Breaches Of Directors' And Officers' Duties

All of the directors were held to have approved a draft ASX announcement that was misleading and deceptive, thereby breaching their statutory duties of care and diligence under section 180(1) of the Act. This included 2 directors who participated in the relevant Board meeting by telephone, but who failed to ask for a copy of the draft announcement or otherwise explicitly abstain from voting on that item of business.

The former CEO and former in-house counsel/company secretary were also held to have breached their duties under section 180(1) of the Act for failing to advise the Board appropriately. The CEO was held to have committed further breaches of this section by approving various final ASX announcements and making various public disclosures on the same terms.

The court is yet to consider whether to impose penalties in respect of these breaches, or otherwise relieve any of the defendants from civil penalty liability.

Several of the defendants have foreshadowed that an appeal against their convictions will be lodged in due course.

Key Implications Of This Decision

Although ASIC considers this to be 'a landmark decision in Australia on corporate governance', other commentators have suggested that this may be an overstatement, largely because the case turns on its particular facts.

Nonetheless, directors and other officers should consider whether any refinements to existing corporate decision-making processes are required in light of the decision. Among other matters, it may be prudent to consider:

+ What protocols are in place to ensure the veracity of disclosures made to the market, both at management level and at Board level?

+ Do they require amendment in light of this decision, and what internal training may be required to ensure that all company personnel understand their responsibilities? This applies not only to ASX announcements but also to media releases, investor briefings and 'road shows', and, potentially, to disclosure documents such as prospectuses.

+ Do all directors understand the parameters within which the law permits them to delegate their powers to others, and rely on information or advice provided by others? (The James Hardie decision certainly provides directors with greater guidance on these matters).

+ How are Board meetings conducted and Board minutes prepared and settled? What changes to existing practices are required in light of this decision? In particular:

• Are all directors provided with the relevant papers (even if attending by electronic means)?
• Are Board minutes accurate and contemporaneous? Do Board minutes accurately record the identity of those present and voting, or abstaining, on each item of business? (The James Hardie decision arguably lends additional weight to the argument that the 'consensus' approach, whereby matters are discussed until unanimous agreement is reached but without a formal vote being taken, may be undesirable from a governance perspective).

Further to the ongoing debate regarding whether client legal privilege attaches to advice provided by in-house counsel, and more broadly the proper role of in-house counsel within a corporation, the James Hardie decision arguably reinforces the view that in-house counsel (and, potentially, company secretaries) must play a 'gatekeeper' role.

In James Hardie, the in-house counsel/secretary was held to have breached his statutory duty of care and diligence largely through a 'failure to advise', understood in light of his duty to protect the company from legal risk. Among other matters, he breached this duty by failing to warn the Board that its approval of the draft ASX announcement 'put JHIL in jeopardy'.

It may be beneficial to review existing reporting structures and relationships in light of this. For example, what capacity does in-house counsel have, in real terms, to challenge management or the Board? What changes may be required, and how might they best be implemented?

© DLA Phillips Fox

It just makes sense

Chit chat between medical students enrolling at the University of Chicago

--------------

Hi Guys,
I know this may raise some eyebrows, but I did not get a 2-step TB test. I got the Quantiferon test (blood test), and apparently that was fine with the admissions office. I just turned in my immunization forms today. I know they clearly state "Only 2-step TB test is accepted", but I thought I would give it a try anyway. And it was fine.

Hopefully that will save somebody on this thread some time.

-Faizan
--------------

Thanks for letting us know. I did the same thing, as the form says "Optional: QTBG Quantiferon". I think that the QTBG test is actually a better test (no allergic reactions/less false positives) , so it makes sense that they would accept that one.

--------------

Never say Nyet

Cellestis moves into the land of drug resistant TB - Russia

With tuberculosis infection widespread and extensively drug resistant disease prominent throughout Russia, there is an urgent need for improved tuberculosis testing. For years the tuberculin skin test has been the only diagnostic for latent tuberculosis available in this region. The skin test's major limitation is that it is highly confounded by the BCG vaccination, which is mandatory in Russia at birth and again between 7 and 14 years of age. Falsely positive skin test reactions induced by BCG vaccination prevent accurate tuberculosis diagnosis in the Russian population. However, public health programs and tuberculosis clinics in the region are now beginning to use QFT for one-step tuberculosis diagnosis because it is not influenced by BCG vaccination and is proven to be a more accurate and cost-effective means of detecting tuberculosis.

Nursing mums..

..are getting their collective backs up over having to have their kids TB tested by the Mantoux method;

I also object to this test because I am currently breastfeeding and there are NO KNOWN published studies that demonstrate that tuberculin PPD or the toxic chemicals contained as preservatives listed above do not pass to breastmilk. Also Tubersol has not been evaluated for its carcinogenic or mutagenic potentials for impairment of fertility.

Fair enough too but how to comply with the regulation? - use QFT

there is a blood draw test you can have drawn to check instead of the skin injection.
it is more expensive and you might have to search for a lab that does it, but that way you aren't putting anything into you,

Eventually some of those mums tracked down the elusive QFT

I am in San Diego, & did the Quantiferon Gold (blood draw) test when I was required to take the TB test while pregnant - I had to look high & low for somewhere to get it done though, & I think I finally ended up getting it done at the county health dept.

