Talk:Lyme disease/Archive 5
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The word "chronic" should not be in quotes
Even though chronic Lyme Disease is not a legitimate diagnosis per the IDSA, the word "chronic" should not be in quotes.
There are over 100 studies that demonstrate Lyme Disease itself, and more specifically the causative spirochete can be chronic and persistent with or without antibiotic treatment. These can easily be found with a simple PubMed search (or elsewhere).
Just because antibiotic treatment doesn't perform well after 4 months, does not prove that the infection is eradicated and not persistent. All it proves is that the antibiotics didn't work.
The quotes also make the article look biased against chronic Lyme Disease in my opinion. In my opinion removing the quotes promotes a more neutral point of view.
I tried making the changes, but they were reverted.
Why are the quotes necessary? I think they should be removed again. —Preceding unsigned comment added by 173.74.147.158 (talk) 05:53, 10 November 2010 (UTC)
- And I have removed them. Even though it may not be an official diagnosis, it appears to be a valid description of the illness to call it chronic, and there is no need for scare quotes. I have left the quotation marks around the first time the term is used, because it's referring to the term and not the condition. —C.Fred (talk) 05:58, 10 November 2010 (UTC)
- The problem is that the phrase "chronic lyme disease" is not a neutral phrase, but one that is widely used (often criminally) as a quack diagnosis in non-RS, and by using the phrase without signalling that it's not a legitimate phrase, we're violating the weight we are supposed to give the mainstream scientific POV as found in RS. We are violating NPOV by giving more weight to unscientific opinions not found in reliable sources, but only in unreliable sources. This principle is embodied in our MEDRS policy, where we give mainstream medical sources priority. To repeatedly use a misleading term without putting it in quotes is to give the quacks and frauds ammunition which they will use to defraud patients. We should use the terms used in RS, and when not doing so it should be made clear we aren't doing so. Maybe we should simply remove most of those instances, and when we are forced to use the phrase, to use words to make it clear, rather than quotes alone. -- Brangifer (talk) 06:39, 10 November 2010 (UTC)
- A consensus hasn't formed yet because we're still discussing, and that edit deals with the situation in a very appropriate manner by using the wording from the source, rather than using some editor's choice of words. When in doubt we follow the source. -- Brangifer (talk) 16:34, 10 November 2010 (UTC)
- Edit conflict... Richiez, your reference actually makes a good case for us using quotes, since the mainstream uses are instances of debunking, but it also presents another possibility for us. First, let's look at the summary from your source (which should be included in the article):
- "Studies have shown that most patients diagnosed with chronic Lyme disease either have no objective evidence of previous or current infection with Borrelia burgdorferi or are patients who should be classified as having post-Lyme disease syndrome, which is defined as continuing or relapsing nonspecific symptoms (such as fatigue, musculoskeletal pain, and cognitive complaints) in a patient previously treated for Lyme disease. Despite extensive study, there is currently no clear evidence that post-Lyme disease syndrome is caused by persistent infection with B burgdorferi. Four randomized placebo-controlled studies have shown that antibiotic therapy offers no sustained benefit to patients who have post-Lyme disease syndrome. These studies also showed a substantial placebo effect and a significant risk of treatment-related adverse events. Further research to elucidate the mechanisms underlying persistent symptoms after Lyme disease and controlled trials of new approaches to the treatment and management of these patients are needed." PMID 18452806
@Brangifer - Re "A consensus hasn't formed yet because we're still discussing" - So why did you make a change to something under discussion? Anyways, there is a consensus (both here and at Wikipedia_talk:WikiProject_Medicine#.22Chronic.22_Lyme_disease_controversy). You appear to be the only one who is "unsure" about how to proceed. May I respectfully suggest that you self-revert? NickCT (talk) 17:47, 10 November 2010 (UTC)
- Do you think that one instance - where I actually improved the wording by removing OR (editorializing) and using the actual wording in the source - should be reverted? I think not. It's a definite improvement and I'm not going through every instance and restoring the scare quotes. Restoring what was there would definitely be a negative for the article by restoring OR. I have every single policy behind that edit. I hadn't seen MastCell's comment, but I appreciate it and think we can move on. -- Brangifer (talk) 18:18, 10 November 2010 (UTC)
- Well, I have enough experience here to allow me to engage in a bit of hyperbole....;-)
IfSince no policy is against that improvement of wording, I assume all policies back it up, especially NOR and V. Otherwise you have basically gotten what you wanted, and that is a removal of nearly all instances of scare quotes. I'm okay with that as the article currently stands. -- Brangifer (talk) 19:12, 10 November 2010 (UTC)
- Well, I have enough experience here to allow me to engage in a bit of hyperbole....;-)
Would it be more neutral if only the mainstream view was represented in the article (leaving out all references to chronic Lyme), and then have a separate section dedicated opposing views? If done right, I think this could help the neutrality of the article. The truth is, there is science on both sides, and Wikipedia should not aim persuade someone to developing a "right and wrong" mentality. I understand Wikipedia follows the mainstream thought and therefore there should be more emphasis on the mainstream views, but it does look to the reader as if these views are the ones that Wikipedia promotes. The opposing views section should be more condensed, and only represent a small part of the article. Does anybody else agree? Or will this not work?
I only suggested removing quotes, because in my eyes, the quotes are both unnecessary and add a biased look. You can agree or disagree with me. I am not saying I am right. —Preceding unsigned comment added by 173.74.147.158 (talk) 18:37, 10 November 2010 (UTC)
- Well, the consensus seems to be to leave them out, except the couple of instances where they are necessary, so I'm leaving it as is. As to your suggestion, we've discussed this before quite extensively, IIRC, and determined that it would be a violation of our NPOV policy and an improper fork article. That content is now included in this one, and that seems to work quite well. -- Brangifer (talk) 19:12, 10 November 2010 (UTC)
- How about renaming the paragraph into something like "late complications of effectively treated lyme disease" ? I would donate a lead/overview for that. While "post lyme" and "chronic lyme" are widely used neither seems to accurately express the prevailing uncertainty about exact mechanism(s). Also "chronic untreated lyme" is at least of historical interest and needs to be distinguished. Sorry.. I am slow responding these days. Richiez (talk) 12:11, 12 November 2010 (UTC)
- That wording ("late complications of effectively treated lyme disease") would suggest a causal link (between the prior Lyme infection and the subsequent symptoms) that would not reflect scientific consensus. "Symptoms experienced after treated Lyme disease" would be more neutral. -- Scray (talk) 16:38, 12 November 2010 (UTC)
I'm a little late. But I looked over over the article once more and in "Post-Lyme disease symptoms and chronic Lyme disease" and "Controversy and politics" there are multiple instances of "chronic Lyme Disease" in quotes. I think using quotes may be acceptable for defining what the term is, but the I think the quotes are overused. - WP:Quotations#Overusing_quotations / WP:Quotations#When_not_to_use_quotations -- 173.74.147.158 (talk) 02:07, 16 November 2010 (UTC)
- I went ahead and fixed the overuse of quotes. I think the Wikipedia guidelines support my edit. -- 173.74.147.158 (talk) 02:35, 16 November 2010 (UTC)
I'll agree with the deletion of the quotes based upon consensus. As one who may well have chronic lyme, I have a bit of conflict of interest. On a scientific basis, the quotes are justified, as there is NO consensus in medicine on treatment, diagnosis or even IF chronic lyme exists, regardless of the reported cases. On the other hand, the "alternative" medicine suggestions in the US are alarming at best, hence, one has grave reservations regarding giving any potential emphasis, lest someone go to leeches or some other idiocy (OK, a bit extreme, but try to grasp the notion.)Wzrd1 (talk) 06:23, 24 November 2011 (UTC)
- There is at least one large study (Seltzer, Gerber, et al, JAMA 283:609-16 2000) which showed no difference in the incidence of fatigue and non-specific pain in populations with and without documented Lyme disease history. This is not definitive, but it certainly raises the question as to whether Borrelia infection truly is responsible for prolonged non-specific symptoms of fatigue and lassitude. Mention should be made of this study, which is respectable work and quoted in medical textbooks.98.170.214.134 (talk) 00:23, 13 April 2013 (UTC)
Create subsection for misplaced content?
I'm also wondering if the "Controversy and politics" section doesn't more logically belong as a subsection in the preceding "Post-Lyme disease symptoms and chronic Lyme disease" section? After all, the controversy is about its existence, symptoms and treatment. -- Brangifer (talk) 16:31, 10 November 2010 (UTC)
- I completely agree. However, I don't think the subsections "Harrassment of Researchers", and "Media and Internet material" fit. Perhaps those can just have their own subsection under Society and Culutre. Does that work? If so, I vote to move it. -- 173.74.147.158 (talk) 23:09, 10 November 2010 (UTC)
- Done. See if you think it works. The Society and Culture section is lacking in my opinion, but not sure what I'd add/change to make it better. -- 173.74.147.158 (talk) 05:26, 11 November 2010 (UTC)
Just for the record, the controversy isn't just about chronic LD, it's also about diagnosis and testing, in early, midstage, and late LD. Also about the recommended treatment regimen(s) for patients once they're diagnosed. For instance, see Greer et al. 2007, PMID 17429088 for an example of how these issues might play out in an individual case, managed strictly according to the prevailing guidelines. (and please don't shoot me, I'm just the messenger. ;-) Happy editing, Postpostmod (talk) 17:24, 17 November 2010 (UTC)
Postscript to my preceding comment: I should have said, the case in PMID 17429088 was managed strictly according to guidelines by the primary care and EM physicians at a community hospital and at MGH, until a particular expert was called in to allow the guidelines to be broken. Just in time: the patient almost died.
