Talk:Dementia with Lewy bodies

More from Ceoil

Done? SandyGeorgia (Talk) 13:25, 16 April 2018 (UTC)
The following discussion has been closed. Please do not modify it.
dementia is diagnosed - alliteration I still don't like at all what has happened to the first three sentences of the lead, and want to go back to: SandyGeorgia (Talk) 14:05, 14 April 2018 (UTC) Memory loss does not always present early, but dementia relentlessly worsens over time, and the condition is diagnosed when cognitive decline interferes with normal daily functioning. deterioration in memory function is related to retrieval - not sure if "related" is the right word, as a reader I honed in on this sentence, but it confirmed experience rather than explained cause and new memories may be encoded but not retrieved? SandyGeorgia (Talk) 14:11, 14 April 2018 (UTC) Is there something we could say here about the underlying type of damage? Ceoil (talk) Are we there yet? SandyGeorgia (Talk) 17:59, 14 April 2018 (UTC) This is very helpful. Ceoil (talk) 03:48, 15 April 2018 (UTC) While the specific symptoms may vary - While specific In "Core features", why is "spontaneous cardinal features of parkinsonism" in quotes The individual with RBD may not be aware that they - An individual, or the patient bed partner: coy - sleeping partner' As a reader, I didn't know what epidemiology means, so "dementia with Lewy bodies is under-recognized,[11]" is more than a little confusing. And maybe merge this section into one para. Ceoil (talk) 12:44, 14 April 2018 (UTC) Do these suffice? SandyGeorgia (Talk) 14:34, 14 April 2018 (UTC) Yes overall. Good improvement on linking epidemiology (effective), but am still not getting "under-recognized". If we could go into why "not retrieved", that would be great. Ceoil (talk) 14:38, 14 April 2018 (UTC)

In case its not clear my criteria here is accessibility; reasonably intelligent family members may read this, and I believe it should be aimed at them rather than qualified professionals. In this regard, now consider the article as a success, to be further verified by the qualified professionals I see at work here. Ceoil (talk) 12:54, 14 April 2018 (UTC)

Sandy: can you also see if "Severe sensitivity" is the best way to put it. It doesn't read well, but may be necessarily precise, so leaving it with you. Ceoil (talk) 22:56, 15 April 2018 (UTC)

Yes, awkward. The intent of severe is like, can cause death. @Ceoil: your prose is (infinitely) better than mine, and you have been through the article so thoroughly now that I kinda think it's fine for you to tackle my sucky prose in instances like this one :) Bst, SandyGeorgia (Talk) 23:09, 15 April 2018 (UTC)

now "Severe reaction". Re prose, haha not quite, you talking to one who had to make over 700 edits to a 16kb article :) :) Ceoil (talk) 00:00, 16 April 2018 (UTC)

• Last from me but "Relentlessly worsening over time"; "relentlessly worsening" sounds overwritten and needless when progressive is far more familiar. Ceoil (talk) 22:05, 15 April 2018 (UTC)

I agree with that. I found "relentlessly" excessive when I saw it, but I forgot until now to point that out. --Tryptofish (talk) 22:08, 15 April 2018 (UTC)

• @Ceoil: As it's written now, I think it's a tongue twister (relentlessly worsening and a convoluted order). If we went back to:

  • Memory loss does not always present early, but dementia relentlessly worsens over time, and the condition is diagnosed when cognitive decline interferes with normal daily functioning.

  would you still dislike the "relentlessly"? Also, Ceoil and Tryptofish, I am still not happy with the flow of the part about Memory (encoding v retrieval) that I reworked yesterday, in case you can improve. SandyGeorgia (Talk) 22:11, 15 April 2018 (UTC)

About "relentlessly", I think that sentence, as you show it just above, would work well if we simply changed "relentlessly" to "steadily". I'll take a look at the memory part now. --Tryptofish (talk) 22:15, 15 April 2018 (UTC)

That works for me. SandyGeorgia (Talk) 23:09, 15 April 2018 (UTC)

Done, SandyGeorgia (Talk) 04:58, 19 April 2018 (UTC)

Good, thanks. --Tryptofish (talk) 18:04, 19 April 2018 (UTC)

This is a better formulation but would still drop relentlessly. However you now have three timelines (early, over time, when cognitive decline interferes). Are these defined stages? Ceoil (talk) 22:18, 15 April 2018 (UTC)

Not necessarily (if you mean, as in the defined stages of Alzheimer's). SandyGeorgia (Talk) 23:09, 15 April 2018 (UTC)

Memory relative to AD

Memory loss is not always noticeable early on. In contrast to AD, where the hippocampus is among the first brain structures affected and episodic memory loss related to encoding of memories is typically the earliest symptom, memory impairment occurs later in DLB. Deterioration in memory function occurs because new memories may be encoded but not retrieved. DLB memory loss has a different progression than AD because frontal structures are involved early on, with later involvement of temporoparietal brain structures. Verbal memory is not as severely affected as in AD.

References

I started looking at the memory material, and am getting bogged down in the details, so perhaps a more medically or psychologically oriented editor would be better able than me to sort it out. (Also, I think what it says about memory and AD in "Essential features" seems different from what it says in "Differential diagnosis".) But, as I was looking at this source: [1], something brought me up short. The authors place a lot of emphasis on the fact that AD and DLB often co-occur in the same persons, so DLB cases that are completely free of AD are in the minority. In the 6th paragraph of the Memory section, they say: LBD tends to co-occur with AD in 80% of cases, with only 20% having pure LBD. (I realize that's LBD, but I would assume that DLB is a subset.) As of now, the page makes it sound like AD and DLB are two completely separable diagnoses, and I think that may be wrong. --Tryptofish (talk) 22:41, 15 April 2018 (UTC)

@Doc James: could you take a look at what I just said about AD versus DLB? Thanks. --Tryptofish (talk) 22:46, 15 April 2018 (UTC)

That's a 2011 source, Tryptofish; we need to compare that to all of the more current sources. SandyGeorgia (Talk) 23:11, 15 April 2018 (UTC)

Dang computer. @Tryptofish: I just went through every newer source to compile what they said on the matter, and my computer hung and lost the whole post. Summary being that they all mention in passing that AD and DLB can co-occur, but I can find no recent source that mentions anything on the level mentioned by Karantz 2011.

