Aus dem Usenet, File 6

In article <4h3amp$dcb@newsbf02.news.aol.com>, cal230@aol.com (Cal230) wrote:

> It would be interesting to know if there are ANY circumstances under which
> the LDF's Medical Advisory Committee would NOT recommend treating tick
> bites.  Since the LDF's medical advisors appear to be private practice
> physicians--many with Lyme disease practices--one has to wonder if the
> treatment rationale isn't designed to justify their own practices.  The
> absence of disinterested public health officials, entomologists,
> epidemiologists and academic researchers as advisors on the tick treatment
> rationale is noteworthy.  


   I don't quite understand what you're getting at here. Regardless of a
physician's view on prophylactic treatment of tick bites, I would expect
his/her treatment rationale and actual practices to go hand in hand. You
want them to design a treatment rationale that *doesn't* square with the
way they treat patients? It doesn't work that way. The practice follows
from the treatment rationale.

   And what exactly do you mean by "disinterested"? I suspect this is a
not-so-subtle dig at those who elect to treat prophylactically, implying
that they do so for financial gain. If so, I'd appreciate it if you would
elaborate on this point. (And if not, I'd appreciate it if you clarified
your point; I certainly don't want to put words in your mouth.) How does
the physician make out better financially by electing to treat in this
scenario? The patient is already in the office, the meter is running. How
does prescribing oral antibiotics enrich these physicians?

   Finally, I think having physicians with Lyme disease practices serving
on the board of a Lyme disease-oriented foundation seems about right. You
would prefer perhaps urologists?


> In discussing treatment rationale, it would be helpful to know if any of
> Dr. B's cited clinical studies were published in the peer-reviewed
> literature.  Abstracts presented at LDF events are not subject to the same
> level of objective scrutiny as referred journals.  Besides, Dr. B. is also
> a member of the LDF Board.  


   I don't have the document in front of me, so I can't comment on any of
the references Dr. B cited. But there are indeed articles in the
peer-reviewed literature that support prophylactic treatment for ticks
bites, just as there are articles that don't. In 1992, the New England
Journal of Medicine published two papers four months apart that reached
entirely different conclusions -- the first advocated treatment for tick
bites, the second did not. The first [Magid D, Schwartz B, Craft J, et al.
Prevention of Lyme disease after tick bites: a cost-effectiveness
analysis. N Eng J Med 1992;327:534-41] was, as its title implies, a
theoretical cost-effectiveness analysis, in which the authors calculated
the probability that the tick would transmit disease, that a patient would
get sick, what the treatments would cost, the medical outocmes, etc., etc.
They concluded that is was both cheaper and safer from a medical
standpoint to treat prophylactically. The major gripe against this study
was that some of these "probabilities" (which were gleaned from the
peer-reviewed medical literature) may not have been the best estimates,
thus biasing the results toward the "Treat All" strategy.

   The second paper [Shapiro ED, Gerber MA, Holabird NB, et al. A
controlled trial of antimicrobial prophylaxis for Lyme disease after
deer-tick bites. N Eng J Med 1992;327:1769-73] was an actual trial with
real patients that concluded that prophylactic treatment was unnecessary.
The problem with this study was that the sample size was so small that the
findings couldn't be considered significant.

   Frankly, neither of these two studies would be likely to convert anyone
who already holds a contrary view. This tick-bite issue is hard to justify
with hard data, so good-faith physicians on both sides of the issue will
just go ahead and do what they suspect is the right thing to do. 
   
   In any case, your original implication -- that there are no papers in
the peer-reviewed literature to support treatment of tick bites -- is flat
wrong.

   Finally, if you want to engage in a meaningful debate in this forum
about any aspect of Lyme disease, please feel free to do so. I for one
would welcome such an exchange -- it's boring when everybody holds the
same views. :-) But if you want to discuss these issues, please bring
something to the table besides innuendo and smear tactics. Or at least
elaborate on your implication. Do you think that having a Lyme disease
practice should disqualify a physician from dispensing advice about Lyme
disease? Is there some sort of inherent conflict there? What are you
getting at exactly? Be precise, please.


Carl Brenner