Technically, the patient had "no objective evidence of ever having had Lyme disease" at any time in the presented case. The patient didn't have the rash "required" for clinical diagnosis of Lyme disease. Positive PCR evidence is disallowed due to an allegedly unacceptable rate of false positives. The IgM Western blot is not considered valid after the fourth week after onset. The IgG blot was negative by the Dearborn (CDC) criteria, and the positive ELISA is considered irrelevant unless comfirmed by the Western blot.
Therefore, unless that particular expert were called in to override the rules (which he originated), any doctor who treated the patient for Lyme disease would be dangerously liable to ridicule or prosecution by his peers, even in the presence of all the test results reported. Incidentally, I wonder why they didn't say what antibiotics the primary care prescribed for the presumed "virus"? It's a striking omission from the case history. I'd be willing to bet it was 200 mg/day doxycycline for 2 weeks, the standard treatment for early Lyme disease, which he would probably suspect from the symptoms and history, as he's in an endemic area, but would not dare to diagnose. As it's written, it makes the primary care doctor look like a fool (prescribing antibiotics for a virus), but presumably that's preferable to being seen as a "criminal".
If you think I'm being picky and the guidelines either don't say that, or aren't rigidly enforced, read the guidelines (PMID 17029130) carefully, and then look at what is said, and done, to doctors who think they're too rigid and disregard them (for example, the Nature Medicine 2008 article, PMID 18989271) .
Again, please don't shoot the messenger...;-) Best wishes, Postpostmod (talk) 19:03, 23 November 2010 (UTC)
- I can assure you that no physician would ever be disciplined by a medical board for treating a critically ill, hospitalized patient with a short course of ceftriaxone for a suspected diagnosis of neuroborreliosis, even if the guidelines were not met to the T. The physicians who have been disciplined operate well outside those boundaries, as I'm sure you are aware. Comparing the two situations makes sense only as a rhetorical, point-scoring gesture, not as serious commentary. Additionally, you're playing fast and loose with the PCR criteria (as Scray mentions below), and you're ignoring the finding that actually clinched the diagnosis of neuroborreliosis: the production of antibody in the cerebrospinal fluid, which was present in this case and is specifically highlighted in the guidelines. So I think you're off-base in trying to cite this case to make your point. MastCell Talk 00:50, 24 November 2010 (UTC)
- I just read those reports, and while I agree with some of the points you highlight (they could have started treatment before the diagnosis was certain, as doctors often do), some of your characterizations seem inaccurate:
- Nowhere in PMID 17429088 does it say that anyone was bound by guideline, nor that the expert that was called in saved the day. Both Dr. Steere (I assume this is the expert to whom you refer) and the case discussant said that diagnostic testing came in on day 11 at MGH that established the diagnosis.
- Positive PCR evidence is not disallowed. Here is a quote from that guideline (PMID 17029130): "Amplification of B. burgdorferi DNA in CSF using PCR by a laboratory with excellent quality control can also be useful [103, 124, 167], but few laboratories are capable of accurately performing this test. In the absence of erythema migrans, neurologic manifestations are too nonspecific to warrant a purely clinical diagnosis; laboratory support for the diagnosis is required." According to the report you cited, when laboratory evidence (including PCR) was available, the diagnosis was made and treatment was started.
- Those reports do not say that the guidelines you cite are rigidly enforced. They are not laws - just guidelines - and physicians use their judgment all the time.
- I do agree that the omission of the type of antibiotics prescribed by the primary care physician should have been included on the first page. I think it's important that we stick to facts and avoid hyperbole. -- Scray (talk) 00:11, 24 November 2010 (UTC)
- The priceless moment in that case report occurs when the diagnosis of neoplastic meningitis is considered: "An important part of our evaluation of this patient was review of the cerebrospinal fluid findings with a pathologist. This consultation occurred urgently on a Friday afternoon in the summer." You can hear the disbelief that a pathologist was actually located and convinced to review the CSF on a Friday afternoon. In the summer. I mean, even if a patient is in a life-or-death situation, I think most pathologists would agree that it's uncivilized to expect someone to work into the afternoon on Fridays, especially when it's nice outside. :P MastCell Talk 00:26, 24 November 2010 (UTC)
- I’ll answer Scray first, as that post seems to be chronologically first, despite its position in the thread.
Hello, Scray, nice to meet you. Thanks for your detailed and civil response to my comment, and for taking the time to read the articles.
- I’ll answer Scray first, as that post seems to be chronologically first, despite its position in the thread.
- The priceless moment in that case report occurs when the diagnosis of neoplastic meningitis is considered: "An important part of our evaluation of this patient was review of the cerebrospinal fluid findings with a pathologist. This consultation occurred urgently on a Friday afternoon in the summer." You can hear the disbelief that a pathologist was actually located and convinced to review the CSF on a Friday afternoon. In the summer. I mean, even if a patient is in a life-or-death situation, I think most pathologists would agree that it's uncivilized to expect someone to work into the afternoon on Fridays, especially when it's nice outside. :P MastCell Talk 00:26, 24 November 2010 (UTC)
- I’m sorry about the length of the following comment; it seems my previous one was insufficient, and I can’t know exactly where our knowledge bases fail to coincide. So I have no choice but to provide a multitude of detail and hope that some of it helps bridge our gaps.
- Your first and third comments bear on whether following the guidelines is truly optional, or mandated (in the de facto sense). I hope guidelines are optional in other diseases, but unfortunately this isn’t the case in Lyme disease (LD). Doctors who break with the guidelines multiple times are liable to prosecution by their state medical boards, which is why four endemic states have passed “physician protection bills”. As MastCell rightly says, a doctor or a team can get away with it if they do it rarely, but since the disease isn’t rare in the Boston area, most doctors have responded to the situation by simply believing that the guidelines must be accurate or they wouldn’t exist, and therefore that they are acting responsibly by following them to the letter.
- With regard to PCR, I guess the sentences you quoted from the guidelines would seem not to preclude the use of PCR results obtained from the unspecified “few laboratories” that are thought to be accurate. In practice, PCR results have often been discounted in the literature unless they are performed, or commissioned by, an academic laboratory run by one of the guidelines’ authors. (Weird but true). For example, the MGH in-house laboratory neither performs these tests nor sends them out. [1].
- I’ll go on to discuss the CSF antibody situation, which has similar political issues. For example, MGH only offers CNS serology as a send-out test, and ONLY sends it out if a parallel serum sample has previously tested positive (by ELISA, presumably) in-house. This probably accounts for the long delay in getting these results (day 11 of hospitalization), which were the first guideline-acceptable “objective evidence” that the patient had LD (the previous tests are all technically considered insufficient, as I said above.) It need hardly be said that it’s a good thing the guidelines were broken to start treatment on day 5, a day after dyspnea and dysarthria developed. This is the kind of dilemma that the guidelines provoke, rather than help to solve.
- Thanks again for your thoughtful comments. Let me know if you want further references to back up my statements. Best wishes, Postpostmod (talk) 16:42, 28 November 2010 (UTC)
- I'll assume that we're here to understand the tone of the field, so comments on specific institutions are just to inform our edits to the article overall (else this does not belong on this talk page). Your statements regarding the MGH and testing using PCR seem to be at odds with the reality that the PCR test was done on this case from MGH. I point this out to underscore the reality that guidelines are not laws, and physician judgment is given wide latitude. In particularly severe/rapidly progressive cases, the guidelines need not be followed if the physician is willing to defend their actions before peers. In the case you're highlighting, the PCR was clearly sent even though the link you provide indicates no mechanism for doing so. Whether earlier treatment would have improved the outcome in this specific case is purely a subject for speculation (therefore it does not belong here), but the guidelines would not prevent a physician at MGH from prescribing Lyme-specific treatment as soon as the suspicion was high, particularly if that decision were made by consensus (this won't protect an individual practitioner who consistently violates clear guidelines despite warnings from a medical board). It really is a pleasure chatting with you - but I have a sense we should be mindful of the setting in which this discussion is occurring, and should stick to the subject, which is the article. -- Scray (talk) 20:06, 28 November 2010 (UTC)
- Thanks again for your thoughtful comments. Let me know if you want further references to back up my statements. Best wishes, Postpostmod (talk) 16:42, 28 November 2010 (UTC)
Hi, MastCell. Hope you had a nice Thanksgiving (if you’re in the US, that is). Regarding your first comment above, I read the talk page guidelines and some essays for help responding, and I think I’d better just swim away. No hard feelings. I think I addressed your factual concerns in my answers to Scray.
