September 30, 2009

The great leap backwards

T-Spot must be happy with the latest PR where samples of blood were compared with non blood samples to determine TB status
"These findings show us that positive result in the BAL ELISpot was highly indicative of and actual case of active TB," said Dr. Lange. "And a negative BAL ELISpot result almost excludes active tuberculosis."
Thats all very well but other research has shown that T-Spot (or whatever they call it) falls short of the mark again
In BAL, although a rapid diagnosis can be made with the RD-1 ELISPOT assay using alveolar mononuclear cells, usefulness is limited by a high proportion of indeterminate reactions.
The fact of the matter is that when TB becomes active the T-cells are no longer concentrated in the blood
Mycobacterium tuberculosis-specific T-cells are highly selectively compartmentalised at the site of infection in active pulmonary tuberculosis.
At the end of the day QFT has proven to be the best test for latent TB
The patient had a negative TB skin test, normal chest X-ray, and an extensive search for the TB bacteria in body fluids showed nothing. As a consequence, the patient was assumed to be TB negative....

QFT-Gold, however, had indicated TB infection three months before the person was diagnosed with TB disease...

 Further details of the study are available HERE

September 29, 2009

International students in the US

After a student developed active TB Wayne State University made testing foreign students and staff manadatory
Wayne State University requires Tuberculosis Testing (TB) for all international students including Canadians citizens, and all international students who commute from Canada to WSU.
Whilst they are opting for the skin test the results need to be confirmed
Depending on your TB test result, you may also need to have a blood test or chest x-ray.
It seems that of the positive TSTs 25% are false positives
Of the students tested at Wayne State, 40 percent have positive results. Forty percent are given blood tests or X-rays. Of the blood tests, 30 percent come back latent.
There appears to be no problem with compliance
“Our international students are so focused when they get here,” said Linda Seatts, director of the Office of International Students and Scholars. “They’ll do anything they have to do.”

Bad Medicine

I had not fully realised the potential and degree for an adverse reaction to TB antibiotics until reading this thread;
I just went through a horrible ordeal with having a positive skin test myself. My Dr. told me I had a positive TB skin test and said I had "Latent TB". Later, after becoming very sick from terrible side effects from the Latent TB med and having an inflamed liver, I ended up seeing an Infectious Disease Dr. (they know a lot more than MD's about TB) I was given a test called " Quantiferon TB Gold Test", it is a simple blood test and it will determine if you really have Latent TB. My test came back Negative, my Dr. was wrong, I never even had it.

September 28, 2009

Socialism - the riskiest of risk takers

Whilst global leaders agree to clamp down on excessive salaries and risk-taking in the financial sector our very own Government finds risk analysis too hard;
Barrie Cassidy: On the National Broadband Network and the commitment of $43 billion. Now that's a huge investment. Have you done an adequate cost-benefit analysis proportionate with the size of the investment.

Tanner: Cost-benefit analyses of the orthodox kind are basically captives to the assumptions you feed in. If you fed in my assumptions you'd get one result. If you fed in Henry Ergas's assumptions you'd get a very different result because we're dealing here with long-term unknowables. So the kind of traditional cost-benefit analysis that is done for a rail line would only tell you exactly what the assumptions and the prejudices were of the people drafting the initial terms of reference.

Cassidy: So you can't say for sure that it will return $43 billion to the economy. That's a lot of money to put back into the economy.
Communications Minister and now rocketman Senator Conroy said that the NBN will go ahead whatever;
If we can't do a deal with operators who've got satellites in the sky, we're actually looking to do it ourselves,
We're not prepared to accept the argument the market will sort this out.
If they do go ahead with a satellite they could well repeat the mistakes of the past namely the money hungry AUSSAT;
RBS analyst Ian Martin detailed similarities between the satellite investment Aussat and the National Broadband Network: both had a national roll-out plan; both saw government money invested and were presented as inspirational investments; both serviced high growth markets and paving the way for change; both had high start-up costs.

Like the National Broadband Network, considerations of protection also came into play with Aussat, and the government fully expected it to become a commercial, tax-paying enterprise, Martin said.

Yet by 1990/91, the company had cumulative losses of $152 million by late 1991 when it was sold, Martin said.

..Martin put the loss down to misplaced optimism around a game changing technology.

Treasury official Dr Ken Henry advises the Govt needs to act properly
there is a need to ensure that any activity is cost effective. Government spending that does not pass an appropriately defined cost-benefit test necessarily detracts from Australia’s wellbeing.
Alan Kohler feels that the money, whatever the final sum may be, is safe as an angry Telstra employs a Yes, Minister strategy;
...If Telstra were a person, it would now be Sir Humphrey Appleby, smiling and saying “What a courageous decision, Minister”, and “Telstra supports the NBN vision”, while quietly plotting the 12 steps of obstruction.

...Australia’s national broadband network could take a very long time indeed. By the time eight years of meetings have passed, his department, the NBN management and board and Telstra’s special NBN engagement team, headed by Geoff Booth, will be barely up to the policy statement stage

Doctors dont always know best

A study of medication compliance was made in two Victorian TB clinics and those results were compared with estimates made by docotors, nurses and the patients;
Nonadherence is common and poorly predicted by doctors and nurses, even those with extensive experience in treating TB. Contrary to popular belief, patient self-report is more reliable than doctor or nurse assessment of nonadherence. As clinicians, asking patients about adherence may be more valuable than attempting to judge for ourselves.

September 26, 2009

The Great Depression is ancient history. It's high time people get over their fear of falling prices.

Professor George Selgin makes the argument that falling prices reflect improvements in productivity and are economically beneficial
..Nobody predicts Armageddon when, say, the price of computers declines year after year. Everyone understands that the drop in prices has nothing to do with a shortage of consumer demand but is rather due to productivity improvements in the computer industry.

Yet when similar improvements start happening all around, and so affect the general price level, doomsayers start squawking. It is as if they just can't conceive of the possibility of general improvements in efficiency making most people better off, with the gains being transmitted via lower prices.
.. I suggest that the rest of us ignore the squawking and go shopping.

