Wikipedia:Peer review/Rhabdomyolysis/archive2

Rhabdomyolysis

Previous peer review

This peer review discussion has been closed.
I've listed this article for peer review because I think it is an important step in the process towards FA candidacy. I have been the article's principal editor for some time, and it achieved GA status on 24 February 2008. I have now included material from several more recent sources, and the article has become much more comprehensive. In the process of doing this I have attempted to make it as accessible as possible for the general reader. It is of significant worldwide relevance, as many people who survive earthquakes and bombings latter succumb to this complication unless adequate support is provided.

Thanks, JFW | T@lk 18:06, 15 April 2011 (UTC)

• Uploadvirus (talk · contribs) left an extensive list of comments on the talkpage in its own section.[1] I suspect that might count as peer review. JFW | T@lk 21:31, 17 April 2011 (UTC)

• Casliber (talk · contribs) 07:59, 24 April 2011 (UTC)
  • Two "muscles" in the first sentence. I'm racking my brains how we can remove one but it isn't easy.....
  • Actually, what about "...is a condition in which damaged skeletal muscle (Ancient Greek: rhabdomyo-) tissue breaks down rapidly (Greek -lysis)"
  • I recall it being a phenomenon talked about when ecstasy dance parties were first in vogue in hte late 80s/early 90s (overheating and dehydration etc. leading to it) - would be worth looking in to.
    •  Done All recommendations addressed. The sources mention MDMA - hyperthermia and serotonin syndrome have been provided as mechanisms. JFW | T@lk 12:47, 24 April 2011 (UTC)

• Axl ¤ [Talk] 08:32, 24 April 2011 (UTC)
  • From the lead section, paragraph 2: "Since 1999, relief efforts in areas struck by earthquakes have included medical teams with skills and equipment for treatment of survivors with rhabdomyolysis." Prior to 1999, relief efforts didn't include medical skills/equipment for the treatment of rhabdomyolysis?
  • From "Signs and symptoms": "The urine may be dark, often described as "tea-colored"." I think that it's worth mentioning the specific component of the urine that causes this discoloration.
    •  Done Both recommendations addressed. JFW | T@lk 12:47, 24 April 2011 (UTC)
  • From "Causes", I am a little surprised that the table shows "Medications" and "Genetic" types as separate from "Non-physical". Aren't they sub-types of "Non-physical"? I appreciate that it might be useful to classify them separately because of the frequency and variety of the sub-causes. Axl ¤ [Talk] 19:54, 25 April 2011 (UTC)
    • There were so many non-physical causes that I had to split two categories off: medication and muscle metabolism disorders. Suggestions for other names are welcome. JFW | T@lk 23:15, 26 April 2011 (UTC)
      • What headings do the sources use? Axl ¤ [Talk] 08:18, 28 April 2011 (UTC)
    • Different sources have different groupings. CritCare2005 uses physical/non-physical, NEJM and Elsayed use a surgical sieve, Warren uses a hybrid of surgical sieve and pathophysiological mechanism. I understand your concern, and am open to suggestions on how to group the causes in a better way. JFW | T@lk 11:36, 28 April 2011 (UTC)
  • From "Causes", the table describes coturnism as rhabdomyolysis due to consumption of quails that have eaten hemlock. However hemlock (conium) itself contains coniine and I expect that it can cause rhabdomyolysis. How common is coturnism? It may be amusing trivia but it is receiving undue weight. Axl ¤ [Talk] 07:56, 26 April 2011 (UTC)
    • People eat quail, they generally don't eat hemlock. Hard to say how common it is; this has been reported repeatedly in a number of papers, mostly from the Middle East. It needs addressing somewhere. JFW | T@lk 23:15, 26 April 2011 (UTC)
      • "Reported repeatedly" isn't enough justification. Is it listed in secondary sources? If so, it should have a secondary source as its reference. Axl ¤ [Talk] 08:22, 28 April 2011 (UTC)
    • Some of the sources only mention it in the historial section. Warren (which has the most comprehensive list) lists "hemlock (?quail eaters)" as well as Haff disease. There is a good secondary source for Haff disease, but I will slash the quail content to remain compliant with WP:WEIGHT. The main reason I expanded on it was because all the secondary sources attach a lot of importance to the historical aspects. JFW | T@lk 11:36, 28 April 2011 (UTC)

" The main reason I expanded on it was because all the secondary sources attach a lot of importance to the historical aspects. "