Weil 2017 (Current concepts and controversies) says, "Taken together, these studies show that the synergistic relationship between AD pathology and α-synuclein is bidirectional and that each protein synergises the other." NIH says only that, " LBD can occur alone or along with Alzheimer’s or Parkinson’s disease." Weil also mentions "a higher prevalence of Alzheimer’s-like pathology in DLB than PDD" citing PMID 27516115 McKeith Consensus 2017 is silent. Gomperts 2016 says, "with a variable degree of coexisting Alzheimer pathology", and "Because of the frequent coexistence of Alzheimer pathology in DLB, however, the AD CSF pattern does not exclude DLB", that's it. I can't remember all the rest I looked up, but cannot find any other source saying what karantz said in 2011. SandyGeorgia (Talk) 23:41, 15 April 2018 (UTC)

Walker 2015 spends a lot of time on the problems with diagnosis and confusion with AD because of the old criteria. And one place where we can see some real data-- albeit primary source-- is the oft-quoted autopsy results that showed 98% of RBD had synucleinopathy, here. It found (LBD)(n = 77), combined LBD and AD (n = 59), so again, nothing like this older 80%. SandyGeorgia (Talk) 23:48, 15 April 2018 (UTC)

Tryptofish I am not seeing the contradiction you mention memory issues in Essential features and Differential diagnosis ... ??? SandyGeorgia (Talk) 00:33, 16 April 2018 (UTC)

I think the main thing that looks contradictory to me is where the Differential section talks about "visuospatial processing", whereas I don't see anything about that in Essential features. I want to say, however, that I think that I'm the wrong editor to be advising you about memory classification and about differential diagnosis. I just don't know enough about those things, and I can easily be wrong. I do think, however, that since I am confused about how the medical consensus has changed over the past several years, then the page needs to be clearer about it. --Tryptofish (talk) 22:57, 16 April 2018 (UTC)

Visuospatial processing problems are in Core features (essential feature is dementia). SandyGeorgia (Talk) 11:45, 17 April 2018 (UTC)

Well, I find all of the stuff about different kinds of mental impairment and their diagnostic implications confusing. In part, I don't really understand the different kinds of memory. So again, I may be a sort of barometer of how understandable those parts of the page are, but I'm clearly the wrong editor to give advice about it. --Tryptofish (talk) 22:57, 17 April 2018 (UTC)

This was in the article before, but long uncited: SandyGeorgia (Talk) 13:20, 16 April 2018 (UTC)

A loss of acetylcholine-producing neurons (in the basal nucleus of Meynert and elsewhere) similar to that seen in Alzheimer's disease also is known to occur in those with DLB. Cerebral atrophy also occurs as the cerebral cortex degenerates. Autopsy series have revealed the pathology of DLB is often concomitant with the pathology of Alzheimer's disease. That is, when Lewy body inclusions are found in the cortex, they often co-occur with Alzheimer's disease pathology found primarily in the hippocampus, including senile plaques (deposited beta-amyloid protein), and granulovacuolar degeneration (grainy deposits within and a clear zone around hippocampal neurons). Neurofibrillary tangles (abnormally phosphorylated tau protein) are less common in DLB, although they are known to occur, and astrocyte abnormalities are also known to occur.

Feedback from LeadSongDog

Major points:

• Suggest opening with "Dementia with Lewy bodies (DLB) is one of two types of Lewy body dementia (the other being Parkinson's disease)..."
• The 'difficult-to-diagnose while alive' and 'only palliative treatments' factoids are rather buried. Consider moving them up in the lede.

Some trivial points:

• The usages "Lewy body disease" or "Lewy body dementia" both are pretty common, should likely disambiguate in a hatnote or in line one.
• Under Society and culture, the listings appear to be based simply on personal celebrity rather than a particular connection to LBD beyond having it. Comparing Alzheimer's disease#Media, it shows individuals who wrote or talked about the disease, organized fundraisers for it, etc. and were separately noted for doing so.

• Oh, my. I just looked at Alzheimer's disease for the first time in years, hoping to find a page of people with dementia (eg Ronald Reagan) that we could piggy-back on to. Promoted in 2008, not reviewed in more than 10 years, NOT up to Featured article standard by any stretch. Maintenance tags, very outdated text, rambling TOC, one-sentence sections ... WP:OTHERSTUFFEXISTS, but nothing useful there :( I wish I had not looked. SandyGeorgia (Talk) 01:27, 10 April 2018 (UTC)

• Refs use a mix of title- and sentence cases for article titles. Journal names should be consistent, either abbreviated or full. LeadSongDog come howl! 16:53, 9 April 2018 (UTC)

Home for the day, catching up; thanks LeadSongDog. I will hold off on any changes to the lead while we get bigger wrinkles out. The criteria in Society in culture is people who meet Wikipedia notability. I will add hatnote. And I will convert all citations to sentence case ... for some reason, I though Boghog was already doing that, but apparently not (??). Thanks again! SandyGeorgia (Talk) 17:15, 9 April 2018 (UTC)

PS, to avoid edit conflicts with people who are combing over the prose, I will fix these items at a time when folks are done, so please let me know when you're in and out :) SandyGeorgia (Talk) 17:16, 9 April 2018 (UTC)

Wikipedia notability sure, but we don't want to be treating celebrity gossip rags as RS in medical articles. We know where that leads.LeadSongDog come howl! 18:48, 9 April 2018 (UTC)

Do we have those? I don't speak French, so I'm not sure what we have there ... anyone? SandyGeorgia (Talk) 18:50, 9 April 2018 (UTC)

I read French, if there are any you'd like to point me to. --Tryptofish (talk) 20:57, 9 April 2018 (UTC)

Hang on @Tryptofish: I am about to add a new source, and then you can check them both. By the way, could you prettify the second quote box the same way you did the first? I am not entirely sure what you did, but it looks good. SandyGeorgia (Talk) 21:32, 9 April 2018 (UTC)

Done for the second box. When you have both sources, please indicate to me which two sources they are, so I know where to look, and I'll check them. --Tryptofish (talk) 21:39, 9 April 2018 (UTC)

Weird. I could have sworn that earlier today I saw Entertainment Tonight cited, but there's no trace I can find in the history. Sorry for the runaround. Still, these sections do tend to attract that sort of thing. LeadSongDog come howl! 22:01, 9 April 2018 (UTC)

Here are the French sources ... SandyGeorgia (Talk) 22:02, 9 April 2018 (UTC)

... and Canadian singer Pierre Lalonde.

