User:Bob the goodwin/sandbox

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My Sandbox is a place where I am going to make statements about the Lyme Wars and the associated medicine that I believe I can support with secondary reliable sources. I may put placeholders in temporarily with the notations (Need Ref), (OR), or (Primary), or (Opinion) where I have incomplete work. Please feel free to comment here or on My talk page. Dissent is appreciated. I will not be doing any edits on Wikipedia while the consensus remains that chronic lyme is a fringe opinion. I tested this belief, and believe that is the current consensus. Talk:International_Lyme_And_Associated_Diseases_Society. I repeat, the following is NOT a proposed article, nor I am writing this as a way to promote language in Wikipedia. I am writing this to answer questions I have been given by editors.

Contents

Summary[edit]

The "Lyme Wars" is an ongoing controversy between two "bitter and vengeful" camps of Lyme disease researchers and doctors about the nature and treatment of chronic sequelae of Lyme disease. http://nymag.com/nymetro/health/columns/bodypolitic/2225/

The majority group, predominantly university-based physicians, consider Lyme disease easily curable with 2-4 week course of antibiotics. In their opinion, chronic sequelae of acute Lyme disease occur infrequently. They are only consequences of Lyme infection, such as autommune reaction, but not the infection.http://nymag.com/nymetro/health/columns/bodypolitic/2225/

The minority group, consisting mostly of practical physicians, insist that Lyme disease bacteria may survive a short course of antibiotics. These surviving bacteria may cause, in their view, the long-term consequences of acute Lyme disease. Hence such cases have to be treated by additional, long-term antibiotic therapy, until the symptoms clear.http://nymag.com/nymetro/health/columns/bodypolitic/2225/

According to the majority opinion: "There has been no clinical trial that demonstrates long-term treatment of Lyme is beneficial." Normal 0 false false false EN-US X-NONE X-NONE To this, the proponents of the minority respond that in many cases ("60 scientific studies") standard tests miss the Lyme bacteria. In many patients who went through course of antibiotics but whose symptoms lingered, more advanced tests found remaining Borrelia infection.http://nymag.com/nymetro/health/columns/bodypolitic/2225/

The Lyme Wars may be a Proxy War for larger issues in medicine, including the high cost and low benefit of treating chronic diseases, public information and self-treatment trends on the internet, and pressure on doctor patient relationships and clinical diagnosis.

The history of the misunderstanding[edit]

The "Lyme Wars" grew steadily through the 1980s and 1990s as increasing populations of people presented themselves to doctors with clinical symptoms of Lyme disease and doctors began using longer doses of antibiotics. The war entered a hot stage, when a leading establishment figure, the discoverer of Lyme disease Allen Steere wrote in 1993 Journal of American Medical Association had become "overdiagnosed" and overtreated. Steere noted that 57% of the patients referred to his specialized clinic do not have Lyme disease according to the test Steere clinic conducted. 45% of these patients had positve test results in other clinics; however, Steere considered the false positive. [1]. In several responses to JAMA (JAMA. 1993;270(22):2683. doi:10.1001/jama.1993.03510220038019) (JAMA. 1993;270(22):2682-2683. doi:10.1001/jama.1993.03510220038018) (JAMA. 1993;270(22):2682. doi:10.1001/jama.1993.03510220038017) pointed out to several shortcomings in Steere article. Their authors "dismayed to read that Steere et al ignored many of the basic principles of the practice of medicine as well as of good research" For example, Steere appeared to imply that his test for Lyme disease is the best one, with perfect sensitivity and specificity. Other authors "were saddened and disturbed by the article by Steere et al. There exists in the scientific literature ample evidence of persistent chronic infection despite recommended treatment, documentation of seronegativity as a real phenomenon in Lyme disease, sufficient information regarding the mechanisms of evasion of the organism by antibiotics and the immune system, and evidence for the unreliability of diagnostic tests." In 1993, Joeseph Burrascano gave testimony alongside Allen Steere to the Senate, were he asserted that a few researchers discredit opponents to create bias within federal agencies and medical journals in order to promote flawed science. [2]

The reasons that Allen Steere and Gary Wormser initially rejected the concept that would later be commonly called chronic Lyme disease are not known, but there is an explanation for the current thinking within the IDSA guideline for the treatment of Lyme Disease, namely:

  • Lyme bacteria does not have antibiotic resistance (presumably in vivo)
  • Persistent symptoms of Lyme disease do not correlate with either inflammation or with later objective evidence of disease.
  • improbable that chronic B. burgdorferi infection can occur in the absence of antibodies
  • The only other Spirochete, Syphilis was easily treated with antibiotics.
  • None of the factors exist that allow other infections to survive antibiotics exist with Lyme bacteria, namely:
  • Lyme bacteria does not primarily persists in people with compromised immune systems.
  • Lyme bacteria are not partially damaged by antibiotics, they are killed
  • Available antibiotics are fully effective against Lyme bacteria in vitro.
  • Lyme bacteria are not caused by an intracellular pathogen
  • Lyme bacteria are not involved within a biofilm
  • Lyme bacteria are not on a heart valve.
  • Lyme bacteria are not involved in within a ischemia, foreign body, sequestrum, or frank pus.
  • Lyme bacteria can survive antibiotic treatment when they are in the cystic form, but these have no clinical significance. no cyst involvement in disease

The debate has taken many forms in the following two decades, but the main points of dispute are

Post-treatment symptoms were postulated to be auto-immune by researchers who dismiss the existence of chronic Lyme.

The two sides[edit]

(no references in this section, will come back)

The mainstream medical view of Lyme disease comes from the IDSA Lyme treatment guideline, written by the following authors:

Wormser GP (New York Medical College), Dattwyler RJ (New York Medical College), Shapiro ED (Yale), Halperin JJ (NYU), Steere AC (Harvard), Klempner MS (UMASS), Krause PJ (Yale), Bakken JS(University of Minnesota), Strle F (Slovenia), Stanek G (Austria), Bockenstedt L (Yale), Fish D (Yale), Dumler JS (Johns Hopkins), Nadelman RB (New York Medical College)

The Guideline governs care throughout all western nations. Although nominally the guideline is written as optional, and physicians are licensed by individual states, in practice they limited physicians and patients choices. Insurance companies used the more restrictive IDSA guidelines to limit coverage for chronic Lyme disease (ref needed), and doctors were intimidated by the investigation or sanctioning of 50 physicians for prescribing longer term treatment approaches to Lyme disease. (ref to Blumenthal press release)

Today the minority opinion comes the ILADS in the US, and the German Borreliosis Society in Europe.

Doctors in the US who treat patients using the ILADS protocol are often referred to as 'Lyme Literate Physicians' or LLMD's. ILADS was founded in 1999 by doctors who aggressively treated Lyme disease in response to the polarization, the state actions against Lyme doctors, and the restrictions on insurance coverage for their patients. The organization ultimately expanded into medical research, training of new LLMDs, lobbying states governments to protect the doctor patient relationship, drafting an alternative treatment guideline for Lyme disease, and advocating against the IDSA Lyme guideline.