September 25, 2009

Thick skinned

Those dermatologists are an exciting bunch
We report a case in which a diagnosis of latent tuberculosis infection in a patient with extensive bullous pemphigoid was clarified by the use of an interferon-gamma release assay after equivocal tuberculin skin test results.

CONCLUSION:Interferon-gamma release assays are useful adjuncts to the tuberculin skin test in the diagnosis of latent tuberculosis infection in the setting of extensive cutaneous disease.

September 23, 2009

Julie Novak looks for monkeys and only finds nuts

Suppose I walk up to you and forcibly take from your wallet $3636. That is roughly about the amount of the Federal Government's combined stimulus programs per head of population.

I immediately give you back $900 of this for you to spend on anything you want - cigarettes, clothing, computer games, fridges, handbags, mobile phones, tattoos, anything you care to buy. You could even deposit it straight back into your own bank account.

I then spend $2227 of your money on things that take my fancy.

The rest here

Friday night is curry night

The India Times is running a chat line covering most topics with medical aspects being by attended to by the enthusiastic Dr Aniruddha Malpani. Dr Malpani runs the Malpani Infertility Clinic which operates out of Mumbai India and is also kept busy running his blog The Patients Doctor, the "world's largest free patient education library" HELP, is a director on the Board of a Healthcare BPO Inventurus and Yos Technologies, which provides a comprehensive "Personal Healthcare System" including PHRs, Healthcare tools and applications for Preventive and Continuous Care.


Anyway "Ranjana" wrote to the tireless Dr Malpani saying;
I am a 30 years old female and have been planning a baby for the last one year but did not succeed. My husbands and my fertility tests have yielded normal results. Recently, I got an interferon gamma release assay (IGRA), which tested positive for latent Tuberculosis. My gynecologist asked me get a chest X-ray, a trans vaginal scan and other ultrasounds done, which were all normal. She asked me to go for an endometrial biopsy, which I was not willing to undergo. I have also got my fallopian tube imaging done and it is all clear and normal. Now, I have been put on anti-TB medication for six months. I have finished one month of these medicines and also got a liver test done to see if the medicines were not adversely affecting the liver and the test results were fine and within reference range. My concern is that can latent TB be a cause of infertility and will this treatment help?
Dr Malpani wasted little time in displaying his ignorance;
There is no such thing as latent TB. This is rubbish. I don't think you have TB at all! These tests are very unreliable..
After reading this I had a closer look at Dr Malpani's CV, it would appear that his awards were gained as a student and of his numerous publications only 4 are listed in PubMed (and one of those is about his Help line) Not that this matters too much, it is the misreporting of the truth that concerns me. Elsewhere Dr Malpani says
While the initial exposure to the tubercle bacillus is through the lungs (because the bacillus is inhaled), most of us can fight off the infection, as a result of which it remains silent in the body, causing no harm. However, sometimes these latent bacilli can get reactivated, and then spread throughout the body through the blood stream.
OK, so now he is saying that latent TB does exist!

At the very least Dr Malpani's advice is inconsistent and should be taken with caution.

.

September 22, 2009

From Bear to Bull - James Grant in WSJ




As if they really knew, leading economists predict that recovery from our Great Recession will be plodding, gray and jobless. But they don't know, and can't. The future is unfathomable.

Not famously a glass half-full kind of fellow, I am about to propose that the recovery will be a bit of a barn burner. Not that I can really know, either, the future being what it is. However, though I can't predict, I can guess. No, not "guess." Let us say infer.

The very best investors don't even try to forecast the future. Rather, they seize such opportunities as the present affords them. Henry Singleton, chief executive officer of Teledyne Inc. from the 1960s through the 1980s, was one of these enlightened opportunists. The best plan, he believed, was no plan. Better to approach an uncertain world with an open mind. "I know a lot of people have very strong and definite plans that they've worked out on all kinds of things," Singleton once remarked at a Teledyne annual meeting, "but we're subject to a tremendous number of outside influences and the vast majority of them cannot be predicted. So my idea is to stay flexible." Then how many influences, outside and inside, must bear on the U.S. economy?

Though we can't see into the future, we can observe how people are preparing to meet it. Depleted inventories, bloated jobless rolls and rock-bottom interest rates suggest that people are preparing for to meet it from the inside of a bomb shelter.

The Great Recession destroyed confidence as much as it did jobs and wealth. Here was a slump out of central casting. From the peak, inflation-adjusted gross domestic product has fallen by 3.9%. The meek and mild downturns of 1990-91 and 2001 (each, coincidentally, just eight months long, hardly worth the bother), brought losses to the real GDP of just 1.4% and 0.3%, respectively. The recession that sunk its hooks into the U.S. economy in the fourth quarter of 2007 has set unwanted records in such vital statistical categories as manufacturing and trade inventories (the steepest decline since 1949), capacity utilization (lowest since at least 1967) and industrial production (sharpest fall since 1946).

It isn't just every postwar disturbance that sends Citigroup Inc. (founded in 1812) into the arms of the state or has General Electric Co. (triple-A rated from 1956 to just this past March) borrowing under the wing of the Federal Deposit Insurance Corp. Neither does every recession feature zero percent Treasury bill yields, a coast-to-coast bear market in residential real estate or a Federal Reserve balance sheet beginning to resemble that of the Reserve Bank of Zimbabwe. Yet these things have come to pass.

Americans are blessedly out of practice at bearing up under economic adversity. Individuals take their knocks, always, as do companies and communities. But it has been a generation since a business cycle downturn exacted the collective pain that this one has done. Knocked for a loop, we forget a truism. With regard to the recession that precedes the recovery, worse is subsequently better. The deeper the slump, the zippier the recovery. To quote a dissenter from the forecasting consensus, Michael T. Darda, chief economist of MKM Partners, Greenwich, Conn.: "[T]he most important determinant of the strength of an economy recovery is the depth of the downturn that preceded it. There are no exceptions to this rule, including the 1929-1939 period."

