text:
Toward 2021: The Power—and Limitations—of Policy
Stephen S. Poloz - Former Governor (2013 - 2020)
The Chamber of Commerce of Metropolitan Montreal
Montréal, Quebec
Available as: PDF
As the country's central bank, our responsibilities are spelled out in the Bank of Canada Act. Its preamble says that our job is to "promote the economic and financial welfare of Canada"—a lofty assignment.
Few mention the phrase that comes right before that: "so far as may be possible within the scope of monetary action." Even in 1935, the drafters of our legislation recognized that monetary policy cannot do everything. There are limits to its power. I will talk about three of these limitations today.
Our understanding of these limits has evolved with experience. Forty years ago, it was widely believed that monetary policy had very limited power. Today, especially after the global financial crisis, people seem to have a pretty high level of confidence in the power of monetary policy.
Every five years, the Bank undertakes a wide-ranging research and public consultation process to recommend to the government how we should carry out our responsibilities. We will make our next recommendation in 2021. So now is a good time to take stock of our understanding of the power—and limitations—of monetary policy. That is what I aim to do today.
The power of inflation targeting
For more than 25 years, the Bank has focused its monetary policy directly on keeping inflation low. For someone who remembers well the inflation of the 1970s, this focus makes perfect sense. But fewer and fewer people remember how difficult those times were. Inflation was not only high—much higher than today—it also jumped around from year to year. For both households and businesses, making financial plans was a very risky exercise.
The transition from an inflation-prone world was not an easy one. Central banks needed to break inflation psychology by raising interest rates dramatically during 1979–81. In 1981, when I arrived at the Bank, the average posted rate for a five-year mortgage in Canada peaked at over 20 per cent. Can you imagine paying 20 per cent for a five-year fixed-rate mortgage? Today, most mortgages of the same terms have an interest rate under 4 per cent.
To prevent future outbreaks of inflation, in 1991, the Bank of Canada became one of the first central banks to adopt the policy framework known as inflation targeting. Many other major central banks soon followed.
To put things very simply, the Bank influences inflation by lowering or raising interest rates to heat up or cool down the economy. The idea is to adjust rates to balance total demand and supply, thereby stabilizing inflation. Low interest rates stimulate demand by encouraging people and businesses to borrow, spend and invest. High interest rates do the opposite.
In practice, inflation targeting is much more complex and difficult than this. Many forces that affect demand and supply in the economy lie beyond our control. What is more, our policy actions take time to have their full impact—up to two years. This means that we are always working with forecasts of where the economy and inflation will be in two years, and attempting to influence those things in the future.
A crucial feature of this framework is that we have just one policy instrument: our influence over interest rates. This represents the first major limitation on the power of monetary policy. With only one instrument, we can aim at only one objective. If inflation is our objective, we cannot use interest rates to target other things, such as the exchange rate or the unemployment rate, at the same time. Of course, that is not the same as saying that interest rates do not temporarily affect other things, such as economic growth and employment, as we go about targeting inflation. But ultimately, inflation is the sole target of the policy.
In the late 1980s, when inflation targeting first came under active consideration, many were skeptical that it could work at all. As it turns out, it has worked very well. Inflation expectations have become firmly anchored on our 2 per cent target. A symptom of our success is the fact that many people do not appreciate how problematic high and variable inflation and interest rates can be. This is a gift to the next generation, if you will. My children will never pay anything like the kind of interest rates I have paid in my lifetime.
It is not just that inflation and interest rates have been lower and more stable. With inflation expectations well anchored, monetary policy is more effective. The economy adjusts more quickly to shocks than in the past. Firms and households can make longer-range plans. Wage negotiations are much simpler. Economic cycles are less severe. Unemployment is lower on average and less variable. These observations are based on global experience from the early 1990s to the mid-2000s, a 15-year tranquil period called the Great Moderation.
All that success has led many to conclude that keeping inflation low, stable and predictable is the best contribution monetary policy can make to the economy. It sounds less ambitious than the preamble to the Bank of Canada Act, but the results have been very powerful.
Nevertheless, the widespread belief that keeping inflation low and stable would keep the economy out of trouble proved to be misplaced. The global financial crisis laid bare the second important limitation of monetary policy: low inflation can still lead to a buildup of dangerous imbalances in the economy. In effect, prolonged economic and financial stability can lead to excessive risk-taking and rising leverage. Regulatory complacency also played an important contributing role.
Imbalances can make the economy fragile. When a shock hits the economy, its effect can be amplified by these imbalances, and the central bank may have difficulty achieving its inflation target for some time. In other words, low and stable inflation may be necessary for sustainable economic growth, but it is not sufficient on its own. More on this later.
The perils of low for long
Policy-makers, both monetary and fiscal, have worked extremely hard for more than a decade to nurse their economies back to health.
By 2014, we appeared to be within a year of returning "home"—by which I mean the point where the economy is running at full capacity, with supply and demand in balance and inflation at target. When the economy is truly home, it can grow sustainably without policy stimulus.