Clearly there is a need for QFT and the CTCA have put IGRAs on their front page but is that enough?

Clear and understood

Washington State Department of Health Tuberculosis Program has produced their first issue of “TB News”

Front page news is all about change

The TB program has changed vastly over the last year. According to Chris Jeffris, Public Health Nurse, TB Program Coordinator, “We have improved almost every inch of our program, including the culture in our workplace, but I don’t think we’ll ever be done. It’s a continuous quality improvement process. I’m already revising the revisions!”

including using QuantiFERON

In addition, the number of LTBI patients has dropped by 68% since beginning QuantiFERON® (QFT) blood testing. By lifting the burden of case management, CDHD can now provide education and increased consultation to physicians, nurses, homeless shelters, and high risk groups and strengthen relations with community partners. In May, CDHD invited DOH to do the first local program evaluation in the state.

Tilting at windmills

Yet another study comparing QuantiFERON with TST, this time from Spain. Maybe it's me but I suspect that the medical science community speak in another language, perhaps exasperanto?

Starting off with the known knowns, they clearly state that

..it (QFT) has a higher specificity to LTBI than does the TST.

Logically this would mean that a QFT negative has more weight than a TST negative however not so

the most problematic issue in our study was discordant results between the TST and the QFT-G test. Disagreement was present in 5% of HCWs for whom results of both tests were available.

It seems fairly clear to me that if one test was more accurate than an other then there is a good chance that there would be disagreement between the two and when there is a disagreement the more accurate would be the obvious choice.

Even though the study was run over only 115 HCWs the same old no show was evident

In 8 HCWs (6%), the result of the TST was unknown because the HCWs did not return for evaluation.

By any measure the final number tested was minimal. For the TST they read each result according to patient status

All TSTs that showed any induration were interpreted by the same physician. Induration of at least 5 mm in non–BCG-vaccinated HCWs or at least 15 mm in BCG-vaccinated HCWs was considered positive.

Plus the same old double dip testing

In BCG-vaccinated HCWs, if the first TST was negative, a second TST was carried out 7–10 days later (TST in two stages), and the induration of the second TST was considered definitive.

Despite expending considerable resources in identifying and chronicling the obvious handicaps of TST, in both operation and diagnosis, they were unable to form any conclusion that was meaningful

In any case, in the absence of long-term follow-up data, it could be too early to replace the TST with the QFT-G test for LTBI screening of HCWs.

Mucho exasperante!

We'll all be runed..

The impressively titled Economic Research Cycle institute claims to have an impressive track record of success when it comes to casting the runes to divine all things economic.

Be that as it may, in an effort to bring peace to the latest batch of Hanrahans they offer the following;

The modest pullback in stock prices that followed the springtime rally, along with a worse-than-expected June jobs report, allowed the skeptics to re-emerge, asserting that without actual improvement in hard economic data, the “green shoots” had wilted away. What they do not realize, as we reasserted in ECRI’s June U.S. Cyclical Outlook report to Professional Members, “is that the cyclical improvement in the economy is proceeding in a textbook sequence, from long leading indicators to short leading indicators to coincident indicators.” In fact, “there are now pronounced, pervasive and persistent upturns in a succession of leading indexes of economic revival.”

..In fact, “what is impressive here is the degree of unanimity within and across ECRI’s leading indexes, along with the classic sequence of advances in those indexes. Such a combination of upturns – a resounding confirmation of our April forecast that the recession will end this summer – does not happen unless an end to the recession is imminent.

In sum, the economy has a raft of problems that will take a long time to resolve. But none of them can head off the imminent economic recovery that ECRI’s objective leading indexes are promising today.”

Loony landings

Writing in the Washington Post Charles Krauthammer gets all silly and teary eyed over missed opportunities for greater glory;

..look up from your BlackBerry one night. That is the moon. On it are exactly 12 sets of human footprints -- untouched, unchanged, abandoned. For the first time in history, the moon is not just a mystery and a muse, but a nightly rebuke. A vigorous young president once summoned us to this new frontier, calling the voyage "the most hazardous and dangerous and greatest adventure on which man has ever embarked." And so we did it. We came. We saw. Then we retreated.

compelling Don Boudreaux to bring him to earth;

While I share Charles Krauthammer's admiration for the scientific brilliance that put men on the moon and returned them safely to the earth, I disagree that "the wonder and glory" of manned lunar exploration is a sufficient reason for Uncle Sam to again undertake such missions.

Such "wonder and glory" is funded with money forcibly taken from taxpayers. This process inspires no awe and is decidedly inglorious. Moreover, achievements even more wondrous and glorious than moon shots surround us daily - for example, New York City is fed day in, day out, without fail. Millions of people from around the world work to grow, process, warehouse, deliver, cook, and serve food so that eight million New Yorkers eat well each day. No one plans this wondrous achievement, and no one is forced to contribute toward its realization. It's the happy result of hundreds of millions of persons peacefully pursuing their own self-interests within markets.

Is a moon shot really as wondrous as the intricate coordination of the plans and actions of these countless suppliers and consumers? Is putting a human being on the moon really as glorious as the fact that hunger has been all but eliminated everywhere that markets operate?

