Guidelines for Diagnosis and Treatment German Borreliosis So

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inmacdonald
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by inmacdonald » Sun 30 Sep 2012 2:03

European physicians who are experts in all aspects of Lyme borreliosis
and who joined together to form a Society,namely the
German Borreliosis Society
collectively oppose the IDSA guidelines, and followed through by
writing down their objections to the IDSA guidelines--
delivering the same to the IDSA and posting SAME ON THE INTERNET:

You, Spanky JD, filled with contempt for the ILADS guidleines and for ILADS
physicians, now must make some additional room for More Contempt
for the German Borreliosis Society. Please note that the German Borreliosis
Society white paper is heavily referenced
and that the Society will publish their paper in support of Chronic antibiotic
refractory Chronic Lyme Borreliosis ( which you and the IDSA dispute)

This has everything to do with Germany's best physicians in Lyme Borreliosis practice.
It has nothing to do with my basement, my ivory tower, or my personal and professional
viewpoints on the weaknesses of the IDSA Lyme Disease guidelines.

There are other centers of distinction and excellence who like the German Borreliosis
Society oppose the IDSA guidelines for Lyme disease diagnosis and treatment.
Please return to Page one of this discussion thread and confront the opposition
from Germany about IDSA directives for Lyme Borreliosis practice in the USA.

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Spanky
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by Spanky » Sun 30 Sep 2012 2:08

"inmacdonald":
You, Spanky JD, filled with contempt for the ILADS guidleines and for ILADS
physicians, now must make some additional room for More Contempt
for the German Borreliosis Society.
They aren't bothering me.

duncan
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by duncan » Sun 30 Sep 2012 10:05

Alan, thank you for this discussion about the German Borreliosis Society.

I am hopeful this is already in the works, and perhaps you can verify: Is there any movement to collapse the German objections to the IDSA Guidelines into a more digestible format for the U.S. market? Like in News?? Condense its sweeping laundry list into three to five bullet points of contention, translate it into a PR piece, and fire it off to the various media outlets? Who's doing this? ILADS? Do you know?

It's great that we can discuss it amongst ourselves in the community, but it's outside awareness and pressure we need to generate if we are going to realize any progress, and that means publicity that highlights the challenges we confront. I no longer assume any of this is just being done for us.

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Spanky
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by Spanky » Sun 30 Sep 2012 15:41

"duncan":
I am hopeful this is already in the works, and perhaps you can verify: Is there any movement to collapse the German objections to the IDSA Guidelines into a more digestible format for the U.S. market?
As previously discussed in this thread, the German Borreliosis Society furnished the IDSA Review Panel with their objections to the current IDSA Guidelines, as follows:
DBG Objections to the IDSA Lyme Guidelines

The Deutsche Borreliose-Gesellschaft (German Society of Lyme-Borreliosis) raises objections to the IDSA Lyme Guidelines published in 2006. The fundamental basis for our objections is that the implementation of the IDSA guidelines extends beyond the United States and into Europe. Accordingly, our ability to diagnose and treat patients with Lyme disease is being severely restricted by these guidelines, and we believe that the guidelines must be revised to provide greater flexibility in the diagnosis and treatment of Lyme disease given the poor laboratory test sensitivity, the persistence of the organism despite adherence to IDSA protocols, and the seriousness of this illness.
http://lymedisease.org/wp-content/uploa ... 774413.pdf

Please notice the highlighted portion.

The problem for ILADS and the German Borreliosis Society is that the IDSA Guidelines are far more widely accepted. Both in the United States and Europe.

The IDSA Review Panel found the German Borreliosis Society's objections to be equally unpersuasive.

Old news, I'm afraid.

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inmacdonald
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by inmacdonald » Sun 30 Sep 2012 16:13

Dear Duncan,

I know of no diplomatic or Scientific negotiations between the IDSA
( and by this I mean the handful of members of a society of several thousand
IDSA members-who may or may not speak for the entire IDSA membership)
and the Full United Membership of the German Borreliosis Society to come
to common ground on what is and what are not the facts in Lyme borreliosis pathobiology.