Regarding your second comment – yes, that is a gem. A Friday afternoon in the summer, indeed.
I’ve obtained and read the two books about medical culture you recommended in our discussion on your talk page. Did you get a chance at Groopman’s How Doctors Think yet? I’m looking forward to resuming a friendly discussion there, when this one winds down. As always, best wishes from the loyal opposition, Postpostmod (talk) 22:32, 29 November 2010 (UTC)
- Hello Scray, thanks for responding, and for your friendly tone. We seem to be talking past each other on whether LD PCR results that will be considered acceptable by the most influential LD researchers are possible to get, as you rightly point out they are, or are made inconvenient and slow to get by institutional factors, as I rightly point out.
- Concerning the guidelines being voluntary, I just realized that I’m unintentionally hitting a nerve by suggesting that doctors are limited in their autonomy. It won’t change the point of my comments if we say the guidelines are “highly influential” rather than "mandatory".
- These are mostly, I think, semantic and cultural problems. I’m a scientist, not a doctor, so it’s likely that I’ll unwittingly violate from time to time some of medicine’s internal idiom and social context. I'm sorry about any discomfort this might cause.
- Regarding the relevance of the topic to improving the article, yes, part of it is in regard to the tone of discourse in the field, and in the article, neither of which meet WP standards of “impartial tone” as described in WP:NPOV. But specifically, my comment was made to correct the impression that the controversy is only about chronic LD, as Brangifer said, above, in his (implemented) suggestion to subsume the controversy under the chronic LD section. It’s broader than that, as well as clinically relevant, as this case study suggests. Since the article falls under WP:MED, it can only be corrected with permission from that group.
- I’m glad you’ve enjoyed our discussion, I have too. If you’d like to discuss science relevant to LD, or medical culture, or epistemology in general, please drop me a note on my user page. Best wishes, and thanks again,Postpostmod (talk) 16:56, 4 December 2010 (UTC)
New government study, and the government's position
My wife is steadily weakening from chronic lyme disease, and I think my disgust with this article is or should be well known. However, there is a new government study just out.
In [2], over the period of 1999 to 2003 (when most doctors probably couldn't spell Lyme, let alone recognize it), "there were 114 records listing Lyme disease as a cause of death" of which "23 records showed the disease as the underlying cause."
Further down, "According to the CDC, ... a 'small percentage' of those treated with antibiotics report symptoms that last for months to years, including arthritis pain, memory problems and fatigue." So the CDC admits that the chronic lyme disease condition can exist.
Further, "As for the lethality of Lyme disease, it is plausible that certain documented long-term effects of Lyme disease could contribute to some deaths, according to Dr. Kevin S. Griffith of the CDC's National Center for Emerging and Zoonotic Infectious Diseases."
Critics of course noted that the CDC made no attempt to look at deaths that may have been from Lyme but weren't recognized as such. Since so much effort was then placed on diagnosing the condition as anything but Lyme, one would have thought that an honest effort to do so would have been made by the CDC.
It was added that "There is, however, no proof of that in the scientific literature, Griffith said." Just in the suffering and dying patients. I'd like to see a study of deaths where the CD-57 test results were available. Simesa (talk) 11:38, 12 January 2011 (UTC)
- Wikipedia is not a place to go if you want to push for a new study. We're just here to report what reliable third-party sources have reported. Call your Congressperson or the CDC and encourage them to conduct such a study.
- Oh and no, you've misread the article. The CDC does not admit that "chronic lyme disease" exists, they merely state that there may be some long-term side effects after the patient has had lyme disease. — The Hand That Feeds You:Bite 13:20, 12 January 2011 (UTC)
- And you've misread the comment. They didn't claim that the CDC admitted that chronic Lyme exists, just that "the chronic lyme disease condition can exist," which is true. The CDC admits that Lyme symptoms can persist after treatment -- they just don't believe that these symptoms are due to ongoing Lyme infection. It's a bit messy (as is everything else around chronic Lyme), because both sides admit that symptoms can persist without infection. The main disagreement is about whether, in some cases, the infection itself will persist after the recommended treatment, which has huge implications with regards to heavy, long-term antibiotic treatment. For the record, I support the ILADS position and believe chronic Lyme, with ongoing Bb infection, occurs in a minority of Lyme patients. But I don't want to get in a flame war over it. 65.96.203.212 (talk) 22:04, 20 January 2011 (UTC)
$590,000 NIH grant for research on persistent infection in mouse model
The grant is to Stephen Barthold at UC Davis, using his mouse model. "These studies are needed to develop better strategies for effective management of patients with persistent infections. Relevance: Pathogen persistence and evasion of host immunity are highly relevant issues for all chronic infectious diseases, but Lyme borreliosis in particular. The proposed studies will incisively investigate the mechanisms of Borrelia burgdorferi persistence, which will help lead to more effective treatment." http://projectreporter.nih.gov/project_info_description.cfm?aid=7738961&icde=6766672 Postpostmod (talk) 19:33, 21 January 2011 (UTC)
- Hopefully, that funding will lead to research that will advance the field, at which point we can reflect those advances in our Wikipedia article. MastCell Talk 22:18, 21 January 2011 (UTC)
- MastCell! Welcome back! Here's a list of all 151 NIH grants related to Lyme disease research: http://projectreporter.nih.gov/reporter_SearchResults.cfm?icde=6766672 . Catch you later on your talk page, Postpostmod (talk) 18:06, 22 January 2011 (UTC)
Lymes disease and Lyme's disease
Should the article include something about the misnames of the disease? 199.184.30.51 (talk) 17:38, 3 March 2011 (UTC)
- Got any sources about that? — The Hand That Feeds You:Bite 01:05, 5 March 2011 (UTC)
Lyme Disease in animals
Hi there, is there someone knowledgeable about such things who could write a section on Lyme Disease is animals (pets, etc.), My dog had it, and I came here seeking info on how it works with dogs, and found nothing. 72.86.37.79 (talk) 22:02, 3 April 2011 (UTC)
Chronic /post-Lyme disease syndrome
Should this section be split off into its own article and just a summary left here? Chronic Lyme disease is really a separate entity from other forms. Doc James (talk · contribs · email) 06:10, 27 June 2011 (UTC)
- Well, I wouldn’t say it’s a separate entity. When LD is undiagnosed or undertreated, it becomes “late Lyme disease”. Late LD is harder to cure due to multiple sites of dissemination throughout the body in tissues that are less easily permeated by antibiotics, such as collagen and the brain. In the late 1980s, it was recognized by the leader of the field (Steere) that many people had complications that resembled the symptoms of late LD, after treatment, which was one of the rationales for the vaccine, which began development at that time. This much is not controversial.
- The original term “chronic LD” was later disowned by the mainstream, because of its connotations of persistent infection, which the mainstream believes can’t exist. They coined the term “post-LD syndrome”, which implied that the LD infection was over, though the symptoms were not. Then there was a minor split between Steere and some other members of the field. Steere, at the top of the academic pyramid due to his early study of the disease, suggested the hypothesis that PLDS was an autoimmune phenomenon, perhaps related to molecular mimickry by OspA. OspA was the antigen used for the vaccine Lymerix, for which Steere
, unaccountably,led the clinical trial, simultaneously with publishing his autoimmune theory (which would suggest that immunizing people with OspA is not a good idea). The theory was never proved, and remains in limbo, with occasional publications coming out that indicate it is still alive in Steere's lab.
- The other mainstream researchers, who usually follow Steere, seem unconvinced by his autoimmune theory. There seem to be coexisting views in the mainstream, one of which says that neither “chronic Lyme disease” nor “PLDS” exist, while the other view says that PLDS exists but is not related to persistent infection, and the mechanism is unknown. Both agree that it should not be treated with antibiotics, in the interests of antibiotic stewardship. Small randomized, double-blinded studies showed that 3 months of antibiotics do not cure CLD or PLDS (although they disagree as to whether it temporarily alleviates the symptoms). The mainstream cites this as evidence that persistent infection does not occur. Because late LD does not usually give rise to spirochetemia in the blood, but rather is characterized by widely dispersed small colonies of spirochetes in various solid tissues, there is no way to biopsy directly for the presence of spirochetes in late LD (or CLD or PLDS), and the maintenance of IgM and IgG antibodies in the serum is taken to be a result of the prior infection. Spirochetes can be found in tissues of antibiotic-treated animals, but this is said to be irrelevant to the human case due to differences in pharmacodynamics and other such problems.
- Thus the transition from early or late LD, to CLD or PLDS, is currently defined solely by whether the patient has been treated with the recommended course of antibiotics. If he hasn’t yet, it’s LD; once he has been treated, it’s PLDS. So I wouldn’t say it’s a separate entity. I’ll provide refs if you want them, in the form of search terms in Pubmed, so you can see I’m not cherry-picking.