Sincerely,
Donald J. Boudreaux

When you hear hoofbeats, think horses, not zebras

"In summary, it is time for child health providers to embrace IGRAs rather than to cling to the antiquated TST"

Dr Deborah A. Lewinsohn
Oregon Health Sciences University

In reading over the following two studies I was reminded again over the dilemma that exists for some medical people and their contribution to the continuance of that dilemma. Two particular studies, Interferon Gamma Release Assays in the Evaluation of Children With Possible Mycobacterium tuberculosis Infection and Embracing Interferon-y Release Assays for Diagnosis of Latent Tuberculosis Infection are published in the latest edition of the Pediatric Diseases Journal and concern themselves with the finding of the study (yet to be published) by Hausein et al "The likelihood of an indeterminate test result from a whole-blood interferon-y release assay for the diagnosis of Mycobacterium tuberculosis infection in children correlates with age and immune status"

Of the study *Dr Deborah A. Lewinsohn says

This well-performed study represents the largest study of IGRA test performance in this vulnerable population to date. It provides just the sort of informative data needed to direct clinical use of IGRAs in pediatric populations. However, the main message is sobering. In this group of 237 children cared for at a tertiary care medical center, the QFT-IT assay was indeterminate in 83 children, a full 35% of the total study population. Moreover, an indeterminate result was associated with young age and immunocompromising conditions. As stated by the authors, an indeterminate result equates with an uninformative result. Hence, the test was most often uninformative in the children at high risk for developing TB after infection. Despite this finding, these results, as well as the growing body of literature regarding IGRAs in young children, support increasing use of IGRAs in children.

In his reply **Dr Dwight A. Powell says

Although I agree with many of Dr. Lewinsohn’s comments, I think there are several areas in need of additional research before a universal acceptance of the use of IGRAs for children. These are
(1) explaining the high incidence of indeterminate results in young children assessed with whole blood IGRAs;
(2) assessing the risk of progression to TB disease in children with possible latent tuberculosis infection (LTBI) based on high tuberculin skin test (TST) reactions (> 15 mm induration) but negative IGRAs; and
(3) better defining the role of IGRAs as a reliable marker of TB disease in children.

He concludes by saying

What would be my approach to diagnosing TB in children? Until more data are available, I feel comfortable using an IGRA assay to screen children older than 4 years for LTBI who have had known contact with an adult case of TB disease within the past year.

As I see it Powell expresses reluctance in using a diagnostic on children under 4 due to a lack of the same research that he is reluctant to provide. By using the diagnostic (and it has been universally proven and accepted as being more accurate) experience can be gained and as we all know, wisdom does not come before experience.

Dr Lewinson leads the way;

In summary, it is time for child health providers to embrace IGRAs rather than to cling to the antiquated TST. Expanded use of IGRAs in children, both through well-designed clinical research studies and reports of clinical practice would serve to promote better health care for children. As noted above, dual testing with IGRA’s and TST can be used in high risk young and/or immunocompromised children to increase sensitivity of diagnosed LTBI. Additionally, IGRA’s may be useful as a more specific test than TST in low risk BCG-vaccinated children. Recommendations for use of IGRAs in young children are curtailed not by negative data, but rather by lack of sufficient data in young children to support such guidelines. Cumulative clinical data can inform these guidelines. Moreover, cumulative clinical experience will clarify the deficiencies of the currently available IGRAs and proactively push manufacturers to improve the performance of their test(s) in young children. If child health providers reject IGRA use in young children, how can we expect continued improvements? There is no doubt that critical research gaps and test performance deficiencies remain, preventing the replacement of TST with IGRAs in young children at the current time. Especially, regarding QFT-IT, better test performance in young children and decreased blood volume requirements are needed. IGRAs need to be studied in a large household study of young contacts of adults with infectious TB conducted in the United States/Europe. But these issues need not immobilize us. We need to keep moving forward to prevent child health from falling behind, gain more experience with IGRAs to create rational guidelines, and continue to demand attention to one of the most vulnerable populations to TB.

*(from the Division of Infectious Diseases, Department of Pediatrics, Oregon Health Sciences University, Portland, Oregon)

**(from both the Department of Pediatrics, The Ohio State University College of Medicine and Section of Infectious Diseases, Nationwide Children’s Hospital, Columbus, OH)

Swines flew over the cuckoo nest

The ASX keeps 'em spinning

In their latest advertorial the Australian Stock Exchange gave us penniless punters the inside nod on some winning strategies. Just by picking and holding 4 stocks "Carlo" (strangely called Italian Cashflow) was able to turn $50,000 into $104,454 in 15 weeks. Ditto "Barrie" who magically transformed $50,000 into $100,860

However "Howard" bought nine times and sold six times for a profit of $49,503 whilst hyperactive "Kosmas" made 26 buys and 21 sells for a pot of $96,540.

What to make of all this priceless information?

What we can safely ascertain is that of 54,000 entries 53,996 were unremarkable.

Teens aren't twits

A 15 year old intern at Morgan Stanley produced a report that has grabbed media attention; titled How Teenagers Consume Media it has rattled media investors, particularly those in print.