Growth snapped back following the depressions of 1893-94, 1907-08, 1920-21 and 1929-33. If ugly downturns made for torpid recoveries, as today's economists suggest, the economic history of this country would have to be rewritten. Amity Shlaes, in her "The Forgotten Man," a history of the Depression, shows what the New Deal failed to achieve in the way of long-term economic stimulus. However, in the first full year of the administration of Franklin D. Roosevelt (and the first full year of recovery from the Great Depression), inflation-adjusted gross national product spurted by 17.3%. Many were caught short. Among his first acts in office, Roosevelt had closed the banks. He had excoriated the bankers, devalued the dollar, called in the people's gold and instituted, through the National Industrial Recovery Act, a program of coerced reflation.

"At the business trough in 1933," Mr. Darda points out, "the unemployment rate stood at 25% (if there had been a 'U6' version of labor underutilization then, it likely would have been about 44% vs. 16.8% today. . . ). At the same time, the consumption share of GDP was above 80% in 1933 and the household savings rate was negative. Yet, in the four years that followed, the economy expanded at a 9.5% annual average rate while the unemployment rate dropped 10.6 percentage points." Not even this mighty leap restored the 27% of 1929 GNP that the Depression had devoured. But the economy's lurch to the upside in the politically inhospitable mid-1930s should serve to blunt the force of the line of argument that the 2009-10 recovery is doomed because private enterprise is no longer practiced in the 50 states.

To the English economist Arthur C. Pigou is credited a bon mot that exactly frames the issue. "The error of optimism dies in the crisis, but in dying it gives birth to an error of pessimism. This new error is born not an infant, but a giant." So it is today. Paul A. Volcker, Warren Buffett, Ben S. Bernanke and economists too numerous to mention are on record talking down the recovery before it fairly gets started. They collectively paint the picture of an economy that got drunk, fell down a flight of stairs, broke a leg and deserves to be lying flat on its back in the hospital contemplating the wages of sin. Among economists polled by Bloomberg News, the median 2010 GDP forecast is for 2.4% growth. It would be a unusually flat rebound from a full-bodied downturn.

Our recession, though a mere inconvenience compared to some of the cyclical snows of yesteryear, does bear comparison with the slump of 1981-82. In the worst quarter of that contraction, the first three months of 1982, real GDP shrank at an annual rate of 6.4%, matching the steepest drop of the current recession, which was registered in the first quarter of 2009. Yet the Reagan recovery, starting in the first quarter of 1983, rushed along at quarterly growth rates (expressed as annual rates of change) over the next six quarters of 5.1%, 9.3%, 8.1%, 8.5%, 8.0% and 7.1%. Not until the third quarter of 1984 did real quarterly GDP growth drop below 5%.

One may observe that Ronald Reagan stood for enterprise, free trade and low taxes, whereas Barack Obama stands for other things. Yet President Obama's economic policies seem almost as far removed from Roosevelt's as they are from Reagan's. (Not for Obama, at least not yet, is a new National Recovery Administration). Certainly, Roosevelt never attempted anything like the fiscal and monetary resuscitation organized over the past 12 months. In the post World War II era, the government has attacked recessions with an average fiscal stimulus of 2.6% of GDP and an average monetary stimulus of 0.3% of GDP, for a combined countercyclical lift of 2.9%. (Fiscal stimulus I define as the cumulative change in the federal budget, monetary stimulus as the cumulative change in the Fed's balance sheet, both measured from the peak of the boom to the trough of the bust.) This time out, the fiscal stimulus is likely to measure 10% of GDP, monetary stimulus 9.5% of GDP, for a combined pick-me-up equivalent to 19.5% of GDP. Our Great Recession would be marked for greatness if for no other reason than by the outpouring of federal dollars to repress it.

What did we do before Timothy Geithner and Ben Bernanke? In the day, it was the self-regenerative power of markets that lifted us off the rocks. The brutality of the depression of the early 1920s could not have been far from the mind of President Harry S. Truman as he signed into law the 1946 act to make it the government's business to maintain the economy at full employment. That 1920-21 crackup featured a deflationary collapse—wholesale prices plunged by 37%—and, by 21st century lights, a highly unconventional set of government measures to set things right. To meet the downturn, the Fed raised, not lowered, interest rates and Congress balanced the budget—indeed, ran a surplus. Yet the depression ended. How, exactly, did it end? Falling prices opened wallets, the monetary historian Allan H. Meltzer explains. Finding bargains, consumers and investors snapped them up. "The fall in market prices raised the public's stock of real [money] balances above the desired amount, just as if the Federal Reserve had increased base money at a constant price level," Mr. Meltzer relates in his "A History of the Federal Reserve." After falling by 4.4% in 1920 and by 8.7% in 1921, inflation-adjusted GNP shot up by 15.8% in 1922 and by 12.1% in 1923.

Bargain-hunting is the balm of recovery even today, dead set against low prices the Federal Reserve might be. Detroit is a living laboratory in many things, including the so-called real balance effect. As Marshall Mandall, a RE/MAX agent in that city, tells the story, house prices are still falling at the high end of the market, though they have stabilized at the low end. Transaction volumes are rising. Speculators are on the prowl, but so, too, are ordinary home buyers. It seems—who'd have guessed it?—that value sells. "They can buy something for half of what they could three years ago," Mr. Mandall says. "Everybody perceives bargains in their house-hunting." At the end of the second quarter, according to the Detroit Free Press, the supply of unsold houses was equivalent to 8.5 months' sales, down 39% from the year before.

Through the first six months of 2009, the Case-Shiller 10-City Composite index of house prices fell by 5.5% compared to year-end 2008. However, the rate of decline has been slowing and, indeed, the index recorded month-to-month appreciation in May and June. It may just be that the Fed's assumption of a 14% decline in prices this year (built into the base case of its bank stress test) is unrealistically bearish.