Unfortunately, the economy hit a major setback late in 2014, when oil prices collapsed. The Bank lowered its key policy interest rate twice in 2015, to a very stimulative level of 0.5 per cent, to help the economy work through the shock of lower oil prices. The government also introduced new fiscal stimulus. Over the next two to three years, the economy gradually made its way back home, absorbing excess capacity and seeing inflation return to target. In this context, the Bank began withdrawing its extraordinary stimulus, raising interest rates by a total of 1.25 percentage points, to 1.75 per cent. But with that rate still lower than inflation, it is clear that monetary policy continues to deliver stimulus to the economy today.
Indeed, monetary policy has been stimulating the economy for much longer than anyone expected when the crisis began back in 2008. And we have seen the natural results of leaving interest rates very low for a long time. For one thing, this has been hard for people, such as retirees, who rely on interest from their savings for their income. Further, people have taken on a lot of debt, mostly in the form of mortgages and home equity lines of credit. By 2017, the ratio of household debt to disposable income had hit a record—with the average household owing more than $1.70 for every dollar of disposable income. If we remove households that do not have mortgages, the ratio becomes much higher—close to $3 for every dollar of disposable income. And house prices were rising extremely quickly in some of Canada's biggest cities.
This brings us back to the second major limitation on the power of monetary policy I mentioned above. When low interest rates persist, debt can reach levels that become risky for the borrowers and for the entire economy. When households carry a lot of debt, they become less able to manage through a temporary period of unemployment. The effect of shocks can be magnified when they interact with elevated debt. This can cause the economy to underperform for extended periods.
Let me illustrate by describing what might have happened had we not started to raise interest rates over the past couple of years as the economy approached home. If we had kept our interest rate at 0.5 per cent from mid-2015 until now, our models tell us that we would have seen stronger economic growth—no surprise there. By now, the level of GDP would be about 2 per cent higher than it is today. That sounds good, but inflation would also be higher—it would be close to the top of our 1–3 per cent target range, and very likely would be heading even higher. Faced with that prospect, we would need to raise interest rates forcefully to guide inflation back to its target over the next year or two.
Forceful increases in interest rates would pose problems for households carrying a lot of debt, of course. Indeed, if we had left rates down at 0.5 per cent, that debt load would be even greater by now, over $60 billion higher, or about $2,000 in additional debt for every Canadian. And it is certain that house prices would be even higher today—our models suggest by around 5 per cent nationally.
This scenario shows how monetary policy has the power to affect not just growth and inflation in the broader economy, but also financial vulnerabilities. In other words, in pursuing our inflation target, we may create side effects that make the economy vulnerable to new shocks. This is what happened during the Great Moderation, and it is what has happened during the recovery from the global financial crisis. Of course, the fact that we have only one policy instrument means that we cannot independently try to manage those side effects without putting our inflation target in jeopardy.
The implication is that policy-makers need additional instruments to address these side effects. To this end, Canada has developed a number of what we call "macroprudential policies." These measures include new rules for mortgage borrowing, the so-called B-20 guideline, for example, which was implemented by the Office of the Superintendent of Financial Institutions. The aim of these measures has been to reduce the economy's vulnerability by ensuring borrowers will be able to manage their debt, even when interest rates rise. Let me stress that the goal of these measures has always been to improve the quality of new household debt, not to slow down housing markets. That said, we have also seen various provincial and municipal governments put rules in place that are aimed specifically at containing house price growth.
To help guide the use of macroprudential tools, we need a way to measure the economic importance of financial vulnerabilities as they rise and fall. This would allow us to account for these side effects of monetary policy.
Recently, the Bank has started using a framework that estimates the economic growth that is at risk from financial vulnerabilities. When we forecast economic growth, there is always a range of possible outcomes around that projected path. Rising financial vulnerabilities make it more likely that an economic shock will cause the economy to follow a much weaker growth path, as the shock interacts with high levels of debt, for example. The gap between our most likely scenario and the possible adverse scenario where financial stability risks are realized is called "growth at risk." We can estimate how much economic growth is at risk with our models.
Let us go back to the hypothetical scenario where we simulated keeping our policy rate unchanged at 0.5 per cent from 2015 until now. As I said before, economic output would be higher, but inflation would be approaching
3 per cent by now and likely continuing to climb. Household debt and house prices would also be higher, which would mean the economy would be more vulnerable to a new economic shock. The downside risk from these vulnerabilities to economic growth—and therefore to inflation as well—would be rising throughout the scenario.
Fortunately, we did not follow this scenario. Both macroprudential and fiscal policies were also put in place, and this produced better outcomes.
It is important to understand the role that expansionary fiscal policy played. Our models show that if fiscal policy had remained unchanged following the collapse in oil prices in late 2014, the Bank would have had to set interest rates as much as 50 basis points lower during the 2015–18 period to get the economy back home. Instead of approaching full capacity in mid-2017, it would have taken until the end of 2018 for the economy to get home with inflation on target. This demonstrates that, at low interest rates and high debt levels, monetary policy has less power than fiscal policy in stimulating the economy.
Meanwhile, that lower track for interest rates would have led to even higher household debt and house prices. Our growth-at-risk framework shows that this would have meant an even greater risk that a new economic shock would cause the economy to fall into a low-growth scenario with inflation below target.
The bottom line is that the mix of monetary, fiscal and macroprudential policies matters. In certain circumstances, relying less on low interest rates to bring the economy home can mean a more resilient economy.