On newspapers: No teenager that I know of regularly reads a newspaper, as most do not have the time and cannot be bothered to read pages and pages of text while they could watch the news summarised on the internet or on TV. The only newspapers that are read are tabloids and freesheets (Metro, London Lite…) mainly because of cost…

On radio: Most teenagers nowadays are not regular listeners to radio. They may occasionally tune in, but they do not try to listen to a program specifically… With online sites streaming music for free they do not bother, as services such as last.fm do this advert free, and users can choose the songs they want instead of listening to what the radio presenter/DJ chooses.

On (yellow pages) directories: Teenagers never use real directories (hard copy catalogues such as yellow pages). This is because real directories contain listings for builders and florists… (and) because… they can get the information for free on the internet, simply by typing it into Google

Facebook is popular as one can interact with friends on a wide scale.

On the other hand, teenagers do not use twitter. Most have signed up to the service, but then just leave it as they release that they are not going to update it (mostly because texting twitter uses up credit, and they would rather text friends with that credit). In addition, they realise that no one is viewing their profile, so their ‘tweets’ are pointless

What is hot?
• Anything with a touch screen is desirable.
• Mobile phones with large capacities for music.
• Portable devices that can connect to the internet (iPhones)
• Really big tellies

What is not?
• Anything with wires
• Phones with black and white screens
• Clunky 'brick' phones
• Devices with less than ten-hour battery life


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QFT mandatory - University of Toledo

Thats what they say;

...all international students from countries of high tuberculosis (TB) prevalence as determined by the World Health Organization (WHO), and all students born in the US who have lived abroad in one of these high TB prevalence countries, will be subject to mandatory onsite screening for tuberculosis and latent tuberculosis...

... screening for active or latent TB will be done using the QuantiFERON-TB test (QFT).

...As recommended by the CDC and ACHA, the Quantiferon TB GOLD test will be used in place of the tuberculin (PPD) skin test for screening international students for TB

..and the winner is..Stephen Conroy

The Internet Services Providers' Association UK (ISPA UK) held its annual awards and Stephen Conroy won 1st prize

Internet Villain


Stephen Conroy and the Australian Government - "For continuing to promote network-level blocking despite significant national and international opposition"

بني رشيد, الرشايدة

From the tribe of Bani Rashid (one of the largest tribes in the Arabian Peninsula) comes this snippet; QFT-G is being used to test HCWs at King Khalid University Hospital in Riyad.

Translation here.

Obama and his white glasshouse

Whilst spreading the word to the good citizens of Ghana President Obama let this slip;

No business wants to invest in a place where the government skims 20 percent off the top ...

If only he was as good as his word

Volume as a trading indicator

Business investment tends to fall into two camps, those that conduct a Fundamental Analysis (FA) of the business and those that rely on a Technical Analysis (TA) as a guide to forecasting stock movements. Generally TA ignores the nature of the company or market and use charts which illustrate market activity as functions of both price and volume.

TA is used primarily by traders and finance professionals and is the subject of ongoing debate amongst academics.

Arnuk and Saluzzi of Themis Traders say that volume and volatility has been greatly exaggerated by sophisticated computer programs or algorithmic trading. In their paper titled Toxic Equity Trading Order Flow on Wall Street (The Real Force Behind the Explosion in Volume and Volatility) they describe how these high frequency trading programs are increasing volatility;

Traders Magazine estimates high frequency traders may account for more than half the volume on all U.S. market centers.
...high frequency traders searching for hidden liquidity. Some estimates are that these traders enter anywhere from several hundred to one million orders for every 100 trades they actually execute.

Says John Mauldin;

All this "algo" (algorithmic) trading also gives a very false impression of volume. If you are a fund and see 10 million shares a day traded, you might feel comfortable that you could hold one million shares and exit your trade easily. But if 80% of the volume is false "algo" trading, that volume isn't really there. You may have a position that will be a problem if you want to exit, and not know it.

Themis Traders argue that investors should be concerned by high frequency traders (HFT) for the following reasons;

1. HFTs provide low quality liquidity.
2. HFT volume can generate false trading signals.
3. HFT computer servers are faster than other trading systems.

Q: What if a “rogue” algorithm entered the market?

A: Many HFTs are hedge funds that enter their orders into the market through a “sponsored access” arrangement with a broker. Many of these arrangements do not have any pre-trade risk controls since these clients demand the fastest speed. Due to the fully electronic nature of the equity markets today, one keypunch error could wreak havoc. Nothing would be able to stop a market destroying order once the button was pressed.

Gives new meaning to the term “mutually assured destruction?”

BCA Research - U.S. Economy: It Looks Like A Recovery

The U.S. economy is transitioning to a recovery path, though it will be bumpy and subdued compared with past cycles.

Source

The Revolution Will Not Be Televised: Democracy, the Internet, and the Overthrow of Everything

A provocative title and one well used by Joe Trippi for his book on power;

When Joe Trippi signed on to manage Howard Dean's 2004 presidential campaign, the long-shot candidate had 432 known supporters and $100,000 in the bank. Within a year, Trippi and his energetic but inexperienced team had transformed the most obscure horse in the field into a front-runner, creating a groundswell of 640,000 people and raising more money than any Democrat in history -- more than fifty million dollars -- mostly through donations of one hundred dollars or less.

