This presentation tackles the controversy regarding Lyme disease by reviewing the evidence for immune evasion and persistent infection by the Lyme spiorchete, Borrelia burgdorferi. The evidence shows that physicians called upon to assist patients with this potential diagnosis should be open to the possibility of persistent infection even in patients who have already received antibiotic treatment for their condition. Lacking evidence on how best to treat a chronic infection of this kind, physicians should be allowed to rely on their experience and to exercise their best clinical judgment in managing patients with Lyme disease.
Basic description of Lyme disease from Microbiological and Clinical point of view with discussion on Pathology, Clinical Features and, Laboratory Diagnosis.
Legionellosis is a respiratory disease caused by Legionella bacteria.
The term“legionellosis” may be used to refer to either Legionnaires’ disease or Pontiac fever.
https://www.cdc.gov/legionella/index.html
Basic description of Lyme disease from Microbiological and Clinical point of view with discussion on Pathology, Clinical Features and, Laboratory Diagnosis.
Legionellosis is a respiratory disease caused by Legionella bacteria.
The term“legionellosis” may be used to refer to either Legionnaires’ disease or Pontiac fever.
https://www.cdc.gov/legionella/index.html
“Debate: Host vs Microbiome in the pathogenesis of Periodontal Disease”- A point-counterpoint session at the 17th National ISP PG Convention at Chennai, India on 17/02/2018.
Role of Virulence Factors in Pathogenic Bacteriaaboalhassan1
Pathogenic bacteria utilise a number of mechanisms to cause disease
in human hosts. Bacterial pathogens express a wide range of
molecules that bind host cell targets to facilitate a variety of different
host responses.
The molecular strategies used by bacteria to interact with the host
called virulence factors, can be unique to specific pathogens or
conserved across several different species. A key to fighting bacterial
disease is the identification and characterisation of all these different
strategies.
The availability of complete genome sequences for several bacterial
pathogens coupled with bioinformatics will lead to significant
advances toward this goal. However, in this article I will talk
specifically about the virulence factors of pathogenic Neisseria.
Porphyromonas gingivalis belongs to the phylum Bacteroidetes and is a nonmotile, Gram-negative, rod-shaped, anaerobic, pathogenic bacterium. It forms black colonies on blood agar.
It is found in the oral cavity, where it is implicated in certain forms of periodontal disease, as well as in the upper gastrointestinal tract, the respiratory tract, and the colon. It has also been isolated from women with bacterial vaginosis. Collagen degradation observed in chronic periodontal disease results in part from the collagenase enzymes of this species. It has been shown in an in vitro study that P. gingivalis can invade human gingival fibroblasts and can survive in them in the presence of considerable concentrations of antibiotics.P. gingivalis also invades gingival epithelial cells in high numbers, in which cases both bacteria and epithelial cells survive for extended periods of time. High levels of specific antibodies can be detected in patients harboring P. gingivalis. Dr Harshavardhan Patwal , explains the various enzymes enzyme peptidyl-arginine deiminase, which is involved in citrullination.[4] Patients with rheumatoid arthritis have an increased incidence of periodontal disease, and antibodies against the bacterium are significantly more common in these patients.
P. gingivalis is divided into K-serotypes based upon capsular antigenicity of the various types.
Includes definition, classification, history, formation, salient features, gene transfer( conjugation, transformation, transduction), antibiotic resistance, nutritional influence, quorum sensing, role in pathogenesis, and controversies.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
2. Lyme Wars, circa 2013
ILADS
Is not a persistent infection! vs. Is so a persistent infection!
3. The 2011 Institute of Medicine Report
Underpowered studies that purport to
demonstrate universal efficacy must be
viewed with circumspection.
Everyone is studying the early stage of this
infection; no one is studying the persistent
phase of the disease. It is important that 2011
those studies occur.
All the bitterness of the debate does not
serve the science or the patient...[it]
drowns out the complexity and nuance of
the work that needs to be done.
4. What is the physician’s duty
when assisting patients with Lyme disease?
Know and teach the evidence for
immune evasion and persistent
infection in Lyme disease.
Learn the varied clinical
presentations of Lyme disease.
Apply evidence-based care strategies
within a shared decision-making
model that respects patient values.
Monitor and document clinical
outcomes.