The Fed's voice is among the saddest in the lugubrious choir of bearish forecasters, and for good reason. By instigating a debt boom, the Bank of Bernanke (and of his predecessor, Alan Greenspan) was instrumental in causing our troubles. You might have thought that it would therefore see them coming. Not at all. Belatedly grasping how bad was bad, it has thrown the kitchen sink at them. And it maintains this stance of radical ease lest it get the blame for a relapse. However, by driving money market interest rates to zero and by setting all-time American records in money-printing ($1.2 trillion conjured in the past 12 months), the Fed is putting the value of the dollar at risk. Its wide-open policy all but begs our foreign creditors to ask the fatal question, What is the dollar, anyway? Why, the dollar is a scrap of paper, or an electronic impulse, the value of which is anchored by the analytical acuity of the monetary bureaucracy that failed to predict the greatest financial crackup since the 1930s.

The Fed may be worried about something else. By sitting on interest rates, it is distorting every business and investment decision. If mispriced debt was the root cause of the narrowly-averted destruction of global finance, the Fed is well on its way to setting the stage for some distant (let us hope) Act II. In the meantime, ultra-low interest rates have lit a fire under the stock and debt markets.

By rallying, equities and corporate bonds not only anticipate recovery, but they also help to bring it to fruition. By opening their arms wide to such previously unfinanceable businesses as AMR Corp., parent of American Airlines, and Delta Air Lines Inc., the newly confident credit markets are implementing their own stimulus program. "Reflexivity" is the three-dollar word coined by the speculator George Soros to describe the dual effect of market oscillations. Not only does the rise and fall of the averages reflect economic reality, but it also changes it. One year ago, the Wall Street liquidation stopped world commerce in its tracks. Today's bull markets are helping to revive it.

I promised to be bullish , and I am (for once)—bullish on the prospects for unscripted strength in business activity. So, too, is the Economic Cycle Research Institute, New York, which was founded by the late Geoffrey Moore and can trace its intellectual heritage back to the great business-cycle theorist Wesley C. Mitchell. The institute's long leading index of the U.S. economy, along with supporting sub-indices, are making 26-year highs and point to the strongest bounce-back since 1983. A second nonconformist, the previously cited Mr. Darda, notes that the last time a recession ravaged the labor market as badly as this one has, the years were 1957-58 —after which, payrolls climbed by a hefty 4.5% in the first year of an ensuing 24-month expansion. Which is not to say, he cautions, that growth this time will match that pace, only that growth is likely to surprise by its strength, not weakness.

And that is my case, too. The world is positioned for disappointment. But, in economic and financial matters, the world rarely gets what it expects. Pigou had humanity's number. The "error of pessimism" is born the size of a full-grown man—the size of the average adult economist, for example.

The State of Healthcare

As reported in the LA Times private insurer and Fortune 500 company Humana Medicare sent out this mailer on the proposed changes to US healthcare policy.
With the media reporting daily on Congress' and President Obama's efforts to enact meaningful health reforms this year, many Humana Medicare Advantage (MA) members are contacting us with
questions. Members just like you want to know what these reforms might mean for their Medicare health plan and how they can get involved to help protect Medicare Advantage.

...Leading health reform proposals being considered in Washington, D.C., this summer include billions in Medicare Advantage funding cuts, as well as spending reductions to original Medicare and Medicaid. While these programs need to be made more efficient, if the proposed funding cut levels become law, millions of seniors and disabled individuals could lose many of the important benefits and services that make Medicare Advantage health plans so valuable. ~
The Government got wind of this and sent off this rocket
CMS is concerned that, among other things, this information is misleading and confusing to beneficiaries, represents information to beneficiaries as official communications about the Medicare Advantage program, and is potentially contrary to federal regulations and guidance for the MA and Part D programs and other federal law, including HIPAA. As we continue our research into this issue, we are instructing you to end immediately all such mailings to beneficiaries and to remove any related materials directed to Medicare enrollees from your website.

Please be advised that we take this matter very seriously and, based upon the findings of our investigation, will pursue compliance and enforcement actions.

Several points here;

1. is it proper for the Government to issue instructions to individuals and companies based on "potential" contraventions of the Law?

2. as they are yet to finalise their investigation hasn't the Government already prejudged the outcome of those findings?

3. has the Government overstepped the mark by using the Law to restrict debate of its policies?

As President Barack Obama said recently
Now I think that what's driving passions right now is that health care has become a proxy for a broader set of issues about how much government should be involved in our economy..

.

September 21, 2009

The Ken Henry Tax Review

Peter Martin has signaled what we might expect later this year
THE review of the nation's tax system led by the Treasury secretary, Ken Henry, is set to recommend a cut in the company tax rate to as low as 25 per cent, offset by higher taxes on capital gains and mining profits.
Elsewhere Peter Martin indicates that we could be in for
pay-as-you-drive road taxes policed by geosynchronous satellites, death duties, wealth taxes, higher capital gains and resource rent taxes, the withholding of superannuation until the age of 67, the shaving of corporate tax rates and the slashing of taxes on insurance.
The Govt has already told Henry to lay off superannuation and dividend imputation and are in no need to implement immediate reform
Henry speaks about the review as a once-in-a-generation game changer. This is partly good news for Rudd and Swan because it releases them from the obligation to act on the recommendations quickly in what will be the lead-up to an election.
However cuts to company tax should happen sooner not later
A nation's rate of company tax turns out to be pivotal to its ability to attract and retain foreign capital. The Henry review is utterly convinced of that....gains from even small cuts to a nation's corporate tax rate are so big that Australia would be doing itself a disservice by leaving its rate at an uncompetitive 30 per cent.

September 20, 2009

TB skin test - a stab in the dark

Funny how you read something and takes a while for the penny to drop? - I previously referenced this spanish study into HCWs and only now has the implications struck home

Of those subjects who were positive TST and negative IFN-γ and whose blood samples successfully completed the prolonged stimulation test (where they assessed the IFN-γ samples after 9 days of incubation) 8 remained negative and 2 were positive.