Trippi was eventually replaced on the Dean team and Dean fell down. Since then a host of social networking devices have transformed the way we can experience life. Trippi reflects on the political success of Barrack Obama

the whole reason he exists, the whole reason he wins the Democratic nomination is because of the resources that millions of Americans gave to him in small numbers, under $100 contributions, over half a billion dollars raised on the internet. 13 million Americans who joined with him and join in and they're out there working and organising for common purpose.

Trippi looks forward;

To think that any country is immune, or any industry is immune from the changes that are coming because of this communications revolution, is - I mean I wish you luck, it's just not, that will not hold.

Change is going to go everywhere. You'll have industries who will adopt it faster, understand it, and there'll be those who say, 'No, no, no, it's not happening', and CEOs will hope that none of this change happens until they've retired. But it's all coming.

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A new kid in town

Google is set to take on Microsoft and its Windows operating system;

We hear a lot from our users and their message is clear — computers need to get better. People want to get to their email instantly, without wasting time waiting for their computers to boot and browsers to start up. They want their computers to always run as fast as when they first bought them. They want their data to be accessible to them wherever they are and not have to worry about losing their computer or forgetting to back up files. Even more importantly, they don't want to spend hours configuring their computers to work with every new piece of hardware, or have to worry about constant software updates. And any time our users have a better computing experience, Google benefits as well by having happier users who are more likely to spend time on the Internet.

Up the creek

The arrest of 4 RIO employees by the Chinese government has rattled some markets; rumours of heavy handed crack downs and shake outs has increased tensions within western businesses wishing to do business in China. Whilst it has been argued that the arrests were payback by the central government over a loss of face with the failed RIO/Chinalco deal the reality might be far simpler; what passes as routine intelligence gathering by commercial enterprises can be viewed as espionage if the business is an enterprise backed by a totalitarian government.

Not that China's slate is squeaky clean; they have actively practiced espionage at every level;

During the past 20 years, China has established a notable intelligence capability in the United States through its commercial presence.

China's commercial entities play a significant role in its pursuit of proprietary/trade secret U.S. technology. The vast majority of Chinese commercial entities in the United States are legitimate companies; however, some are a platform for intelligence collection activities. Although a commercial entity may not be directly involved in the acquisition of information/technology, it may provide cover for both professional and non-professional intelligence collectors. Professional collectors are usually affiliated with one of China's intelligence services, while non professionals usually collect for themselves. These collectors enter the United States to gather sensitive and/or restricted proprietary/trade secret information or to act as a liaison to consumers of intelligence back in China.

The primary targets from which China seeks to acquire sensitive and restricted proprietary/trade secret U.S. technology are the U.S. Government, private U.S. Corporations, academic institutes, laboratories, as well as persons involved in sensitive and/or restricted work. These operations are usually low-key and singular in nature, thus creating a significant counterintelligence dilemma for the FBI.

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Thermometers at 20 paces

In his piece Medicare Administrative Costs Are Higher, Not Lower, Than for Private Insurance Robert Book makes the claim

on a per-person basis Medicare's administrative costs are actually higher than those of private insurance--this despite the fact that private insurance companies do incur several categories of costs that do not apply to Medicare.

and then, by using data supplied by Medicare, sets out to explain why.

Esteemed economist Paul Krugman went straight for the soft tissue; Whenever you encounter “research” from the Heritage Foundation, you always have to bear in mind that Heritage isn’t really a think tank; it’s a propaganda shop. Everything it says is ef="http://krugman.blogs.nytimes.com/2009/07/06/a-bit-more-on-administrative-costs/#comment-195793">dismisses this as being illogical

in short, Medicare Advantage gets the healthiest Medicare Patients.

..administrative costs incurred by Medicare Advantage plans (as measured by the CBO report) include not just the cost of running the health plan, but also costs of administration by providers; that is, costs incurred by doctors and hospitals.

Brook later argues;

96% of Medicare administrative costs got to activities other than claims processing — activities like signing people up, deciding payment rates, and “general management.” None of these are a function of the number of claims, visits, or procedures, or the dollars paid out. They are all either related to the number of people, or fixed at the program level.

...Private insurance has to pay for marketing, working capital, returns to shareholders, etc…. yet they STILL spend less on administration per patient than Medicare. The fact that Medicare doesn’t have those costs yet still spends more means that Medicare is even more inefficient than the raw numbers indicate.

In testimony before the US Senate Professor Sparrow from Harvard indicated that fraud may be significantly boosting Medicare costs

in 1993 that Attorney General Reno declared Health Care Fraud to be the number two crime problem in America, second only to violent crime. That was an extraordinary position for a white collar crime to hold, and it reflected how seriously the Clinton administration viewed the problem.

...The units of measure for losses due to health care fraud and abuse in this country are hundreds of billions of dollars per year. We just don't know the first digit.

Imagine if the government was to run all healthcare.

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Riding the iron rooster

Author Paul Theroux was exasperated by travel in China and now management at RIO must be wondering if, in a past life, they had killed a Chinaman;

"It appears four employees from Rio Tinto's Shanghai office have been detained for questioning by the Chinese authorities," spokesman Nick Cobban said.

