Wikipedia:Peer review/Hepatic encephalopathy/archive1

Hepatic encephalopathy

This peer review discussion has been closed.
This page has recently undergone a major rewrite and expansion using several high-quality sources. Before submitting for GA I thought some feedback would be useful. Specifically, I should like to know if the prose is too difficult to comprehend, as the topic is tricky. I will get a peer review from a colleague with regards to the scientific content.

Thanks, JFW | T@lk 00:08, 4 March 2010 (UTC)

Comments from Colin:

This article was easier to read than its title might imply. Well done for explaining most of the technical terms. I'd never heard of this before so thanks for working on it and polishing it. The sources look to be first class. At a first pass through, I've made some comments below. I'll try to find time later to confirm the source-accuracy and comprehensiveness.

1. Definition mentions "altered level of consciousness" -- these range from confusion to coma according to our WP article. So is there some redundancy in our definition which also mentions both extremes. The source says "functional disturbance of the brain" and later says it is characterised by "personality changes, impaired intelect, disturbed sleep patterns and depressed level of consciousness". On the latter includes those we list.
2. "tendon reflexes may be lively" -- I suspect the use of "lively" here is jargon, of which I'm unfamiliar. Is this the same as "exaggerated"?
3. In the "Electrolyte or metabolic disturbance" box, explain hyponatraemia (low blood sodium), hypokalaemia (low blood potassium), alkalosis (alkaline blood), hypoxia (insufficient oxygen).
4. Is it "PSE-Syndrom-Test" or "PSE-Syndrome-Test"?
5. "stage IV encephalopathy". Is this the same as the "Grade 4" above or referring to some other scale? See elsewhere too.
6. "TIPSS" or "TIPS". Seem like both are acceptable but consistency?
7. Several sentences cite four sources. This is overkill for what is often just one fact. Can we just pick the most appropriate source from the four?
8. "Given the frequency of infection...is sometimes required". I'm not sure about "required" as the need isn't established for sure. How about "antibiotics are sometimes administered empirically (...".

Colin°^Talk 23:33, 11 March 2010 (UTC)

Have taken the liberty of changing your bullet points to numbers so I can respond to each.

1. Conciousness is only impaired in more severe forms; I am not keen to refer to confusion as impaired consciousness.
2. Have changed to "exaggerated" as the term "lively" implied that this was normal and not really pathological.
3. Agree that these terms needed expansion and have done as suggested
4. The name is hyphenated because it is German; I thought I should stick to the German spelling rather than introduce an English word in an otherwise German term
5. In the sources, the White Haven grading is with Arabic numerals; generally grading is doing with Arabic numerals while classes (e.g. NYHA) use Roman
6. Have changed to TIPS for consistency
7. Is there a guideline prohibiting this? I feel more comfortable that claims are thoroughly sourced; it also implies that the Harrison's chapter leaves out of a lot of treatments that were already known at the time of its writing
8. Have rephrased as suggested.

Thanks for your input! JFW | T@lk 23:47, 11 March 2010 (UTC)

I've read over some of the sources and compared to the article (to my limited ability). It does appear to be accurate and comprehensive. I did notice that the West Haven Criteria was a match for source 7 but not source 1, which in addition to different text had a grade 0 (subclinical). Wrt multiple citations, I think that if you are confident your source is good, then one is sufficient unless multiple is literally needed (e.g. you say "several authors report..." and cite several sources). I find multiple citations to be common in poor articles where the editors are citing primary sources or multiple unreliable sources as if quantity can make up for quality. This is often a sign that the editor is trying to prove a case in front of the reader, rather than cite one authority who has judged the literature for us. It is rare for FA-level articles to do this. Good luck with the GA. Colin°^Talk 20:43, 14 March 2010 (UTC)

Officially there is no grade 0 on the West Haven scale because it is only used for overt encephalopathy. The entity of MHE was introduced properly by Ferenci et al.

I have never had trouble with multiple references, and I'm sure you'll concede that my references are all MEDRS-compliant. Again, I will immediately yield to any policy on this matter. Thanks for your input! JFW | T@lk 21:49, 14 March 2010 (UTC)

Comments by BirgitteSB

This has good material but the article overall needs more meat. The biggest issue is that there just is not enough context to really flesh out a narrative structure. I wonder if you might back up a notch on your sources, maybe sources with more of an overview perspective would help you. Maybe check out Liver#Further reading.