The 8 TST positives that remained IFN-γ negative indicate that something is not quite right with the TST. The researchers considered this option
we have to consider as potential explanation the fact that we cannot confirm the accuracy of the previous positive TST results performed in other institutions, because the tests were not done under study conditions, and maybe some of them were erroneously considered as positive (the milimetres of induration of the previous positive TST were not recorded).

Interestingly the subjects appeared not too impressed by the TST
we asked some HCWs about the possibility of repeating the TST and they all refuse.
Normally TST is not conducted under laboratory conditions and therefore the degree of accuracy of the test cannot be measured or confirmed - it is not an accurate scientific procedure and the accuracy of most if not all currently available TST data is debatable.

Those TST positives that became IFN-γ positive support the hypothesis that IFN-γ detect only effector T-cells whereas the TST is unable to discriminate between memory and effector Tcells.
Given that the risk of developing active TB is higher in the first 2 years after infection, the detection of recent TB infection by means of IFN-γ tests in HCWs (mainly immunocompetent) seems to be very useful for targeting the high risk population that really need LTBI.
This is more important than being able to discriminate between active and latent TB, a notion which seems to have possessed and dominated some thought.

.

September 18, 2009

Did the stimulus work?

No, according to these academics who looked at past and present government efforts in light of available data;

Incoming data will reveal more in coming months, but the data available so far tell us that the government transfers and rebates have not stimulated consumption at all, and that the resilience of the private sector following the fall 2008 panic--not the fiscal stimulus program--deserves the lion's share of the credit for the impressive growth improvement from the first to the second quarter. As the economic recovery takes hold, it is important to continue assessing the role played by the stimulus package and other factors. These assessments can be a valuable guide to future policy makers in designing effective policy responses to economic downturns. 

Fed -vs- FedEx

Whilst Ben Bernankes economic forecast was cautiously luke warm
from a technical perspective the recession is very likely over at this point, it's still going to feel like a very weak economy for some time
FedEx reports from the coalface
FedEx Corp reported a 53 percent drop in quarterly profit on Thursday as the worldwide economic downturn continued to weigh on shipping volumes.

But the package delivery giant and economic bellwether said most of its markets were continuing to show signs of improvement, raising the prospect of a wider rebound that might help lift other companies and sectors out of the slump.

"Confidence appears to be improving, the housing sector seems to have bottomed and the auto sales have picked up," Fred Smith, FedEx's chairman, chief executive and president, said during a conference call to discuss the results. 
"These are encouraging signs of a more stable economy."
Smith also predicted that the U.S. economy would grow by 3 percent in the third quarter, 4.9 percent in the fourth quarter and 2.9 percent in 2010.

"The tide is rising," said Dan Ortwerth, an analyst at Edward Jones. "And volumes are improving faster than I thought."..

Interscience Conference on Antimicrobial Agents and Chemotherapy - September 2009

A round up of relevant ICAAC presentations. In the last presentation the author, Dr Madhukar Pai, strays considerably off topic and speaks about the role of IGRAs in detecting active TB among selected populations such as young children, immunocompromised persons, and individuals with smear-negative and extrapulmonary disease..IGRAs may offer supporting evidence to help establish a diagnosis of active TB


BCG-Vaccination Status and Testing for Latent Tuberculosis in an HIV Cohort from a Low Prevalence TB Country
In HIV-patients, we found significant interference of TST results with BCG-vaccination, although this had been abandoned in the late 1970’s. Interferon-gamma tests are unaffected by prior BCG-vaccination and therefore seem to be more appropriate for testing latent TB infection in HIV-patients.


Usefulness of an Interferon-γ Release Assay in Comparison with Tuberculin Skin Test (TST) for Latent Tuberculosis Infection (LTBI) in HIV Infected Patients
Overall concordance between QFT and TST in HIV infection was moderately high, but agreement among patients with positive tests by either modality was low

Comparison of Quantiferon-TB Gold in Tube Assay (QFT-G) with Tuberculin Skin Test (TST) for Detecting Latent Tuberculosis Infection (LTBI) Prior to Transplantation
QFT-G appeared to be comparable to TST for the diagnosis of LTBI in transplant candidates with acceptable concordance. Variable results were observed for different pre-transplant populations. Discordance between the two tests was more likely to occur in younger persons.
High Prevalence of Latent Tuberculosis Infection in End-Stage Renal Disease Patients on Hemodialysis, Using QuantiFERON-GOLD In-Tube Test and Tuberculin Skin Test
This study confirms that end-stage renal disease patients on hemodialysis have a high prevalence of latent TB infection (34.4%) by QGIT positivity. The risk factors for this observation remain to be elucidated.


Feasibility of the QuantiFERON-TB Gold In-Tube for the Diagnosis of Tuberculosis Infection in HIV-Infected Adults
1. Performance of QFT-GIT is impaired by advanced HIV-associated immunosuppression, but less than TST.
2. Poor agreement between TST and QFT-GIT among positive patients on either test would advocate for simultaneous testing in HIV  


Diagnosis of LTBI in BCG Recipients
Overall, IGRAs are useful tests for the detection of LTBI, and their use is rapidly expanding in low incidence countries.

September 17, 2009

Kling on the crisis

Dr. Arnold Kling, who served as a senior economist at Freddie Mac from 1986–1994 and was an economist on the staff of the Board of Governors of the Federal Reserve System from 1980–1986, has produced this paper on the Financial Crisis of 2008;
Unless the United States comes to terms with the fact that the actions of policy makers and regulators contribute to financial fragility, it has little hope of moving in the direction of a less fragile system for the future. 
In testimony to US Congress on “The Risks of Financial Modeling: VaR and the Economic Meltdown.” David Colander commented on the apparent lack of commonsense that permeates institutions
The dominant model in macroeconomics is the dynamic stochastic general equilibrium (DSGE) model. This is a model that assumes there is a single globally rational representative agent with complete knowledge who is maximizing over the infinite future. 
..Had the DSGE model been seen as an aid to common sense, it could have been a useful model.
..Unfortunately, the warning labels on the models that should have been there in bold print—these models are based on assumptions that do not fit the real world, and thus the models should not be relied on too heavily—were not there
..The over-reliance on a single model used without judgment is a serious problem that is built into the institutional structure of academia that produces economic researchers. That system trains show dogs, when what we need are hunting dogs.