— Jfdwolff

Then put it in the "History" section. In my opinion, the table in the "Causes" section should follow one of the secondary sources. (I have looked in a few sources. Harrison's Principles of Internal Medicine does not have a single table about rhabdomyolysis. Neither does Kumar & Clark. However the Oxford Textbook of Medicine does have such a table.) Axl ¤ [Talk] 08:25, 30 April 2011 (UTC)

I see that it is in the "History" section. Axl ¤ [Talk] 08:27, 30 April 2011 (UTC)

• From "Pathophysiology", paragraph 1: "When damaged, muscle tissue rapidly fills with fluid from the bloodstream, as well as sodium and chloride." Doesn't the sodium and chloride come from the bloodstream? Axl ¤ [Talk] 08:34, 30 April 2011 (UTC)
  • Yes, I will rephrase this. JFW | T@lk 22:21, 30 April 2011 (UTC)

• From the same sentence, "sodium" links to a description of the metal. The muscle tissue doesn't fill with the metal. Axl ¤ [Talk] 08:36, 30 April 2011 (UTC)
  • Can't really help the fact that we don't have a separate article on sodium ions or sodium in biology (we do have Calcium in biology for some reason). What alternative would you propose? JFW | T@lk 22:21, 30 April 2011 (UTC)
    • The chloride ions aren't relevant to the following text. How about: "When damaged, muscle tissue rapidly fills with fluid from the bloodstream, including sodium ions. The swelling itself may lead to destruction of muscle cells, but those cells that survive react by pumping sodium ions out of the cells in exchange for calcium ions (through the sodium-calcium exchanger)." Axl ¤ [Talk] 08:30, 5 May 2011 (UTC)
  • Sounds great. Changed as suggested. JFW | T@lk 09:07, 5 May 2011 (UTC)

I am still unhappy with the layout of the "Causes" table. Here is the table from Oxford Textbook of Medicine, chapter 33:- 1. Focal muscle damage

a. Obvious, e.g. crush injury, electrical injury

b. Not so obvious, e.g. ischaemic injury following arterial embolus to leg

2. Generalised muscle damage

a. Excessive muscular activity

i. Severe exercise, e.g. marathon running

ii. Prolonged epileptic fitting

iii. Status asthmaticus

iv. Severe dystonia

v. Acute psychosis

3. Infections

a. Septicaemia

b. Viral myositis, e.g. influenza

4. Toxins

a. Prescribed drugs, e.g. HMG-CoA reductase inhibitors

b. Substance abuse, e.g. alcohol, barbiturates, opioids …

c. Other, e.g. snake bite, spider (black widow) … hemlock (quail that have eaten hemlock)

5. Heatstroke

6. Malignant hyperpyrexia

7. Neuroleptic malignant syndrome

8. Myopathies

9. Metabolic/endocrine

a. Hypothyroidism

b. Electrolyte disturbance, e.g. hypokalaemia in diabetic ketoacidosis

Axl ¤ [Talk] 08:18, 5 May 2011 (UTC)

The Oxford Textbook does include the quail/hemlock cause in its table. Therefore I am going to backtrack and support the inclusion of this. Axl ¤ [Talk] 08:18, 5 May 2011 (UTC)

" Different sources have different groupings. CritCare2005 uses physical/non-physical, NEJM and Elsayed use a surgical sieve, Warren uses a hybrid of surgical sieve and pathophysiological mechanism. "

— JFW

I would like to see a single secondary source used as the reference for the whole table. I have suggested the Oxford Textbook's format above. However if you think that one of the other sources provides a better table, more suited to a general encyclopedia while remaining equally reliable & authoritative, I would be happy with that. Axl ¤ [Talk] 08:23, 5 May 2011 (UTC)

I am not personally convinced that the table of causes definitely needs to be built on a single secondary source. All the reviews I have cited provide different lists, mostly collated from 100s of case reports. Warren contains the longest list by far, and attempts to organise them by the suspected mechanism at myocyte level. I have attempted to strike a balance by including the causes that are consistently reported in practically all the sources, or are otherwise important for the flow of the article. The lists of medications in Warren and Elsayed are extremely long and unhelpful. The Oxford Textbook of Medicine list you kindly provided follows a "surgical sieve" kind of approach. We already follow its distinction between focal and generalised rhabdomyolysis.