The most prominent advocates for ILADS and the existence of chronic Lyme include Dr Fallon (Columbia), and Willy Bergdorfer (Namesake and discoverer of the Lyme bacteria.) Dr. Waisbren is a founding member of IDSA and pro-chronic Lyme, Dr. Auwaerter of Johns Hopkins spoke at an ILADS conference to express the position of the IDSA, and the IDSA guidelines stated it had reviewed scientific data and opinions provided by ILADS.

In 2006 Connecticut attorney general sued the IDSA for antitrust. [citation needed]) ILADS was a vocal supporter of the suit. [citation needed] Although the suit was eventually settled, and the IDSA did not substantially change its guidelines, the state actions against Lyme doctors eventually stopped, and ILADS has slowly built a portfolio of research to back up their opposition to the IDSA guidelines. [citation needed]

All three Medical Societies (ILADS, IDSA, GBS) hold medical conventions on Lyme disease around the world.

Patient Activism and the Lyme Loonies[edit]

The N.I.H. head of research funding for Lyme disease commented in an email in 2007 his disdain for the “the Lyme loonies.” poughkeepsiejournal He states he received vile, vicious, profane and abusive telephone calls.

It is unlikely that Baker was referring the neuropsychiatric aspects of late stage Lyme disease. Lyme disease: a neuropsychiatric illness However it is observed that Lyme advocates are often working against their own interests with their statements and actions. Controversial treatments and claims are seen across the Internet. New Yorker Michael Specter compares many Lyme advocates unfavorably with early days AIDS activists who were some of the most knowledgeable people in the field. Lyme activists often are associated with conspiracies such as Plum Island (a government bio-warfare that created Lyme), New York Times (they were told not to report on Lyme honestly), N.I.H. (had an agreement with pharmaceutical companies to deny the existence of chronic Lyme disease) New Yorker

The activists have been lumped with other anti-science movements (anti-vaccine and HIV virus deniers) and have been accused of fostering pseudoscientific practices and lobbying for legislation to subvert medicine and science. IDSA guideline authors slam Lyme activists

In response to an unknown document about a Lyme protest at University of Connecticut Health Center in 2007, Professor Durland Fish of Yale University wrote in an email to other IDSA guidelines authors and federal public health officials "This battle cannot be won on a scientific front. We need to mount a socio-political offensive; but we are out-numbered and out-gunned. We need reinforcements from outside our field." Fish emails

Much of the activism stems from the impression that IDSA guidelines were de-facto policies, as insurance coverage was linked to the guidelines, and because doctors fears sanctions for treating outside the guidelines, [citation needed](ref to Blumenthal) and so expressed their [Political dissent] through protests political lobbying and public opinion. [citation needed](possible ref Lyme Disease Update: Science, Policy & Law, published by the Lyme Disease Association.)

Other groups have focused on raising money for research, such as XXX and XXX which provided the initial funding if the Columbia University Lyme and Tick-Borne Diseases Research Center, and TBDA which has helped fund research into Lyme biofilms at the University of New Haven, and has funded the training of 125 LLMDs through ILADS.

High cost and low benefit of treating chronic diseases[edit]

The care of individuals with chronic conditions is estimated to account for 78% of health expenditures in the United States and insurance companies have begun to target high cost chronic illness for savings. In the future computerized treatment decision models will anticipate doctors overlooking or overprescribing treatments.Multiple Chronic Conditions: Prevalence, Health Consequences, and Implications for Quality, Care Management, and Costs

As early as the 1990's insurance companies used tightened requirements enough to make insurable treatment rare. Insurance companies understood that only certain people would fight for coverage. [2]

Chronic inflammatory diseases (chronic Lyme, multiple sclerosis, rheumatoid arthritis, fibromyalgia, chronic fatigue syndrome, lupus, Crohn's disease, HIV or other autoimmune and neurodegenerative diseases) generally damage multiple organs and are presented as multiple simultaneous disease conditions or "Systemic disease". The costs of treating patients with high numbers of conditions can exceed ten times the costs of treating patients without any chronic conditions. [3]

Organ Damage from Lyme Symptom
Joints Inflammatory Arthritis [4] Pain, immobility
Brain and Nervous System meningoencephalitis, encephalitis, stroke, atrophy, cranial nerve palsies, fibromyalgia, polyneuropathy [5] Headaches, Cognitive Decline, Memory Loss, Chronic pain, fatigue, dementia, neuropsychiatric disorders, localized paralysis and involuntary movements[6], hearing loss.
Heart Carditis[7] Chest Pain, Congestive heart failure, palpitations
Urology Lichen sclerosis [8] Pain, itching, urinary tract blockage.
Skin Many [9]
Possibly others Liver [10][11][12][13],

Eyes [citation needed], Gastro-Intestinal [citation needed]

As health care costs continue to rise there will be more pressure to ration treatments that have higher costs and lower benefits.

It is widely agreed that Lyme disease is virtually curable if diagnosed and treated early [citation needed] but that the disease is only diagnosed 10% of the time.[citation needed]

Lyme testing is not considered reliable by some doctors, especially as the disease progresses, Template:Citation needed - GBH guidelines has one and so a clinical diagnosis is made based symptoms and other factors. Symptoms alone cannot differentiate Lyme from other inflammatory systemic diseases due to their similarity. [citation needed] There is a hypothesis and risk that everyone with inflammatory systemic diseases would be drawn to a Lyme diagnosis and many would receive expensive and unwarranted treatment. [14]

A Lyme vaccine was developed by some of the authors of the IDSA Lyme treatment guidelines that would have prevented 80% of infections in people who were inoculated. The vaccine was pulled off the market for lack of demand, primarily due to bad publicity in the same year about an unrelated vaccine.[15]

It has been proposed by Dr. Waisbren (IDSA Fellow, and pro-chronic Lyme disease) that doctors should treat Amyotrophic Lateral Sclerosis and Multiple Sclerosis with Anti-Lyme Disease Antibiotics because of the high rate of misdiagnosis, and the low risk of antibiotic treatment.

Prevention is the key to affordable care of chronic disease. [citation needed] Vaccines, early detection and early treatment produce far better outcomes than treating a systemic disease at far lower cost.

Self-treatment trends on the internet[edit]

Economic factors are driving some patients towards less treatment for chronic diseases. 15% of the US population does not have medical insurance, and increasing out-of-pocket medical costs [16][17][18] will discourage medical treatment. [19][20][21][22] Insurance companies need to reign in costs, which they accomplish by creating barriers to treatment of expensive diseases.

Lyme disease information, advocacy and medical social networking on the internet are pervasive.Inaccurate information about Lyme disease on the internet is reported in a paper that compared activist websites unfavorably with government sites when they made assertions in conflict with mainstreams medicines and the IDSA Lyme treatment guidelines.