.

QFT and kids

Two studies out, one from Italy assessing 336 at-risk children in a head-to-head study of QFT and TST
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.

The other from Australia is presently only available in abstract form and deals with NTM in children. The google alert contained this snip from the full study
In tuberculosis, interferon-gamma release assays are an increasingly used alternative to the human PPD skin test in managing patients with suspected 
which makes sense as how else do you quickly differentiate TB infection from non TB infection? The concept of using QFT to isolate TB from non-TB in children has been successfully trialled in the US
Their (IGRA) advantage in this study, when performed in addition to the TST, was the ability to distinguish positive TST results caused by nontuberculous mycobacterial disease, thereby reducing overdiagnosis of TB and guiding clinical management. 

These trials continue to reinforce the increased accuracy of QFT.

.

Japan Xrays- revisted

In comments Bob says
I read that article and have the impression that may only refer to the materials and life sciences x ray applications, not medical...
...So I think the medical x rays in japan is probably much greater than $150 mil 
Spot on Bob however in assessing the market size the Google machine will only spit out links to sites that want thousands of dollars for market research. As always its not the question but how you ask it and after reframing 'Bingo' we have a study of X-ray frequencies in Taiwan
It was estimated that 521 X ray examinations per 1000 people were annually performed in Taiwan. Chest examinations provided the largest contribution - 46% of all X ray examinations.
Its a start - with TB rates in Taiwan being comparable to those of Japan (Japan has 7.7/100K and Taiwan has ~7/100K) we could assume that Japan and Taiwan share similar testing rates

With a population of 127.3M Japan could well conduct 64.9M X-rays per year of which 29.8M are for chest examinations.

We dont know what proportion of chest examinations are for TB however a wild stab at 60% leaves is with some 18M TB X-rays per year.

However all these guesstimates are thrown into disarray when considering the age of the Taiwan data - 1993. Since that time the world has shifted to one of risk assessment with Japan amending its TB control practices
The "indiscriminate" screening scheme in the periodic mass health examination has been replaced with a selective one.
So the short answer is - nobody knows

.

September 16, 2009

Myths busted

Jeffrey Friedman identifies the most commonly accepted reasons for the current GFC;

1. Irrational Exuberance - before accepting his role as FED chairman Ben Bernanke gave his expert opinion that he did not think that the housing boom was a bubble ready to burst and his thoughts were supported by then chairman Alan Greenspan who also said that there was no national bubble in home prices, but rather "froth" in some local markets.

2. Bankers’ Bonuses - not only were bankers bonuses made up of stock, which they then lost in the downturn, it was later shown that bankers mostly invested in secure (AAA) product foregoing higher returns from higher risk products.

3. Capitalism Caused the Crisis - the issuance by the regulators and acceptance by the market of the Recourse Rule meant that risk was valued and codified allowing banks to issue mortgages regardless of the soundness of the borrower and then sell these to investment banks who then bundled them up into securities which were then sold back to the banks as collateral.

Friedman concludes;
If we seek the sources of a systemic failure, a logical place to look is among the legal rules that govern the system as a whole. Unfortunately, being legal mandates, these rules--unlike the different strategies pursued by competing capitalists--aren't subjected to a competitive process. So if they are based on mistaken ideas, we all suffer the consequences. That turned out to be the case with the Recourse Rule.

Contrary to popular belief, then, the crisis of 2008 is best described as a crisis of regulation—not a crisis of capitalism

Twitty?

This popped up on Twitter
Interferon gamma testing (Quantiferon Gold, TB-Spot) will eventually replace the TST for tuberculosis screening. CDC recommends it now!
Sent by Twitperson Nicholas Fogelson who also runs a medical/academic blog for the "OB/GYN Physician"

Not sure how popular this site is however the blog meister assures lurkers that the number of downloads of his medical podcasts is in the thousands.

September 15, 2009

Japan

NIHON BCG are now advocating that QuantiFERON be used to assist in the diagnosis of active TB, particularly when X-rays are inconclusive.

The X-ray market in Japan has been estimated at $150M per year and as TB control has been mandated TB diagnosis would form a significant proportion of the X-ray market.

September 11, 2009

A theory about Australia

Professor Bill Mitchell takes a peek at the latest retail figures and comes up with the following;

H1: Australian are drinking less alcohol and sobering up after decades of alcohol abuse.

H2: Australians have decided that they are obese and have decided to eat less.

H3: Australians have given up on their Bunning’s binge realising that the stuff there is mostly junk.

H4: Australians have stopped buying shoes because they have have too many anyway. I have witnessed this personally!

H5: Australians have given up reading News Limited newspapers because they got sick of the economic commentary! (no link required).

Further we can conjecture the alternatives:

AH1: Australians are going to specialised food outlets to get organic vegetarian-based food as part of a lifestyle change.

AH2: Australians are buying more vitamins and deodorants because they are exercising more (alternative to H1 and H2 and H3).

AH3: Australians are buying more recreational goods beause they are exercising more (alternative to H1 and H2 and H3).

Conclusion: fiscal policy is good!



Well, thats his story!


.

QFT and TST; a head-to-head comparison

From Statens Serum Institute, Denmark, comes this comparison of latent TB diagnostics among patients with inflammatory disease before and during treatment;
The study documented a high degree of discordant positive QFT and TST results. A positive QFT was more closely associated with risk factors for M. tuberculosis infection than the TST. The use of corticosteroids affected test outcome by increasing the risk for an inconclusive QFT result and decreasing the risk for a positive TST result. 
The corticosteroids would have suppressed the immune system which is why the QFT would have returned an indeterminate.

September 10, 2009

Finally, an objective, sensitive, specific, and cost-effective replacement for the 100 year old tuberculin skin test!