- Best regards, Postpostmod (talk) 18:32, 3 July 2011 (UTC)
- I would be in favor of making the language here more concise and well-organized instead. A lot of the current coverage (mea culpa for some of it) is written in a "I found a reference, shoehorning in a sentence" style instead of good encyclopedic style. See Wikipedia:Articles for deletion/Lyme disease controversy if you do decide to spin out an article along these lines. - 2/0 (cont.) 05:15, 4 July 2011 (UTC)
Negative on ELISA but positive on Western blot
I recently edited the article to say that many Lyme patients reportedly test negative on ELISA but positive on the Western blot. I cited the book by Weintraub that's already in the references section of this article. MasCell reverted.[3] because of doubts about the source. MastCell, for more info about the book (e.g. awards and reviews), I found the following website: www.cureunknown.com. The website quotes various reputable reviewers and describes a prestigious award won by the book, and all of that info can be independently confirmed. If you still don't think the source is adequate, then I urge you to look around for a better source; presumably being a doctor, you have quicker access to medical sources than I do. If Weintraub's statement about the testing is correct, then I'd hope you would agree this is something that ought to be mentioned in this wikipedia article, if it can be adequately sourced.Anythingyouwant (talk) 04:53, 12 July 2011 (UTC)
- In general terms, I think that when we discuss the operating characteristics of a diagnostic test, we should reference medical sources rather than a popular-press book for specifics, regardless of how well the popular-press book is reviewed. In specific terms, I'm not sure what the text in question means. The whole idea of two-tiered testing is that confirmatory Western blotting is performed only in patients with indeterminate (or positive) ELISA. If a patient has a negative result on ELISA, then Western blotting shouldn't even be performed. This is central to the concept of two-tiered testing (as in the serologic diagnosis of HIV), so I'm not sure what the book means when it describes people with negative ELISA but positive Westerns.
Official recommendations for two-tiered testing for Lyme disease are available from the American College of Physicians (PMID 9412315), the Centers for Disease Control (PMID 7623762), and the Infectious Diseases Society of America (PMID 17029130); I believe all are freely available, and they outline two-tiered testing (specifically, that patients with a negative ELISA generally don't go on to have Western blotting performed). In light of that, I'm not sure how to interpret the book's claim about patients with negative ELISA and positive Western blots; such a combination is outside the standard two-tier testing approach. MastCell Talk 17:44, 12 July 2011 (UTC)
- Thanks for the thoughtful reply. First of all, this was not some vague unexplained comment in Weintraub's book. Aside from the cited page 218, she writes at page 116: "Stony Brook researchers said that patients with high levels of Lyme antibody, including those who later passed the far more specific confirmatory test, failed the screening test some 30 percent of the time." The quote at Weintraub's page 218 is this: "Like so many Lyme patients, the individual had tested negative on the ELISA test but positive on a Western blot."
- So, you may wish to argue that Weintraub's reporting is not consistent with the majority establishment view of infectious disease doctors, but it would not be correct to say that Weintraub's meaning is not fathomable or not consistently clear.Anythingyouwant (talk) 18:06, 12 July 2011 (UTC)
- I guess I meant that her meaning was not clear to me. Does she give a footnote or other reference for the "Stony Brook researchers" she quotes? If there's a specific study or publication she's referring to, that would at least be a start. In general, in contrast to the book's implication, the sensitivities of Lyme ELISA and immunoblotting are thought to be similar (with the possible exception of acute erythema migrans, but serologic testing isn't recommended in that setting anyway). See PMID 16020686 (Table 4), for example. MastCell Talk 18:37, 12 July 2011 (UTC)
- She gives dozens of sources en masse for the chapter, and I don't have easy access to them right now. Keep this issue in mind please, MastCell, because Wikipedia should not be telling people who get negative ELISA to never bother getting Western blot, unless that is a very firm medical consensus (which I don't think it is).Anythingyouwant (talk) 19:08, 12 July 2011 (UTC)
- It's not really necessary to lecture me about responsible medical coverage; I appreciate its importance as much as anyone. There is an actual medical consensus on how to perform two-tier testing for Lyme disease, as one can verify through the sources I presented above (the ACP, the CDC, the IDSA). Your edit implied that a negative Lyme ELISA was likely meaningless. I don't think the source you cited is sufficient to support that edit, especially in light of scholarly sources which say essentially the opposite. It sounds like Weintraub doesn't directly cite/identify the "Stony Brook researchers" or their published work - is that an accurate statement? MastCell Talk 20:03, 12 July 2011 (UTC)
- There's no need for you to get
bitchyoffended MastCell, I was not trying to lecture you. I have said everything I intend to say on this subject, for the time being. Cheers.Anythingyouwant (talk) 20:12, 12 July 2011 (UTC)
- There's no need for you to get
- It's not really necessary to lecture me about responsible medical coverage; I appreciate its importance as much as anyone. There is an actual medical consensus on how to perform two-tier testing for Lyme disease, as one can verify through the sources I presented above (the ACP, the CDC, the IDSA). Your edit implied that a negative Lyme ELISA was likely meaningless. I don't think the source you cited is sufficient to support that edit, especially in light of scholarly sources which say essentially the opposite. It sounds like Weintraub doesn't directly cite/identify the "Stony Brook researchers" or their published work - is that an accurate statement? MastCell Talk 20:03, 12 July 2011 (UTC)
- She gives dozens of sources en masse for the chapter, and I don't have easy access to them right now. Keep this issue in mind please, MastCell, because Wikipedia should not be telling people who get negative ELISA to never bother getting Western blot, unless that is a very firm medical consensus (which I don't think it is).Anythingyouwant (talk) 19:08, 12 July 2011 (UTC)
- I guess I meant that her meaning was not clear to me. Does she give a footnote or other reference for the "Stony Brook researchers" she quotes? If there's a specific study or publication she's referring to, that would at least be a start. In general, in contrast to the book's implication, the sensitivities of Lyme ELISA and immunoblotting are thought to be similar (with the possible exception of acute erythema migrans, but serologic testing isn't recommended in that setting anyway). See PMID 16020686 (Table 4), for example. MastCell Talk 18:37, 12 July 2011 (UTC)
- So, you may wish to argue that Weintraub's reporting is not consistent with the majority establishment view of infectious disease doctors, but it would not be correct to say that Weintraub's meaning is not fathomable or not consistently clear.Anythingyouwant (talk) 18:06, 12 July 2011 (UTC)
I think the "negative ELISA, positive Western blot" issue is a little too complex to include in the article, in its present state of disarray. We're still on the lower rungs of Wittgenstein's ladder. If it were politically possible to edit the article to reflect the controversial status of the two-tier-test as a diagnostic requirement, a source that should be acceptable to WP:MED would be the IDSA guidelines hearings report. The review panel (seven IDSA doctors and one veterinarian) voted 4-4, half for and half against, retaining the Executive Statement at the beginning of the IDSA guidelines in its present form. This is the section of the guidelines which calls for a positive result on standardized serological testing (i.e. the two-tier test) as a requirement for diagnosing LD in the absence of EM.
When I reported this split vote, in response to a WP:MED member's post on the outcome of the hearings , it was ignored. Later on, the same WP:MED member added to the LD article a summary of the hearings results based on the IDSA’s press release, calling the panel “independent” and not mentioning the split vote regarding the guideline’s Executive Summary diff. I didn’t bother disputing it, as the editor who inserted it has always had the full support of WP:MED. It’s not what you know, it’s who you know. ;-) I think you’ll find that the same dynamic is still functioning. But who knows? Try adding it and see what happens.
Here’s a URL directly to that portion of the report, Review of Executive Summary, for the convenience of talk page readers. In the article, it would probably be better to cite the full report with page numbers of the relevant portion, thusly: IDSA Lyme Disease Final Report p. 26-7. If such an edit looks like it’s going to stick, I’ll be glad to reformat the ref if it's too bare-URL.
Best regards to all, Postpostmod (talk) 22:21, 12 July 2011 (UTC)
- I'm not sure what you're proposing to add. The split vote centered around allowing clinicians to treat based on a high pre-test probability even with negative serology, which is interesting from a Bayesian perspective but has nothing to do with the relative sensitivities of ELISA vs. Western blot.
Insofar as the IDSA review panel touched on the subject, they affirmed: "When laboratory testing is done to support the original diagnosis of Lyme disease, it is essential that it be performed by well-qualified and reputable laboratories that use recommended and appropriately validated testing methods and interpretive criteria." Which is sort of an implicit endorsement of two-tier testing. That recommendation was considered "medically/scientifically justified in light of all of the evidence and information provided" by a unanimous vote of 8-0.
