How does all that misinformation online affect Lymies?

I have been working toward this for two years now, and I can finally talk about the work we’ve done with the help of many volunteers. My paper, “Competing Online Viewpoints and Models of Chronic Illness” will be published at the premier venue in my field, the 2011 conference on Computer Human Interaction. For those of you with a medical background, in my field, this is equivalent to a journal publication in impact. Needless to see, I’m very excited to have finally gotten the work to this point, and extremely grateful to all of my co-authors, who helped me with every aspect of the research and writing, and all of the lymies who helped us to collect the data on which the study is based. I could go on for a long time about the personal accomplishment this represents and what it means to me (and I may in another post), but what I want to do here is say a little about what we did.

I am not a doctor, and however much I would have liked to do so, I am not qualified to conduct research that can identify a cure or otherwise directly affect the medical experience of individuals with Lyme disease. Rather, my area of specialty is information technology, and how people interact with it. Because of this, my work focused on how people with Lyme disease use online information in the course of their illness. I specifically wanted to understand how people negotiate the competing viewpoints present online (consider the contrast between the IDSA/Mayo Clinic/CDC/Wikipedia style information and that found on websites such as CALDA and ILADS). I knew that I personally had encountered both sets of information when I was diagnosed, and as a result I ended up putting my trust in doctors who did not treat me correctly. In my study, I wanted to document what happened to others, and identify possible solutions to any problems we discovered. My next step will be to begin to implement these solutions.

So what did we find? We found many examples of people who grappled with the mix of information online. Surprisingly, the kind of information that people trusted seemed to be affected by their diagnosis experience/initial beliefs about Lyme disease: Read the rest of this entry »

IDSA fails the test

Editorial note: I posted the content below but forgot to discuss the implications. Here goes: The restrictive guidelines for diagnosis and treatment of Lyme disease published by the IDSA (Infectious Disease Society of America)  have caused some doctors and insurance companies to restrict the treatment options available to patients. There is enough evidence that these guidelines are biased that the IDSA was prosecuted by the Attorney General of CT (a lyme-endemic state) on an anti-trust basis. In the end, they settled out of court and held hearings to reconsider the guidelines. As I explain below, the hearings did not lead to any major changes in the guidelines. This is bad news for Lyme patients. However, the hearing process itself was flawed and biased. Luckily, there is one crucial thing the hearing panel disagreed on — whether or not a Lyme diagnosis can be made clinically, even without clear test results. Since the tests are flawed, this would represent an important change for Lyme patients. It could help reduce the number of people who are diagnosed late and thus develop chronic Lyme, and allow those who’s Lyme is already chronic to be counted, get treated, and so on. As described below, even with regard to this issue, the panel recommended no immediate changes to the guidelines. However, it is still possible that the Attorney General will be able to push the IDSA in the right direction, and that at least that change will be made. Now back to my original post:

The IDSA posted its final report based on the hearings held last fall (videos available until about 1/2011). The report concludes that no changes are necessary to the current guidelines, though small modifications are suggestion on the next revision. This report, and the process that generated it, are currently being reviewed by the office of the Attorney General. I will be following the details on Lyme Policy Wonk as they unfold.

In the meantime, here are some flagrant examples of how entrenched the IDSA is: Read the rest of this entry »

New hope for Chronic Fatigue patients

When you live in the nether world of questioned diagnosis, you spend a lot of time wondering if perhaps those doctors who say the problem is in your head, your lifestyle, and your diet are right. In my case, I was lucky to have a variable enough illness that I was constantly reminded that I was not the cause — as soon as I felt better I did more, no matter how short a time it lasted. I never had to think about it, plan it, or convince myself to do so, I just DID.