Knowledge limitations
Even though it can be hard to imagine counterfactual scenarios, these model simulations demonstrate some of the trade-offs that policy-makers face. They also highlight the third major limitation of monetary policy—how uncertainty limits the ability of the policy-maker.
Complex economic models are indispensable tools for economists, particularly those who work at central banks. However, these tools are all based on historical averages and embrace several simplifying assumptions that may not hold in reality. Every relationship in the Bank's models is meant only to approximate how part of the economy will behave, on average, over time.
The importance of this uncertainty is magnified by the fact that our policy operates in the future. Actions we take today will have their ultimate effects only in the next couple of years. In hockey, we must pass the puck not at the feet of our teammate, but to where he or she will be when the puck arrives. The sense of motion in the economy adds to the uncertainties we face as modellers and forecasters.
The reality is that conducting monetary policy requires a lot of judgment. Rather than the finely tuned mechanical process many people imagine, policy is much more akin to an exercise in risk management. As we said at the Bank's most recent interest rate announcement, we judge that we will need to move our policy rate up into a neutral range over time, to a point where it is not stimulating or constraining economic growth. However, the path back to that neutral range is highly uncertain. We will watch the data as they come in, and use judgment to deal with the uncertainties and manage the associated risks.
One important uncertainty that we are dealing with today is the impact of higher interest rates on highly indebted Canadians. Rising interest rates will mean these people will have to spend more of their income servicing debt, leaving less for other goods and services. Clearly, given these elevated levels of debt, raising rates will have more of an impact on the overall economy than in the past. This is one reason why we have been gradual in our approach to raising interest rates.
Housing markets are adjusting not only to higher interest rates, but also to new mortgage guidelines and rules aimed directly at cooling certain housing markets. Given the unique situation, we are monitoring the impacts carefully. Housing activity has been a little weaker than we expected recently. Mostly it is housing resales that have been soft, suggesting there may have been more froth in certain housing markets than previously thought. Housing markets that were not experiencing bidding wars appear to be adjusting in line with our expectations. However, more data will help us better understand the full situation in Canada's housing market.
A second area of intense interest is the outlook for business investment, which has been less robust than our models indicated for the past couple of years, mainly due to uncertainty about the future of the North American Free Trade Agreement. Although uncertainty remains around ratification of the new Canada-United States-Mexico Agreement, we expect investment spending to regain momentum in 2019, especially in light of the government's new accelerated capital depreciation rules. However, we must acknowledge that the future of the global trade environment is highly uncertain right now. An escalation of the US-led trade war would, of course, be a negative for the outlook, but a resolution would be a source of new lift for the global and Canadian economies.
Given these uncertainties, we have kept interest rates unchanged at 1.75 per cent since last October. We will remain decidedly data-dependent as the domestic and international situations evolve.
It is time for me to conclude.
We have learned over time just how powerful monetary policy can be. Canada has more than a quarter century of experience with inflation targeting. And this experience has taught us that using monetary policy to bring about low, stable and predictable inflation is the best way for the Bank to meet its responsibilities.
Of course, there is more than one way to keep inflation low and stable. Between now and 2021, when we next renew our inflation-control agreement with the government, we will be doing in-depth research and wide-ranging consultations on alternative policy frameworks.
Meanwhile, we must never lose sight of the fact that there are limitations on the power of monetary policy. We have only one instrument at our disposal. History proves that even a highly successful monetary policy can generate harmful side-effects. And uncertainty intrudes everywhere in monetary policy practice. The development, and future refinement, of macroprudential policies shows considerable promise in addressing some of these limitations. The rest may just be a matter of hard work and ingenuity.
As we head toward 2021, we will keep working hard on deepening our understanding of the power—and the limitations—of monetary policy. We are gaining important experience in seeing how various types of policies interact. I know we have some of the sharpest economic minds in the world, both inside and outside the Bank, working on this issue. And we will have lots more to say about it ahead of the next renewal.
I would like to thank Jing Yang for her help in preparing this speech.
Content Type(s): Press, Speeches and appearances, Remarks
Topic(s): Central bank research, Financial stability, Inflation targets, Monetary policy and uncertainty, Monetary policy framework, Recent economic and financial developments
History demonstrates the power and limitations of monetary policy, Governor Poloz says
Media Relations Montréal, Quebec
Monetary policy has proven to be a powerful instrument to control inflation and promote Canada's economic welfare, subject to a number of limitations, Bank of Canada Governor Stephen S. Poloz said today.
Content Type(s): Press, Press releases
Chamber of Commerce of Metropolitan Montreal - Speech (Webcasts)
Monetary Policy - Stephen S. Poloz, the Governor of the Bank of Canada, speaks before the Chamber of Commerce of Metropolitan Montreal (13:00 (Eastern Time) approx.)
Content Type(s): Press, Speeches and appearances, Webcasts
Chamber of Commerce of Metropolitan Montreal - Press Conference (Webcasts)
Monetary policy brings benefits—but has limits
Speech summary Stephen S. Poloz Montréal, Quebec
In his first speech of 2019, Governor Stephen S. Poloz explains that monetary policy is a powerful tool to promote our economic welfare. But he also notes that it has some key limits that need to be better understood in the face of uncertainty.
Content Type(s): Press, Speeches and appearances, Speech summaries Topic(s): Inflation targets, Monetary policy framework