I think there's a general sense in the literature that existing diagnostic tests are suboptimal, and quite a bit of effort to develop better diagnostic tests, but at the same time two-tier testing seems to be endorsed as the best currently available laboratory-based methodology, subject of course to the caveat that it's frequently negative in early acute Lyme disease. MastCell Talk 22:47, 12 July 2011 (UTC)
- Hi MastCell; I’m not proposing to add anything. It’s politically untenable, as your comment confirms. I believe the split vote revolved around the wording of the statement in the guidelines, italicized for emphasis, that positive serology (presumably by the two-tier test) is “required” for diagnosis. In our previous discussion of the guidelines here, both you and another editor made the point that “guidelines are just guidelines”, that it’s not appropriate to say that guidelines “require” anything, because physicians have autonomy in how they treat patients. There seems to be a misunderstanding of this point, on the part of the IDSA Lyme guidelines’ authors.
- The real-world problem with the statement is that it adversely affects both research and appropriate clinical diagnosis.
- When seriously inaccurate tests are promoted as if they are almost perfect, you get significant numbers of patients with treatable Lyme disease being told they definitely don't have Lyme disease, but rather have diseases of unknown origin that can only be treated symptomatically, like fibromyalgia and chronic fatigue syndrome. See, for example, the influential paper I asked you to read several weeks ago, PMID 8459513, and the published comments on it. I’d still be interested to hear your take on this paper, from a scientific, rather than political, standpoint.
- I guess a certain amount of undiagnosed, untreated late Lyme disease is considered to be a form of negligible collateral damage, subsidiary to the higher goal of asserting the correctness of whatever paradigm is dominant in the field. (Sorry if that sounds harsh – I do get it that most doctors are true believers in the idea that top authorities can be implicitly trusted to provide the best that science has to offer, so they don’t think their stance can be harmful to patients. And I think most medical authorities mean well; they just haven't been adequately trained in what good scientific thinking requires, beyond a plausible story and a knack for politics. That's just my opinion, of course ;-) The idea promoted by Wormser et al. that late Lyme disease is now rare, due to most of the cases being caught in the early stages, must be soothing, especially to a conscious or unconscious Bayesian who hasn’t noticed the GIGO problem. You can’t check the science on every disease, or cure every patient. It’s all about the perceived odds.
- Thank you for your continued willingness to engage in dialogue on this. One of the most mystifying aspects of the situation for patients and their caregivers is understanding “how doctors think”. (By the way, did you ever read Groopman’s book?). Your responses in discussions like these are illuminating. Best regards, Postpostmod (talk) 16:26, 13 July 2011 (UTC)
- You should be aware that a) I don't treat Lyme disease and have no special disease-related knowledge or expertise, and b) I'm not sure I'm representative of "how doctors think". In my experience, there is no one way that doctors "think". I understand the human tendency to seek heroes and villains in complex, nuanced situations, and I think that the medical community has, in this case, been caricatured as a monolithic, closed-minded behemoth filling the role of "villain". I guess I view that as a cop-out on some level - it's a lot easier to vilify Allen Steere and the IDSA than it is to confront the possibility that physicians are generally trying to do the right thing for patients based on available, albeit highly imperfect, knowledge.
It's also counterproductive - the vilification and politicization drives off researchers who could actually move things forward. I can't imagine that any serious researcher in their right minds would want to study Lyme disease in the present environment - certainly I'd strongly advise any impressionable trainees against it, and toward another field where their science won't earn them death threats if it proves inconsistent with the preconceived ideas of an activist group. As we've discussed elsewhere, the current state of affairs also attracts every manner of snake-oil salesman ready to step into the breach. But I digress. MastCell Talk 23:46, 13 July 2011 (UTC)
- You should be aware that a) I don't treat Lyme disease and have no special disease-related knowledge or expertise, and b) I'm not sure I'm representative of "how doctors think". In my experience, there is no one way that doctors "think". I understand the human tendency to seek heroes and villains in complex, nuanced situations, and I think that the medical community has, in this case, been caricatured as a monolithic, closed-minded behemoth filling the role of "villain". I guess I view that as a cop-out on some level - it's a lot easier to vilify Allen Steere and the IDSA than it is to confront the possibility that physicians are generally trying to do the right thing for patients based on available, albeit highly imperfect, knowledge.
- Thank you for your continued willingness to engage in dialogue on this. One of the most mystifying aspects of the situation for patients and their caregivers is understanding “how doctors think”. (By the way, did you ever read Groopman’s book?). Your responses in discussions like these are illuminating. Best regards, Postpostmod (talk) 16:26, 13 July 2011 (UTC)
- If the number of Lyme patients who test negative on ELISA but positive on Western blot is 0% then that would be an interesting factoid for this article. Same if it is 5%, or is somewhere between 10% and 12%. I don't know what percentage range is given by reliable sources, but it would be interesting to know, and interesting to read about in this Wikipedia article. So please regard this as a question, to which I do not know the answer.Anythingyouwant (talk) 00:09, 13 July 2011 (UTC)
- Hi Anythingyouwant; There’s no way of establishing what that number might be, from the current literature, in a way that would be acceptable here. One can only point out that the chain of evidence in the literature, cited to support the current recommendation, is fatally flawed. And that doesn’t matter to WP:MEDRS. Basically, if the top authorities on a subject says the ELISA is very sensitive, and the Western blot should only be performed after a positive ELISA, then no amount of published data showing the contrary could change the WP:MED take on the subject. This is explicitly laid out in WP:MEDRS; secondary sources (review articles) and tertiary sources (textbooks) are privileged over primary sources (the ones with the actual data). The ELISA issue has been discussed before on the LD talk, for example, here. Take a look at how that argument came out. That’s why I didn’t spend time collecting the sources Weintraub used. They would be disallowed, first, because a recognized medical authority like one of the guideline authors, will always trump a dissenting journalist as a “reliable source”, regardless of the biological facts. And second, because if we cite the primary sources Weintraub used, they’ll be considered invalid by WP:MEDRS, since they disagree with the currently dominant paradigm.
- That paradigm tells the story that the two-tier test is 95 to 100% sensitive in disease of greater than a few weeks' duration. The data seeming to support this assertion is obtained by using a circular definition that a positive two-tier test is “required” for a disease to be diagnosed as Lyme disease, in the absence of an EM rash. MastCell understands that, as you can see here. But as long as IDSA sticks to their story, that wraps it up as far as the larger medical community and WP:MED is concerned. I know it seems strange. I’ve come to understand it as a byproduct of medical culture and training. Doctors are trained not to examine the official story – their training is to learn the story, and then to repeat it, defend it, and follow it in practice. You can see how this system evolved – if all the doctors say the same thing, then anyone who conforms isn’t accountable for bad results. As for the authorities, there's no law against mistakes in science, so they're not accountable either.
- It’s generous of MastCell to educate us by showing us in detail how it’s customarily done. Expecting anything more is unrealistic – though you never know, occasionally an individual rises to meet a challenge. Best wishes for you and yours, Postpostmod (talk) 17:28, 13 July 2011 (UTC)
- I'm not really going to respond to your observations about medical culture, other than to say that they differ from mine and lead me to suspect that you have a very limited exposure to or understanding of actual medical culture. If we're making gross generalizations, I'll say that doctors are fundamentally practical (in contrast, again as a gross generalization, to basic scientists). Doctors are trained to be skeptical of what you call "the official story", but they need a better story to replace it. I could spend all day tearing down other peoples' science. That's easy. The hard part is replacing it with something better.
I think we agree that there are weaknesses in the current diagnostic approach to Lyme disease. I hope that in 5 years, the current two-tier approach will be an anachronism. But for that to happen, there needs to be something better to replace it, and so far there isn't. Designing and testing better approaches is hard. Shooting holes in the existing data and vilifying people who disagree with you isn't hard, but it only gets you so far unless it's paired with a serious effort to create something better.
As to your complaint about "WP:MED", I think it stems from the fact that Wikipedia is intended to convey the current state of knowledge, rather than to provide a forum in which to critique it. MastCell Talk 00:07, 14 July 2011 (UTC)
- I'm not really going to respond to your observations about medical culture, other than to say that they differ from mine and lead me to suspect that you have a very limited exposure to or understanding of actual medical culture. If we're making gross generalizations, I'll say that doctors are fundamentally practical (in contrast, again as a gross generalization, to basic scientists). Doctors are trained to be skeptical of what you call "the official story", but they need a better story to replace it. I could spend all day tearing down other peoples' science. That's easy. The hard part is replacing it with something better.
- It’s generous of MastCell to educate us by showing us in detail how it’s customarily done. Expecting anything more is unrealistic – though you never know, occasionally an individual rises to meet a challenge. Best wishes for you and yours, Postpostmod (talk) 17:28, 13 July 2011 (UTC)
- Hi MastCell. I’m afraid your comments substantiate my point, rather than refute it. As you know, I’ve been waiting several weeks for you to rejoin our discussion about the two-tier test and possible superior alternatives. You asked me to share my thoughts about it, and I said I’d be glad to, and suggested you read two rather short and simple papers, PMID 8459513 plus comments and PMID 1537905, to get up to speed on the subject, as you’ve already told me you don’t have anything to do with LD professionally. You haven’t responded yet, but we’ve had breaks in our conversations before, and I’m still patiently waiting. My offer still stands to help you and your colleagues understand why it's not unreasonable to think that another diagnostic heuristic might be a better choice, based on current mainstream science. The politics is the result of scientific problems, not vice versa.
