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Flawed Literature Base for Guidelines

To the IDSA, AAN and ACR regarding the proposed Lyme disease guidelines I’ve reviewed the draft of the new Lyme disease guidelines. I am struck by a few things On page 6 the draft states “Abstracts and conference proceedings, letters to the editor, editorials, review articles, and unpublished data were excluded. The panel made an a priori decision to only include sufficiently peer-reviewed articles to avoid serious risk of bias associated with a lack of editorial oversight.”

My concerns are as follows:

1. The choice not to include letters to the editor in the literature reviewed for guideline creation makes it easier to make studies cited as definitive, even though they may contain crucial flaws in design, content or conclusions
revealed by letters to the editor.
2. The decision to omit Review Articles in the literature surveyed is also a way to bias information. A good review article will provide different viewpoints, or conflicting findings, by a variety of authors. A commentary
on the quality of the different studies should then be noted, but at least discordant findings would be acknowledged and provide a more complete and fair review.
3. The decision to review only literature from standard peer review journals can also be a way to limit results presented to the guideline creators. It is well known that controversy exists regarding the diagnosis and treatment of
Lyme disease. Often, an article or commentary that expresses doubt in the official IDSA doctrine that Lyme disease is easy to both diagnose and treat, has a very difficult time getting published in mainstream top tier journals.

Many editors as well as reviewers are strongly involved in supporting the stated Lyme guidelines (not uncommonly having been involved in their creation). This in effect results in omitting studies that challenge the status
quo. Unfortunately, guidelines based on review of selective literature cannot be expected to halt the dramatic increase in the number of individuals affected by this potentially devastating disorder. They have been quite
ineffective so far. Doing the same thing and expecting a different outcome is fraught with problems from the start, even if it is advertised to be a new start.

Rosalie Greenberg, MD, FAPA, DFAACAP

Summit, New Jersey

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