Lyme disease patients at least have the existence of a known pathogen to hold onto when they fight the external discrimination, and associated internal questioning, that characterizes their disease. For those with Myalgic Encephalomyelitis (known popularly as Chronic Fatigue Syndrome), until this week, that did not exist. On October 8th, the journal Science published an article by Lombardi et al. titled “Detection of an Infectious Retrovirus, XMRV, in Blood Cells of Patients with Chronic Fatigue Syndrome.” (also see this discussion by the author of Osler’s Web). Pamela Weintraub, in her blog Emerging Diseases reflects on the continued efforts of physicians and researchers to label diseases like Lyme disease and Myalgic Encephalomyelitis (ME) as pyschiatric illnesses. This is a form of discrimination and institutionalized myopia that has systemic negative affects on patients. It stifles research, reduces access to treatment, and forces patients who are already fighting a difficult disease to also fight for respect. Perhaps worst of all, they must devote mental and physical energy to all of this, while simultaneously fighting the internal battles necessary to keep believing in themselves despite a lack of definitive anything and constant encounters with naysayers. Read the rest of this entry »

Hearing talks now available online

Quick update to my previous post: you can now view a video archive of the IDSA hearings online here: http://webcast.you-niversity.com/idsaArchives/

Picking a road by consensus

Two roads diverged in a wood, and I—
I took the one less traveled by,
And that has made all the difference

– Robert Frost

The Road Not TakenLyme politics have been on my mind recently, due to  the efforts to reconvene the IDSA panel that was responsible for creating a very restrictive definition of Lyme Disease and it’s treatment. The question I am concerned with in this post is how thinking, caring people could write down something so narrow and incomplete. The divided politics of this situation have never adequately explained to me how we got here.

Now, there is a lot of evidence that the individuals who wrote the IDSA guidelines are biased*, and that is certainly a possible explanation for what happened. In fact, as a result of investigations into this bias, a new panel has been convened. To the dismay of many individuals with Lyme disease, the new panel, although lacking conflicts of interest, still seems unlikely to make major changes to the IDSA treatment guidelines. Yet its web page states that its members are “committed to considering all points of view” and the panel is taking public comments until April 3, 2009.

Let’s for a moment take the optimistic viewpoint that the members of the panel are truly committed to this. Let’s suppose that they chose medicine because they are compassionate individuals who want to help people, that they are smart and capable of understanding scientific literature, and that they lack bias. Why do so many doctors choose to believe in a version of Lyme disease that excludes so many of us?
Read the rest of this entry »

Ways of knowing

Wooden blocks used to create a path for a marble

I just finished an interesting book, “Patient from Hell” (Schneider and Lane). The central thesis of the book has to do with the types of evidence that can lead to knowledge about how to treat something and how the medical profession fails to make use of some of those types of evidence. A second key point in the book is that certain types of decisions should be in the hands of patients, not just doctors. Let me try to clarify these points, since I think they are very relevant to the experience of Lyme disease. As a side note, the book itself is a little difficult to follow, this is not necessarily a recommendation of the book, just my attempt to restate their conclusions in terms that make sense to me and relate to Lyme disease.

The type of knowledge that is most commonly used in medicine is called “frequency knowledge” by Schneider and Lane. This is the knowledge that is created by trying something over and over again and seeing what happens. For example, flip a coin enough and you’ll know if it’s balanced or not. Give long term antibiotics to enough people with Lyme disease and maybe you’ll find out whether it can help them. This kind of knowledge is  relatively easy to generate in an easily controlled, repeatable situation (like flipping a coin). However, it is much harder to get solid frequency knowledge in a more complex situation where every coin you are flipping is different (or every person with Lyme disease is different). Clinical trials generate frequency knowledge, and in the case of Lyme disease, they will probably be at least partly inconclusive until many more trials are run.

A different, equally valid type of knowledge that is sometimes ignored is “process knowledge.” This kind of knowledge complements frequency knowledge, but is sometimes not considered to be truth by doctors because it is “untested”. As an example, consider the image at top right. It’s made with wooden blocks that can be put together in any number of combinations. No “studies” have been done of this particular construction, yet you can look at it and with a fair amoutn of certainty, you can predict where the red marble will end up (even though you do not have complete informatino about the structure). Not only that, you can predict with complete certainty what will happen if I remove a critical block. You are using logic to draw valid conclusions about the world that are likely to be true even though they are untested. The wonderful work being done to understand Bb’s life cycle, the ways in which it may resist antibiotics, and so on, are all examples of process knowledge. This knowledge can be used by researchers to infer potential was of treating lyme disease. It can also be used by patients and doctors to decide, now, given a lack of frequency knowledge, what the best choices are. This is one part of the  path taken by LLMDs.