It is therefore natural that people would be increasingly utilizing the internet to make informed decisions on how to use limited resources. Numerous papers show concern for quality and a desire to control the information on the web. [23] [24] [25] [26] [27] [28] [29] [30] [31] The transparency of on open internet seems unethical to some when it undermines mainstream medicines ability to regulate quality and conformity of care. [32] Self-diagnosis is discouraged, [33] and doctors fear untreatable patients will be influenced by unsubstantiated claims seen on the internet.[34]. While he Internet is reshaping the content of the conversation between doctor and patient, for some it may be replacing the doctor.

Chronic Lyme is not accepted by mainstream medicine, but does exist on the Internet, and that information is frustrating the authors of the IDSA Lyme treatment guidelines who believe they are losing the public relations battle. [35] A survey in a Lyme endemic region showed that most people believed that Lyme bacteria can persist after antibiotic treatment, half thought long term antibiotic treatment was sometimes useful, and a quarter thought it was always useful. [36]

Dr. Auwaerter in comments attached to the paper said "They are, in fact, fighting the notion of evidence-based medicine."[37] Patient advocate groups who demonstrate against the IDSA believe they are fighting for access to appropriate medical care.[38]

Doctor Patient Relationships and Clinical Diagnosis[edit]

Lyme Doctors use clinical diagnosis (the experience of the doctor and his subjective interpretation of the patients symptoms and history) rather than relying directly on scientifically accepted objective tests they feel are too inaccurate. [39] Some Lyme doctors were subjects of sanctions for not adhering to IDSA treatment standards. The articles and testimony show the defendants arguing on behalf of the traditional doctor patient relationship based on clinical findings and judgment. While the prosecuting doctors were advocating on the side of guidelines, conformity and oversight of treatment options.

Increasingly medical researchers are uninterested in what happens within clinical practices, because of the need for experimental controls. [40] This in turn has only increased animosity, because each believes deeply in their perspective, and yet draw very different conclusions.

Cost reduction strategies used by health insurers (such as managed care and requiring that specialists can only be seen after a referral) have negative impacts on the quality of the doctor-patient relationship. [41]

In the politics of health care, the Doctor Patient Relationship is considered threatened by some. More dissatisfied doctors are converting to concierge medicine [42] practices that are cash only and free from oversight, much like today's Lyme clinics.

The Lyme Wars today[edit]

(No References in this section, will come back)

A subculture of LLMDs and Lyme patients has grown up around the internet and patient advocacy groups. For many years patients were careful to protect the names of their physicians. Fringe ideas come from some LLMDs, some advocacy groups, and some patients, and anger and confusion is commonly found on Lyme websites. (OR) However there is also a strong and growing belief within the subculture in both the clinical outcomes, and scientific underpinnings of the LLMD movement. Many LLMDs do not bill insurance companies, and are essentially cash-only clinics. [citation needed]

ILADS has trained hundreds of physicians[citation needed] as LLMDs with financial help from donors, and protests by Lyme advocacy groups against the IDSA continue to grow.[citation needed][clarification needed] Mainstream doctors remain reluctant to treat Lyme disease, and the media attention given to the cause of chronic Lyme disease is growing.

The distrust between the two sides remains high, as is evidenced by explicit attacks within medical research [43] and unfounded mutual accusations of corruption and dishonesty. Meanwhile there is a reluctance of doctors to treat Lyme patients, [citation needed] and despite significant numbers or research papers, almost no change in the treatment of Lyme disease in over a decade. (ref may not be possible, MD fear + unchanged guidance => unchanged treatment)

Meanwhile, the disease rate has steadily increased[citation needed][clarification needed], there is an emerging understanding that a large majority of patients go untreated, and that a small percentage of these untreated patients will go on to suffer from a debilitating chronic disease.

Controversial Lyme Treatments and Claims[edit]

These treatments are not attributable to any medical society. Lyme quackwatch site linked by

These claims are not attributable to any medical society. antiscience claims by IDSA panelists.

  • Most patients have only subjective symptoms
  • Incurable illness when not treated very early
  • Causes autism, Morgellon's disease, multiple sclerosis, Parkinson's disease, amyotrophic lateral sclerosis, homicidal behaviour, birth defects, and Alzheimer's disease
  • Serological testing is of no value in the diagnosis of extracutaneous manifestations of Lyme disease
  • IgM testing is appropriate for assessment of patients with illness of long duration
  • Serology is less sensitive for detection of Lyme disease in women than in men

The IDSA case against ILADS[edit]

http://www.ncbi.nlm.nih.gov/pubmed/21867956

In a 2011 opinion papter Antiscience and ethical concerns associated with advocacy of Lyme disease. by some authors of the IDSA Lyme Guidelines, a strong case is made against Lyme disease advocacy. While it does not distinguish between the [ILADS] and activists in its general claims it describes a parallel universe of pseudoscientific practitioners, research, publications, and meetings.

The specific claims that are attributable to ILADS are:

Current and Former Board Members Disciplinary Actions

Use of IGeneX diagnostic tests for Lyme disease

  • IGeneX founder Dr. Nick Harris is a co-author of the ILADS treatment guidelines for Lyme disease
  • IGeneX products spurred a warning from the US Food and Drug Administration and the CDC about the potential unreliability of unvalidated diagnostic tests for Lyme disease
  • IGeneX tests are not compliant with CDC and IDSA standards (April, 2007)
  • IGeneX has been the subject of investigations, but is currently compliant.

ILADS past president had prior research that was shoddy

ILADS disagrees with the mainstream view of the scientific evidence

  • ILADS supports long term use of antibiotics based on clinical observation on ongoing symptoms.
  • IDSA does not see any evidence that the Lyme bacteria persists after proper antibiotic treatment in a human.

Claims By Lyme Doctors[edit]

  • Charles Ray Jones MD said that 80 percent of his patients are children chronic Lyme disease, some who are blind, paralyzed, or wracked with pain. About 75% are now without symptoms.Hartford Courant article
  • Bernard Raxlen, MD says he sees very ill Lyme patients that respond to aggressive long-term antibiotic therapy, "It literally turns their lives around." Chicago Tribune

Terminology used[edit]

  • Post Lyme Disease Used to denote post treatment symptoms hypothesized to be autoimmune.
  • Chronic Lyme Disease Used to denote post treatment or untreated late disease symptoms hypothesized to be due to infection.
  • Post-treatment Lyme Disease A compromise term now seen from prominent adherents of both camps.
  • Late stage Lyme Disease Usually associated with untreated Lyme disease or with chronic Lyme disease
  • Co-infections Used to denote bacterial infections that coexist with Lyme Bacteria.
  • Bb name of Lyme Bacteria Borellia Bergdorferi.
  • IDSA camp Represents the mainstream medical position, but specifically the authors of the IDSA guidance on the treatment of Lyme disease. Prominently Steere, Wormser, Auwaerter.
  • ILADS camp Represents the opposing position, see below on ILADS. Prominently Fallon.
  • doctors Represents any physician who is in a position to know the evidence, but generally is seen as working in the mainstream without being outspoken.
  • LLMD Represents any physician who self identifies as a Lyme Literate Physician, and should be considered part of the ILADS camp. (Ref needed to LLMD term used in research)
  • Borrelia synonymous with Bb
  • Borreliosis synonymous with Lyme disease
  • neuroborreliosis is Lyme disease with neurological symptoms
  • carditis is inflammatory disease of the heart, usually but not exclusively associated with Lyme disease.