I see the German Borreliosiis Society as a body whose membership is far more specialized
and far more sophisticated in the minute corner of Infectious disease practice which
is the Lyme Borreliosis arena. IDSA contends with all Infectious Diseases known for mankind.
I seriously doubt that all card carrying members of the IDSA march in lockstep
with the sub-sub committee of people who wrote the Lyme Disease guidelines.
Indeed, have close personal friends who are IDSA members who practice
as their judgment directs based on individual patient circumstance and do not
feel restricted to the IDSA guidelines.

Readers of this symposium will note the discussion thread devoted to Dr Andrew Norwalk
who is a pediatric infectious disease specialist in Pittsburgh.Pa. Dr. Norwalk ,in the linked LNE site video link makes it clear that he treats his patients as soon as an Ixodid tick bite. Dr Norwalk is not a member of ILADS, and may not bea member of the IDSA either.
But he is board certified in Pediatrics and Infectious Disease. His experience includes
years of clinical practice in a heavliy Lyme endemic area ( 70% Ixodid tick carriage of Bb
in his county is described by him in the video); and by several years of Bench research
at the cutting edge molecular biology level under some of the leading basic science Lyme borreliosis researchers in the USA, with an impressive output of original manuscripts
in first line ( non-pay-to-publish journals).
Quite simply, Dr Andrew Norwalk, and Infectious Disease physicians like him,
make the exhorations by some correspondents on the LNE website look ludicrous.
The German Borreliosis Society white paper of Objections to the IDSA guidelines
also make the exhortations of some correspondents on the LNE website look
ludicrous.
It is interesting to recall that Harvard University gave us the name "ixodes dammini"
which was picked up by the entire Lyme scientific community in manuscripts
published over many years.
I. dammini disappeared from the scientific literature in year 1992-93, when
a very knowledgeable Medical entymologist, Dr James Oliver, from Georgia Southern Univesity, pointed out that the Ixodid tick vector in New England was actually
Ixodes scapularis. Ixodes scapularis originated in the southern USA states and moved
progressively northward to reach New England . The idea bandied about by the IDSA
that Ixodes scapularis is moving southward is yet another example of error. But the
entire IDSA is not to blame for any possible errors in the "Guidleines". Any and all possible errors are the responsibility of the sub-sub Committee of persons who wrote the
guidelines.(aminute fraction of the entire membership)
If you survey the IDSA national meeting Agendas for the last 10 years, there are
NO AGENDA listings for any IDSA national meeting on the subject of the IDSA
Lyme Disease Guidelines.It is somewhat like the example of President George Bush
regarding the hiding place of Osama Bin Laden.." I just don't spend much time thinking about it"
Best,
Alan

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Spanky
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by Spanky » Sun 30 Sep 2012 16:59

"inmacdonald":
The German Borreliosis Society white paper of Objections to the IDSA guidelines
also make the exhortations of some correspondents on the LNE website look
ludicrous.
I would have to think that ILADS, the German Borreliosis Society...and the IDSA are all entitled to their opinions.

The essential question is, then, whose opinions are accepted, generally, within the medical community? Whose viewpoint is persuasive and whose viewpoint is adopted as the consensus?

And despite the extremely foolish attempts to force their opinions on the IDSA by a few...the simple fact remains that it is the IDSA viewpoint that is widely accepted by medical professionals in both Europe and North America.

That is not to say that this viewpoint is absolutely correct in every respect, but it is based on evidence, rather than raw opinion and anecdotal observation.

What is "ludicrous" here, I would say, are the continual attempts by some correspondents on LNE to elevate their personal opinions and observations to some level that they seem to think equals actual evidence.

After observing this for some time, one does come away with the impression that these misguided resorts to political action, rather than evidence, are, in fact, naked assaults upon the scientific method, itself.

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inmacdonald
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by inmacdonald » Sun 30 Sep 2012 17:39

Spanky JD:

"The fundamental basis for our objections ..." { German Borreliosis Society Objections to the IDSA guidelines as recited by Spanky}

Beyond lines of Geography "sphere of influence"
are the following DETAILED objections - a "Bil lof Particulars" {Lawyer terminology}
----
o Persistent symptoms of LB with Bb identification despite intensive antibiotic treatment (28-46).

o Members of the Deutsche Borreliose Gesellschaft have documented

150 such cases (ISBN 978-3-640-19378-3, submitted for publication).
Objection excerpted from the white paper from the German Borreliosis Society to the IDSA-------------------Full list of objections is posted below
_________________________________________________________________________
___
Objections from the German Borreliosis Society submitted to the IDSA ( Excerpted fromoriginal document pages 3-6)

_____________________________________________

Our objections relate to diagnosis and treatment of Lyme disease (LD), chronic

Lyme borreliosis (LB) and the so-called “post-Lyme syndrome” (PLS).