References

The two sources are very similar. They are obits from publications that are basically the pop culture sections of newspapers. The first is an obit that focuses on his entertainment career, and states that it was the cause of death, but does not treat it as something that otherwise was a prominent part of his life (as in speaking as a patient etc.). The second is a brief report that his wife said that he died after courageously living with the disease(s). The first says that he "suffered since 2010 from Parkinson's disease and also from Lewy body dementia". The second says that his wife "revealed that, in addition to Parkinson's, he also suffered from Lewy body dementia, the same disease that afflicted Robin Williams". I can't really tell whether they mean LBD or DLB. --Tryptofish (talk) 22:24, 9 April 2018 (UTC)

In use

Yea, now it's bugging me :) Unless anyone is actively copyediting, I will put the article in use to correct all journal titles to sentence case ... please speak up if doing this shortly would cause edit conflicts! SandyGeorgia (Talk) 19:21, 9 April 2018 (UTC)

 Done SandyGeorgia (Talk) 20:03, 9 April 2018 (UTC)

Further comments

• "abnormal myocardial MIBG scintigraphy" means what? A scan of the myocardium using MIBG radioactive markers?
  • Will use this to beef up that section: SandyGeorgia (Talk) 18:40, 12 April 2018 (UTC)
    • Chung EJ, Kim SJ (May 2015). "(123)I-Metaiodobenzylguanidine Myocardial Scintigraphy in Lewy Body-Related Disorders: A Literature Review". J Mov Disord (Review). 8 (2): 55–66. doi:10.14802/jmd.15015. PMC 4460541. PMID 26090077.
      • Whew. Does this address that? Scroll down to scintigraphy stuff (past other edits made by Tryptofish in the interim). SandyGeorgia (Talk) 21:11, 12 April 2018 (UTC)
• "REM sleep without atonia evidenced on polysomnography" is indicative how? How can polysomnography show that atonia is absent during REM phase sleep, and why does that matter? Is it the same thing later discussed in the Clinical history and testing section under RBD? Perhaps it should just say that "muscle movement during REM sleep is termed RBD".

• @LeadSongDog: I am not sure how to unravel this, because I'm not understanding yet what is not clear. RBD can be diagnosed in one of two ways: by sleep study, or by clinical history. Polysomnography records when REM sleep is occurring, and when there are movements during REM sleep (loss of atonia). History, questionniare, involves reports of dream enactment behavior. Yes, it is the same thing discussed later, because if RBD cannot be confirmed by questionnaire (for example no bed partner report, subject is not aware, etc) the loss of atonia can be captured on polysomnography. And vica versa. The reason it matters is that DLB cannot be diagnosed only on biomarkers, so if polysomnography is all they've got, no diagnosis. I suspect I am not clear what the question is? (Going to the Kosaka book for some of your other questions.) SandyGeorgia (Talk) 03:41, 12 April 2018 (UTC)

• @SandyGeorgia:If I'm understanding correctly, the indicative factor is the anomolous muscle movement seen during REM, and polysomnography simply discerns when REM occurs. A camera in a sleep study bedroom could substitute for a bed partner (at least as regards this aspect of diagnostics).LeadSongDog come howl! 16:17, 12 April 2018 (UTC)

• Under Epidemiology, "DLB affects more than one million individuals in the United States", but is this representative of global prevalence?

• Possible sourcing at [2] p.29 for a statement about how uncertain the global prevalence is and why. LeadSongDog come howl! 16:17, 12 April 2018 (UTC)

• I am not sure what to add there, LeadSongDog. The Hogan source on epidemiology that was added by Doc James seems to include a lot of non-US studies and represent as thorough of a survey as possible. While the WHO source is 2012-ish, and is not specific to LBD. Could you suggest what we might add? SandyGeorgia (Talk) 20:59, 12 April 2018 (UTC)

• Under Management, the first sentence runs on. It would be better split.
  • Sure was! Chopped in two, SandyGeorgia (Talk) 22:32, 11 April 2018 (UTC)
• Under Research directions, perhaps some sense of how advanced each direction of investigation is? What phase of clinical trial? Each statement made in the section seems to be backhanded: Rather than "Pimavanserin is approved by the U.S. FDA for treating psychosis in PD, and "holds promise"[15] in DLB, but as of 2017, there were no controlled studies of its use for psychosis in DLB.[9][12]" I would suggest "As of 2017, there were no controlled studies of Pimavanserin use for psychosis in DLB,[9][12] but it "holds promise"[15] in DLB and its use for treating psychosis in PD has been approved by the U.S. FDA."
  • In trying to find info about what phase of trials might be going on for pimavanserin, this bad news is all I could come up with: [3] SandyGeorgia (Talk) 01:03, 13 April 2018 (UTC)
    • Oddly, the manufacturer has not published those negative results on the trial. There was an earlier Ph2 trial (for Alzheimer's) with published results at PMID 29452684 and correction at PMID 29496302. Its finding was essentially the same as placebo (at N=90 vs. 91). LeadSongDog come howl! 15:29, 17 April 2018 (UTC)
      • Considering the deaths mentioned above, I am wondering how others feel about completely removing mention of pimavanserin from Research directions? All we say is that there are no controlled studies for DLB, and with the deaths, one wonders if there ever will be. SandyGeorgia (Talk) 15:33, 17 April 2018 (UTC)
        • I think we should only cover something in Research if it is clearly seen by sources as promising, so it sounds to me like pimavanserin should not be mentioned at all. --Tryptofish (talk) 23:24, 17 April 2018 (UTC)