Thats the opening line for this very recent publication from Quest Diagnostics Nichols Institute. It's worth noting that with 43,500 full time employees and earnings of $6.7B Quest Diagnostics is the leading diagnostics supplier in the US.  Quest Diagnostics is also a member of Fortune 500 and the S&P 500.

September 9, 2009

Follow that stamp collector

Following publication of Warren Buffetts biography Snowball various pundits have speculated that he had a version of autism known as Aspergers.
This lack of empathy seems to me almost pathological. Although Schroeder never once raises the possibility in her epic account of the greatest capital accumulator in history, it seems perferctly possible that Buffett is a case of high-functioning Asperger's syndrome. As a child, he was an obsessive collector. As an adult, his most treasured possession is a model train set, which he shows only to his most trusted friends. His other idea of relaxation is to play bridge on a computer for hours every evening.
The Tyler Cowen book Create Your Own Economy: The Path to Prosperity in a Disordered World argues that autistic tendencies toward classification, categorization and specialization can be used as a vehicle for understanding how people use information. Scott Sumner, Professor of Economics at Chicago made the following observation;
When I decided to read Tyler Cowen’s new book on the airplane to China, I pretty much knew I was going to arrive in Beijing convinced that I was autistic.  Here are some reasons:

1. Any time I read some psychology I think they’re talking about me.

2. I recently heard an autistic guy on NPR who was a wizard with numbers.  His description of the autistic personality reminded me a bit of myself.

3. I had heard Tyler talk about his book, and knew that he had a favorable view of what he called “the autistic cognitive profile.”

4. Autistic people like to make lists of things.

Professor Sumner then notes that autistic people are often the most rational and are
less swayed by framing effects and also less swayed by emotions such as envy and revenge, which can be counterproductive.

He then proposes that the post-Lehman crash was a very powerful framing device because its a great story and quotes Tyler
Most people are programmed to think in terms of stories and they have an especially good memory for stories....The media is good at portraying heroes and villains and conspiracies, while it is bad at giving people an understanding of abstract or unseen social and economic forces.
Non autistic people are prone to listen to horror stories whilst those with autistic tendencies
the implications are clear; monetary policy is the key to the crash of 2008.  But of course the framing effects made this hard to see, so we relied on fiscal stimulus.
...So let me finally get to the point. I believe that the financial crisis of 2008 was the mother of all frame jobs.  The commercial bankers were framed, when it was really the central bankers that created the severe recession.

.

Diagnosing latent TB in children - guidelines

The UMDNJ have published their updated guide to managing latent TB infection in children and adolscents and due to demand have included a section on IGRAs. Once again the emphasis is on risk analysis and due to the difficulties experienced in testing children for TB they have stipulated that children without risk factors should not be tested; NO RISK NO TEST

IGRAs have been approved for use in adults in all circumstances where a TST would be used. However, there is a lack of published data related to IGRA use in children and the American Academy of Pediatrics only recommends its use in place of TST in immunocompetent children 5 years of age or older. The 2009 Red Book offers the following guidelines for interpretation of IGRA results:
• Children with positive results should be considered infected with M. tuberculosis
• Negative results cannot universally be interpreted as lack of infection
• Indeterminate results do not exclude tuberculosis infection
• May be useful in determining whether a reactive TST in a BCG-vaccinated child is due to TB infection or a false positive result caused by BCG


Children for whom immediate TST or IGRA is indicated:
• Contacts of persons with confirmed or suspected contagious tuberculosis
• Children with radiographic or clinical findings suggesting tuberculosis disease
• Children immigrating from countries with high prevalence of TB (e.g., Asia, Middle East, Africa, Latin America, and countries of the former Soviet Union), including foreign adoptees
• Children with travel histories to endemic countries or substantial contact with people who live in these countries
*Countries in Eastern Europe also have a high prevalence of TB

Children who should have annual TST or IGRA:
• Children infected with HIV (TST only)
• Incarcerated adolescents

Curiously the UMDNJ booklet version does not refer to the recently published American Academy of Pediatrics Red Book so the guide on IGRA is somewhat ambiguous and inconsistent;
Two methods of testing for infection with M. tuberculosis are available; the Mantoux tuberculin skin test (TST) and a blood test, interferon-gamma release assays (IGRA) such as QuantiFERON®-TB Gold or T-SPOT®.TB. Although IGRAs have not been approved for use in children, increasing data on their use in the pediatric population suggests they may be an alternative to the TST in the future and show great promise for improving the diagnosis of latent TB infection.

September 8, 2009

The taxpayer and the candyman

Whoops, hold off the celebratory champers for now..

The UK think tank Institute of Economic Affairs have produced a report saying that
there are "troubling similarities" between the approach of the current US government and the disastrous economic policies of President Roosevelt during the 1930s.


.."Now is a particularly bad time to enact socialistic reforms to the market for healthcare, pursue wealth-destructive cap and trade environmental programs, or force additional federal tax dollars into state and local education markets. Such policies imply higher government spending and, eventually, either higher taxes or runaway inflation, thus depleting taxpayer and business confidence in the economy…"


In an article in the Telegraph the authors of the above report warn that
Prosperity and full employment in the US will only be restored by a return to laissez-faire capitalism. Our study outlines a radical, but politically feasible, approach. Monetary policy should be expansionary. But, on the micro-economic side, tariffs and other trade barriers should be repealed unilaterally; a "Right-to-Work" Act should reduce the minimum wage and curtail the powers of unions; and business regulation should be reduced. Individual banks and their counterparties should not be bailed out, although the system should be protected by ensuring that failing banks are wound up in an orderly fashion – this is the only way to restore market discipline.

September 6, 2009

New Mexico sticks to its guns


After originally announcing their swearing off the TST the New Mexico Department of Health show how they plan to do it -

"..the TB Program has purchased five portable incubators to be placed throughout the state in order to enable the pre-incubation of specimens prior to their courier transport to SLD for testing.

Several public health nurses and TB Program personnel have completed their training in specimen collection for the QFT and everyone is ready for the first trial of the new Test!"

.

