“When Evidence Based Medicine is based on biased evidence”

Medical topics with questions, information and discussion related to Lyme disease and other tick-borne diseases.
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LHCTom
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“When Evidence Based Medicine is based on biased evidence”

Post by LHCTom » Tue 26 May 2015 23:20

aka “The Art of Selective Evidence and misleading Doctors”

The powers who drive the medical views of Lyme and tick Borne diseases reach deep. This article appeared in Sonoma Medicine - The magazine of The Sonoma County Medical Association representing all North Bay Area County Medical Societies.

http://www.nbcms.org/en-us/about-us/son ... &tabid=747

http://www.cdph.ca.gov/HealthInfo/disco ... nsinCA.pdf

It was written by the author team of Gary Green, MD, IDSA, Anne Kjemtrup, PhD, DVM, and Michael Ferris representing respectively, Northern California Kaiser Permanente ID Medicine, the California Department of Health Biologists, and the local medical lab director ( who tests ticks) . It is intended as an educational piece for all the physicians in the North Bay Area Counties. It’s a shockingly sad example of how Evidence Based Medicine can have its evidence selected for minimization and biased to mislead physicians who trust the authors. The North Bay Area Counties are among California’s highest Lyme and other tick borne disease endemic areas in California and the US. See map below. Lyme and other tick borne disease cases such as B. miyamotoi, Ehrlichia, Babesia duncani ( the West Coast species) and Anaplasma cases are viewed as a percentage of the states total population of 40 million people. The bulk of the population resides in southern California where tick-borne disease rates are very low while areas in the North Bay Area are similar to East Coast infection rates. This gives the impression that tick borne diseases such as Lyme are fairly rare since they tend to occur in hotspots that appear almost insignificant against the 40 million people in California. But in the North Bay Area, infection rates in rural areas are comparable to the East Coast.

The article presents a biased inaccurate message or theme that tick borne diseases are rare, discouraging physicians from even considering them in a diagnosis. At the same time, the article is full of inaccuracies which are all biased toward minimizing the risk of acquiring Lyme or a tick borne disease in the North Bay Area. It fails to even mention the ecology concept of hotspots where tick infection rates peak much higher than other nearby areas. A person living in one of these hotspots is far more likely to acquire a tick borne disease than someone living inside a city. In one paragraph it misquotes its source by adding a % sign to a probability thereby incorrectly altering the risk lower by 100 times. Its data and discussion are minimized from and contradictory to the author Kjemtrup's own California Department of Health’s own TBD publications (4,5). It cites scientific literature that minimizes while ignoring studies by the same researcher and even one contradictory study by author Kjemtrup (3) which documents a severe hotspot in Sonoma Valley.

The West Coast’s most prominent researcher and most cited by the article is Dr Robert Lane who been quoted in the local press with a contradictory view. His studies are cited more often by the article than any other researcher. The contradictory CDPH reports (3) (4) are not utilized since they contain contradictory data. The article could have been replaced by the CDPH reports and been more accurate but would not have allowed the authors the liberty of biasing the data. For each of Dr. Lane's study's cited, another which indicates a much higher risk is ignored and not cited. Studies are hand selected by the authors in a manner which appears to support their inaccurate message. This is a blatant example of how science can be misused yet seem to support the authors views. Evidence Based Medicine is only as good as the evidence utilized. Most knowledgeable of the various Lyme controversies know this a common approach to misusing science at the expense of ethics.

The article is heavily Lyme biased ( fighting the IDSA battle maybe) and could have been summarized in one statement by a true honest expert.
“Some physicians tell their patients that Lyme disease doesn’t exist in California or is very rare,” Dr. Bob Lane said, a UC Berkeley entomologist. “Lyme disease is locally an issue in some Bay area counties, such as in Sonoma and Marin.”
https://baynature.org/articles/bay-area ... e-disease/

A crucial study (1) by Dr. Robert Lane published in 2011 found one rural community approximately 20 miles north of the Santa Rosa Kaiser facility in Hopland with 23.7% of the 114 people tested positive for Lyme. This study was not cited and ignored. The risk of Lyme Disease varies dramatically by North Bay location ranging from tick infection rates of a few percent to rates of 41.3% near Hopland which is comparable to the US East Coast. This study (2) is not cited and ignored. The risk of Babesia duncani and Ehrlichia also vary dramatically by hotspot and the CDPH’s own co-author Kjemtrup failed to mention her own 1999 study in Sonoma Valley that showed a 4.6% Ehrlichia chaffeensis and a 17.8% Babesia-duncani/WA1 infection rates. This study is not cited and ignored. How could author Kjemtrup miss her own study? It glosses over B. miyamotoi which has recently been found to be as much as 1/2 as common as B. burgdorferi in the Bay Area by a number of researchers at Stanford (6) and the CDPH’s own Kerry Padgett (7) and has no reliable or FDA approved or cleared test available. So there is no way of even knowing how many people have been infected by Bm.
Borrelia miyamotoi is an emerging tick-borne spirochete pathogen in Europe and the East Coast, and it has been detected in almost 2% of the western black-legged ticks in California since 2000,12, but no human cases have yet been confirmed in the state.