LeadSongDog come howl! 13:54, 11 April 2018 (UTC)

I should be able to find some Japanese epidemiology in Kosaka, and I think I've seen French somewhere. And I should find more on myocardial scintigraphy in Kosaka as well, since it's used in Japan. My reading over the next week ... SandyGeorgia (Talk) 03:44, 12 April 2018 (UTC)

Abbreviations in imaging terminology

• The criteria section seems to have Imaging Terminology Easter Egg Syndrome (ITEES). Readers shouldn't need to hunt to learn that SPECT, PET, CT, and MRI are imaging techniques while EEG is not. LeadSongDog come howl! 13:54, 11 April 2018 (UTC)
  • Does this solve that? SandyGeorgia (Talk) 03:26, 12 April 2018 (UTC)
    • Not really, though it is an improvement. Initialisms should be spelled out at their first appearance, not just pipe-tricked. Some readers are seeing these things on paper, so hovertext doesn't help them.LeadSongDog come howl! 14:27, 17 April 2018 (UTC)
      • ah, ha, I think I see what you want now :) You would like to see spelled out

        PET, SPECT, CT, MRI and EEG as ...

        positron emission tomography, single-photon emission computed tomography, CT scan, magnetic resonance imaging, and electroencephalography.

      • Is that correct? I wonder how others feel about that, as this will result in quite a chunk of text, and I am unsure if those can be viewed as common terms? SandyGeorgia (Talk) 14:39, 17 April 2018 (UTC)
        • They should not be spelled out. Unlike terms like AD and PD, which seem to be initials used only by workers in this field, PET, SPECT, CT, MRI, EEG are all initials by which the scan/procedure is called. It would be like spelling out GIF, NATO, FAQ. The doctor does not send you for a single-photon emission computed tomography scan, and nor would you have any more clue about what it is if he did. -- Colin°^Talk 15:08, 17 April 2018 (UTC)
          • @Colin: Please see Wikipedia:Manual_of_Style/Abbreviations#Exceptions. If the initials truly are "what the scan/procedure is called" then are those target articles mistitled? To a significant section of our readership there's a difference between wearing a special skullcap vs. being injected with radioactive chemicals or put into a tiny space inside a huge magnet. It's not that hard to change the first use from "[[single-photon emission computed tomography|SPECT]] scan" to "[[single-photon emission computed tomography]](SPECT) scan" and it will serve some readers better.LeadSongDog come howl! 16:25, 17 April 2018 (UTC)
            • MOS is a guideline, hence its application here (particularly wrt FAC) will be applied based on consensus. It would be helpful to hear if others want those abbreviations spelled out. If so, I can do it easily enough, but IMO it's going to complicate an already complex paragraph. (But yes, they may be mistitled ... note for example that the Wikipedia article is CT scan, because that's what it is usually called, rather than computed tomography scan ... so if we follow convention here, we will end up with an inconsistent list. It's not our problem on this article to deal with misnamed articles outside of here ... here, we should decide based on this article.) And then, to make the Wikipedia inconsistency even better, why is it computed tomography scan but not single-photon emission computed tomography scan? We can't go by what Wikipedia does, because ... it's a wiki. Additionally, the very source this text is taken from (McKeith Consensus 2017) uses the abbreviations. (Among the sources written since the new guidelines, using biomarkers, were issued, Tousi 2017 is not available online, but he doesn't spell out the abbreviations either. Weil 2017 does spell them out.) I am not trying to talk you out of it LSD, so much as ask that others weigh in so we can build consensus. SandyGeorgia (Talk) 17:08, 17 April 2018 (UTC)
              • We're interested in the clinical aspect of these terms rather than the physical and technological aspects. Nobody is ever referred for a single-photon emission computed tomography scan. Nor for a magnetic resonance imagery scan with T1-weighted-fluid-attenuated inversion recovery sequence. Knowing what the letters stand for does not actually provide any meaning, and will not in fact help our readership know if one requires injection with radioactive chemicals, or being put inside a huge magnet with a force greater than the earth's own gravitational pull. As far as this article is concerned, these are just "names of medical procedures". It is quite irrelevant if one involves big magnets and the other x-rays. If they want to know more about the procedure, they can follow the link to the article. The names are more concerned with the physics than with the clinical procedure from the patient's point of view. If it was the latter, it would be a "Huge doughnut-shaped loud-banging mega-magnet scan". -- Colin°^Talk 17:32, 17 April 2018 (UTC)

Feedback on imaging abbreviations

• Option 1: abbreviations for imaging techniques, like this version.
• Option 2: spell out abbreviations for imaging techniques, like this version.

Could others please weigh in? SandyGeorgia (Talk) 17:46, 17 April 2018 (UTC)

• Option 1. I still do not think these need to be spelled out, especially if they are blue-linked at the first mention. But if we go instead with option 2, I would probably leave out the abbreviations that are in parentheses: just spell the words out. --Tryptofish (talk) 23:01, 17 April 2018 (UTC)