text:
Q: Extra TinyMCE editor strips  and  tags? Hey guys, I've added a TinyMCE to some textareas that are displayed in a custom meta box. All of the formatting works perfectly fine, except that the editor will not save
 or
 tags. It doesn't preserve the line breaks.
The TinyMCE is setup like this:
wp_tiny_mce(true, array('editor_selector' => $field['class'] ) );

'<textarea name="', $field['id'], '" class="', $field['class'], '" id="', $field['id'], '" cols="60" rows="8" style="width:97%">', $meta ? esc_html($meta) : $field['std'], '</textarea>';

And that all works perfectly fine. All the formatting buttons work fine, except for the
 and
 tags.
I'm not sure if the editor is stripping them out before or after the post meta is saved.
Ideas?

A: This seems to have changed a little in subsequent versions of Wordpress. You can now disable this functionality thusly:
add_filter('tiny_mce_before_init', function($init) {
    $init['wpautop'] = false;
    return $init;
}

A: Here's (a pared-down version of) what I use to custom-configure TinyMCE:
// http://tinymce.moxiecode.com/wiki.php/Configuration
function cbnet_tinymce_config( $init ) {

    // Don't remove line breaks
    $init['remove_linebreaks'] = false;

    // Pass $init back to WordPress
    return $init;
}
add_filter('tiny_mce_before_init', 'cbnet_tinymce_config');

I assume this is what you tried already?
EDIT:
You may need to include some other config changes, such as:
// Convert newline characters to BR tags
$init['convert_newlines_to_brs'] = true;
// Do not remove redundant BR tags
$init['remove_redundant_brs'] = false;

Play around with the TinyMCE configuration parameters, and find the one that you need to change.