Read the rest of this entry »

Books

Hi folks,

I’ve been meaning to write this for a while, and having recently acquired a new book that I especially love has pushed this up as a priority. I’ve read three books so far about lyme disease, each with a very different perspective, and I want to tell you a little about them. The books are Cure Unknown, The Top 10 Lyme Disease Treatments, and Healing Lyme (and hopefully soon in a future post, Beating Lyme). Full references below. Full disclosure: I was given the top 10 Lyme Disease Treatments for free in return for agreeing to review it.

I read these books over the last 6 months as I was beginning my own journey into the act of healing lyme disease. At the same time, I was beginning to do my own research into the disease, it’s actions on the body, cures, and the doctors who administer those cures. Each of these books provides a very different perspective on how one might approach a cure, and each has a different emphasis regarding how lyme affects the body. All three discuss the lyme-wars, and all three are written by people who feel that the IDSA view of the world is limited at best. As with the information available in person, the quality and perspective of the books I have read varies widely.

In my mind, the book that is most comprehensive, balanced, and informative is Cure Unknown, by Pamela Weintraub. Weintraub is a senior editor at Discover Magazine, and she, her husband, and both of her children went through years of misdiagnosed lyme, followed by years of treatments with varying success. Her book reviews everything about lyme — the history, the studies, everything. It’s got all the interviews in it and all the literature in it that I wish I had time to read. Despite her experiences, which do color the book, the literature review in the book comes across to me as complete and relatively unbiased. It was the first book that adequately explained to me how an auto-immune disorder might result from lyme, while also reviewing what I see as conclusive evidence that lyme may also persist past 6 weeks of antibiotic treatment. It does not attempt to tell the reader how they should heal their own lyme, but it does describe one family’s path to healing. It is a political book, a science book, and a deeply engaging story of despair and hope. Perhaps the only flaw in this book, in my mind, is the fact that it spends almost no space on the possible role of alternative treatments in healing: she does she interview practitioners of alternative treatments, or literature about them, and only briefly mentions them. Despite that, I highly recommend this book to anyone touched by lyme, or simply interested in a disease that has spawned a society of people and doctors defined by the fact that mainstream medicine has rejected the possibility or appropriateness of their existence, driven by tragedy, and enabled by the Internet. If you buy one book, buy this one.

Perhaps the complete opposite of Cure Unknown is the Top 10 Treatments. Despite the word “conventional” in its subtitle, this book is almost exclusively about alternative treatments for lyme disease. Almost no space is spent on the history or politics of lyme, and the book is really aimed at an advanced reader who has already familiarized him or herself with much of what is in Cure Unknown. As with Cure Unknown, the impetus for this book was personal experience — in particular, the experience not only of having lyme disease, but having even the lyme literate doctors run out of ideas of how to cure it after extensive antibiotic treatments did not work.

The Top 10 Treatments suffers from a lower quality of writing than Cure Unknown, and the work is not as clearly referenced as Cure Unknown. Neither Cure Unknown nor the Top 10 Treatments is written by a doctor, but Cure Unknown includes detailed information about studies and interviews with doctors that is missing from the Top 10 Treatments. Finally, at least in Pittsburgh, finding a doctor willing to administer any of the top 10 treatments listed is difficult at best (and some of the treatments are a little scare to administer on one’s own).

That said, this passionately written book was clearly based on extensive research and presents a comprehensive look at ways to support any treatment protocol you choose to undergo, and regardless of the accessibility of all 10 treatments, the treatments described in Chapter 4 (Detoxification) such as detoxification of the liver, sauna therapy, salt baths and exercise should be part of any treatment plan (and are sadly often not mentioned by doctors or in books). As Rosner says, “it should be standard practice to utilize supportive therapies that increase antibiotic effectiveness” — and I will add, therapies that reduce side effects (such as taking sacromyces daily while on antibiotics to reduce the risk of a yeast infection).