Hippocratic Oath
on papyrus, 200 AD
5. 2012 Yale Lyme Risk Map
• Map produced by the Yale
School of Public Health
• Released February, 2012
• Includes a high risk “sliver”
in Northern Illinois
• Most of Northern Illinois
considered a transitional
area
6. July 2012 Illinois Tick survey
56.4% of over 1,067 ticks collected from 17 sites in Cook,
Lake, McHenry, and DuPage counties were deer ticks.
7. Bloated tick on a Cedar Waxwing
Dispersal of Borrelia burgdorferi
by songbirds can help account
for the dramatic increase in the
incidence of tick-borne diseases
in North America and Europe
over the past 16 years.
8. Research shows a 7 to 10-
fold increase in Chicago
area Bb-infected deer ticks
between 2005 and 2007.
In a 2007 tick survey of Lake and Cook Questing Deer tick
counties, 37% of adult deer ticks collected
were + for Borrelia burgdorferi. (1)
A 2006 report by this team found that Borrelia burgdorferi
only 3-5% of adult deer ticks in Cook and
DuPage counties were + for Bb. (2)
(1) Jobe DA, Nelson JA, Adam MD, Martin SA.
Lyme disease in urban areas, Chicago. Emerging
Infectious Diseases. 2007;13(11):1799-1800.
(2) Jobe DA, Lovrich SD, Nelson JA, et al. Borrelia
burgoderferi in Ixodes scapularis ticks, Chicago
area. Emerging Infectious Diseases.
2006;12:1039-1041.
10. Evidence for Immune Evasion in Lyme Disease
A Flexibly Adaptive Genome
“Borrelia species may well have the most
unusual genomes on the planet. No other
bacteria have such a large complement of
extra-chromosomal elements. They
perform an uncommon process known as
telomere resolution that can explain the
wide-ranging variability in linear plasmid
size, content, and sequence scrambling.”
- George Chaconas, the Canadian Society for
Microbiology Murray Lecture
Canadian Journal Microbiology 2011;58(3):236-48.
11. Evidence for Immune Evasion in Lyme Disease
Bb Commandeers Tick Salivary Protein
Tick salivary protein (Salp-15) binds to CD4 on T helper cells and to OspC on
Bb, which delays the humoral response to Bb, allowing early dissemination
into connective tissue and the central nervous system. Salp-15 and OspC
collaborate to enhance the virulence of Bb during the early stages of infection.
Hovius J, et. al. Tick-host-pathogen interactions in Lyme borreliosis. Trends in Parasitology 2007;23(9):434-438.
Ramamoorthi N, et al. The Lyme disease antigen exploits a tick protein to infect the mammalian host. Nature 2005;436(7050):573-7.
12. Evidence for Immune Evasion in Lyme Disease
Antigen Masking
Kurtenbach K, et al. Host
association of Bb sensu
lato - the key role of host
complement. Trends in
Microbiology. 2002;10(2):
74-9.
Bb’s Factor H
“hall pass”
Bb evades complement-mediated killing by interacting with complement regulators through
distinct complement regulator-acquiring surface proteins (CRASPs). CRASP-1 is a multifunctional
protein of Bb that binds to several human extracellular matrix proteins and plasminogen. These
interactions contribute to adhesion, bacterial colonization, and organ tropism and assist with
dissemination of Bb in the host.
Kraiczy P, Stevenson B. Complement regulator-acquiring surface proteins of Bb: structure, function, and
regulation of gene expression. Ticks and Tick Borne Diseases. 2013 Feb;4(1-2):26-34.
13. Evidence for Immune Evasion in Lyme Disease
Bb Usurps the Host’s Plasminogen Activating System
The Blood-Brain Barrier
Plasmin + MMPs
Bb spirochete able to disrupt
tight junctions causing a leaky
blood-brain barrier and a
portal of entry into the brain.
Bb’s outer membrane protein, OspC, binds to plasminogen, activating the serine
protease, plasmin. Plasmin induces the release of collagenases and MMPs (matrix
metallproteinases), which enhance Bb’s ability to pass through tight junctions. Bb
thus usurps the fibrinolytic pathways of its host to help it penetrate otherwise
impermeable tissue barriers. The result: rapid deep tissue invasion.