A: Found perhaps a simpler workaround for this:
on the actual template, change this:
<?php echo get_the_content());?>

to this:
<?php echo wpautop(get_the_content());?>

This way wpautop() adds the tags stripped out by TinyMCE on a template by template basis.

A: why not you use wordpress new function wp_editor to render the tinymce. That way everything will get handled. And when you show the content to the user apply the filter the_content.
Like this:
$meta = "content of the metabox";
echo apply_filters('the_content', $meta);

The filter the_content will autmatically convert the link brakes to
 and
.

A: I recently got this working. You should search and replace metaname with your meta box name.
The key to maintaining formatting was using wpautop(); when saving the data.
add_action( 'add_meta_boxes', 'add_metaname_box');

add_action( 'save_post', 'metaname_save');

function add_metaname_box() {
    add_meta_box(
        'metaname_id',
        __( 'metaname text', 'metaname_textdomain'),
        'metaname_custom_box',
        'page'
    );
}

function metaname_custom_box() {
    global $post;
    wp_nonce_field( plugin_basename( __FILE__ ), 'metaname_noncename' );
    $data = get_post_meta($post->ID, 'metaname_custom_box', true);
    echo <<<EOT

    <textarea id="metaname_custom_box" name="metaname_custom_box">$data</textarea>
EOT;
}

function metaname_save($post_id) {
    global $post;

    // Verify
     if ( !wp_verify_nonce( $_POST['metaname_noncename'], plugin_basename(__FILE__) )) {
         return $post_id;
     }
     if ( 'page' == $_POST['post_type'] ) {
         if ( !current_user_can( 'edit_page', $post_id ))
             return $post_id;
     } else {
         if ( !current_user_can( 'edit_post', $post_id ))
             return $post_id;
     }

     $key = 'metaname_custom_box';
    $data = wpautop($_POST[$key]);

     // New, Update, and Delete
     if(get_post_meta($post_id, $key) == "")
         add_post_meta($post_id, $key, $data, true);
     elseif($data != get_post_meta($post_id, $key, true))
         update_post_meta($post_id, $key, $data);
     elseif($data == "")
         delete_post_meta($post_id, $key, get_post_meta($post_id, $key, true));
}

A: Another simple solution: Use Shortcodes!
Place this code into functions.php and use [br] in the content editor - HTML or visual - wherever you want a br tag to appear.
add_shortcode("br", "br_tag");

function br_tag(){
    return("
");

}

A: this is for who use the metaboxes for wordpress:
Plugin Name: Meta Box
Plugin URI: deluxeblogtips com/meta-box
i have modify the /vendor/meta-box/inc/fields/wysiwyg.php
in static function :
static function html( $html, $meta, $field )

//just after the else i have added :
$meta = html_entity_decode($meta); //
//and solve the problem ;)

--  BUT THE BETTER SOLUTION IS --
Put this into functions.php, it calls the filter from the metaboxes pluggin:
function meta_wysiwyg_antes_save($meta)
{
    $meta = html_entity_decode($meta);
    return $meta;
}
add_filter("rwmb_(ID-OF-METABOX-FIELD)_meta", "meta_wysiwyg_antes_save"); //en meta-box.php 194

redpajama_set_name: RedPajamaStackExchange


OK, This is a project that has actually been in my life since I was a little kid and has a lot of history with me. This four door Chevy was parked next to a field at my grandfathers as long as I can remember. This was my grandfathers car and JAK were his initials. Even as a little kid I loved the looks of the thing. To me it seemed as though it never changed. The ratio of original green paint to rust probably changed over the years but I never noticed.
When I was in high school I asked my dad about the car and if I could try to get it running. We used our backhoe to pull it out of the spot it sat for decades and pulled it to our barn some 20 miles away. I didn't know a ton about mechanic stuff at the time. We popped in a fresh six volt battery and was surprised that the original horn, lights, and turn signals all still worked. We had to hot wire the ignition because who knows where the original keys ended up. Touching the wires together we go a lot of……nothing.
The engine was seized solid. Like a bunch of morons we drug the car behind our truck and tried to pop the clutch a bunch of times thinking it would magically free the engine. Yeah, not going to happen.
The car was parked behind a small rental house we had at the time and put on the back burner. I went off to college. Years later I was told the bad news that the car was stolen from behind the rental house along with some other vehicles we had been storing back there. Suckage!!
More years went by and I had written the car off as long gone. A friend of my father was driving along a dirt road out in the desert when he saw two cars parked outside a trailer from a distance. For some reason the cars triggered something and he came back with some binoculars and took a closer look. Lo and behold was two cars that were taken year earlier, one of which was the '51.
After a visit from the sheriff the car was returned. I was still busy with school and other life events and the car sat for many more years. Well, it's time to start a slow build of this thing. I'm going to work on it with my younger son Cole and the goal is for him to have it ready to drive when he gets his license. He's thirteen now.
At this time I'm thinking about a Mustang II front suspension and power rack and pinion. Some variety of small block Chevy engine and an S10 rear axle.
This will be a fun build. Updates as they come!