Healing Lyme, unlike the previous two books, is written by a master herbalist and psychotherapist named Stephen Harrod Buhner. This book is not driven by his personal experience with lyme disease, but rather by his experience healing patients with lyme disease. This book is older than the other two, and does not include all the most current research, but it is extremely well referenced and clearly written. It was the first book I read, and after reading it, I had a much deeper understanding of how lyme operates in the body and the ecosystem. At the same time, I found myself questioning how much in this book was true and how much was not. As a patient exposed to the lyme wars, I was disappointed by the style of the literature review in this book. Unlike Cure Unknown, this book does not explain the controversy around pieces of related work, nor does it directly argue why one view point may be more correct than another. Instead, it presents quotes taken from references. As an academic, I know that reading quotes out of context does not really answer any questions about a controversial research area. Despite these flaws, the book is a worthy read, especially after having read Cure Unknown. Also, this book is not simply a biology/ecology text — it is a treatment guide to using herbs to cure lyme. The use of herbs is completely ignored in Cure Unknown and mostly not a factor in the Top 10 treatments, so this provides a valuable additional resource (again, assuming you have access to a practitioner who can guide you if you select this treatment approach).

After reading all three books, I must admit that I am no closer to knowing what the right way to treat lyme disease is. For now, I am going with the approach that is closest to mainstream/for which I can find the most knowledgeable docs & most research — antibiotics. I’m also throwing everything I can at supporting the antibiotics, with supplements, salt baths, yoga, and so on as you have seen in my posts.

  1. Cure Unknown: Inside the Lyme Epidemic (by Pamela Weintraub). St. Martin’s Press, 2008
  2. The top 10 Lyme disease treatments: Defeat Lyme Disease with the Best of Conventional and Alternative Medicine (by Brian Rosner). BM Publishing Group, 2007
  3. Healing Lyme: Natural Healing and prevention of Lyme Borreliosis and Its Coinfections (by Stephen Harrod Buhner). Raven Press, 2005
I’d also like to add to this list: BEATING LYME: Understanding and Treating This Complex and Often
Misdiagnosed Disease (by Constance A. Bean with Lesley Ann Fein, M.D., MPH, AMACOM, 2008.

A mom’s worst fear

ADDENDUM 11/24/2010: I’ve modified this post to reflect some of my more current understanding about Lyme disease. Mods are marked with the word ADDENDUM below.

I’ve been worried about it since I got my diagnosis… but it was only recently that those worries turned into action. I brought my son in to see his doctor last week because he had another ear infection, and we sat down and talked about how often he’d been sick in the last year and a half … and I was shocked to discover a pattern similar to my own — sicknesses of various sorts monthly almost the entire time. Sometimes even more frequent, and for one two month period less frequent. This is a child who had never had an ear infection until the year he turned 3, and was not frequently sick. I was also concerned because he seemed fatigued more frequently than I’d expect — in fact, his teacher told me that he often appeared glassy eyed by snack time.

I decided that I couldn’t wait any longer and asked his pediatrician to test him for lyme. If I was right, and didn’t find out for another year or longer, I’d be so angry with myself. If I was wrong, I’d feel bad that I made a child who is scared of needles get blood drawn, but it seemed like much less of an issue. Luckily (and of course) my pediatrician was able to take a less biased view of the whole situation. She pointed out that we needed to test for other causes, so we did allergy tests, blood work, and a Western Blot. We skipped the ELIZA and some other tests that he might need, but even so he had 8 vials of blood drawn. Needless to say, this was very traumatic and I’ve been feeling guilty all week. Until today.