Chronic Lyme disease is a large and growing public health crisis.[edit]

Evidence of the War in the research archives[edit]

the investigation or sanctioning of 50 physicians for prescribing longer term treatment approaches to Lyme disease[edit]

50 physicians in New York, New Jersey, Connecticut, Michigan, Oregon, Rhode Island and Texas have been investigated, disciplined or had licenses revoked over three years. [44] Patient advocate groups found the unprofessional ccnduct actions to be biased. [45]

Date State Physician Resolution Accusation Notable Involvement
DECEMBER 1999 NY Dr. Perry Orens medical license revocation "rarely if ever" were more than 2-3 weeks of antibiotics were necessary to cure the illness.[3] Ordering excessive tests and/or treatment and inaccurate patient records. gross negligence and fraud. [4] Dr. Dattwyler (Harvard, ISDA, CDC) Wayne Osten (Director OHSM)
NY Joeseph Burrascano overdiagnosis/treatment of Lyme Disease, Dr. Burrascano's investigation began seven years before the hearing after he testified in Congress against limiting antibiotics for Lyme patients. State inspectors took files of his Lyme patients.[5] OPMC informed him just weeks after the IDSA protocol was first released in late August that they will proceed with their case against him. Arthur Weinstein (New York Medical College) [6]
April 2006 NC Joeseph Jemsek 1-year medical license suspension with stay [7] use of intravenous antibiotics for several months outside of recognized standards. not adequately informing patients of departure from recognized standards. Dr. Brian Fallon testified for Dr. Jemsek (Columbia). Dr. Wormser initiated the complaint [8]
2002, 2006 CT, NY Bernard Raxlen, M.D. Reprimand (CT), Censure and Reprimand (NY) prescribed antibiotics for Lyme Disease which are not acceptable for that purpose, poor record keeping, lack of malpractice insurance. NY action is an automatic response to CT action [9]
2007 NY Richard I. Horowitz, MD Non-disciplinary action confidential confidential
2007 CT Charles Ray Jones, MD 4 years probation violating "the applicable standard of care" for his treatment of two young siblings who live in Nevada. The complaint was initiated by the children's father, who is involved in a custody dispute with their mother, an emergency room nurse. After investigating the complaint, the health department brought charges to the medical board, alleging that Jones diagnosed Lyme disease in the children without examining them, that he failed to consider other causes for their symptoms, and that he improperly prescribed antibiotics.[10] Peter Krause, M.D (Yale, IDSA)[11]

IDSA antitrust investigation[edit]

In 2006, Richard Blumenthal, the Connecticut Attorney General, opened an antitrust investigation against the IDSA, accusing the IDSA Lyme disease panel of undisclosed conflicts of interest and of unduly dismissing alternative therapies and chronic Lyme disease. Patients groups led by the California Lyme Disease Association had urged Blumenthal to take this action, however ILADS was also a vocal supporter of Blumenthal's attempted takedown of the IDSA guideline.[46]

The investigation was closed on May 1, 2008, without charges when the IDSA agreed to submit to a review of its guidelines by a panel of independent scientists and physicians which would occur on July 30, 2009.[47] The investigation raised concerns about conflicts of interest on the part of members of the IDSA panel that were never publicly disclosed. The settlement statement from Blumenthal's settlements mentioned several patient concerns, the use of guidelines to limit patient care because guidelines are treated as mandatory within the medical community, the investigation or sanctioning of 50 physicians for prescribing longer term treatment approaches to Lyme disease, and the refusal of insurance companies to cover treatments not covered by guidelines. [get proper ref to press release http://lymeinfo.wordpress.com/2009/04/13/corrupt-profoundly-flawed-lyme-disease-guidelines/]

The investigation was closed on May 1, 2008, without charges when the IDSA agreed to submit to a review of its guidelines by a panel of independent scientists and physicians which would occur on July 30, 2009.[47] Views on the motivation and outcome of the investigation varied. Blumenthal's press release described the agreement as a vindication of his investigation and repeated his conflict-of-interest allegations.[48]

A Forbes piece described Blumenthal's investigation as "intimidation" of scientists by an elected official with close ties to Lyme advocacy groups.[49] The Journal of the American Medical Association described the decision as an example of the "politicization of health policy" that went against the weight of scientific evidence and may have a chilling effect on future decisions by medical associations.[50]

The medical validity of the IDSA guidelines had not been challenged in the original investigation, and in 2010 the IDSA voted to reissued the 2006 guidelines unchanged by a unanimous vote. Cite error: The opening <ref> tag is malformed or has a bad name (see the help page).

Doctor/Patient Advocacy[edit]

ILADS was (and remains) active in working with patient advocacy groups in getting state laws passed that explicitly allow the use of long term antibiotics in the treatment of Lyme disease.[46] The states of Connecticut[51]Rhode Island[52] California[53] Massachusetts[54] and New Hampshire[55] have such laws. Advocacy is continuing in Connecticut, Pennsylvania and Virginia [56]

The Association of American Physicians and Surgeons (AAPS) worked with the ILADS to criticize the IDSA Lyme guidelines with the goal of fostering private, physician-patient centered medicine. AAPS spokesperson Jane Orient, MD, said, "Those doctors have been viciously attacked, even by their own medical boards and by the societies that consider themselves the only source of expertise. Insurance companies are behind this because they don't want to pay for the treatment. Long-term antibiotics can be very expensive." [46]

Impact of War on research and treatment[edit]

Safety of long term use of antibiotics[edit]

BELOW ARE UNCHECKED REFERENCES FROM GBS Guidelines demonstrating safety and effectiveness of long term antibiotics.