Expert review

In pending list, below, decide on Expert review. SandyGeorgia (Talk) 13:27, 16 April 2018 (UTC)
The following discussion has been closed. Please do not modify it.
Once the current editors are happy with the accuracy and comprehensiveness of this article, would you like me to arrange for the world's top DLB experts to review it? --Anthonyhcole (talk · contribs · email) 10:58, 9 April 2018 (UTC) Brief response from ipad at clinic ... I am already on that ... which of them did you have in mind? SandyGeorgia (Talk) 12:52, 9 April 2018 (UTC) I would approach BMJ. When I asked them to review Parkinsons disease they recruited five researchers including a (the?) leading contributor to the last set of diagnostic criteria and a leading contributor to the new diagnostic criteria. The latter is also the most published author of peer-reviewed journal articles on the topic. But if you've got it under control, I'll leave it with you. --Anthonyhcole (talk · contribs · email) 23:56, 9 April 2018 (UTC) Anthonyhcole if you can get Ian McKeith via the BMJ, that would take the cake. I am aiming at the top tier, but he's the one. SandyGeorgia (Talk) 23:59, 9 April 2018 (UTC) I would certainly suggest McKeith but ultimately the choice would be BMJ's. They didn't let me down with Parkinsons disease. What I like about doing this via BMJ is the reviewers are chosen by an entity independent of the Wikipedia authors. I know it's not the case here but I can envision a future case where Wikipedia editors select reviewers who represent just one side of a controversy. In the case if PD, for instance, BMJ put the main proponent (I think) of the old criteria together with a leader in the design of a new set of criteria. Things were a little tense at times but we got a neutral result. Let me know if you'd like me to kick this off. --Anthonyhcole (talk · contribs · email) 00:46, 10 April 2018 (UTC) My approach was going to be to call in a favor; yours might be a more neutral approach? And it sounds like you already have some irons in the fire, which could be good, while I would be just starting. So, question is, how close are we to ready? Is it best to have them look sooner rather than later, so we can work in suggestions? SandyGeorgia (Talk) 01:09, 10 April 2018 (UTC) Go ahead and try to get help/advice, while you're rewriting the article, from any experts you can - up to and including McKeith - and then, once you are all satisfied with what you have - I guess that means when it has passed FAC - I'll bring in BMJ for an independent review. One of the problems with the PD review was there was way too much wrong with the article, and the "reviewers" ended up becoming the writers. Wikipedia needs experts contributing to the writing of its articles as well as different, independent experts reviewing its articles. --Anthonyhcole (talk · contribs · email) 01:38, 10 April 2018 (UTC) And the problem with having the reviewers have to re-write the article is that ours are not supposed to be journal articles-- they are supposed to be encyclopedic, for general readers. I am curious to hear from Colin how his external review process went, because I was thinking of something like what I understood to be what he had. Get one of the top 5 DLB guys in the world to look it over, tell us if it is comprehensive and accurate, but not turn it into a journal article. SandyGeorgia (Talk) 01:55, 10 April 2018 (UTC) OK. If you change your mind, let me know. I'd like to talk to you about making Wikipedia articles WP:RSs (not journal articles, but reliable encyclopedia articles) one day, but now's not the time. --Anthonyhcole (talk · contribs · email) 02:34, 10 April 2018 (UTC) I just looked at the Parkinson's FAC ... and remembered that I was off skiing at Whistler-Blackcomb most of the time it was at FAC and when it was promoted. 'Twas not I ! SandyGeorgia (Talk) 02:07, 10 April 2018 (UTC) For the record, at Ketogenic diet, I chose someone who appeared to the an authority on the subject (many papers, member of consensus panel, experience of large KD clinic, etc). Sent them a short email explaining the article was receiving 800 hits a day and I was aiming for it to be reviewed for Featured Article status. If it was good enough, it would appear on the main page of Wikipedia and get millions of eyes. I asked if he (or a colleague) could do an expert review. He agreed readily and I sent him some more info. He suggested I format the article into a Word document, which he would review and tweak with the Track Changes feature, and this also allows sections of text to be highlighted and a note added. This worked well: we had a stable version and it used technology he was familiar with, rather than Wiki markup. Generally the suggestions were easy to apply, though a couple of points I couldn't add because there were no sources for it. When I made changes to the article, I noted in the summary that this was from expert review. The textual revisions suggested were very minor, so there was no problem with attribution that their might be if a lot of text had been written by the expert. Although this expert was a fan of reading Wikipedia, they had never edited it. I would definitely recommend doing this last, when the text is very stable. Although the copyediting we've seen in the last few days is very helpful, it runs a big risk of changing meaning/emphasis and deviating from sources: because most folk copyediting are doing so without reading the sources, without deep knowledge of the subject. So once it stabilises I recommend comparing the before/after revisions and check that what is said now really is what was meant. Of course, when it goes to FAC, an whole new bunch of folk will hack at it, but Sandy knows all about that. -- Colin°Talk 16:10, 11 April 2018 (UTC) Regarding procedure: I tried to get the Parkinsons reviewers on-wiki but they just wouldn't and the review began only when one of them copied it into Word. They passed it in sequence from one to another, using "track changes", and they discussed it in an email chain. Wikitext was a hurdle but, mainly, most of them do peer review while they're flying between conferences offline, and Word is ideal for that. With requests and prompting from me, they suggested sources for about half of their proposed changes but I had to find sources for the remainder. I incorporated their changes in the article, announcing in the first edit summary and on the talk page what I was doing, with a link to their proposed changes and annotations, which I had transcribed from the Word doc into wikitext and moved onwiki. It might be best to save the field-leaders for the final review when the article is quite stable, after FAC (if only because these are very busy people), and try to involve other authors and researchers during this writing/re-writing stage - if you have a choice in the matter. --Anthonyhcole (talk · contribs · email) 19:32, 11 April 2018 (UTC) Ok to all ... we still aren't quite finished, ready, stable enough. I ditched the idea of calling in a favor for avoidance of COI. I may (when I get a free moment) go ahead and email Boeve instead to ask if he or a member of his team might be interested, and if so, that we would be in contact later and work out technicalities then. I am hoping they will be interested because of this, but worry about having an advocacy organization (LBDA) want to take over ... what do others think of approaching Boeve? Or would people feel better about McKeith, because he may be less tied to an advocacy group? Boeve is head of LBDA scientific advisory board as well as this new Research Centers of Excellence initiative. SandyGeorgia (Talk) 20:21, 11 April 2018 (UTC)

Famous cases

If this is going for FAC the famous cases should go; we do not favor these per MEDMOS. Jytdog (talk) 15:05, 9 April 2018 (UTC)

I don't entirely agree - the first two, posthumously diagnosed, might be kept as indicative of the growth of understanding, long period before symptoms appear, etc. But not the rest, who are all American & only locally known anyway. Johnbod (talk) 15:18, 9 April 2018 (UTC)

WP:MEDCASE does not say "the famous cases should go". How, specifically, do you think this could be improved, according to guidelines? Although this disease is not rare, it does seem to be under diagnosed, and so perhaps the number of notable "famous cases" is very low. If that assumption is wrong, or the number of cases grows, then MEDMOS encourages considering more restrictive criteria, and making that explicit, or splitting off to another article. It doesn't, anywhere, say "they should go". -- Colin°^Talk 15:22, 9 April 2018 (UTC)