For the average reader, I remain unsure whether a surgical sieve is a particularly accessible way of listing the causes. I faced a similar dilemma on hypopituitarism, where I eventually settled for a surgical sieve. I'm actually going to take this one to WT:MEDMOS,[2] because it is something that affects other articles also. JFW | T@lk 09:07, 5 May 2011 (UTC)

• From "Pathophysiology", paragraph 3: "Finally, destroyed muscle cells release potassium ions, phosphate ions, myoglobin (a heme and therefore iron-containing protein), creatine kinase (an enzyme) and uric acid (a breakdown product of purines from DNA) into the blood." Is it relevant that myoglobin contains heme and iron? Perhaps change to: "'Finally, destroyed muscle cells release potassium ions, phosphate ions, myoglobin (a protein), creatine kinase (an enzyme) and uric acid (a breakdown product of purines from DNA) into the blood." Axl ¤ [Talk] 08:49, 12 May 2011 (UTC)

The relevance of heme in that context is the putative importance of heme in renal damage that results from rhabdomyolysis. I think we could drop the "and iron" there, then in the following paragraph replace "Iron released from the myoglobin..." with "Iron released from the heme... ". -- Scray (talk) 23:05, 12 May 2011 (UTC)

I've left the heme but removed the iron (seemed unnecessary). JFW | T@lk 03:47, 13 May 2011 (UTC)

• From "Mechanism", paragraph 4: "Finally, the most important problem is the accumulation of myoglobin in the tubules." Why note the most important problem last? Axl ¤ [Talk] 09:11, 16 May 2011 (UTC)
  • Agree. I have restructured the paragraph in question to place more initial emphasis on the role of myoglobin. JFW | T@lk 12:25, 17 May 2011 (UTC)

• From "Mechanism", paragraph 4: "Under acidic conditions, myoglobin also interacts with Tamm-Horsfall protein." Should this use an endash? Axl ¤ [Talk] 09:22, 16 May 2011 (UTC)
  • Agree. Fixed. JFW | T@lk 12:25, 17 May 2011 (UTC)

• From "Mechanism", paragraph 4: "Myoglobinuria (the appearance of myoglobin in the urine) occurs when the levels in plasma exceed 0.5–1.5 mg/dl; this becomes visible to the naked eye when the levels reach 100 mg/dl." Will general readers understand "mg/dl"? Axl ¤ [Talk] 08:44, 18 May 2011 (UTC)
  • It's no different from any other concentration. Do you think this needs restating? JFW | T@lk 09:07, 18 May 2011 (UTC)
    • Well, it hasn't been stated earlier in the article, so I'm not asking for it to be "restated". Either a link to another article page or a full description at the first usage ("milligrams per decilitre") would be helpful. Axl ¤ [Talk] 09:33, 18 May 2011 (UTC)
  • Meant "stating differently" rather than "stating again". I will add a link to the gram per litle article. JFW | T@lk 18:42, 18 May 2011 (UTC)
    • You mean "gram per litre". ;-) Axl ¤ [Talk] 08:21, 19 May 2011 (UTC)

• From "Mechanism", paragraph 4: "low blood pressure leads to constriction of the blood vessels and therefore a relative lack of blood flow to the kidney." This implies that low blood pressure leads to vasoconstriction, and vasoconstriction leads to a lack of blood flow. Low blood pressure certainly leads to a lack of blood flow. But does reactive vasoconstriction like this lead to a lack of blood flow? Of course, when pathological vasoconstriction is the primary problem, blood flow is reduced, such as fibromuscular dysplasia. I have never seen a good explanation of "physiological" reactive vasoconstriction in a textbook. Axl ¤ [Talk] 09:47, 18 May 2011 (UTC)
  • All the secondary sources refer to this concept. I suspect that it has to do with autoregulation to preserve flow with lower pressure. The same happens in other organs. Renal vasoconstriction is the principal mechanism behind disease states like hepatorenal syndrome (the kidney remains morphologically unaffected). JFW | T@lk 18:42, 18 May 2011 (UTC)

" I suspect that it has to do with autoregulation to preserve flow with lower pressure. "

— JFW

Exactly! It preserves flow; it doesn't reduce flow. I'll do some more digging around. Axl ¤ [Talk] 08:24, 19 May 2011 (UTC)

• From "Diagnosis", subsection "General investigations", paragraph 1: "Depending on the extent of the rhabdomyolysis, levels up to 100,000 units are not unusual." Shouldn't this be a concentration (per litre)? Axl ¤ [Talk] 08:32, 19 May 2011 (UTC)
  • Enzyme assays are usually recorded in activity (U) rather than in concentrations, but I agree that this should be per litre. JFW | T@lk 16:05, 19 May 2011 (UTC)

• From the same paragraph: "levels below 20,000 are unlikely to be associated with a risk of renal impairment." I think that this should also be a concentration. Axl ¤ [Talk] 08:35, 19 May 2011 (UTC)
  • Agree, U/l it is. JFW | T@lk 16:05, 19 May 2011 (UTC)