- If, as you say, your concern is all about the best science currently available, why are you ignoring the science? it’s a bit absurd for you to accuse others of “vilification” and “politicization”, merely for looking carefully at the published research and pointing out its flaws. That’s done all the time in real science, and that’s how it progresses. You seem to have me and other dissenting scientists confused with the unnamed “stalkers” and “harrassers” in David Grann’s human interest story in NYT Magazine, which you inserted into the article and recommended to other WP:MED members in your recruiting effort, here.
- I don't see how looking at the science can damage the article, Wikipedia, or the reputation of your profession. The dominant view will still be dominant, and will be presented as such in the article. The minority’s specific critiques of it should be summarized without prejudice as a notable minority view. A description of the skirmishes that have characterized the debate should be summarized in a cool and impartial tone. As for the political action, if the reader thinks it’s a terrible thing, or a good thing, or simply an interesting phenomenon, for people to demonstrate or take political action to ensure access to tests and treatment that are scientifically reasonable but not condoned by the dominant view, that’s his call. Just say what has happened. It's not helpful to use the article to vent your, or the medical community's, irritation about it.
- Instead, perhaps you might use your excellent professional expertise and communication skills to help understand and describe the substantive scientific issues in a way people can understand. If the article ever meets WP:NPOV, in both substance and tone, I’ll be glad to help patrol it to keep it that way, including WP:WEIGHT. Of course, then I'll be the one trying to explain Wikipedia policy to new editors - that might be your best revenge. ;-0
- No hard feelings, I'm looking forward to continuing our discussion of the science. I'll be offline for about a week - going to visit family. Maybe I'll see some new birds. I've been watching a cedar waxwing incubating her eggs. Come to think of it, they'll probably hatch while I'm away - wah. But I can see the babies when I get back, no hurry. Best regards, Postpostmod (talk) 22:20, 14 July 2011 (UTC)
- Maybe you've misunderstood me, or I didn't express myself clearly. Looking at science and pointing out its flaws is a vital process, but it's at best half of the equation - one needs to also present better science. I don't see what diagnostic heuristic the "Lyme-literate" community is proposing to take the place of the current approach; if you can enlighten me on that point, I'd be appreciative.
There is clearly a group of people who are so invested in a particular view of this issue that they're willing to threaten death to scientists whose work doesn't agree with their preconceived notions. That's important context for anyone thinking about editing a Wikipedia article on the topic, since such emotions and threats have a tendency to spill over here at times. Hence my warning, which you linked above. MastCell Talk 23:37, 14 July 2011 (UTC)
- Hi MastCell, I’m back, after a nice visit with my family and childhood friends.
- There are better approaches to testing, and I’ll be glad to walk you through them, but right now I’m puzzling over how to respond to your assertion that an inaccurate test is better than no test. A test that is perceived to be more accurate than it really is, misleads the treating physician as to what might be wrong with the patient. This causes misdiagnosis and mistreatment. I’m not sure why that is so hard to understand. Could you explain to me the logic behind your position? Perhaps it would be helpful to explain physicians’ needs first, and then to consider how these might differ in some ways from the needs of the patients, and what might be done to reconcile them. Best regards, Postpostmod (talk) 17:09, 24 July 2011 (UTC)
- I'm not advocating the use of "inaccurate" tests. I'm saying that using the best currently available test is superior to using no test, particularly when the contemplated interventions carry their own set of risks. MastCell Talk 23:39, 29 July 2011 (UTC)
- If A = B, and B = C, then A = C. Best regards, Postpostmod (talk) 21:55, 30 July 2011 (UTC)
- When you’re ready to engage with the matter, please rejoin our discussion on your user talk page. It’s been a couple of months now, and I’ve reminded you politely several times. If you can’t find the time to read the two rather simple papers I recommended as background, PMID 1537905 and PMID 8459513, please answer anyway to let me know you’re ready, and I’ll summarize the most relevant points for you. I’d rather you gathered them yourself directly from the source, since you don’t trust me. But if you won’t do that, I’d still rather have the discussion than not.
- While you're at it, you might want to pick up the Chinese CDC's paper PMID 21112481 and see how they formulated their much less restrictive Western blot criteria - it's an eminently sensible approach.
- Note to bystanders: we’re having the detailed discussion about LD testing on MastCell’s user talk page, rather than on the article talk page, because, somewhat counterintuitively, one of WP’s guidelines is not to discuss the article’s subject on the talk page:
- “Stay on topic: Talk pages are for discussing the article, not for general conversation about the article's subject…” quoted from WP:talk
- Best regards, Postpostmod (talk) 16:59, 2 August 2011 (UTC)
- I'm not advocating the use of "inaccurate" tests. I'm saying that using the best currently available test is superior to using no test, particularly when the contemplated interventions carry their own set of risks. MastCell Talk 23:39, 29 July 2011 (UTC)
- Maybe you've misunderstood me, or I didn't express myself clearly. Looking at science and pointing out its flaws is a vital process, but it's at best half of the equation - one needs to also present better science. I don't see what diagnostic heuristic the "Lyme-literate" community is proposing to take the place of the current approach; if you can enlighten me on that point, I'd be appreciative.
- No hard feelings, I'm looking forward to continuing our discussion of the science. I'll be offline for about a week - going to visit family. Maybe I'll see some new birds. I've been watching a cedar waxwing incubating her eggs. Come to think of it, they'll probably hatch while I'm away - wah. But I can see the babies when I get back, no hurry. Best regards, Postpostmod (talk) 22:20, 14 July 2011 (UTC)
Safety of antibiotics
The sentence I removed is a quite classic case of original synthesis. "However, blah blah", the sentence is clearly intended to oppose the position of the IDSA, AAN, CDC, and NIH. But that was clearly not the intention of the authors of the cited studies. Antibiotic safety is not an absolute matter; it's a cost benefit analysis, and the NIH and others are quite clearly saying in their citations that the potential benefit is not worth the potential cost. If you want to suggest that the NIH, CDC, AAN, and IDSA are wrong in their opinion, you'll have to find a source that actually suggests that, rather than finding a tangetially relevant paper and making the leap from A+B to C. Someguy1221 (talk) 07:36, 27 July 2011 (UTC)
- I'm sorry, but you're wrong. This section of the article deals with "Controversy and politics" and part of the controversy is the implied suggestion that long term treatment with antibiotics is unsafe, when clearly there are differing opinions within the medical community about this, especially in regards to to oral antibiotics. Doxycycline cannot be "safe" for long term treatment of acne, and "unsafe" for long term treatment of LD; this is part of the "controversy" regarding LD. I am going to undo your changes. Damwiki1 (talk) 08:54, 27 July 2011 (UTC)
The above exchange was copied from Damwiki1's talk page. The text in question can be seen here: [4]. I believe my actions were a straightforward application of WP:MEDRS and WP:OR; the cited references do not discuss Lyme disease, but are used to create an illusion of scientific controversy regarding this aspect of Lyme disease treatment. I would appreciate others' input on this. Someguy1221 (talk) 09:27, 27 July 2011 (UTC)
- The section under discussion is entitled: "Controversy and politics". "Controversy" implies conflicting points of view, and if there were no conflicting points of view regarding the safety of long term antibiotic therapy, it would not be a topic in this section of the article. I have presented citations showing that long term treatment with doxycycline and minocycline is common practice for the treatment of adult acne, and that it is considered safe. This doesn't imply that long term mino/doxycycline therapy should or should not be used to treat LD, only that the risks of doing so are extremely low. In any event, you should have started this discussion prior to your edits.Damwiki1 (talk) 10:06, 27 July 2011 (UTC)
- Hello, Someguy and Damwiki. Maybe you'd both be interested in the thread above this one, which has diffs supporting my observations below. Damwiki, I do think WP:SYNTHESIS, as it is customarily applied by WP:MED, is a technical problem with your particular edit. However, even if you cite an impeccable WP:MEDRS in which one, or a group of, dissenting doctors makes your point about the relative safety of oral antibiotics compared to the dangers of undertreated Lyme disease, it will either be disallowed entirely, or call forth additional citations from, um, higher ranking sources, saying that the dissenters can't be trusted and should be disregarded.
- As to why this is, I'll say it again, another way, as I think one needs to understand the politics in order to edit this article effectively. The bottom line is, WP:MED's current membership will not support edits that document credible challenges to the "mainstream view", even in the "Controversy" section. In medical articles, WP:MED can trump WP:NPOV. The preferred solution to controversy seems to be, to identify the more politically powerful side, and then follow it and have faith that it is scientifically correct. This faith makes it more powerful, and so on ad infinitum. A situation where big influential organizations like those mentioned by Someguy, are demonstrably wrong, is thought to be practically impossible, and hence subject to WP:FRINGE. (I'm not suggesting that WP:MED members are acting in bad faith. I can see that if you're going to edit a lot of articles, thus providing medical information on many subjects to millions of people, this would be the quickest way to do it. We all share the hope that the mainstream is usually right, even when we are unfortunate enough to encounter a case where it isn't. ;-)
- These are my personal observations, of course; everyone needs to read at least the article and talk-page histories, if not the primary Lyme disease literature and criticism upon which the mainstream view depends. We can each form our own impression of how the politics works.
