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Friday, September 27, 2013

Of Lyme disease and lemonade

One of the more salient and concerning items of medical news reported recently is an analysis by the Centers for Disease Control and Prevention indicating that there is 10 times as much Lyme disease in the U.S. as formal reporting channels suggest. Rather than the 30,000 official cases each year, which would already make Lyme the most common tick-borne illness in the country, there are roughly 300,000 cases. An increase in Lyme prevalence by an order of magnitude is a disconcerting proposition.

The report, which was issued at medical conference in Boston, combines findings from three separate, ongoing studies overseen by the CDC. One is looking at medical claims, another at lab reports and the third is a survey of the population. The new estimate is the result of triangulating the findings of these diverse approaches, thus lending hybrid vigor to the enterprise.

But before we make this news sourer than it already is, we need to note that this does not mean that Lyme disease rates have gone up tenfold. The data in question are comparing actual rates to reported rates, not comparing trends over time. The new report does not indicate anything about a sharp rise in Lyme disease, just a prevailing tendency to underreport. It still matters that there may be 10 times as much the disease among us as we officially recognize, but it’s not nearly as worrisome as a sudden explosion in the number of cases.

Then again, Lyme disease is cause for concern at almost any level, let alone at the impressive prevalence the new data suggest. The condition is caused by the bacterium,Borrelia burgdorferi, transmitted (as I suspect everyone knows) by tick bite, and specifically in most cases, the blacklegged tick. The bacterium is classified as a spirochete, the particulars of which need not concern us here, except to note that the germ responsible for syphilis, Treponema pallidum, is in in this same category.

Syphilis, a scourge since long before effective treatment was available, is notorious for progressing through complex stages and involving multiple organ systems over a span of decades if left untreated. The Lyme organism can do much the same. Just like Treponema pallidum, Borrelia burgdorferi can, given the opportunity, invade and damage the central nervous system. The late stages of both syphilis and Lyme can impair the functioning of multiple organ systems, the nervous system prominent among them.

So, there is no question about the existence of chronic Lyme. What is controversial is the validity of chronic Lyme in the aftermath of a full course of antimicrobial therapy.

In some cases, a “full” course may not be enough. Like any germs, the Lyme organisms can develop partial or even complete resistance to specific antibiotics. In some cases, the course of treatment may not be long enough to fully eradicate the disease, or the drug chosen might not be optimal. Treatment can fail. But usually, it succeeds. Given that a full course of appropriate antibiotic is administered to susceptible organisms, the evidence is strong that this reliably does the job most of the time. When treatment is prompt and the disease in its early stage, it is almost invariably cured.

And yet, many people report “chronic Lyme” in the aftermath of what should be decisive therapy. Some go on to get very extended courses of antibiotics, which in some cases still fail to resolve the clinical syndrome, or do so only temporarily.

Some such patients, including some in my own practice, undergo very extensive testing to determine if viable organisms have somehow dodged all those bullets directed at them. That testing can include a lumbar puncture with culture of cerebrospinal fluid, one of the places the organisms can hide. When even that is negative, it does indicate with a high degree of reliability that the organisms are indeed dead and gone.

Consequently, many Lyme experts, including my colleagues at Yale, go to some length to refute the validity of “chronic Lyme.” In the absence of the infecting organism, a chronic infection simply isn’t possible.

This is certainly true, but it says nothing about symptoms. The persistence of chronic symptoms after an infection, and the pushback by experts that this is not “chronic Lyme” have led to what some now call “the Lyme wars.”

The wars are an unfortunate distraction. Is the persistence of symptoms from an infection possible long after the infecting organism is gone? Of course. Just talk to anyone using braces after a polio infection decades ago.

The adamancy of some experts that chronic Lyme following effective treatment doesn’t occur, and the insistence by patients that it does may miss the essential point: something is still wrong with these patients. Maybe only the experts are qualified to say if it is Lyme infection, but only the patients can say how they feel.

My own clinical experience indicates that there is a syndrome of chronic symptoms post-Lyme infection. It may be because of injury to the immune system, the nervous system, or due to these and/or other effects. But just as the poliovirus can infect, be dispatched, and leave permanent effects behind, we don’t necessarily need to find viable Borrelia burgdorferi to have lingering consequences of their temporary stay.

In my clinic, and many others, we work hard to treat the aftermath of Lyme accordingly, with varying degrees of success. The infection should be treated decisively, certainly. Once it has been, any lingering symptoms should be given the full measure of respect they deserve and treated diligently as well, whether or not they have anything to do with ongoing infection. Patients should perhaps be less adamant about why they don’t feel well, since it can be hard to know. But clinicians are well advised to remember that only a patient can say how she or he feels, and ultimately, that’s really what matters most.

The one aspect of the debate with clear practical implications is that if chronic Lyme symptoms are due to chronic Lyme, more antibiotic treatment is warranted. If such symptoms are due to the lingering effects of a vanquished infection, antibiotics may be ineffective and more likely to do harm than good. A shared understanding of this between patient and clinician, and a willingness to listen to one another, should allow for the right kind of personalized care.

Fortunately, though, this challenging area is just a small part of the Lyme disease landscape. The large number of cases to which the new report refers mostly represents early-stage Lyme. When identified and treated in its early stages, most Lyme gets better.

This is what the literature tells us, but being a Connecticut resident, I have seen it up close and personally as well. I have treated Lyme in patients, friends and relatives alike. I’ve treated myself for it twice over the years. My horse has been treated several times and some years ago, I had to take one of our dogs to a veterinary hospital at 3 a.m. for what turned out to be Lyme disease, that responded promptly to antibiotics.

A report highlighting the prevalence of Lyme should raise awareness and suspicion, increase early detection and extend early and effective treatment to more of those involved. That’s the good news in a seemingly bad report. This analysis may also stimulate new efforts directed at Lyme prevention by various means, from tick control to immunization.

While waiting, we all have means to defend ourselves. These begin with prevention, most of which is common sense. Clothing can be used as a reliable defense against both excessive sun and ticks. Pets can be treated appropriately so they are less likely to share viable ticks with us. Showering promptly after outdoor activities that represent opportunities for ticks is likely to send them into the plumbing before they can dig into our skin. Ticks need to be embedded for 24 hours or more to transmit Lyme, so just having a tick crawl around a bit and try to get settled is not a danger.

I suspect we are all familiar with the adage about doing the best we can with a bad situation: when life gives us lemons, we are supposed to make lemonade. If 10 times more Lyme among us is the lemons in this case, I’m not sure there’s lemonade to be made. Perhaps that’s just as well, since lemonade tends to be loaded with sugar, and that carries its own liabilities.

Lyme is common, but no more so now than before this report. This is simply recognition of what has been, not a portent of some new threat to come. More awareness means more reliable prevention, detection and treatment. We may not have a recipe for lemonade here, but we have no reason for panic either.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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