Our SEO strategist, Dani, tells us about the Mobile First Index update that took effect March 2018. In summary, Google is going to place more emphasis on how mobile-friendly your website is and accordingly boost the mobile version of your site in search results rather than the desktop version. This is because the majority of users access Google through their phones. If you don't have a mobile version of your site, don't worry. Google will simply continue to use the desktop version in its search results. Also, if you have a "responsive site," you don't need to do anything.
Test the mobile responsiveness of your website(s) by using Google's Mobile Friendly Tool!


text:
Mycobacterium chelonae infection of the parotid gland
Hamid S Shaaban, Sharma L Bishop, Laila Menon, Jihad Slim
Internal Medicine, Infectious Diseases Department, Trinitas Hospital, Saint Michael's Medical Center, Newark, New Jersey, USA
Date of Web Publication 13-Mar-2012
Mycobacterium chelonae can cause numerous infections, including lung disease, local cutaneous disease, osteomyelitis, joint infections and ocular disease. With the exception of lung disease, these syndromes commonly develop after direct inoculation. The most common clinical presentation in immunocompetent individuals is skin and soft tissue infection. We present a case of M. chelonae infection of the parotid gland that was successfully treated with clarithromycin monotherapy. To our knowledge, this is the first case report of M. chelonae parotitis in an adult.
Keywords: Mycobacterium chelonae , Parotitis, Immunocompetent
Shaaban HS, Bishop SL, Menon L, Slim J. Mycobacterium chelonae infection of the parotid gland. J Global Infect Dis 2012;4:79-81
Shaaban HS, Bishop SL, Menon L, Slim J. Mycobacterium chelonae infection of the parotid gland. J Global Infect Dis [serial online] 2012 [cited 2019 Jul 19];4:79-81. Available from: http://www.jgid.org/text.asp?2012/4/1/79/93767
Mycobacterium chelonae (M. chelonae), rapidly growing mycobacteria (RGM), primarily causehuman infection in immunosuppressed patients, including hematogenously disseminated disease. M. chelonae may also cause surgical wound infections and keratitis. [1] However, it rarely causes isolated lymphadenitis. Suppurative parotitis in an adult caused by M. chelonae has never been reported. Recently, we experienced a case of parotitis and parotid mass attributed to an M. chelonae infection.
We report a case of M. chelonae-associated parotitis in a 35-year-old woman. She presented with complaints of painful swelling and redness of the angle of her left jaw that started 1 month prior to admission. She reported that it started as a small 1-cm swelling in the middle aspect of her left jaw that gradually progressed to the angle. She was started on oral clindamycin and levaquin. There was no clinical improvement after a week of therapy. She started experiencing a pulsating pain that was aggravated by eating. A week prior to admission, she noticed progression of the redness and swelling to the left earlobe. She denied having any fever, chills, fatigue, weight loss or hearing impairment. She had a past medical history of neonatal portal vein thrombosis, splenectomy in 1992; and esophagogastric varices diagnosed by endoscopy two years ago. She was originally from Spain and had immigrated to the United States 15 years ago. She gave no personal or family history of tuberculosis. Her father had thyroid cancer. She did not have any history of recent travel. Physical examination [Figure 1] revealed a mobile and tender mass measuring approximately 3 cm and occupying the superficial lobe of the left parotid gland. There were overlying erythematous skin changes suggestive of parotitis. Facial nerve function was normal. Other physical findings were also normal, and there was no palpable cervical lymphadenopathy. The complete blood count, erythrocyte sedimentation rate, results of other biochemical/ autoimmune investigations and chest X-ray were normal. The result of the Human Immunodeficiency Virus (HIV) antibody test was negative. She had a tuberculin test done, which was measured at 4 mm (negative). CT scan [Figure 2] showed diffuse enhancement of the left parotid gland with an enlarged soft tissue mass lesion, measuring 3 Χ 4 cm in size, with a cystic component. A CT-guided fine-needle aspiration was performed, and the smear came back positive for acid-fast bacilli (AFB) [Figure 3]. The working diagnosis at that time was M. tuberculosis-related parotitis, and our patient was empirically treated with oral antitubercular meds (rifampin 300 mg, isoniazid 150 mg, ethambutol 400 mg and pyrazinamide 1000 mg once a day). Ten days later, the cultures grew AFB; and utilizing the genotype TB system (Hain, Nehren), the AFB was identified as Mycobacterium chelonae. Drug susceptibility report showed the organism to be resistant to imipenem, amikacin, ciprofloxacin, cefoxitin and linezolid; and sensitive to clarithromycin. The antitubercular regimen was discontinued, and she was started on oral clarithromycin 500 mg twice a day, with some evident resolution of symptoms, size and inflammation after 3 months of therapy. The management plan wasto continue this antibiotic regimen for at least six months and to regularly follow up with her during the duration of therapy.
Figure 1: Erythema and fluctuance overlying the parotid gland area
Figure 2: CT scan evidence of acute inflammation of the left parotid gland (acute suppurative parotitis)
Figure 3: CT-guided aspirate of the left parotid gland revealing acid-fast bacilli organisms