Hu LT, et al. Binding of human plasminogen to Borrelia burgdorferi. Infection and Immunity. 1995 Sep;63(9):3491-6.
Toledo A, et al. The enolase of Borrelia burgdorferi is a plasminogen receptor
released in outer membrane vesicles. Infection and Immunity. 2012 Jan;80(1):359-68.
14. Evidence for Immune Evasion in Lyme Disease
Bb Encodes for “Best in Class” Antigenic Variation
15
silent
vls
casse-es expressed
vlsE
casse-e
The VlsE sequence variants produce different antigen epitopes. Recombination occurs continuously during
mammalian infection and plays a key role in immune evasion and the long-term survival of Bb in humans.
Norris SJ. How do Lyme Borrelia organisms cause disease? The quest for virulence
determinants. Open Neurology Journal. 2012;6(Suppl 1-M8):119-123.
Ongoing antigenic variation frustrates the host’s antibody response to Borrelia burgdorferi. B-cells become
confused, causing excess B-cell traffic in lymph nodes and a weak and delayed marrow plasma cell response.
Hastey CJ, et al. Delays and diversions mark the development of B cell responses
to Borrelia burgdorferi infections. Journal of Immunology 2012;188(11):5612-22.
15. Sources of Immune Evasion in Lyme Disease
Atypical Forms
Rolled forms A cystic form.
Bb strain ADBI thickened
membrane
Bb strain B31
The results indicate that atypical extra- and intracellular pleomorphic and cystic forms of Borrelia
burgdorferi and local neuroinflammation occur in the brain in chronic Lyme neuroborreliosis.
The persistence of these more resistant spirochete forms, and their intracellular location in
neurons and glial cells, may explain the long latent stage and persistence of Borrelia infection.
Mikossly J, et al. Persisting atypical and cystic forms of Borrelia burgdorferi
and local inflammation in Lyme borreliosis. J Neuroinflammation 2008;5:40.
16. Sources of Immune Evasion in Lyme Disease
Atypical Forms
Rolled forms of Bb
Cystic forms of Bb. Plasma membrane Cystic forms of Bb.
inside cystic structure (i) thinner than
extracystic plasma membrane (e).
Brorsson O, Brorsson SH. Transformation of cystic forms of Miklossy J, et al. Persisting atypical and cystic forms of
Borrleia burgdorferi to normal, mobile spirochetes. Infection Borrelia burgdorferi and local inflammation in Lyme
1997;4:241-46. borreliosis. J Neuroinflammation 2008;5:40.
17. Sources of Immune Evasion in Lyme Disease
Horizontal Gene Transfer
Conjugation Transformation
Gene transfer by bacterial conjugation and by DNA transformation happens
efficiently in biofilms, and this process helps stabilize the biofilm structure.
Molin S. Gene transfer occurs with enhanced efficiency in biofilms and induces enhanced
stabilization of the biofilm structure. Curremt OPinions in Biotechnology. 2003;14:255-261.
21. Evidence for Immune Evasion in Lyme Disease
Advanced Flagellar Maneuverability
22. Evidence for Immune Evasion in Lyme Disease
Evasive Chemotaxis and Niche-Seeking Behavior
Moriarty TJ, et al. Real-time high resolution 3D imaging of the Lyme disease spirochete
adhering to and escaping from the vasculature of the living host. PLoS Pathogen 2008;4(6).
23. Evidence for Immune Evasion in Lyme Disease
Movement through Vascular Walls
Moriarty TJ, et al. Real-time high resolution 3D imaging of the Lyme disease spirochete
adhering to and escaping from the vasculature of the living host. PLoS Pathogen 2008;4(6).
24. Evidence for Immune Evasion in Lyme Disease
Rapid Escape from Vascular Compartment
into the Extracellular Matrix
Spirochetes would transmigrate through the venule wall, typically at the endothelial
cell junctions, and escape into the surrounding extracellular matrix in a process that
averaged 10.8 minutes. The speed of the final escape yielded images in which
spirochetes appeared to burst away from the vessel. The matrix is like a sanctuary
from immune traffic, and Bb escapes to it in a hurry.
Moriarty TJ, et al. Real-time high resolution 3D imaging of the Lyme disease spirochete
adhering to and escaping from the vasculature of the living host. PLoS Pathogen 2008;4(6).