"We haven't been able to make contact with them since and we've asked the Chinese authorities for an explanation and we're haven't received anything from them."

...

On June 5, Rio announced it had dumped plans for a landmark investment from Chinalco and instead decided to seal an iron ore joint venture with rival BHP Billiton

Several days later, China's official Xinhua news agency slammed Rio Tinto's "perfidy" for scrapping the deal.

When the state is everything it pays to say SORRY - the Chinese believe that those who say "yes" when they mean "no" are bad luck.

Summer Job!

Nurse RN2B writes on her blog (a blog about my life as a former nursing student, now a Registered Nurse!)

I am working at the Children's hospital doing research in TB for a new TB test recently approved in Quebec (QFT: Quantiferon) . It's with a Public Healh PhD student and the Respiratory TB Clinic. I am amazed at how much TB there still is in North America, and I just have the kid's number let alone the adults still affected by it.
All I can say is YIKES!

Apples with oranges

Squeaky hinge Paul Krugman defends social insurance by quoting Obama;

Mr. Obama offered a crystal-clear explanation of the case for health care reform, and especially of the case for a public option competing with private insurers. “If private insurers say that the marketplace provides the best quality health care, if they tell us that they’re offering a good deal,” he asked, “then why is it that the government, which they say can’t run anything, suddenly is going to drive them out of business? That’s not logical.”

But it is logical, government enterprises have no profit motive and access to taxpayers funds so therefore can drive down private enterprise.

The Nobel prize winning economist then does some maths;

Currently, Medicare has much lower administrative costs than private insurance companies, while federal health care programs other than Medicare (which isn’t allowed to bargain over drug prices) pay much less for prescription drugs than non-federal buyers. There’s every reason to believe that a public option could achieve similar savings.

What appears to be missing from the equation is that like Fanny Mae and Freddie Mac, Medicare is backed by the government and like Freddie and Fannie Medicare is presently unfunded - and according to Federal Reserve Bank of Dallas CEO Richard Fisher the liability is not small potatoes;

If you wanted to cover the unfunded liability of all three (Medicare) programs today, you would be stuck with an $85.6 trillion bill. That is more than six times as large as the bill for Social Security. It is more than six times the annual output of the entire U.S. economy.

...add together the unfunded liabilities from Medicare and Social Security, and it comes to $99.2 trillion over the infinite horizon.

It is amazing that Paul Krugman can ignore a liability of such enormous proportions. To put it into proportion Richard Fisher also does some maths - he calculates the burden per capita of the presently unfunded liability;

With a total population of 304 million, from infants to the elderly, the per-person payment to the federal treasury would come to $330,000. This comes to $1.3 million per family of four—over 25 times the average household’s income.

These sums have appeared to have frozen the collective mind; in a publication titled Fear and a Lack of Realism pollsters found that the majority blamed rising costs on "drug and insurance company profits" rather than "aging of the population or to new and expensive drugs and treatments" and that "few concrete proposals for Medicare enjoy widespread support" - Paul Krugman's chickens are coming home to roost.


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Socialised health - between a rock and a hard place

In his provocatively titled article America's Fiscal Train Wreck Morgan Stanley bear Richard Berner warns of spiralling debt which will lower living standards and imperil economic and financial stability. And the main reason? - healthcare.

The rise in federal healthcare outlays under Medicare and Medicaid is the main long-term factor boosting deficits. These popular programs create a safety net for the elderly and disadvantaged that has been a band-aid for our flawed system of financing healthcare.

Berner sees that rising enrollments in Medicare, Medicaid and SCHIP (the State Children's Health Insurance Program) will cost 5% of GDP in 2010 increasing to 10% in 2035 and 20% in 2080. Relying on projections made by the government Berner sees that

these programs will account for virtually all of the likely growth in primary federal spending - total spending less interest on debt held by the public - in relation to GDP, and thus all the likely expansion of the deficit and debt.

In the short term Berner sees nothing but spend spend spend by the government on healthcare

in the near term, politics likely dictate that increasing access will take priority over cutting costs.

Here we have political mechanisms not market forces directing how scarce (in this case borrowed) resources are to be allocated. The cost of being socially responsible may be financial ruin.


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Not drowning just waving

Published in the May 2009 Lancet and PubMed, another ripping yarn from WHO dealing with Global Drug Resistant TB;

The countries of the former Soviet Union are facing a serious and widespread epidemic with the highest prevalence of MDR tuberculosis ever reported in 13 years of global data collection. Almost half of all tuberculosis cases in countries of the former Soviet Union are resistant to at least one drug and one in five cases are MDR.

That's a shocking result for the once glorious Motherland and their experiment to socialise medicine; almost 50% of all their TB is drug resistant. Drug resistance is man made and is a reflection of poor health care. What the Soviet health policy once provided was a universal and equal right to health and the health system provided was of universally low quality - a health system that you had to survive.

Borgdorff and Small respond to the article;

Rising trends of MDR tuberculosis in some administrative regions of the former Soviet Union suggest an epidemic of an increasingly untreatable airborne disease.