1. Objections to the IDSA guidelines for diagnosis of LD and chronic LB:


- Seronegativity is frequent in LD and does not rule out a chronic persistent

Borrelia burgdorferi (Bb) infection (1-18).


- The differential diagnosis between multiple sclerosis and neuroborreliosis based on CSF and serum analysis is not possible in at least 25% of cases (9-11, 21).

- Peripheral neuropathy is not rare but occurs in over 20% of LD cases (22-

25).


- So-called two-tier testing is not suitable to diagnose LB, particularly in the late phase, for the following reasons:

o The test methods available on the market are not standardized with respect to their diagnostic value.

o The sensitivity of ELISA and IFA screening tests varies from 50% to

70%.


o The sensitivity of the Lyme Western blot is around 10% higher than that of the screening test.

o This difference in sensitivity means that there is a risk that the screening test will be negative whereas the Western blot shows positive, and the diagnosis of LD will be missed.

o Neither the screening test nor the Western blot can rule out infection with Bb, i.e., there is a problem of seronegativity (based on the screening test and Western blot) even though the illness persists and has been confirmed by identification of the pathogenic agent (1-18).

2. Objections to the IDSA guidelines for treatment of LD and chronic LB:


- In Europe, LD is often associated with generalized dissemination throughout the entire body, including involvement of the central nervous system (CNS). Treatment should therefore be carried out with antibiotics that penetrate the CNS, irrespective of the various manifestations of the illness (arthritis, neuroborreliosis, neuropathy, acrodermatitis, carditis, encephalopathy).

- The oral antibiotics recommended by IDSA, namely low-dose doxycycline, amoxicillin and cefuroxime, do not penetrate the CNS; in contrast, minocycline, gemifloxacin and intravenous third-generation cephalosporins yield high concentrations in CSF above the minimal inhibitory concentration (MIC) for Bb (19).

- Contrary to the negative opinion of IDSA, the following antibiotics and methods of treatment have proven to be advantageous: carbapenems, ketolides and gemifloxacin (19); pulsed-dosing (20).


- The antibiotic treatment of EM displays a therapeutic failure rate of at least

10% (15, 41, 45, 47, 67-74).


- Bb could still be identified in the skin even after multiple antibiotic treatments with ceftriaxone, doxycycline and cefotaxime (47-49).

- The resistance of Bb to numerous antibiotics has been proven (61).


3. Objections to the proposed IDSA definition of “post-Lyme syndrome”
:


- Antibiotic treatment according to the IDSA guidelines does not guarantee elimination of Bb.

- Subjective complaints may reflect ongoing infection with Bb rather than a different illness (PLS).

- The disease situation described by Steere et al (26) as “minor signs and symptoms” and by Bujak (27) as “post-Lyme syndrome” represents serious discomfort for affected patients that is comparable to decompensated cardiac insufficiency, degenerative joint diseases, pronounced diabetes mellitus or a condition after a myocardial infarction according to Klempner et al (2).

- The following facts suggest the existence of chronic LB due to persistent Bb infection:

o Persistent symptoms of LB with Bb identification despite intensive antibiotic treatment (28-46).

o Members of the Deutsche Borreliose Gesellschaft have documented

150 such cases (ISBN 978-3-640-19378-3, submitted for publication).

o There is an extensive body of literature on the existence of chronic

LB (45, 50-55).


o Bb could be cultured in every stage of chronic LB (28-44), even after intensive antibiotic treatment (20, 41, 56-60).


o Numerous publications deal with chronic LB and the problems with its antibiotic treatment (20, 48-49, 62-66).

o There is a high therapeutic failure rate for the antibiotic treatment of

LB in its late phase (52, 54-56, 65, 75-77).



- The so-called (according to the IDSA guidelines) adequate antibiotic therapy is subject to these restrictions:

o Since Bb can possibly resist various antibiotics (including those recommended by the IDSA guidelines) switching antibiotics may be indicated (61).

o While Bb may be resistant to erythromycin, related antibiotics appear to be suitable for treatment of LB (26, 83-85).

o Duration of treatment depends on the organic manifestations, severity and course of disease, as outlined in numerous references (2, 20, 25-26, 41, 45-47, 49, 51, 53-54, 56, 60-66, 71-73, 75, 86-94).