25. Evidence for Immune Evasion in Lyme Disease
Bb Quorum Sensing and Biofilm-Like Behavior
Sapi E, et al. Characterization of biofilm formation by Borrelia burgdorferi In Vitro. PLoS ONE;7(10):e48277.
Bb respond to AI-2 by expressing factor H-binding protein to enhance immune evasion.
Babb K, et al. Synthesis of autoinducer-2 by the Lyme disease spirochete. Journal of Bacteriology 2005;187:3079-87.
Stevenson B, et al. LuxS-mediated quorum sensing in the Lyme disease spirochete. Infection and Immunity 2002;70:4099-4105.
26. Evidence for Immune Evasion in Lyme Disease
Biofilm-Like Aggregations
Bb-induced effects included multilevel arrangements of alginates, calcium, and
extracellular DNA, highly consistent with biofilm. Bb grown on agarose-coated mica
discs. Imaged by atomic force microscopy, measurements made with Nanorule software.
Sapi E, et al. Characterization of biofilm formation by Borrelia burgdorferi In Vitro. PLoS ONE;7(10):e48277.
28. Evidence for Persistent Infection in Lyme Disease
Barthold, 2010 Forms of proof
given for
post-antibiotic
persistence of
viable and
infective Bb
in this study:
Allograft
-transmissible Bb
Xenodiagnosis
-Bb acquisition
by ticks
-Bb transmission
by ticks
-Bb survival
through tick
life cycle
..
..
RNA transcripts
..
..
.. - showing
metabolically
..
..
.. active, viable Bb
..
29. Evidence for Persistent Infection in Lyme Disease
Yrjanainen, 2010
Forms of proof
given for
post-antibiotic
persistence of
viable Bb
in this study:
.. Culture
.. from tissue samples
.. of mice treated with
anti-TNFa 4 weeks
post antibiotic
treatment
..
..
..
30. Evidence for Persistent Infection in Lyme Disease
Embers, 2012 Forms of proof
given for
post-antibiotic
persistence of
viable and
infective Bb
in this study:
Xenodiagnosis
acquisition
transmission
Culture
Immunofluorescence
PCR
C6 antibody
.. Bb antigen
..
..
..
.. RNA transcripts
31. Conclusions
1. Bb has an unusually adaptive combined genome that encodes for a
powerful set of immune evasion capabilities.
2. Bb exploits tick and host proteins, antigen masking and variation, elite
motility skills, strategic niche-seeking, horizontal gene transfer, atypical
forms, biofilm-like behavior, and antibiotic tolerance to help it persist
within mammalian hosts.
3. In mice and primates, Bb subsets are proven to remain viable and
infective despite culture negativity following antibiotic challenge.
4. Immune suppressed mice are more susceptible to the reactivation of
viable Bb that persist despite antibiotic challenge.
5. Solid evidence supports the existence of persistent Lyme disease. Health
care policy needs to accommodate efforts to prevent, detect, and treat it.
33. Sources of Added Complexity in Lyme Disease
Co-infections
Anaplasmosis Babesiosis Bartonella Ehrlichiosis
Granulocytes Red blood cells Red blood cells Monocytes
WBCs, RBCs, platelets Fever, chills, sweats Endothelial cells Fever, chills, body aches
Elevated liver enzymes Headache, fatigue Fever, rash, headache Confusion, GI
Fever, chills, aches Ring forms, Maltese cross Fatigue, brain fog disturbance
Headache, diarrhea Howell-Jolly bodies Endocarditis, sore soles Headache
Morula (colony) forms
Borrelia
burgdorferi (124 strains), afzellii, garinii (European forms)
50+ symptoms reported, invasion of most tissues documented, primarily connective tissue, synovium, liver,
testes, pelvic organs, central, peripheral, and autonomic nervous system cells, heart cells, and immune cells.
A new breed of polymicrobial, polyphasic infection?
34. Sources of Added Complexity in Lyme Disease
Deer Tick Co-infection Rates
Among 286 Ixodes scapularis ticks collected in this study:
Borrelia +
Borrelia + Borrelia +
Borrelia Anaplasma Babesia Anaplasma+
Anaplasma Babesia
Babesia
% positive
182 (64%) 56 (20%) 58 (20%) 45 (16%) 48 (17%) 14 (5%)
ticks
Assessment of polymicrobial infections in ticks in New York
State. Vector Borne Zoonotic Diseases. 2010 Apr;10(3):217-221.