..Surveillance data have no value if they do not precipitate action; enough is now known to start urgent action to prevent and control MDR tuberculosis. Exercising basic tuberculosis control more effectively to prevent MDR disease is the highest priority..

Puts me in mind of the Russian joke;

Ivan sees his friend, Dmitri, fall into an old well. Ivan runs up to the rim of the well and calls down, “Oh my God, Dmitri, can you hear me!”
“Yes,” says Dmitri, “I can hear you.”
“And are you bleeding? Have you broken any bones?”
“No, I’m not bleeding, and I don’t think I’ve broken any bones.”
“And the bottom of the well—what’s down there?”
“I can’t actually say,” says Dmitri, ”I’m still falling.”

Think TB - think QFT

Whilst it is generally acknowledged that sputum culture is the gold test for diagnosing active TB

diagnosis made other than by culture may only be classified as "probable" or "presumed"

sputum culture is of little use in diagnosing TB that is active outside of the pulmonary system, or lungs. Writing in the American Family Physician Drs Golden & Vikram said

the diagnosis of extrapulmonary tuberculosis can be elusive, necessitating a high index of suspicion.

To that extent researchers from Holland found that when using QFT-G

a high PPV (positive predictive value) was observed for extrapulmonary TB and QFT-G might be considered in the diagnostic process in this situation

Peter Davies puts the degree of extra pulmonary tuberculosis as 15% for whites and 50% for non-whites (Bangladeshi, Pakistani or Indian ethnic origin ) whilst Mayo and Yale write that

extrapulmonary involvement can be seen in more than 50 percent of patients with concurrent AIDS and tuberculosis..risk of extrapulmonary tuberculosis and mycobacteremia increases with advancing immunosuppression

Elsewhere it was calculated that extrapulmonary TB occurred in 19.8% of an HIV+ group whilst 9.8% among the non-HIV infected group. Those findings led them to state emphatically

All cases of extra-pulmonary tuberculosis should be screened for co-existing HIV infection and vice versa, for early diagnosis of either infection and appropriate treatment.

Of equal importance to obtaining an early diagnosis is the need to diagnose for TB, to think TB. The case for thinking TB was made by Marguerite Jackson who writes;

Almost two years ago, a woman died from tuberculous meningitis after several weeks of excruciating headaches. Claudia Lacson was a physician in Atlanta, with access to the best medical care available. Several years prior to her illness, she’d had a positive tuberculin skin test and subsequently completed treatment. According to her husband, Dr. Lacson had wondered whether her headaches indicated tuberculous meningitis. Unfortunately, other, more likely, diagnoses were considered first.

More than four decades earlier, a very famous and wealthy woman died of miliary tuberculosis at a hospital in New York City. Her name was Eleanor Roosevelt. The likely source of Ms. Roosevelt’s infection was a reactivation of walled-off Mycobacterium tuberculosis that had remained dormant in her lungs for more than 40 years.

Dr. Lacson became ill when she was pregnant; in Ms. Roosevelt’s case, she was being treated with steroids for persistent anemia. Both pregnancy and steroid use are factors known to increase the risk of developing active tuberculosis from latent tuberculosis infection.

What if the women’s care providers had remembered to “Think TB”? Would these deaths have been prevented? We’ll never know. The delayed diagnosis of tuberculosis can in each case be partially attributed to the fact that nonpulmonary clinical presentations account for 15% of active cases.

In all cases, however, clinicians must do better at diagnosing it. According to the Centers for Disease Control and Prevention (CDC), each year there are almost 15,000 new cases of tuberculosis in the United States and almost 9 million new cases diagnosed worldwide. Yet even when clinicians know that latent tuberculosis infections and risk factors for reactivation are present, they often don’t recognize the signs and symptoms of the disease soon enough. Missed opportunities for early intervention lead to poorer outcomes, and others can be exposed when a person with active pulmonary or laryngeal tuberculosis isn’t managed with airborne infection isolation precautions. At the same time, providers who know they have latent tuberculosis may bear an extra responsibility to undergo treatment; in December 2005 the New York Times reported that a nurse at a New York City hospital, having developed active tuberculosis after 11 years of latency, exposed more than 1,500 patients and infected four infants.

Nothing is more important than to ‘Think TB.’

Successful detection, monitoring, and treatment of latent tuberculosis infections remain crucial to reducing the number of active tuberculosis cases. The tuberculin skin test (TST), which uses a purified protein derivative, has long been the only way to screen for latent tuberculosis infection. A new blood assay for M. tuberculosis (QuantiFERON-TB Gold) is now available and has been approved by the Food and Drug Administration for all situations in which the TST is used. The test eliminates certain interpretive and logistic challenges posed by the TST.

It’s crucial to “Think TB” when caring for patients known to have latent tuberculosis or who exhibit symptoms consistent with the active disease. This means prompt evaluation and, where necessary, the use of airborne infection isolation as a precautionary measure until a diagnosis is confirmed. We must also improve diagnostic and treatment skills among health care students. The National Tuberculosis Curriculum Consortium (http://ntcc.ucsd.edu ) is funded for this purpose by the National Heart, Lung, and Blood Institute of the National Institutes of Health, and resources are available from organizations such as the CDC and the World Health Organization to increase awareness of tuberculosis. The Bill and Melinda Gates Foundation and others provide millions of dollars each year to address tuberculosis research, diagnosis, and treatment worldwide.