People often want to include such lists to "raise awareness" - this is not what we are here for. They generally devolve into celebrity gossip. What I wrote was "does not favor". We can see how this discussion plays out; we can bring it to an RfC if we fail to reach consensus locally here. Jytdog (talk) 17:07, 9 April 2018 (UTC)

Jytdog, please don't make bad faith assumptions about why people include such lists. It really helps collaborative editing if you assume others are here to help improve Wikipedia. Notable cases appear in the literature for medical conditions. You'd expect it in popular "for general reader" writing, of course, but also in "for professionals" writing too. From my experience with epilepsy literature, professionals can't help but name-drop historical figures who may have had epilepsy. One way to make an abstract thing, a medical condition, become real to the reader, is to offer examples. If you watched a TV program on a medical condition, it would interview people with it, or film them in medical care. Since we can't go mentioning our own grandparents on Wikipedia, notable cases are an option for us. Readers can, if they want, go read more about that person. There are other reasons for inclusion too, and generally a handful of well known individuals is in keeping with WP:WEIGHT for the disease-article topic.

Your two statements that "for FAC the famous cases should go" and "we do not favor these per MEDMOS" are both false. MEDMOS is totally neutral on the issue. I know because I wrote the text in that section of MEDMOS, which was a result of discussion on talk (1st archive), and still features as examples, Sandy's Sociological and cultural aspects of Tourette syndrome#Notable individuals and my List of people with epilepsy, which is a featured list. When I worked on List of poliomyelitis survivors (another Featured List), this really brought home the life changing aspects of surviving polio, in a way that the Prognosis section of Polio (a Featured Article I helped with) never can. There's also List of people with hepatitis C, another Featured List. These lists (whether in-article or stand-alone) are all per MEDMOS.

I think your opinion on these is a result of misreading what MEDMOS actually says, bad faith assumptions about why those lists are created, and is at odds with the evidence of abundant featured content on this aspect. -- Colin°^Talk 17:56, 9 April 2018 (UTC)

Please discuss content not contributors. Please. Jytdog (talk) 18:01, 9 April 2018 (UTC)

Jytdog, I'm discussing talk page content you added, where you made a bad faith comment about contributors. You were clear about what you thought MEDMOS favoured and featured content required, and you were clearly wrong. Let's move on. -- Colin°^Talk 19:18, 9 April 2018 (UTC)

We don't agree about these sections and how they are used and the arguments people use in practice to justify additions. That is clear. Jytdog (talk) 19:23, 9 April 2018 (UTC)

Every case/article is different, my views on this article. The first two are significant and should surely stay (for reasons elaborated above). Robin Williams affected public perception of the condition, and Peake presents an interesting journal case of potentially the earliest notable case, as well as the problems of misdiagnosis. After that, we have two very small paragraphs (deliberately and quite seriously pruned down from the crufty verbose list that was in the article when I started editing it). This is a little-recognized condition, and those two small paragraphs aren't taking up a lot of real estate or right now presented in a crufty way (as in the other articles with better known conditions where the lists are ridiculous). My suggestion is that we keep those two paragraphs for now, knowing that as the baby boomers age, DLB is better recognized, and the list may grow, it will be spun off to a Sociological and cultural aspects article, to keep the cruft over there. I don't see it as too crufty at this stage, but this is not a hill I plan to die on either :) SandyGeorgia (Talk) 18:07, 9 April 2018 (UTC)

Back for the day and catching up ... got the Palma article. Jyt, the example given at MEDMOS (which was pretty well written by folks in this discussion :) is Tourette syndrome; I think I know how to write that part for FAC, and I have done that (that is, cut down all the crap :) (PS, Johnbod, they are not all American ... there are at least two Canadians.) SandyGeorgia (Talk) 17:11, 9 April 2018 (UTC)

Dear everyone :) Notable cases amounts to a few small paras at the bottom of the article. We will sort it before approaching FAC. All will have time to weigh in.

Meanwhile, it is not something to lose focus over. I would love Love LOVE for this article to be a collaborative effort of all involved, and one that could be presented to FAC as a collaboration of many authors, rather than one person's work. To get an article FA-ready, we must work according to priorities. The notable folks are a small issue and one that can be sorted as people weigh in and the article progresses.

In terms of priorities, we have 1b, 1c, 1d, and 1e, comprehensive and well-researched, neutral and stable (make sure everything that needs to be covered is covered, neutrally, without major disagreements leading to stability problem), followed by 1a (smooth the prose after all content issues resolved, but we are well along on that already), and then go back and get the technicalities (MOS, links, consistent citations, etc.) Media and length will be easy-- there are plenty of images to choose from, and the article is right now tightly focused, we should be able to keep it that way. So, in the areas of substance (eg, see the dysautonomia discussion above, and History has to be written), I hope we can focus on whether we have everything covered. Bst, SandyGeorgia (Talk) 18:31, 9 April 2018 (UTC)

My quick reaction is that it might be better to integrate the most historically significant cases into the History section, and to leave out most of the persons who are mentioned only briefly. --Tryptofish (talk) 20:54, 9 April 2018 (UTC)

• I see that there is Category:Deaths from dementia with Lewy bodies. The pages in the category do not track the examples here. I think a case could be made to treat the persons who did not significantly affect DLB history as category members, rather than listing on this page. --Tryptofish (talk) 22:36, 9 April 2018 (UTC)

I am going to firmly resist the temptation to worry about either this section or the lead until the substantial parts of the article have progressed :) SandyGeorgia (Talk) 03:30, 10 April 2018 (UTC)

but when I do think about it ... I propose that we combine the sociological and cultural aspects of both LBDs (PDD AND DLB) at Sociological and cultural aspects of Lewy body dementia. @Colin:, how would you feel about moving the last two paras over there? Curiously, there was no article on PDD when I started working here ... SandyGeorgia (Talk) 12:54, 10 April 2018 (UTC)