35. Sources of Added Complexity in Chronic Lyme Disease
Co-morbid Conditions in the Host
Autoimmune
Disease
Chronic Allergic
Toxicity Sensitivities
Psychosocial Degenerative
Stresses Lyme Disease
Mood or
Metabolic
Cognitive
Disease
Disorders
Co-infections
36. Sources of Added Complexity in Chronic Lyme Disease
Host Genetic Variations
The influence of tumor necrosis factor alpha (TNFa) in Bb infection is well documented.
There seems to be a polarity in host reactions, perhaps related to gene polymorphisms in
TNFa or in promoter genes for the pro-inflammatory cytokines. This results in weaker or
stronger cell-mediated immune responses.
In pathology studies of neurological Lyme disease, the following polarity is seen:
Infiltrative Atrophic
cerebral vasculitis frontotemporal atrophy
multi-infarct dementia
white matter lesions hypoperfusion
inflammation apoptosis
Miklossy J. Biology and neuropathology of dementia in syphilis and Lyme disease. In Handbook of Clinical
Neurology, vol. 89, 2008, Elsevier: New York.
37. Sources of Added Complexity in Chronic Lyme Disease
The Limits of Diagnostic Testing
ILADS
• Prefers higher sensitivity on Western Blot • Prefers higher specificity on Western Blot
• Tolerates a higher false positive rate • Tolerates a higher false negative rate
The search is on for biomarkers with better abilities to rule in (ILADS)
and rule out (IDSA) cases of persistent Lyme and associated diseases.
38. Sources of Added Complexity in Chronic Lyme Disease
The Limits of Therapy
There is to date no known therapy for the post-Lyme residual
autoimmune condition postulated by IDSA-aligned researchers.
NIH-sponsored clinical trials were underpowered and likely
ILADS underestimate the benefits of antibiotic therapy in chronic Lyme
patients. There is no surefire way of proving total eradication of
viable Lyme spirochetes.
Guidelines for selecting therapies for patients with chronic Lyme
continues to rest on a weak evidence base. For this reason, physicians
should be allowed to select therapies based on pathophysiologic
rationales supported by clinical experience and judgment, with
decisions that reflect patient values and preferences.
39. Sources of Added Complexity in Chronic Lyme Disease
Patients Caught in the Crossfire
Given the lack of reliable biomarkers for use in monitoring responses
to therapy for chronic Lyme disease, outcomes evaluation must rely
on methods for assessing the subjective dimensions of the patient’s
experience with therapy.
Who will help me?
Overall
The Rationalists Function The Empiricists
Physical Symptoms
? ?
Mental Outlook
Social
ILADS
Finding reasons Finding reasons
not to treat to treat
40. Dimensional
Outcomes Assessments
Dimensional assessment tools used
in NIH-funded chronic Lyme
treatment studies:*
• Quality of Life Score (SF-36)
• Fibromyalgia Impact Questionnaire (FIQ)
• Fatigue Severity Scale (FSS)
• Neurocognitive Dysfunction Index (NDI)
• McGill Pain Questionnaire (MPQ)
• Medical Outcome Scale (MOS)
* Klempner, Krupp, and Fallon
Visual analog scale for practice-based
outcomes monitoring
• Review of Systems Scale (ROSS)
41. We Need a More
Integrative
Medical Model
• Evidence-based medicine 2.0
• Built to handle complexity
• Patient values respected
• Shared decision-making
• Clinical experience valued
• Empirical trials encouraged
• Dimensional outcome tracking
• Biopsychosocial awareness
• Systems theory and practice
A Systems Medicine Model
42. Repairing the Broken Bridge
All the bitterness of the debate does not serve the science or the patient...all the
shouting drowns out the complexity and nuance of the work that needs to be done.
- Institute of Medicine Lyme Report, 2011
Physicians must be allowed to use current evidence, experience, and clinical judgment
to address the complexity of patients with tick-borne illness.
- Keith Berndtson, MD
43. Patient-centered
systems medicine.
15 N. Prospect
Park Ridge, IL 60068
847-232-9800
www.parkridgemultimed.com