Nothing is more important than for health care professionals to “Think TB.” It’s good for their patients’ health—and for their own.

Time after time

One criticism previously levelled at QuantiFERON TB Gold (QFT-G) was that it was short on time eg

QFT-G has practical limitations that include the need to draw blood and to ensure its receipt in a qualified laboratory in time for testing.

(ref CDC)

For some it was felt that this time restriction was a disincentive to switch over from the skin test. However, it would appear that the skin test has its own restrictions. By having to return for a reading within the 48 and 72 hour period after placement meant that for a 5 day working week almost half of that week is compromised. Not much point in placing a test on Thursday when the office is shut on Saturday and much the same applies to Friday morning or Wednesday afternoon.

Both Collin County Texas and the TB clinic at Seattle & King County test on a 4 day week whilst Lorain County TB Clinic Ohio and Cabel Clinic are only open Monday and Tuesday.

Obviously the TST has its own significant time constraints however the major point of departure lies in the responsibility for time management - with the TST the onus is on the patient to return whilst QFT shifts that burden onto the provider with the result that TB clinics have had to lift their game.

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A famous death

From pictures for sad children

(click on image for FULL SIZE)

Tilting at windmills

A report by economics professor Gabriel Calzada from Spain (Spain being a big advocate of green energy) had this to say;

we find that for every renewable energy job that the State manages to finance... expect a loss of at least 2.2 jobs on average, or about 9 jobs lost for every 4 created

Not only has the State been successful in reducing employment (recently Spain posted the highest unemployment rate in the EU at 18.7%) they have demonstrated the ability to create "bubbles";

Even with subsidy schemes leaving the mean sale price of electricity generated from solar photovoltaic power 7 times higher than the mean price of the pool, solar failed even to reach 1% of Spain’s total electricity production in 2008

The Spanish government's activity in the energy market has "crowded out" traditional investment

Renewable technologies remained the beneficiaries of new credit while others began to struggle, though this was solely due to subsidies, mandates and related programs.

Investment in renewables may not fit the definition of "sustainable";

it is axiomatic, as we are seeing now, that when crisis arises, the Government cannot afford this growing subsidy cost either, and finally must penalize the artificial renewable industries which then face collapse.

One should be mindful of the follies of Don Quixote, like the subprime debacle government guided mal investment in renewable energy could form the base for the next black swan event


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Patent upheld by jury

From Bloomberg;

Abbott Laboratories should pay $1.67 billion to Johnson & Johnson’s Centocor unit for using its invention to produce the Humira arthritis drug, a federal jury said in the largest patent verdict in U.S. history.

The jury sided with J&J, the world’s biggest health-care company, after five hours of deliberations today, finding Abbott’s actions were willful and J&J is owed $1.17 billion in lost profits and $504 million in royalties. Abbott pledged to appeal the verdict.

Centocor claimed Humira is made using technology developed by New York University and exclusively licensed to the J&J unit. The NYU property related to antibodies against tumor necrosis factor, or TNF, which is linked to inflammation. Humira works by blocking the action of the TNF protein. Centocor asked the jury to award $2.1 billion in royalties and lost profit.

“We are particularly gratified that the jury recognized our valuable intellectual property, finding our patent both valid and infringed,” said Kim Taylor, the president of J&J’s Centocor Ortho Biotech Inc. unit.

Humira, the biggest seller for Abbott Park, Illinois-based Abbott, generated $4.5 billion in global sales last year, or about 15 percent of Abbott’s total revenue. The company has projected global sales growth of Humira of 15 percent to 20 percent this year.

...cont'd

How much is not good enough?

Frequently studies that attempt to compare QFT with TST include a notation somewhat along the lines of

Five remaining individuals were omitted from this study because they did not return for PPD skin test interpretation

You would think that any non return would have rendered the study invalid.

In New Orleans the TST non return rate amongst HIV+ is 31.9%, which was clearly unacceptable;

We recommend better tests to diagnose LTBI in HIV-infected individuals

Staff from John Hopkins offered incentives in the form of food vouchers etc to increase TST return rates. Whilst there was a rise from 35% to 61% the balance not returning meant that the program had failed

In spite of the impact of our interventions, however, it should be noted that a large proportion of patients still fail to return

Despite tightening up management practices Gouverneur Healthcare Services of New York could only achieve a return rate of 76%, just under the target of 80%

Finally New York DOH felt that a 10% non return was just not good enough and included it as a reason to switch to QFT-G;

Decision to Use QFT-G

•10% of patients did not return for their TST reading and many needed to be retested

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TST and the point of no return

In one clinic in Baltimore 60% of children did not return for a 2nd visit.

In San Francisco the rate of return from homeless and HIV clinics is less than 50%

In the UK a joint pilot implementation study (funded by the HPA) was conducted at a London hospital for all nurses within a single entrant cohort to the UK National Health Service. The results from that study led the researchers to conclude that

For serial or subsequent testing of healthcare workers 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 - Guerin vaccination

The CDC provisional recommendations are that for groups that have either a poor rate of return for TST reading or are BCG vaccinated

IGRA is preferred