"But no human cases have yet been confirmed in the state." How convenient there has been no test available outside research labs to confirm this. I am curious how many B. miyamotoi tests Kaiser has performed in the last decade to validate this suggestion. Dr. Kjemtrup's associate at the CDPH, Kerry Padgett ( a real microbiologist) reported in 2013 that their testing since 2000 had shown"

Kerry Padgett reported at the CDPH LDAC meeting in March 2013:
"Approximately half the adult ticks testing positive for Borrelia were B. burgdorferi and half were B. miyamtoi. ........ Nymphs showed a 2.5x higher prevalence infection for B. burgdorferi than B. miyamotoi"
So half the adult ticks positive were Bb and half were Bm over a 13 year testing period while Nymphs were lower at 20%. So half the people that were bitten by infected adult ticks could have acquired Bm for which there was no test and is not detected by the Bb serological test. But fear not!. The authors confirm the test is no good since it confirmed NO cases of Bm while worldwide researchers have confirmed Bm does cause a Lyme like disease. The articles coverage of B. miyamotoi seems a bit disingenuous at best. The authors did attend the LDAC meeting at which Dr. Padgett reported the state of knowledge about Bm.

White shirt spin at its best!

http://www.cdph.ca.gov/services/boards/ ... -15-13.pdf

Almost every paragraph is based on selected evidence where sound contradictory evidence has been ignored. Its shameful. One IDSA doctor dominates the Kaiser Permanente TBD policy and is responsible for nearly 1/4 million people in the North Bay Area. It does of course help minimize cost so has this doctor sold his Hippocratic oath out for corporate profits? You be the judge!

The same doctor has been quoted by Medscape with his views on the Sapi Lyme culture such as:
One of the healthcare providers experiencing a surge in patient requests for the Advanced Laboratory Services test is Gary Green, MD, infectious diseases chief and clinical director of the HIV Team & Travel Clinic at Kaiser Permanente in Santa Rosa, California. Dr. Green told Medscape Medical News that many patients who request the Lyme blood culture test have symptoms they are convinced are a result of chronic Lyme disease even though they test negative on all other standard tests.

Dr. Green said, "The problem with a test that has not been validated and not been tested outside the source of invention is that we don't know whether it is at all accurate. Using an unvalidated test in modern medicine is dangerous and unethical."
http://www.medscape.com/viewarticle/778482

The test has not been validated like all but 3 TBD tests which have been FDA cleared. Writing articles like this is potentially"
dangerous and unethical
Like the article!


Express your concerns regarding the inadequacies and requesting a correction be printed respectfully to the magazine and authors:

http://www.nbcms.org/AboutUs/SonomaCoun ... ctors.aspx

The SCMA and magazine:

Rob Nied, MD, President robert.j.nied@kp.org
Mary Maddux-Gonzalez, MD President-Elect mmgonzalez@rchc.net
Cynthia Melody, Executive Director cmelody@scma.org
Maryann Eckhout, Executive Director meckhout@ncms.com
Editor osborn53@sonic.net

The 2 key authors:

garygreenmd@gmail.com or gary.m.green@kp.org
Anne Kjemtrup, DVM, MPVM, PhD, Research Scientist III
Vector-Borne Disease Section
Infectious Diseases Branch, DCDC, CID
California Department of Public Health
Anne.Kjemtrup@cdph.ca.gov

This is one of the clearest examples of how selective evidence is used to mislead physicians who trust they are reading accurate vetted Evidence Based Medical data. The North Bay Area includes approximately 3/4 million people with Kaiser Permanente providing medical insurance to nearly half. This article expands Kaiser’s views of the risk of tick borne diseases to the entire North Bay Area by misleading almost all the physicians in the area who receive very little tick borne disease training. The magazine was contacted and its editorial board refused any input, discussion or counter-point "letter to the editor" regarding the errors. Doctors protect doctors. The thin white line!. The authors were contacted and refused to correct any of the errors or add appropriate citations.

Sonoma Magazine Editorial Policy
http://www.nbcms.org/Portals/9/Assets/S ... licies.pdf

(1) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3067736/
(2) http://www.ncbi.nlm.nih.gov/pubmed/10577716
(3) http://www.ncbi.nlm.nih.gov/pubmed/9180183
(4) http://www.cdph.ca.gov/healthinfo/disco ... torial.PDF
(5) http://www.cdph.ca.gov/HealthInfo/disco ... dPrevl.pdf
(6) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3944864/
(7) http://www.cdph.ca.gov/services/boards/ ... -15-13.pdf
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The greater the ignorance, the greater the dogmatism.

Attributed to William Osler, 1902

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