Today I called his pediatrician, and the office said the blood work had come in. I requested that they have a doctor look at it, and my heart sunk when an hour later the doctor called to tell me that his IGg was positive (this means that he may have been exposed, but not recently). My first reaction was to imagine him going through everything I’d been through. Logic was completely absent, and so was self control. Since then 3 hours or so have passed, and I will have even more information after I’ve seen the test results (I’ll probably post an update then). In the meantime, I contacted a very special pediatrician who is based in Pittsburgh and is a leading researcher on pediatric lyme disease. He’s been a great help to me in interpreting my illness and he also helped me see my son’s situation more clearly. I also spoke with a doctor in Ohio who specializes in integrative medicine and will talk later today with my homeopath/MD. Here are the results of my conversations so far:

  • The Western Blot, especially in absence of an ELIZA could indicate that he has a disease other than lyme (such as CMV or Epstein-Barr). This is because it tests for antibodies, some of which are not specific only to Lyme. When I see it, I’ll know much more about how likely it is that he really has lyme disease. Everyone I spoke with wants to see our results to interpret them more carefully and we will be faxing them around later today.
  • It is expected that he would have an IGg but not IGm both because he’s had these symptoms for some time, and because (if this is lyme) he’s only been in Frick park once since my diagnosis and was likely exposed to it when I was — ADDENDUM 11/24/2010: I have since learned that this over simplifies the situation and really is only believed by folks on one side of the lyme wars. In my son’s case, this interpretation turned out to be incorrect.
  • Fatigue, as a symptom, is fairly rare in young kids with lyme, and might indicate other illnesses – ADDENDUM 11/24/2010: This is also disputed.
  • Children tend to respond very well to treatment. Oral antibiotics for about a month is not an uncommon treatment — ADDENDUM 11/24/2010: This is a very short amount of treatment, especially for a chronic case of Lyme disease
  • The lyme researching pediatrician will see us this Friday at his clinic at Children’s Hospital. If it is Lyme, he can help us with the treatment. If it is not, he will help us track down what it is. It’s great to have such a top hospital so close by.

I am also diligently looking into alternative options (still searching for them for myself, and of course would want to understand if they could help my son). I spoke with the folks in Ohio at the integrative medicine center in Columbus. They seem actually willing to work in the context of multiple treatments and not as solo silo-type doctors. They specialize in helping folks who seem to have gotten sicker than one would expect from something, by adjusting diet and other things to try to make the immune system work better. By looking at bloodwork, they can tell if they are likely to be able to be of help. They are willing to take a look at both my bloodwork and my son’s if we want. In addition, I have a friend who’s nephew has lyme disease. He is being treated with ongoing antibiotics and has been on them for 3 years because his symptoms recur when he goes off them. I truly hope that my son doesn’t need that sort of treatment, but I asked her for this doctor’s phone number so I can find out more about when that sort of approach is recommended and used. It is very scary to be in the position of deciding which side of the lyme wars I believe in not only to guide my own future but that of a child who is just at the start of his life. I don’t want to screw this up!

My read on the lyme wars

I’ve sort of been putting off writing this post because it’s a difficult and controversial topic… and I’m sure I will write many more on this topic… but for now, here are my thoughts on the medical disagreement plaguing patients with lyme disease. This is a very long post and only begins to scratch the surface…

First off, lyme is a complex disease, and the disagreements tend center around the more complex manifestations of lyme disease. If you are bitten by a tick, immediately develop a bulls eye shaped rash and other symptoms such as weakness or paralysis in your limbs (as my dad did), and you’re lucky enough to have a doctor who’s heard of lyme disease, chances are they will treat you right away with a long (e.g. 1 month) course of antibiotics and chances are that this will cure you. Also, no matter what view point your doctor subscribes to, he or she will tell you that you have been infected with a spirochete that is related to syphilis, is susceptible to antibiotics, and that you will most likely be free of symptoms when you are done with your antibiotics. If you go on to have symptoms after treatment, an understanding and sympathetic doctor will work with you on treatment. The disagreements most frequently arise in more complex and longer lasting cases, and in the best case have to do with the cause of symptoms.