- One might think there is no point in trying to make the article meet WP:NPOV, under these conditions. On the other hand, the areas of the article (and of the LD field) where dissenters are acknowledged to exist, even when they are disparaged, may be useful in alerting readers that there is some kind of problem with the status quo, thus motivating them to investigate further. The templates at the top of the talk page help in this regard, particularly the sarcastic one about the "manifold evils of ..."). So, proceed as you think best; just thought I'd put in my two cents worth. My best regards to all involved in working on this difficult article, Postpostmod (talk) 16:50, 27 July 2011 (UTC)
- I fully understand that there is an orthodox view regarding treatment of LD. It is not my intent nor does my edit imply that long term oral antibiotic treatment is preferable to shorter courses of treatment. However, it is not synthesis or OR to suggest that the proven safety of long term oral antibiotic therapy to treat acne demonstrates its safety (but not efficacy) to treat other diseases. For example here: Adverse events associated with prolonged antibiotic use the authors explicitly use medical databases to examine the rate of adverse events with doxycycline (and others) to determine its safety in potentially treating a rare disease (anthrax). The problem of synthesis does arise when it is implied that long term oral antibiotic therapy creates a greater likelihood of serious adverse events while treating LD, than in the general population, yet there are no studies that suggest this, yet the article, as written implies that this is the case.Damwiki1 (talk) 18:05, 27 July 2011 (UTC)
- You may be missing the point that Someguy made in his initial post. "Safety" is a relative term and generally depends on the context in which a drug is used. Cisplatin is acceptably safe for treating someone with testicular cancer, but absolutely unsafe to treat, say, acne. Since long-term antibiotic therapy has no proven efficacy in "chronic" Lyme disease, even rare side effects make it unacceptably unsafe. Moreover, the major concern is not necessarily individual adverse reactions, but the generation of antibiotic resistance, which is typically not easily quantified in the studies you're describing.
The underlying point is that we need to accurately convey the state of knowledge in the field. Right now, major medical bodies feel that long-term antibiotic use for "chronic" Lyme disease is unacceptably unsafe. Trying to "rebut" those expert bodies by selecting and juxtaposing individual studies is exactly the sort of editorial intrusion that WP:MEDRS warns against. MastCell Talk 18:53, 27 July 2011 (UTC)
- I am trying to "...accurately convey the state of knowledge in the field..." and the long term safety of oral antibiotics is part and parcel of that state of knowledge. The study I linked to, above, shows an overall rate of serious adverse events of .9/100,000 person years of treatment for doxycycline, by way of contrast the probability of a US resident being hit by lightning is .13/100,000 person years: [5]. Perhaps these figures should be included in the article to adress the absolute safety of oral antibiotic therapy? Some US States have laws allowing physicians to treat LD via long term antibiotic therapy, in specific defiance of mainstream LD treatment protocols and the safety of such therapy needs to be addressed within this article. Long term treatment of LD with antibiotics is an established fact, as is the safety of long term oral treatment via antibiotics. The decision as to whether "...long-term antibiotic use for "chronic" Lyme disease is unacceptably unsafe..." is a decision that patients and doctors must make, based upon the available literature, rather than solely on the treatment opinions of any medical association. Again, this is a simple fact, established by law in many jurisdictions, and the article will be remiss if it does not address the issue of the long term safety of antibiotic therapy, especially since legal authority to prescribe long term therapy is part of the "controversy and politics" surrounding LD. Whether long term antibiotics should be used to treat LD and the merits or drawbacks to doing so is a separate issue.Damwiki1 (talk) 19:54, 27 July 2011 (UTC)
- If the risks outweigh the benefits with the use of antibiotics, then let's see actual reviews saying that. We should not be committing clear synthesis by implying safety using studies of other conditions. There are clear safety concerns outside of mere adverse events to the patients, including the development of resistance to antibiotics. Please find reviews per WP:MEDRS that state it in the context of this disease before putting any information like this back in. Yobol (talk) 20:29, 27 July 2011 (UTC)
- I am trying to "...accurately convey the state of knowledge in the field..." and the long term safety of oral antibiotics is part and parcel of that state of knowledge. The study I linked to, above, shows an overall rate of serious adverse events of .9/100,000 person years of treatment for doxycycline, by way of contrast the probability of a US resident being hit by lightning is .13/100,000 person years: [5]. Perhaps these figures should be included in the article to adress the absolute safety of oral antibiotic therapy? Some US States have laws allowing physicians to treat LD via long term antibiotic therapy, in specific defiance of mainstream LD treatment protocols and the safety of such therapy needs to be addressed within this article. Long term treatment of LD with antibiotics is an established fact, as is the safety of long term oral treatment via antibiotics. The decision as to whether "...long-term antibiotic use for "chronic" Lyme disease is unacceptably unsafe..." is a decision that patients and doctors must make, based upon the available literature, rather than solely on the treatment opinions of any medical association. Again, this is a simple fact, established by law in many jurisdictions, and the article will be remiss if it does not address the issue of the long term safety of antibiotic therapy, especially since legal authority to prescribe long term therapy is part of the "controversy and politics" surrounding LD. Whether long term antibiotics should be used to treat LD and the merits or drawbacks to doing so is a separate issue.Damwiki1 (talk) 19:54, 27 July 2011 (UTC)
- You may be missing the point that Someguy made in his initial post. "Safety" is a relative term and generally depends on the context in which a drug is used. Cisplatin is acceptably safe for treating someone with testicular cancer, but absolutely unsafe to treat, say, acne. Since long-term antibiotic therapy has no proven efficacy in "chronic" Lyme disease, even rare side effects make it unacceptably unsafe. Moreover, the major concern is not necessarily individual adverse reactions, but the generation of antibiotic resistance, which is typically not easily quantified in the studies you're describing.
- I fully understand that there is an orthodox view regarding treatment of LD. It is not my intent nor does my edit imply that long term oral antibiotic treatment is preferable to shorter courses of treatment. However, it is not synthesis or OR to suggest that the proven safety of long term oral antibiotic therapy to treat acne demonstrates its safety (but not efficacy) to treat other diseases. For example here: Adverse events associated with prolonged antibiotic use the authors explicitly use medical databases to examine the rate of adverse events with doxycycline (and others) to determine its safety in potentially treating a rare disease (anthrax). The problem of synthesis does arise when it is implied that long term oral antibiotic therapy creates a greater likelihood of serious adverse events while treating LD, than in the general population, yet there are no studies that suggest this, yet the article, as written implies that this is the case.Damwiki1 (talk) 18:05, 27 July 2011 (UTC)
- Since this edit has been in the article for some time and is under active discussion, I would strongly urge you to undo your previous edit until consensus has been reached here.This is wikipedia policy.Damwiki1 (talk) 20:36, 27 July 2011 (UTC)
- At this point, I see 3 editors noting they think this is inappropriate, with a 4th also noting significant OR problems here. Consensus appears to be coalescing against this material, and should stay out until you such time as consensus is reached it is appropriate. That bad material has stayed in the article for all of two months does not make it immune to removal, especially when it is a clear violation of our policies. Yobol (talk) 20:43, 27 July 2011 (UTC)
- That's not how wikipedia is supposed to work and the policy is for disputed articles to remain as is until consensus. However, to return to the topic of antibiotic safety, there are a number of sources that discuss the use of long term antibiotic therapy for LD, with tetracycline class antibiotics, and none of them state safety as an issue: [6], [7],[8]. I have previously provided large scale studies showing a very low rate of severe adverse events: .9/100,000 person years of treatment for doxy, and to draw another comparison, the rate of fatal MVAs in the USA is about 14/100,000 person years[9]. The State of Connecticut is on very solid ground in granting Drs the right to prescribe long term antibiotic therapy, since the science and statistics of long term therapy is well known. Again, it is clearly misleading for this article to remove all references to long term antibiotic safety statistics, from large scale databases, and it clearly violates a NPOV.Damwiki1 (talk) 00:55, 28 July 2011 (UTC)
- Agree with others here who have expressed concern about WP:SYNTH with respect to the content regarding long-term antibiotic safety. This has nothing to do with orthodoxy. -- Scray (talk) 01:33, 28 July 2011 (UTC)
- Additionally, I don't think the references cited by Damwiki1 actually mean what he thinks they mean.
PMID 8740119 does note that, 15 years ago, many physicians used long-term antibiotics for "chronic" Lyme disease, but the paper explicitly attributes long-term antibiotic use to poor physician education, not as a desirable practice.
PMID 9233665 (which, incidentally, is a 14-year-old conference presentation, not a regular journal article) explicitly states that randomized, controlled trials need to be performed to definitively evaluate the safety and efficacy of long-term antibiotic therapy. Such trials were, of course, subsequently performed, and the negative results of these trials heavily influenced the positions of the IDSA, AAN, CDC, etc. It seems a bit misleading (at best) to cite the observational 1997 conference presentation without acknowledging the subsequent randomized, controlled trials which it called for.