Krugman and his attack on markets

In his latest piece in the NYT (How did economists get it so wrong?) Paul Krugman refers to Keynes advocacy of active government intervention to fight unemployment and finishes with
When it comes to the all-too-human problem of recessions and depressions, economists need to abandon the neat but wrong solution of assuming that everyone is rational and markets work perfectly.

UCLA Professors Harold L. Cole and Lee E. Ohanian have just released a paper stating that Government policies prolonged the Depression by 7 years
"The fact that the Depression dragged on for years convinced generations of economists and policy-makers that capitalism could not be trusted to recover from depressions and that significant government intervention was required to achieve good outcomes," Cole said. "Ironically, our work shows that the recovery would have been very rapid had the government not intervened."

In the WSJ they write that Government
Policies that decreased competition in product and labor markets were especially destructive.

and
wholesale government intervention can -- and does -- deliver the most unintended of consequences. This was true in the 1930s, when artificially high wages and prices kept us depressed for more than a decade, it was true in the 1970s when price controls were used to combat inflation but just produced shortages. It is true today, when poorly designed regulation produced a banking system that took on too much risk.

Krugman irrationally blames the free market for what is arguably a government failure.

.

Swings and roundabouts

By definition meta analysis can be paradoxical
A good meta-analysis of badly designed studies will still result in bad statistics.
However its not all bad news; the Pai Menzies meta analysis of T Cell based assays for diagnosing latent TB indicated that there currently exists is a discordance between QuantiFERON and the Elispot based diagnostics. This lack of agreement prevents the Elispot tests from claiming or sharing data attributed to QuantiFERON viz
A recent report of predominantly immunocompetent adult tuberculosis contacts who refused preventive therapy showed that a higher proportion of those who were initially positive by whole-blood ELISA (Quantiferon-Gold in-tube, Cellestis Inc, Carnegie, Victoria, Australia) developed active tuberculosis over two years follow-up than TST-positive contacts using a 5 mm cut-off point (29). However, this important observation, which was based on 6 incident tuberculosis cases, cannot be extrapolated to ELISpot because of substantial discordance between the two assays..

September 4, 2009

TB and the Law

The Californian Division of Occupational Safety and Health (better known as Cal/OSHA) proposed standard on aerosol transmissible diseases (ATDs), such as tuberculosis, SARS, measles, or pandemic flu, was approved by the Office of Administrative Law on July 7, 2009, and became the first such regulation in the country.

Employment lawyers Littler Mendelson made the following comments;

The vast majority of health care employers, and certain other employers whose employees are likely to come into contact with persons infected with aerosol transmissible diseases, are required by the regulation to take affirmative steps to ensure that the diseases are contained as much as possible.

Specifically included are the following:
Hospitals, Skilled nursing facilities, Clinics, Medical offices, Home healthcare services, Long-term healthcare facilities, Emergency service providers, Medical transport

Certain other high-risk facilities outside of the health care profession also are covered by the regulations. These include:
Police services during transport or detention of persons suspected to be cases of aerosol transmissible diseases, Homeless shelters, Drug treatment programs, Medical examiners' offices, Pathology laboratories, Correctional and detention facilities, Maintenance or repair operations involving air handling systems or building areas that can be anticipated to be contaminated with the aerosol transmissible pathogens
It is important to note that these laws are specifically designed to protect the workers from infection.

All covered employers (including referring employers) must:

* designate an administrator, who is in charge of establishing and maintaining procedures for infection control;
* establish written source control procedures including a means of informing persons with whom employees will have contact about the infection control procedures;
* establish procedures for screening persons who may have infectious diseases and for referring these persons to medical services if the employer is not a health care provider;
* establish written procedures to communicate with employees about infectious disease status of referred patients; and
* establish procedures to reduce the risk that the infected person might transfer the disease to other persons in the facility, including placing the person in a separate room and supplying respiratory protection to employees entering the room. 

Previously whilst guidelines had been established and issued compliance was not mandatory. Employers will now be compelled by law to follow those guidelines and establish and maintain proper infection control practices. Importantly these practices are to include the screening of all persons who will have contact with employees.

September 3, 2009

Japan - again

After this case where QFT was the only diagnostic to successfully identify non pulmonary active TB infection comes another;
Interferon-gamma release assay (IGRA) using specific tuberculous antigens is a rapid, specific and sensitive method for the detection of tuberculous infection, and usually done in peripheral blood sample. We examined IGRA in cerebrospinal fluid (CSF) in a patient strongly suspected of having tuberculous meningitis. A 53-year old woman had a month history of headache and fever with meningeal sign. Routine systemic bacterial, tuberculous and viral analyses all resulted in negative study except for increase of adenosine deaminase in CSF. Neither of antibacterial or antiviral treatments were effective, but she was successfully treated with antituberculous agents. In IGRA, the interferon-gamma concentration in her CSF was high in the background level and increased further after the antigen stimulation, suggesting theoretically that tuberculous antigen-specific T cells were presented in her CSF. IGRA of CSF in combination with peripheral blood-IGRA could be a useful and rapid method for diagnosing active tuberculosis in the central nervous system.

September 2, 2009

Everything that you always wanted to know about interferon gamma..

..but were too afraid to ask? I dont blame you, reading this expose (Interferon-y: an overview of signals, mechanisms and functions) is daunting so lets just cut to the chase;
Although IFN-y production was shown to be disease-limiting in autoimmune models such as murine experimental allergic encephalomyelitis (EAE), it may contribute to autoimmune nephritis. In humans, IFN-y is implicated in pathology of diseases such as systemic lupus erythematosus, multiple sclerosis, and insulin-dependent diabetes mellitus.

IFN-y function is significant in tumor surveillance.  
Lets just leave the speculation at that - detection of IFN-y of various medical conditions by the QFT platform has potential.

September 1, 2009

Medicare Australia - update

Latest data plotted; remember that QFT has not been fully embraced by the TB authorities in Australia and does not enjoy as large a rebate as in the US. It would appear that the medical community has acted independently.

(click on image for FULL SIZE)