• Lead: Should be a complete overview of the article per WP:LEAD. If it has a subheading in the TOC it should have a passing mention in the lead. Granted I think some of the subheadings should go, but the grading systems at least deserve mention.
  • What information do you think is missing? JFW | T@lk 00:55, 18 March 2010 (UTC)

• Signs and symptoms: Way to many parentheticals. Some of these are needed and should be converted to commas, some should just disappear. One of the best tricks is to use the mainstream understandable version linking to jargon named article. (i.e. swelling of the brain tissue)

• • This is the only way to sensibly offer translations of medical terminology. I want the text to mention both because the reader may be familiar with either version. JFW | T@lk 00:55, 18 March 2010 (UTC)
  • Addendum: I think the grading systems are rather too technical to be mentioned in the lead. JFW | T@lk 09:23, 18 March 2010 (UTC)

• Causes:
  • While some forms of hepatic encephalopathy are directly due to liver failure (particularly acute liver failure) from any underlying cause, the majority of cases are precipitated or aggravated by particular situations and conditions. Yikes! That doesn't scan at all.
  • Table is just plain bad. Type of what? Convert this all to prose (and get rid of parentheticals).
  • Hepatic encephalopathy may complicate the creation of a transjugular intrahepatic portosystemic shunt (TIPS), a treatment used in refractory ascites, bleeding from oesophageal varices and hepatorenal syndrome. Switch it around so the cause is mentioned before the effect. I had to read other parts of the article to realize the shunt caused the encephalopathy.

• • • Will deal with the grammar. I'm not sure what can be done about the table, keeping in mind Colin's suggestion of offering translations for the terminology. JFW | T@lk 00:55, 18 March 2010 (UTC)

• • • • See my suggestions at Talk:Osteochondritis dissecans#Lead, which was in a much worse state than this article, and simply wikilinked the jargon. There are other alternatives than "jargon (lay)". Colin°^Talk 08:57, 18 March 2010 (UTC)

• Classification and grading: This needs an intro before the subsections. Explaining the existence two systems and how their purposes deffer.

• Pathogenesis: Perhaps this section should be merged with "Causes".

• Diagnosis: Why the sub-heading "investigations"? I would remove that. I would start this section by mentioning that it is a clinical diagnosis and what that means at the very beginning. The rest is nice and clear except the parentheses count keeps creeping upwards. Since "Minimal HE" only a single paragraph, I would kill the subheading. Just start the paragraph by saying "Minimal HE cannot be diagnosed by the regular methods, but instead . . ."

• • I'll look into this. JFW | T@lk 00:55, 18 March 2010 (UTC)

• Treatment: The organization of this section is very poor. It needs a complete overhaul. The sub-headings aren't needed but some sort of order is.

• • I thought the sections were needed because each is dedicated to a particular treatment, discussing the strength of available evidence and pros and cons. JFW | T@lk 00:55, 18 March 2010 (UTC)

• Epidemiology and prognosis: What is here is nice, but type B is missing.

• • I think the data on type B are in there somewhere, but not in this section. JFW | T@lk 00:55, 18 March 2010 (UTC)

• History: This is just so small I wonder if it could be merged into "Classifications and Grading" to give that section some background material.

• • I think the historical angle (e.g. Hippocrates/Galen) would be a big distraction elsewhere. JFW | T@lk 00:55, 18 March 2010 (UTC)

I also felt some "big-picture" stuff was missing. How prevalent is this disease? Is more of less common than other types of encephalopathy (or at least the similar types that were worth mentioning under diagnosis? Does everyone who needs a liver transplant have this or is destined to get it without transplant? Why do people have Minimal HE? --BirgitteSB 03:50, 17 March 2010 (UTC)

There is simply no data to suggest that HE is more or less common than other forms of encephalopathy. It is also treated by different kinds of doctors, meaning that few will be in a position to make a comparison. I also don't think there is reliable data as to whether HE is a "must" for requiring a liver transplant. JFW | T@lk 00:55, 18 March 2010 (UTC)

Thanks BirgitteSB, for your very thorough review. Colin°^Talk 08:57, 18 March 2010 (UTC)

• I was think about the organization in this article. There are two intrinsic sorts of order at war here. Chronologically where you organize the sub-topic by information relevant as the disease proceeds or breaking it up by type A, B, or C. Causes obviously lend themselves to the latter but I would try and manage to use the former in the Treatment section. You can mention the things specific to type as they reach the state of the disease that they must be considered, like removing a shunt (or whatever occlusion means there if not removal). --BirgitteSB 12:46, 18 March 2010 (UTC)