To understand these disagreements, it is important to understand a little bit about the disease. Like syphilis, lyme will act on the body differently as time passes, and may invade more diverse areas of the body. When it is misdiagnosed either due to flawed tests or lack of familiarity with the disease, which mimics many other diseases, it may be made worse by (1) too short a course of antibiotics thought to be treating something else (2) a course of steroids, which actually helps lyme disease attack the body more successfully (3) the simple passage of time (it may take years for the correct diagnosis to be achieved). But the question that causes the most controversy is what happens after antibiotic treatment in one of these situations. There are essentially two hypothesis:

  1. The lyme spirochete most certainly can survive a treatment of antibiotics. In cases where it does, you may have a relapse or a re-occurrence or may simply not improve. In fact, you may get worse over time if you are not treated appropriately (e.g. perhaps with stronger antibiotics or for a longer period of time). It would be malpractice not to treat you.
  2. The lyme spirochete absolutely cannot survive a treatment of strong antibiotics lasting 4-6 weeks. If you have had this treatment and you are still symptomatic or become symptomatic again, you must either have some other illness or be suffering from some sort of auto-immune response caused by the original lyme infection. For various reasons any tests that might indicate the presence of lyme spirochetes in your system should not be trusted. It would be malpractice to give you more antibiotics as long-term antibiotic therapy can be quite dangerous and would have no point since there is no spirochete left to kill off

I have stated these in strong terms because the emotions around them are strong, and doctors in both camps will cite many articles supporting their viewpoint. Two good articles summarizing the literature supporting each argument are “‘Lyme disease’: ancient engine of an unrecognized borreliosis pandemic?” (1, above) and “A critical appraisal of ‘Chronic Lyme Disease’” (2, above). See more discussion of both viewpoints on this blog’s links page.

Now, I am no medical specialist, but I do work in a field where we study human beings and prove hypotheses about them. Although the stakes are less high, disagreements may arise in my field too. And when they do, conscientious researchers often try to create carefully controlled studies to help verify their point of view in the disagreement. As a friend and colleague pointed out to me recently, this strategy may lead to a situation in which one group of researchers is designing studies that are so carefully controlled that they eliminate the situations in which the conflicting hypothesis is true. So, both camps continue to prove their point without realizing that both points of view may be correct in some cases.

I would not presume to have a definitive explanation for why both points of view are true if this is even so, but I can give some examples of how this could occur. For example, it is possible that for many individuals including most of those for whom it is easiest to prove that they have lyme disease and no other infection, a single, strong treatment of antibiotics is quite effective and additional symptoms may be auto-immune related. These are also the individuals likely to qualify for studies designed by researchers in camp 2 (which states that lyme cannot re-occur). It is equally possible that in other more complex cases, lyme may re-occur, and that these folks are being studied by researchers in camp 1. A more inarguable possible explanation for lyme re-occurrence is re-infection: It seems highly plausible that individuals who live a lifestyle that causes tick exposure may continue that lifestyle, and may be bitten again, and perhaps this may happen more frequently than we know (since many lyme patients don’t actually remember being bitten by a tick).

In any case, what is not in question is that some individuals suffer long after they are treated for lyme. Whether this is solely an auto-immune response or co-occurrence of some other disease or whether it is instead caused by re-infection, they are suffering. They need access to lyme literate physicians who are willing to explain both sides of the situation, acknowledge where ambiguity or uncertainty exists, and support the need of these patients to find both the cause and the cure for their illness. Luckily, these physicians exist, but sadly for many patients they are hard to find.

Another study weighs in on post-lyme/chronic lyme

I’m always on the look out for more research that helps to resolve the controversial question as to whether lyme can re-occur. One test of this is whether antibiotics help with post-lyme symptoms (since they would presumably not help if those symptoms are caused exclusively by an auto-immune reaction). I haven’t read this full paper, but from the abstract, it appears that antibiotics did have an impact on symptoms for some folks with post-lyme but it only lasted 12-24 weeks. Note that many many individuals were screened out in searching for the people qualified to participate in this study.

 A randomized, placebo-controlled trial of repeated IV antibiotic therapy for Lyme encephalopathy

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