  • CIMMINO, M. A.; ACCARDO, S.: Long term treatment of chronic Lyme arthritis with benzathine penicillin. Ann Rheum Dis 51 (1992), 1007–1008
  • CLARISSOU, J.; SONG, A.; BERNEDE, C.; GUILLEMOT, D.; DINH, A.; ADER, F.; PERRONNE, C.; SA- LOMON, J.: Efficacy of a long-term antibiotic treatment in patients with a chronic Tick Associated Poly-Organic Syndrome (TAPOS). Med Mal Infect 39 (2009), 108–115. http://dx.doi.org/10.1016/j.medmal.2008.11.012
  • COOPER, C.: Safety of Long Term Therapy with Penicillin and Penicillin Derivatives. FDA, US Food and Drug Administration (2001), Dec. 6. http://www.fda.gov/Drugs/- EmergencyPreparedness/BioterrorismandDrugPreparedness/ucm072755.htm
  • DATTWYLER, R. J.; HALPERIN, J. J.; PASS, H.; LUFT, B. J.: Ceftriaxone as effective therapy in refractory Lyme disease. J Infect Dis 155 (1987), 1322–1325
  • DONTA, S. T.: Macrolide therapy of chronic Lyme Disease. Med Sci Monit 9 (2003), PI136–PI142
  • FALLON, B. A.; KEILP, J. G.; CORBERA, K. M.; PETKOVA, E.; BRITTON, C. B.; DWYER, E.; SLAVOV, I.; CHENG, J.; DOBKIN, J.; NELSON, D. R.; SACKEIM, H. A.: A randomized, placebo-controlled trial of repeated IV antibiotic therapy for Lyme encephalopathy. Neurology 70 (2008), 992–1003. http://dx.doi.org/10.1212/01.WNL.0000284604.61160.2d
  • GASSER, R.; DUSLEAG, J.: Oral treatment of late borreliosis with roxithromycin plus co- trimoxazole. Lancet 336 (1990), 1189–1190 (
  • GASSER, R.; REISINGER, E.; EBER, B.; POKAN, R.; SEINOST, G.; BERGLÖFF, J.; HORWARTH, R.; SE- DAJ, B.; KLEIN, W.: Cases of Lyme borreliosis resistant to conventional treatment – Im- proved symptoms with cephalosporin plus specific beta-lactamase inhibition. Microb Drug Resist 1 (1995), 341–344 (
  • KLEMANN, W.; HUISMANS, B.-D.: Patienten mit Erreger-Direktnachweis bei chronischer Lyme-Borreliose – Klinik, Labordiagnostik, Antibiotika-Therapie und Krankheitsver- lauf. Eine retrospektive Studie. Umwelt-Medizin-Gesellschaft 2 (2009), 132–138
  • STRICKER, R. B.; GREEN, C. L.; SAVELY, V. R.; CHAMALLAS, S. N.; JOHNSON, L.: Safety of intra- venous antibiotic therapy in patients referred for treatment of neurologic Lyme dis- ease. Minerva Med 101 (2010), 1–7 (

Evidence for and against the use of long term antibiotics for treatment of chronic Lyme disease[edit]

The highest quality primary study that showed some effectiveness of antibiotics was done by Fallon. The study showed that the antibiotics were effective until they stopped being used. Fallon is respected by both sides (my opinion) because he was trying to find patients who met the mainstream restricted guidelines for diagnosis and treatment. (Columbia Lyme Center) ILADS Camp primary study often cited by both sides: Fallon, A randomized, placebo-controlled trial of repeated IV antibiotic therapy for Lyme encephalopathy.

Secondary Reviews that state that antibiotics are unwarranted because the benefit did not persist.

Secondary Reviews that state that antibiotics may be effective in treating ongoing Lyme infection

Antibiotics and Lyme carditis. Carditis may not be primarily chronic, there is some debate.

Evidence for and against persistent infection (chronic lyme) vs. autoimmune response (post lyme disease)[edit]

Secondary reviews that state lack of proof and lack of belief in persistent infection

  • There are many. will get to it.

Secondary reviews that support persistent infection

Comparisons of treatment guidelines by 3 medical societies[edit]

Claim Infectious Diseases Society of America Treatment Guideline International Lyme And Associated Diseases Society Treatment Guideline Borreliose-Gesellschaft Treatment Guideline
early Lyme symptoms Erythema migrans rash or neurological Lyme disease or Lyme carditis 0 2
late Lyme symptoms Lyme arthritis or late neurologic Lyme disease especially Bell's Palsy 0 2
post treatment symptoms lack of biologic plausibility, lack of treatment efficacy 0 2
post treatment Lyme argument Risks and adverse effects of antibiotics. Also considered were the inconvenience of prolonged therapies, the potential impact of the indiscriminate use of antibiotics on the development of antibiotic resistance in the community, and the economic costs 0 2
Do viable B. burgdorferi persist in tissues despite antibiotic treatment? There is no convincing evidence in North America for the persistence of B. burgdorferi in the skin of humans after treatment with antibiotic regimens known to be active against B. burgdorferi in vitro. It is highly implausible as evidenced by (1) the lack of antibiotic resistance in this genus, (2) the lack of correlation of persistent symptoms with laboratory evidence of inflammation or with the eventual development of objective physical signs, and (3) the lack of precedent for such a phenomenon in other spirochetal infections. 0 2
Acceptable evidence that B. burgdorferi persist in tissues despite antibiotic treatment. culture should be regarded as the gold standard to address viability of B. Burgdorferi.PCR results cannot prove that B. burgdorferi is viable (i.e. it might be dead or harmless) 0 2
Validity of antibody testing. The panel is unaware of any chronic infection in which antibody titers diminish despite persistence of the causative organism. In syphilis, patients who are regarded as having treatment failure typically have persistent or rising titers of antibodies 0 2
characteristics of infections that justify longer treatment courses. infections in immunodeficient hosts, infections in which a pathogen is inhibited but not killed by antimicrobial therapy or in which available antimicrobials are minimally active in vitro, infections caused by an intracellular pathogen, infections involving a biofilm, infections on a heart valve, or infections involving a clinical site in which there is ischemia, a foreign body, a sequestrum, or frank pus. The “cystic” forms of B. burgdorferi that have been seen under certain growth conditions in vitro have not been shown to have any clinical significance. 0 2
Animal studies on persistent infection failure to recapitulate the T>MIC found in humans receiving antibiotic treatment is a potentially serious limitation of almost all of the reported treatment studies of animals. In other words animals need to get antibiotics more often than humans or else the treatment will fail. Rare animals may remain culture positive after antibiotic treatment. 0 2
diagnosis Two-tier (ELISA and IgG immunoblot) seropositivity or Erythema migrans. Erythema migrans is the only manifestation of Lyme disease in the United States that is sufficiently distinctive to allow clinical diagnosis in the absence of laboratory confirmation. 0 2
Chronic Lyme Diagnosis Not appropriate 0 Serological monitoring tests in order to assess the success of treatment are not useful in chronic Lyme borreliosis. The success of treatment must be assessed clinically
neuroborreolis diagnosis Two-tier (ELISA and IgG immunoblot) seropositivity plus seropositive lumbar puncture or MRI evidence of neuraxis inflammation 0 2
oral antibiotics 7-21 days 0 2
success of oral antibiotics early stage Less than 10% of individuals do not respond to antibiotic therapy 0 A failure rate of 10% is to be expected. Therapeutic success may be delayed or fail to materialise completely, with the consequence that follow-up treatment is necessary, possibly with a different antibiotic.
success of oral antibiotics post-treatment Lyme No statistically significant benefit 30–62% failure with short course treatment. 94% failure in fibromyalgia patients with short course treatment (2-4 weeks) Considerable therapeutic failure rates when treatment is 4 weeks or less. The duration of treatment is of decisive importance for the success of antibiotic treatment. a failure rate of up to 50%.
IV Antibiotics 14-28 days. intravenous administration should only rarely be needed. 0 2
success of IV antibiotics 0 doubling treatment time from 2 to 4 weeks improved the success rate from 66 to 80%
co-infections Simultaneous infections are rare, but other infections may clinically appear similar to Lyme. HGA, babesiosis, A. phagocytophilum, A. phagocytophilum or B. microti 0 2
erythema migrans The great majority of persons with B. burgdorferi infection present with erythema migrans 0 2
Prevelance 0%–4.6% of ticks have bB. 0 2
Regions of infection New England, in parts of the mid-Atlantic States, and in parts of Minnesota and Wisconsin, but not in most other locations of the United States. Southern ticks are rarely infected with B. burgdorferi. 0 2
Incidence Because most patients with Lyme disease are now diagnosed and treated early in the course of infection, (late Lyme) forms of neurologic Lyme disease are quite rare 0 2
1 000 000 18 488 885 18 488 874