Combining them might make sense, particularly if there is difficulty distinguishing the two at times. What I don't currently see, is any need at present for the daughter article, or to move material out. If I look at Tourette syndrome and the Sociological and cultural aspects of Tourette syndrome I see that the equivalent sections in this article are smaller than at TS and there doesn't appear to be any expansion going on here. If you have > 2x as much material you would like to add, then perhaps. Tryptofish, categories for people-with-medical-condition (or who have died from one) have always been problematic. Sourcing a category is difficult and there is no place to indicate any doubt over the diagnosis. For example, there is a good case that most of the historical figures "diagnosed" with epilepsy did not in fact have epilepsy. So IMO I would not encourage the use of such categories. The description on this article about Robin Williams is a good case for why prose beats categories every time. -- Colin°^Talk 13:37, 11 April 2018 (UTC)

I was initially queasy about Robin Williams (the image in particular), but having stepped back from the article for a week and read it through again this afternoon on lunch, it may offer some level of shared comfort to invested readers, after a pretty harrowing and heavy read of the page. Ceoil (talk) 22:16, 13 April 2018 (UTC)

I agree that an article like this can be a hard read. And fact after fact is a difficult way to learn for some people, who need a face or story to hang the information off of. For example, being told when someone got diagnosed, how they coped, what support they got, etc, can make those facts stick better than just abstract diagnostic techniques and prognosis figures. An illustration or photo can also help facts stick by linking to visual memory. I'm not sure Williams' story is a comfort, though, but is highly notable. He's a highly recognisable face, and there will be people who remember this article topic solely because of the Williams link. -- Colin°^Talk 07:58, 16 April 2018 (UTC)

Proposal for Society and culture

From this version, keep Robin Williams and Mervyn Peake in this article. Cut the final two paragraphs. Create Sociological and cultural aspects of Lewy body dementia, which can then be linked from all three LBD articles (Lewy body dementia, dementia with Lewy bodies, and Parkinson's disease dementia), solving the other problem that the media is not always clear which LBD the person had/has. SandyGeorgia (Talk) 14:24, 16 April 2018 (UTC)

Done. SandyGeorgia (Talk) 04:50, 19 April 2018 (UTC)

Hypersalivation

I have the Palma review now. The article had:

Botulinum toxin injections in the parotid glands may help with hypersalivation.

which could be written and sourced as:

Botulinum toxin injections in the parotid glands have been shown to help with hypersalivation in persons with PD.

References

I will be adding other text per the Palma review, but am unsure/indifferent as to whether we keep the hypersalivation text. On the one hand, I have not come across this in any other review specific to DLB, and Palma mentions it in the context of Parkinson's disease. On the other hand, the article is about autonomic dysfunction in Parkinson's disease and other synucleinopathies. What do others think? SandyGeorgia (Talk) 17:39, 9 April 2018 (UTC)

@Jytdog: I suspect all of this can be sorted and sourced better to one article, Palma. I am reading it now, so perhaps hold off on improvements to autonomic stuff for now. SandyGeorgia (Talk) 17:51, 9 April 2018 (UTC)

On the other hand, if you can also get hold of Palma, perhaps you want to write and beef up the entire para on dysautonomia? Let me know so I can stop reading :) SandyGeorgia (Talk) 17:54, 9 April 2018 (UTC)

Sure, that would be fine. btw that section is kind of "signs and symptoms"ish, isn't it? Those two sections often drift together and I think they have somewhat here... Jytdog (talk) 18:11, 9 April 2018 (UTC)

@Jytdog: how about this plan? I am looking over all of the articles I picked up today, and I still have my hands full with History stuff to complete. And now Palma is another handful. Not sure what you are asking re: signs & symptoms, because the dysautonomia section is in signs & symptoms ...? All of Essential, Core and Supportive features are in Signs & symptoms. If you are interested in using Palma to beef up all other areas of dysautonomia (like that it is 2018, but don't like that it is not freely available as so many of our good sources here are), I will work on the non-pharmaceutical management and caregiving aspects-- there is a lot to be mined from Palma, but you have to take care that the text applies equally to DLB as to PD, and it's not easy reading. If you take on beefing up the Signs & symptoms and pharmaceutical treatment portions of dysautonomia, I will work in non-pharmaceutical and caregiving. Deal? SandyGeorgia (Talk) 18:18, 9 April 2018 (UTC)

ooo i am sleepy. :( struck. Jytdog (talk) 18:21, 9 April 2018 (UTC)

refs

if anybody needs refs please feel free to email me; i can send them to you. Jytdog (talk) 18:11, 9 April 2018 (UTC)

Checklist for next pass

Starting point. SandyGeorgia (Talk) 13:16, 16 April 2018 (UTC)

Done items moved to Talk:Dementia with Lewy bodies/Archive 2. SandyGeorgia (Talk) 13:30, 16 April 2018 (UTC)

Recognizing that there is still a LeadSongDog section to work on (above), but working towards being in position to archive everything that is done. If anyone else has anything else unresolved above, please let me know, so I can start archiving done stuff. Putting here a checklist for our next pass (not yet!  :) SandyGeorgia (Talk) 21:51, 11 April 2018 (UTC)