Rapidly growing mycobacteria (RGM) are ubiquitous environmental organisms that usually take a week to grow in subculture. They have been isolated from soil, dust, water, terrestrial and aquatic animals, hospital environments and contaminated reagents and pharmaceuticals. [2] These RGM include three clinically relevant species: M. fortuitum, M. chelonae and M. abscessus. On review of the literature of RGM-associated infections, M. fortuitum was found to be most commonly associated with clinical disease.
M. chelonae can cause lung disease, local cutaneous disease, osteomyelitis, joint infections and ocular disease. With the exception of lung disease, these syndromes commonly develop after direct inoculation. The most common clinical presentation in immunocompetent individuals is skin and soft tissue infection. Disseminated disease with cutaneous manifestations has been linked to immunosuppression related to defects in cell-mediated immunity (e.g., HIV) or tothe Interleukin 12 / Interferon gamma pathway. [3]
Systemic findings of fever, chills and marked toxicity are not typical of RGM-related parotid gland infections, and chest radiographs are almost always normal. Some of these cases are associated with fistulae formation and/ or cervical lymphadenitis.
The histopathologic and microbiologic diagnoses of non-tuberculous Mycobacteria (NTM) parotitis are made by fine-needle aspiration of parotid gland material. CT scans and Magnetic Resonance Imaging (MRI) may help if they reveal subcutaneous necrotic, ring-enhancing lesions with typically minimal stranding of subcutaneous fat, which are suggestive of NTM infections.
NTM-related parotid gland infections are very rare; and to our knowledge, this is the first case report of M. chelonae parotitis in an adult, and there are no guidelines in the medical literature specifically for this infectious entity. The diagnosis of this rare condition was made by fine-needle aspiration; and although the presence of M. chelonae may have been incidental rather than etiologic, the fact that the patient responded very well to oral clarithromycin antibiotic therapy supports the latter.
Lindeboom et al. showed that complete surgical excision of the gland had higher rates of complete regression when compared to medical antibiotic therapy alone (96% vs. 66%, respectively). [4] There are a few cases of NTM parotitis that were successfully treated with clarithromycin-based antibiotic regimen alone; or if necessary, along with drainage of an abscess. [5] When the diagnosis was made by fine-needle aspiration, we opted to treat the patient medically with antibiotics first because (1) we had established an etiologic agent and there is literature to support that these cases can be treated medically; and (2) our patient's concerns with having to go through a surgical resection of the parotid gland.
Most strains of M. chelonae have in vitro susceptibility to tobramycin, linezolid and tigecycline; whereas imipenem, doxycycline and ciprofloxacin are less effective. All strains of M. chelonae are susceptible to clarithromycin; therefore, it should be part of any antibiotic regimen for M. chelonae infections.
To our knowledge, this is the first case report of unilateral parotitis caused by Mycobacterium chelonae in an HIV-negative immunocompetent adult that was successfully treated solely with clarithromycin antibiotic therapy. We conclude that rare organisms from the rapidly growing mycobacteria family, like M. chelonae, should be included in the differential diagnosis for etiologic agents of suppurative parotitis.
1. Chang MA, Jain S, Azar DT. Infections following laser in situ keratomileusis: An integration of the published literature. Surv Ophthalmol 2004;49:269-80.
[PUBMED] [FULLTEXT]
2. Wolinsky E. Nontuberculous mycobacteria and associated diseases. Am Rev Respir Dis 1979;119:107-59.
3. Remus N, Reichenbach J, Picard C, Rietschel C, Wood P, Lammas D, et al. Impaired interferon gamma-mediated immunity and susceptibility to mycobacterial infection in childhood. Pediatr Res 2001;50:8-13.
4. Lindeboom JA, Kuijper EJ, Bruijnesteijn van Coppenraet ES, Lindeboom R, Prins JM, et al. Surgical excision versus antibiotic treatment for nontuberculous mycobacterial cervicofacial lymphadenitis in children: a multicenter, randomized, controlled trial. Clin Infect Dis 2007;44:1057-64
5. Green PA, von Reyn CF, Smith RP. Mycobacterium avium complex parotid lymphadenitis: Successful therapy with clarithromycin and ethambutol. Pediatr Infect Dis J 1993;12:615-7.
Hamid S Shaaban
Internal Medicine, Infectious Diseases Department, Trinitas Hospital, Saint Michael's Medical Center, Newark, New Jersey
DOI: 10.4103/0974-777X.93767
[Figure 1], [Figure 2], [Figure 3]
1 Cholecystectomy for the Treatment of Mycobacterial Cholecystitis in a Pacific Gopher Snake (Pituophis catenifer)
Matthew E. Kinney,Sathya K. Chinnadurai,Raymund F. Wack
Journal of Herpetological Medicine and Surgery. 2013; 23(1-2): 10
2 Clinical and laboratory aspects of the diagnosis and management of cutaneous and subcutaneous infections caused by rapidly growing mycobacteria
Kothavade, R.J. and Dhurat, R.S. and Mishra, S.N. and Kothavade, U.R.
European Journal of Clinical Microbiology and Infectious Diseases. 2013; 32(2): 161-188
3 Document Non-tuberculous mycobacterial infection of the parotid gland in an immunocompetent elderly patient
Yamanaka, T., Okamoto, H., Hosoi, H.
BMJ Case Reports. 2013;
Shaaban HS
Bishop SL
Menon L
Slim J
Mycobacterium chelonae
Parotitis
Immunocompetent