-----------
The flaw dear Spanky JD lies not in our stars by in yourself..

It is always good practice to read the entire document -[hint: look for the words in blue and notice how many times it appears in the Gerrman boreliosis Society document] --
A Bill of Particulars-if you will.

Best,
a

duncan
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by duncan » Sun 30 Sep 2012 17:50

Many individuals believe the IDSA Guidelines for Lyme Diagnosis and Treatment are in some regards flawed. The trick is getting any movement toward - or even recognition of - resolving those flaws.

As an independent group, the opinions of the German Borreliosis Society might help both clarify points of contention between the IDSA and ILADS, and help legitimize complaints that the IDSA has been, in some regards, intransigent on much of its stance on debated issues. I certainly believe the objections noted by the German group deserve attention precisely because they do underscore potential problems with the IDSA Guidelines which the IDSA doesn't seem inclined to admit.

The press campaign to which I alluded would have been targeted at neither the IDSA nor ILADS, but rather the public at large, or at the very least physicians in general, to spotlight some of the white paper's key findings that are reflective of the issues which seem to paralyze the Lyme landscape and reduce progress to a snail's pace.

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Spanky
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by Spanky » Sun 30 Sep 2012 18:08

"duncan":
Many individuals believe the IDSA Guidelines for Lyme Diagnosis and Treatment are in some regards flawed. The trick is getting any movement toward - or even recognition of - resolving those flaws.
Yes, I understand that, and, as I mentioned, above, I believe that those that oppose the IDSA viewpoint are certainly entitled to express their point of view.

But what I have in mind, in essence, is the concept of the "free marketplace of ideas"...where the merit of the idea is the deciding factor. Let the value of the ideas themselves, decide.

Sadly, in the case of the IDSA Guidelines, a few decided to try to leverage, or muscle, their own perspectives onto the IDSA process, instead of providing evidence that would support their own perspectives. These same people are advocating political action, rather than science.

So far as I am concerned, this was an assault upon the "free marketplace of ideas"...and an insult to the spirit of American antitrust law upon which the attack was claimed to have been based. On legal and public policy grounds...it is hard to express my personal disgust for that action, and even harder to understand how an attorney general of one of our states allowed himself and his office to participate in such a disgraceful stunt.

But, as you are no doubt aware, ILADS and their supporters, including the German Borreliosis Society, were allowed to have their say, their "day in court", before an independent review panel.

And their arguments were unanimously rejected.

Actions, as they say, speak louder than words.

And what you saw there was an attempt to force one viewpoint...instead of allowing competing ideas to tip the scales.

The irony, I suppose, is that the very basis of antitrust laws is predicated upon attempts to gain an unfair competitve position in the marketplace.

And there, you could see that the adherents of a particular viewpoint used those very laws to try to do just that...

Now who is it that tried, and continues to try to play the game with a card up their sleeve?

(Edited to correct typos).
Last edited by Spanky on Sun 30 Sep 2012 22:30, edited 2 times in total.

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Spanky
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by Spanky » Sun 30 Sep 2012 19:16

And one additional thought that I should like to add to the above...

If you consider the entire problem from the "big picture" point of view...as two competing viewpoints, arguing their positions before a jury...

...then the credibility of the 'experts' presenting expert testimony certainly is something that the 'jury' is going to weigh and assess.

The IDSA is a widely respected professional organization, whose opinions are based upon the best evidence collected by respected and acknowledged research experts in their fields.

ILADS is a collection of general practitioners, who rely on their own experimental treatments on their patients...many of whom have been previously subjected to professional discipline by their peers...

...and many, if not most, who have DIRECT financial conflicts of interest in the issues.

The simple problem for the detractors of the IDSA view is the respect and esteem with which the collective medical professional community holds the opinions of the IDSA.

If ILADS wishes to dispute those opinions and somehow overcome the relative strength of the IDSA in terms of respect and weight the IDSA's opinions carry...then they need to present more than the same tired arguments and personal opinions and theories based on their own self-serving observations.
Last edited by Spanky on Sun 30 Sep 2012 22:29, edited 1 time in total.

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