Evidence of Physician Practices[edit]

With competing guidelines, studies have shown various rates of agreement and compliance with the dominant medical position, the IDSA guidelines.

UNVERIFIED REFERENCES IN ILADS TREATMENT GUIDEDLINES SHOWING DOCTORS USE LONG TERM ANTIBIOTICS

  • Feder HM Jr. Differences are voiced by two Lyme camps at a Connecticut public hearing on insurance coverage of Lyme disease. Pediatrics 105(4 Pt 1), 855–857 (2000).
  • Fallon BA, Tager F, Keilp J, Weiss N, Liebowitz MR, Fein L, Liegner K. Repeated antibiotic treatment in chronic Lyme disease. J. Spiro Tick Dis. 6, 94–102 (1999).
  • Battaglia HR, Alvarez G, Mercau A, Fay M, Campodónico M. Psychiatric symptomatology associated with presumptive Lyme disease: clinical evidence. J. Spirol. Tick Dis. 7, 22–25 (2000).
  • Fallon BA. Chronic Lyme Disease Research Study. A double-blind placebo-controlled randomized clinical trial evaluating the efficacy of tenweeks of iv. ceftriaxone and effects on brain imaging. Enrollment since 2000.
  • Cameron DJ. Lyme Disease Retreatment Study. A double-blind placebo-controlled randomized clinical trial evaluating the efficacy of oral amoxicillin for seropositive and seronegative Lyme disease. Enrollment since 2001.
  • Peña CA, Mathews AA, Siddiqi NH, Strickland GT. Antibiotic therapy for Lyme disease in a population-based cohort. Clin. Infect. Dis. 29, 694–695 (1999).
  • Wahlberg P, Granlund H, Nyman D, Panelius J, Seppala I. Treatment of late Lyme borreliosis. J. Infect. 29, 255–261 (1994).
  • Donta ST. Tetracycline therapy for chronic Lyme disease. Clin. Infect. Dis. 25(Suppl. 1), S52–S56 (1997).

Lyme Literate Physician (LLMD) Training[edit]

125 physicians have completed a three week course that included ILADS class room studies, and a week working alongside the most experienced LLMDs.TBDA LLMD Training

How many has ILADS trained???

Chronic Lyme Diagnosis and Treatment[edit]

Burrascano and Herxheimer

Unsupported and Inflammatory Claims[edit]

Chronic Lyme and LLMDs in RS Media[edit]

Geographic distribution And time series of evolving neurological diseases[edit]

Public cases of chronic lyme[edit]

Below are references to look into....

  • Alice Walker Pulitzer prize winning author
  • David Letterman
  • Yolanda Foster

Patient Advocacy Organizations[edit]

Research Organizations[edit]

Demonstrations[edit]

Kenneth B. Liegner, MD (need better link)

END OF ARTICLE[edit]

old prose below for future harvests.

ILADS[edit]

The International Lyme And Associated Diseases Society (ILADS, pronounced /ˈaɪlædz/) is a medical society and advocacy group which advocates for greater acceptance of the controversial medical entity of chronic Lyme disease and argue that the traditional approach to diagnosis and treatment, put forth by most American physicians, all but guarantees failure.[58]

Background[edit]

Lyme disease is not well understood, can not be reliably detected, and sometimes has serious long term symptoms that are resistant to treatment. [references probably fallon, and others] It is reported that 300,000 people contract the disease each year, but only 10% of that number are reported to the CDC as diagnosed cases of Lyme. [CDC reference]. Since the day the disease was discovered in 1978 through today there are a large number of untreated cases of Lyme disease, as well as cases of treated Lyme disease that continued to have serious symptoms. Late stage Lyme disease can have symptoms similar to many other diseases, such as multiple sclerosis, rheumatoid arthritis, fibromyalgia, chronic fatigue syndrome, lupus, Crohn's disease, HIV or other autoimmune and neurodegenerative diseases.

The "Lyme Wars" grew steadily through the 1980s and 1990s as increasing populations of people presented themselves to doctors with clinical symptoms of Lyme disease and doctors began using longer doses of antibiotics. Allen Steere wrote in 1993, that Lyme disease had become "overdiagnosed" and overtreated.[59]. Clinical diagnosis in medicine is not rare, but infectious diseases are very hard to treat with out objective evidence that an infection is actively causing disease. [made this up, may need to drop.]

ILADS was founded in 1999 by physicians and academics who believe mainstream medicine is too conservative in its treatment of Lyme. Some of those physicians had been treating Lyme disease for two decades. [46] The same year saw the first protests by Lyme patient activist against Allen Steere due to concerns his treatment guidelines were causing insurance companies to refuse coverage. The protesters claimed that Dr. Steere's testimony against their doctors before medical licensing boards had caused some of them to stop giving aggressive treatments. [60]

Doctors who are members of ILADS, or who have been trained by them are often known as "Lyme literate Medical doctors." or LLMD's.

2000 IDSA Guidelines[edit]

In 2000, The Infectious Diseases Society of America published their Practice guidelines for the treatment of Lyme disease. [Clean ref needed for (Clin Infect Dis 2000; 31[Suppl 1]:1–14).] In those guidelines, IDSA stated that there was no convincing evidence for the existence of chronic symptomatic B. burgdorferi infection, and that the risks of long-term antibiotic therapy do not outweigh the benefits.