redpajama_set_name: RedPajamaCommonCrawl


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In recent years, more college grads are choosing to blaze their own career paths over competing with thousands, perhaps millions of equally qualified applicants for a handful of positions.
While starting a business sounds exciting and carries the possibility of success, it is not a guarantee. In fact, according to smallbusinessesplanned.com, about 50 percent of businesses survive the first five years and just a third survive a decade. There are a number of reasons businesses fail (or don't succeed, depending on your classification) but to the new generation of entrepreneurs, here are five tips that will help you start off on the right foot.
Like the saying goes, you can't please everyone. Finding your niche begins with a focused business plan and targeting a market in need of disruption. A common mistake is to try to reach everyone. Don't overextend your business just to get noticed. Hone your craft and develop a product based on a sturdy business strategy that is better than your competitors.
You're going to make mistakes. Plenty of them. But making mistakes can be beneficial to the growth of your business, as long as you learn from them. Don't waste time sulking over a mistake; figure out where you went wrong, change course and move forward.
In the early stages of development, many young entrepreneurs make the mistake of focusing on quantity over quality. Don't sacrifice quality to achieve "most-in-class" status. Rather, take your time in developing a "best-in class," product you can proudly stand behind. In time, you can be sure that consumers will find their way to you.
Often, we fail to distinguish between confidence and arrogance. One is of the mindset that they're better than everyone else. The other believes that they're as good as everyone else. Half the battle of running a successful company is believing you can do it. If you don't, who will?
You might never know what your career as an entrepreneur could have been unless you give it a go. The path to starting a successful business is long, unpredictable and full of roadblocks but not impossible. All you have to do is figure out you're passionate about and pursue it, not matter what anyone says.