PMID 14586290 is very interesting. The author apparently took patients with vaguely defined symptom constellations and gave them tetracycline and Plaquenil "until patients' symptoms were resolved or improved." Ten points for Gryffindor if you spot the logical flaw here. Hint: if I have a sprained ankle and you treat me with tetracycline "until symptoms resolve", you would (using this paper's logic) conclude that tetracycline heals ankle sprains. The success rate of any treatment is going to be high if it's continued "until symptoms resolve", and if any resolution of symptoms is attributed to the intervention.
But I digress, I suppose. MastCell Talk 23:31, 29 July 2011 (UTC)
- Additionally, I don't think the references cited by Damwiki1 actually mean what he thinks they mean.
- Agree with others here who have expressed concern about WP:SYNTH with respect to the content regarding long-term antibiotic safety. This has nothing to do with orthodoxy. -- Scray (talk) 01:33, 28 July 2011 (UTC)
- That's not how wikipedia is supposed to work and the policy is for disputed articles to remain as is until consensus. However, to return to the topic of antibiotic safety, there are a number of sources that discuss the use of long term antibiotic therapy for LD, with tetracycline class antibiotics, and none of them state safety as an issue: [6], [7],[8]. I have previously provided large scale studies showing a very low rate of severe adverse events: .9/100,000 person years of treatment for doxy, and to draw another comparison, the rate of fatal MVAs in the USA is about 14/100,000 person years[9]. The State of Connecticut is on very solid ground in granting Drs the right to prescribe long term antibiotic therapy, since the science and statistics of long term therapy is well known. Again, it is clearly misleading for this article to remove all references to long term antibiotic safety statistics, from large scale databases, and it clearly violates a NPOV.Damwiki1 (talk) 00:55, 28 July 2011 (UTC)
- At this point, I see 3 editors noting they think this is inappropriate, with a 4th also noting significant OR problems here. Consensus appears to be coalescing against this material, and should stay out until you such time as consensus is reached it is appropriate. That bad material has stayed in the article for all of two months does not make it immune to removal, especially when it is a clear violation of our policies. Yobol (talk) 20:43, 27 July 2011 (UTC)
I find it interesting that you are willing to find logical flaws in the treatment plans of Drs who use long term antibiotic therapy, but are unwilling to apply the same logic tests to Drs who insist on very short courses of antibiotics.However, it is not our place as wikipedia editors to sit in judgement of Drs, but only to present a neutrally written article for public consumption. Yet it would seem from your comments that you have a non-neutral POV. First off, there are no studies that show that LD patients are more likely to to suffer adverse effects from long term antibiotic therapy than the general population - if such studies existed they would be presented, but it would also be simply amazing and would indicate a severe underlying condition unique to chronic lyme sufferers. The rate of serious adverse effects with the most common antibiotics used are so low, that the patient literally has a much higher chance of dying while driving to see the physician than having a severe adverse event. "Do no harm" is the first rule in medical practise and even if giving antibiotics is no better than placebo in terms of treatment effect, they are also no less safe than placebo, since the rate of adverse events is so low. This is the key point that needs to be addressed since even if oral antibiotics don't work, they are also very "safe", and trying to argue otherwise is complete nonsense, with no scientific validity.
Secondly, antibiotics such as tetracycline, doxycycline and minocycline are noted for their anti-inflammatory and neuroprotective properties. Again, it would be amazing if they did not have some therapeutic effect on a population suffering from neurocognitive and arthritic symptoms. If someone is suffering from 'brain fog' and joint pain subsequent to an LD infection, why wouldn't minocycline be therapeutic? And long term trials do show that patients felt better on antibiotics, only to relapse once they are withdrawn. What's the harm in treating a patient with an antibiotic that makes them feel better, and is safe to use for extended periods and coincidently will destroy any remaining spirochaetes that might be trying to evade destruction in areas of the body with low blood flow? This is a digression as well but it points out the glaring logical fallacy in insisting on very short courses of antibiotics to treat LD since as the length of treatment declines, the rate of incompletely treated patients will increase, but the key point is that there is no scientific basis for disallowing long term oral antibiotic treatment, on the basis of safety and tangentially there are a myriad of studies showing that certain antibiotics have anti-inflammatory and neuroprotective therapeutic properties in addition to their antimicrobial properties. The final point is that the growth in antibiotic resistance is mainly driven by the misuse and overuse of antibiotics in the global livestock industry, and forced animal consumption of antibiotics dwarfs the direct use of antibiotics in humans: farm-animals-get-80-of-antibiotics-sold-in-us.Damwiki1 (talk) 08:44, 30 July 2011 (UTC)
- WP:NOTFORUM. At this point, there should be no further discussion about this on this talk page unless you can provide sources that speak to the safety of long term antibiotics use in the context of treating lyme disease. Everything else is WP:SYNTH, as has been noted by several editors already. Yobol (talk) 14:11, 30 July 2011 (UTC)
- Like I said... :-), Postpostmod (talk) 21:38, 30 July 2011 (UTC)
China’s CDC – Standardized criteria for Bb sensu lato Western blot
PMID 21112481, Jiang et al., 2010
for IgG, at least one band of P83/100, P58, P39, P30, OspC (22kd) , P17, P66, and Osp A (31 kd)
- 73% sensitive, 99% specific
for IgM, at least one band of P83/100, P58, OspA, P30, P17, or P41. “In addition, when the positive band is p41, syphilis, leptospirosis and other related diseases should be excluded.”
- 50% sensitive, 93% specific
Postpostmod (talk) 23:10, 30 July 2011 (UTC)
ELISA - region-specific?
I'm a bit confused by the citation for this statement: "ELISA testing, however, is typically done against region-specific epitopes, and may report a false negative if the patient has been infected with Borrelia from another region than that in which the patient is tested." It's currently citation 87, "Effect of Borrelia burgdorferi genotype on the sensitivity of C6 and 2-tier testing in North American patients with culture-confirmed Lyme disease.". Clin Infect Dis. 47 (7): 910–914. The trouble is, I've skimmed the paper, and I don't actually see any clear statement of a region-specific lack of sensitivity in ELISA testing. If there are other sources, I'd love to see them... in fact, if this is true, it could be important in the life of someone I know very well. I just can't find a clear source either way for this statement. If the current citation does have a statement to this effect, could someone please point me to it? It's possible I just missed it, after all. EPAstor (talk) 12:06, 2 August 2011 (UTC)
Chronic Lyme revisited
Not sure how to classify this, but just as a FYI:
- Some patients with Lyme disease still show symptoms long after their treatment has finished. Now proteins have been discovered that set these people apart from those who are easily cured.[10]
Probably insufficient to include, but feel free to discuss.--- Nomen Nescio Gnothi seautoncontributions 12:25, 8 August 2011 (UTC)
- Hi Nescio, nice to meet you.
- It’s notable because it's in Nature/News, and because the authors are influential in the field. But the paper itself, PMID 21778118, is a primary source that is new, and has not been confirmed. Overall, I don't think it meets MEDRS for inclusion in the article, and it's too detailed a point to be appropriate in such a general overview.
- If it has gotten you interested in post-Lyme disease syndrome (PLDS) and chronic Lyme disease (CLD), feel free to drop me a note on my talk page, or ask me to do it here, and I'll summarize the definitions and issues. There are some subtleties about how each term has been used in the past, and how they're being used now by different authorities. Without that background, it's hard to talk about it in a sensible manner.
- Maybe I should clarify my view of primary references, with regard to what is helpful for improving Wikipedia medical articles. I think that older, influential primary references that form the basis of current recommended practice should be examined carefully, when there’s controversy as to their accuracy. But new primary research papers usually aren’t relevant to improving an article, although I think it's fair to mention them in a talk page discussion, when countering someone’s charge that “there isn’t any evidence to support” a certain view.
- A new primary reference could be discussed on the article talk page, if WP:MED editors are willing to discuss it. If they aren't, then it violates the talk page guideline that the subject of the article should not be discussed on the article talk page. (No offense meant to WP:MED: I understand that the rules of Wikipedia don't require reading of primary papers.) Please read the threads immediately above this one. I’ve had limited success in my attempts to get past editor(s) of the article to read research papers critically and in detail, including those papers fundamental to mainstream medical practice. Given that history, I think initiating a conversation about a new primary paper, without everyone being up to speed on the background, might distract editors from dealing with the more urgent issues affecting the article and its readers.
- Best regards, Postpostmod (talk) 18:39, 9 August 2011 (UTC)
Eytomology
The etymology needs to be included.Curb Chain (talk) 23:12, 8 September 2011 (UTC)
- Do you require something more than the statement in the lead (expanded on and referenced in the History section)? Etymologies as such, of course, belong in a dictionary. — Pingkudimmi 16:40, 12 September 2011 (UTC)
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