ILADS criticized the IDSA for ignoring the "compelling, peer-reviewed, published evidence" of chronic Lyme disease, and ultimately published their own guidelines formulated from scientific evidence in 2006.[46]

Doctor/Patient Advocacy[edit]

ILADS was (and remains) active in getting state laws passed that explicitly allow the use of long term antibiotics in the treatment of Lyme disease.[46] The states of Connecticut[51]Rhode Island[52] California[53] Massachusetts[54] and New Hampshire[55] have such laws. Advocacy is continuing in Connecticut, Pennsylvania and Virginia [61]

The [Association of American Physicians and Surgeons] (AAPS) worked with the ILADS to criticize the IDSA Lyme guidelines with the goal of fostering private, physician-patient centered medicine. AAPS spokesperson Jane Orient, MD, said, "Those doctors have been viciously attacked, even by their own medical boards and by the societies that consider themselves the only source of expertise. Insurance companies are behind this because they don't want to pay for the treatment. Long-term antibiotics can be very expensive." [46]

The 2006 IDSA Treatment Guidance and 2006 ILADS Treatment Guidance[edit]

In 2006 updated treatment guidance was published by the IDSA, and at approximately the same time the ILADS published their first treatment guidance based on a review of the scientific evidence.

The majority of physicians support the IDSA guidelines, and prior to 2006 ILADS had limited its role to criticizing the IDSA guidelines. The 2006 Report [62] in 2007 many of the authors of the IDSA guidance published a paper highly critical of the use of long-term antibiotics in the treatment of Lyme Disease. [63] In this paper they clearly state that the term "chronic Lyme disease" is not recognized in the medical literature and specifically identify the small number of self described "Lyme literate physicians" who treat patients who have no objective evidence that they have been infected with Lyme. ILADS guidelines do support clinically diagnosis of Lyme, as they claim serological tests are unreliable.

The established medical opinion is that there are no scientific studies that show any connection between the clinic symptoms and Lyme bacteria, and as a result the ILADS guidelines were causing a number of serious ailments to be mistreated as Lyme, which is both unethical and dangerous. It is recommended that patients who show symptoms similar to late stage Lyme, but who have been treated should only be given palliative care, as other treatment will be unsuccessful and give false hope.[63]

ILADS disagrees, and a minority of doctors does treat chronic Lyme disease based on a clinical diagnosis with long term antibiotics and gives evidence that many (but not all) improve [show ref here.]

A crucial and unanswered question is whether Lyme bacteria can survive antibiotic treatment and remain viable as a pathogen, or if the few people who remain sick after treatment are simply experiencing an autoimmune reaction to the initial infection that eventually clears.[wormser ref, fallon or ny post ref]

doctors associated with the (IDSA)state that no viable Lyme bacteria exists in a human after a short course of antibiotics. Several mice and primate studies have seemed to show that bacteria survives exposure to antibiotics, however there are questions about whether the bacteria was viable, how well the study was implements, and its applicability to humans. [Wormser rebuttal] It is generally believed that dead bacteria generate a autoimmune response, and this has been demonstrated by detecting Lyme antigens after treatment cleared the bacteria. [See Yale mouse antigen study.] This study too was challenged for failing to prove the bacteria was not longer viable when the antigens were detected. [McDonald ref].

The minority believes that numerous animal studies have shown that the Lyme bacteria very quickly establishes itself in the body in a way that protects in from antibiotics. Lyme bacteria has been shown to colonize into biofilms that have significant protection against bacteria. [ref]

IDSA antitrust suit[edit]

In 2006, Richard Blumenthal, the Connecticut Attorney General, opened an antitrust investigation against the IDSA, accusing the IDSA Lyme disease panel of undisclosed conflicts of interest and of unduly dismissing alternative therapies and chronic Lyme disease. Patients groups led by the California Lyme Disease Association had urged Blumenthal to take this action, however ILADS was also a vocal supporter of Blumenthal's attempted takedown of the IDSA guideline.[46]

The investigation was closed on May 1, 2008, without charges when the IDSA agreed to submit to a review of its guidelines by a panel of independent scientists and physicians which would occur on July 30, 2009.[47] The basis of the lawsuit rested on conflicts of interest that were never publicly exposed. The settlement statement from Blumenthal's settlements mentioned several patient concerns, the use of guidelines to limit patient care because guidelines are treated as mandatory within the medical community, the investigation or sanctioning of 50 physicians for prescribing longer term treatment approaches to Lyme disease, and the refusal of insurance companies to cover treatments not covered by guidelines. [get proper ref to press release http://lymeinfo.wordpress.com/2009/04/13/corrupt-profoundly-flawed-lyme-disease-guidelines/]

The investigation was closed on May 1, 2008, without charges when the IDSA agreed to submit to a review of its guidelines by a panel of independent scientists and physicians which would occur on July 30, 2009.[47] Views on the motivation and outcome of the investigation varied. Blumenthal's press release described the agreement as a vindication of his investigation and repeated his conflict-of-interest allegations.[48]

A Forbes piece described Blumenthal's investigation as "intimidation" of scientists by an elected official with close ties to Lyme advocacy groups.[49] The Journal of the American Medical Association described the decision as an example of the "politicization of health policy" that went against the weight of scientific evidence and may have a chilling effect on future decisions by medical associations.[50]

The medical validity of the IDSA guidelines had not been challenged in the original suit, and in 2010 the IDSA voted to reissued the 2006 guidelines unchanged by a unanimous vote. Cite error: The opening <ref> tag is malformed or has a bad name (see the help page).

ILADS Annual Lyme Disease Conference[edit]

Since 2000 ILADS has held an annualLyme Disease Conference to promote research and training in the treatment of Lyme disease including chronic Lyme disease.

The 2013 Lyme Disease Conference was held in San Diego Oct 17-19 2013. The conference had 420 attendees and 32 speakers.

Notable Past speakers have included:

  • Willy Bergdorfer, who discovered the Lyme Bacteria (Keynote speaker 2008)
  • Brian Fallon, Director of the Columbia University Lyme and Tick-Borne Diseases Research Center (2012)
  • Paul Auwaerter, MD, (Current Director of Infectious Diseases and Professor at Johns Hopkins University) Treatment: the IDSA Perspective. (2007)
  • Eva Sapi, PhD, (Discovered Lyme bacteria biofilm antibiotic resistance). (2013)

Physician Training[edit]

  • section on the hundreds (or thousand) LLMDS trained by ILADS

Columbia[edit]

  • Section on Columbia Lyme center as an organization that does collaborative work in chronic lyme

Both sets of doctors are practicing medicine in a reasonable fashion based on the application of certain diagnostic principles, although the therapeutic approaches differ considerably stemming from the narrow vs broad criteria for diagnosis. This is the essence of the medical controversy surrounding chronic Lyme disease. Until medical doctors have a test that definitively identifies the presence or absence of infection (and such a test does not yet exist), the controversy about the diagnosis and treatment of chronic Lyme Disease will continue. [mfix this]

Borreliose-Gesellschaft[edit]

  • Section on group similar to ILADS in europe

German Chronic Lyme Guidelines you will see that the Deutsche Borreliose-Gesellschaft,

David Roth[edit]

  • Prominent activist funding ILADS LLMD training and Eva Sapi research. The heading will be the name of his organization, not him.

David Roth

In the media[edit]

Pro LLMD article in New Yorker anti LLMD article in Forbes One or two other recent and well researched articles. I can't skip under-my-skin, it is too big, hope to find debunking sources.

Criticisms of ILADS[edit]

  • IDSA had some specific harsh words about some past practices
  • There may or may not be some sources on some of the fringe element within IDSA that is well sourced.

References[edit]

  1. ^ Steere AC, Taylor E, McHugh GL, Logigian EL (1993). "The overdiagnosis of Lyme disease". JAMA. 269 (14): 1812–6. doi:10.1001/jama.269.14.1812. PMID 8459513. Unknown parameter |month= ignored (help)CS1 maint: Multiple names: authors list (link)
  2. ^ Science journalist Pamela Weintraub reported details of Supreme Court of the State of New York hearing in a chapter titled “Red-Flagged at Blue Cross: The Role of Managed Care” in her book “Cure Unknown: Inside the Epidemic.” (pp. 303-306)
  3. ^ http://www.ncbi.nlm.nih.gov/portal/utils/pageresolver.fcgi?recordid=1388880242928323
  4. ^ Lyme Arthritis 2003
  5. ^ Chronic or Late Lyme Neuroborreliosis: Analysis of Evidence Compared to Chronic or Late Neurosyphilis
  6. ^ apoptosis in dorsal root ganglia
  7. ^ CDC 3 cases of Lyme Carditis
  8. ^ cutaneous borreliosis
  9. ^ cutaneous borreliosis
  10. ^ Disseminated Lyme borreliosis preceded by hepatitis in an African American male.>
  11. ^ [Lyme disease with hepatitis and corticosteroids: a case report
  12. ^ Necrotizing granulomatous hepatitis as an unusual manifestation of Lyme disease.
  13. ^ Hepatitis associated with Lyme disease.
  14. ^ The overdiagnosis of Lyme disease.
  15. ^ http://www.ncbi.nlm.nih.gov/pubmed/14711329
  16. ^ New York Times 21 Sep 2012 The High Cost of Out-of-Pocket Expenses
  17. ^ the commonwealth fund 2 June 2009 Study Finds High Underinsurance Rates For Sicker Workers With Modest Incomes
  18. ^ Collins 2013
  19. ^ Goldman, Joyce, and Zheng (2007)
  20. ^ Buntin et al. (2011)
  21. ^ Both Gruber (2006)
  22. ^ Hsu et al. (2006)
  23. ^ Patients' Use of the Internet for Medical Information
  24. ^ Trust in the Internet as a Health Resource Among Older Adults: Analysis of Data from a Nationally Representative Survey
  25. ^ Internet Medical Usage in Japan: Current Situation and Issues
  26. ^ Setting the public agenda for online health search: a white paper and action agenda.
  27. ^ Wikipedia: a key tool for global public health promotion
  28. ^ Exposure to Media Information About a Disease Can Cause Doctors to Misdiagnose Similar-Looking Clinical Cases.
  29. ^ Wikipedia for med students
  30. ^ Wikipedia inaccurate
  31. ^ Quality and accuracy assessment of nutrition information on the Web for cancer prevention
  32. ^ Ethical issues of new communication and information technologies applied in medicine
  33. ^ Self Diagnosis Pitfalls
  34. ^ Untangling the Web — Patients, Doctors, and the Internet
  35. ^ Bullying Borrealia
  36. ^ Long-term Lyme disease antibiotic therapy beliefs among New England residents.
  37. ^ Bullying Borrealia
  38. ^ [1]
  39. ^ ILADS treatment guidelines
  40. ^ Lyme and Science
  41. ^ Managed Care, Primary Care, and the Patient-practitioner Relationship
  42. ^ sun sentinel 26 Feb 2013 Concierge Medicine
  43. ^ #Evidence of the War in the research archives
  44. ^ NEWS ARTICLE from THE NEW YORK TIMES, 11-10-00, By HOLCOMB B. NOBLE
  45. ^ LymeDisease.org & LDA Position Statement on Lyme Disease Specialty Bias in Unprofessional Conduct Actions
  46. ^ a b c d e f g h {{cite news } work = MedPage Today | first=Nancy | last=Walsh | url=http://www.medpagetoday.com/PublicHealthPolicy/GeneralProfessionalIssues/23583 | date = November 26, 2000 | accessdate = December 30, 2013}}
  47. ^ a b c d Cite error: The named reference amnews was invoked but never defined (see the help page).
  48. ^ a b Cite error: The named reference ct_ag_2008 was invoked but never defined (see the help page).
  49. ^ a b Cite error: The named reference forbes was invoked but never defined (see the help page).
  50. ^ a b Cite error: The named reference Kraemer_2009 was invoked but never defined (see the help page).
  51. ^ a b "An act concerning the use of long-term antibiotics for the treatment of Lyme disease". Connecticut General Assembly. 2009-06-18. Retrieved 2009-07-05.
  52. ^ a b "Lyme Disease and the Law". Rhode Island Department of Health. 2009. Archived from the original on May 2, 2005. Retrieved 2009-07-05.
  53. ^ a b California Business and Professions, Section 2234.1, AB 592, passed August 29, 2005.ftp://leginfo.public.ca.gov/pub/05-06/bill/asm/ab_0551-0600/ab_592_bill_20050831_enrolled.pdf
  54. ^ a b Section 12DD Administration of long-term antibiotic therapy upon diagnosis of Lyme disease MGL Chapter 112 Section 12DD (2010)
  55. ^ a b "New Hampshire General Court, HB 295, approved June 9, 2011". Gencourt.state.nh.us. Retrieved 2012-12-15.
  56. ^ {{>Empty citation (help)
  57. ^ {{cite news } work = Boston Herald | first=Michael | last= Lasalandra| url=http://www.medpagetoday.com/PublicHealthPolicy/GeneralProfessionalIssues/23583 | date = November 3, 1999 | accessdate = December 30, 2013}}
  58. ^ Specter, Michael (July 1, 2013). "Lyme, Inc". New Yorker. Retrieved December 30, 2013.
  59. ^ Steere AC, Taylor E, McHugh GL, Logigian EL (1993). "The overdiagnosis of Lyme disease". JAMA. 269 (14): 1812–6. doi:10.1001/jama.269.14.1812. PMID 8459513. Unknown parameter |month= ignored (help)CS1 maint: Multiple names: authors list (link)
  60. ^ {{cite news } work = Boston Herald | first=Michael | last= Lasalandra| url=http://www.medpagetoday.com/PublicHealthPolicy/GeneralProfessionalIssues/23583 | date = November 3, 1999 | accessdate = December 30, 2013}}
  61. ^ {{>Empty citation (help)
  62. ^ "2006 ILADS Treatment Guidelines" (PDF).
  63. ^ a b Feder, HM; Johnson, BJB; O'Connell, S; et al. (2007). "A Critical Appraisal of "Chronic Lyme Disease"" (PDF). NEJM. 357 (14): 1422–30. doi:10.1056/NEJMra072023. PMID 17914043. Unknown parameter |month= ignored (help)

External links[edit]

Category:Lyme disease