• Vascular dementia differential is weak. I am pretty sure it is ruled out based on imaging, but can't find a source that says that.
  • OK now, I think? SandyGeorgia (Talk) 01:47, 14 April 2018 (UTC)
• Pending decision about notable cases.
  • Done. SandyGeorgia (Talk) 04:51, 19 April 2018 (UTC)
• Pending decision about which expert(s) to approach for external review.
• Drug abbreviations.
  • Ok now, I think? SandyGeorgia (Talk) 01:47, 14 April 2018 (UTC)
• Precision in percentages raised by Colin (eg say 59% or say "more than half")
  • I removed those percentages because they were a Boot review reporting on a Boot study, and we can make the same point without the specifics. SandyGeorgia (Talk) 20:52, 12 April 2018 (UTC)
• Incorporation of more autonomic dysfunction items using Palma and Kosaka (ed) Jytdog
• How is History looking?
• Causes and Pathophysiology seem weak.
• Epidemiology looks really weak ... perhaps Kosaka has more, but that is all I could mine from sources.
• Eric Corbett copyedit pass once text is more settled.
• Does anyone maintain email contact with Looie496 to pull him in?
• Ask Graham Beards to look in.
• Have not figured out wikilink for visuospatial function.
  • Visuospatial function does not exist on Wikipedia; I will have to write it. Today. SandyGeorgia (Talk) 14:58, 14 April 2018 (UTC)
    • There is Visual spatial attention, not tagged for MED project, but should be. Visual agnosia, Spatial memory, Visual system, Sensory nervous system and so on. As usual, we probably have too many nearly over-lapping half or 3/4-baked articles & ideally some should be swept up into a new article. Not that I've looked in detail, or know anything about the subject of course. Johnbod (talk) 15:14, 14 April 2018 (UTC)
      • Visual spatial attention is classic student editing[4] ... will need a copyvio and RS check. Best to ignore it and start over? SandyGeorgia (Talk) 15:51, 14 April 2018 (UTC)
        • Quickest certainly - gets about 30 views a day. Johnbod (talk) 16:09, 14 April 2018 (UTC)
• DLB may be more responsive than AD to donepezil. ... still sourced to Neef2006, have not found newer source
  • Not useful as a source, but appears this is still true, from Section 5. Treatment at LBDA.org. SandyGeorgia (Talk) 17:18, 12 April 2018 (UTC)

• Color vision impairment is mentioned in Tousi 2017, but I left it out of the article because it seems that Tousi is the discoverer and Tousi is the only one reporting it. If anyone can find mention of color vision impairment in a non-Tousi review, it could be added. SandyGeorgia (Talk) 13:17, 16 April 2018 (UTC)

Lead suggestions

• SG wants to unsplit the lead sentences, and go back to:

Now: Dementia relentlessly worsens over time, and is diagnosed when cognitive decline interferes with normal daily functioning. Memory loss does not always present early.

Back to: Memory loss does not always present early, but dementia relentlessly worsens over time, and the condition is diagnosed when cognitive decline interferes with normal daily functioning.

• SG wants to change:

Now:Antipsychotics, even for hallucinations, should be avoided because people with DLB are sensitive to them, and their use can result in death.

Change to: Antipsychotics, even for hallucinations, are usually avoided because people with DLB are sensitive to them, and their use can result in death.

• LeadSongDog Major points:
  • Suggest opening with "Dementia with Lewy bodies (DLB) is one of two types of Lewy body dementia (the other being Parkinson's disease)..."
  • The 'difficult-to-diagnose while alive' and 'only palliative treatments' factoids are rather buried. Consider moving them up in the lede.

Others done, but LSD's two suggestions have not yet been discussed. SandyGeorgia (Talk) 05:00, 19 April 2018 (UTC)

That one that you did looks good, thanks. --Tryptofish (talk) 18:11, 19 April 2018 (UTC)

• Anthonyhcole wants:

  Antipsychotics, even for hallucinations, should be avoided where possible because people with DLB are sensitive to them,[1] and their use can result in death.

Isn't that medical advice? "It is recommended ...", "Top men suggest ..." (Which men? Top men). Though perhaps we've moved on while I've been away and we can dish out prescriptions now - I'll have what she's having. Also, when would it not be possible? "This will probably kill you but there is also a chance you will stop having hallucinations. What? Yes, that's right, dead people don't have hallucinations as far as we are aware. Well done you for spotting how this works, now open wide." Yomangani^talk 00:41, 12 April 2018 (UTC)

Contraindication is a standard section in WP:MEDMOS and WP:PHARMMOS and in articles about diseases/conditions we deal with similar matter. It does border on WP:NOTHOWTO but is also important description; a lot depends on wording. This could be better stated as "guidelines avoiding..." or the like. Jytdog (talk) 00:50, 12 April 2018 (UTC)

How about

Antipsychotics, even for hallucinations, are usually avoided because people with DLB are sensitive to them,[1] and their use can result in death.

SandyGeorgia (Talk) 01:52, 14 April 2018 (UTC)

Stating that something is contraindicated isn't a statement about something that doctors generally do as a "common/best practice"; rather, it's largely a regulatory claim of significant medical consequence. A medical indication is a use for a drug which has received the approval of a national drug-regulating entity (e.g., the USFDA); those are listed in a drug's prescribing information and are essentially just the conditions/tests for which a drug should normally (not: can) be prescribed. Contraindications contrast with a a drug's indications in the sense that if a drug has no medical indications, it necessarily has no contraindications. Drug regulatory agencies decide on those simultaneously. Contraindications for which the use of a drug can result in a serious negative outcome (E.G., THIS SENTENCE: Antipsychotics, even for hallucinations, should be avoided because people with DLB are sensitive to them, and their use can result in death. – that underlined part sounds like this is an absolute contraindication) are normally included in a boxed warning in the prescribing information of FDA-approved drugs. Seppi333 (Insert 2¢) 13:51, 17 April 2018 (UTC)

Not surprisingly, all antipsychotics appear to carry a boxed warning about using the antipsychotic for dementia: [5][6][7]. Seppi333 (Insert 2¢) 13:55, 17 April 2018 (UTC)

Yes, both typical and atypical, for about 10 years now. But, as Cas points out, they are still used. So we have to find a balance for what to say in this article. SandyGeorgia (Talk) 14:04, 17 April 2018 (UTC)

Well, you could do the following:

• use language that sounds like medical advice: Antipsychotics should be avoided...
• use language that states a frequency: Antipsychotics are seldom/sometimes/never used for...
• use language that correctly describes the relationship between antipsychotics and dementia: Antipsychotics are contraindicated...

I suppose an equally acceptable but more verbose alternative would be to explicitly state the FDA's boxed warning in the article and attribute that warning to the FDA; after all, that boxed warning is the contraindication. Seppi333 (Insert 2¢) 14:41, 17 April 2018 (UTC)

See next section. SandyGeorgia (Talk) 14:48, 17 April 2018 (UTC)

I'm OK with language based either on frequency or contraindication (or even that they are contraindicated and therefore almost never used, or something like that). But not with how-to or "should" language. --Tryptofish (talk) 23:21, 17 April 2018 (UTC)

Feedback from Cas Liber

• Material from paras 1 and 3 of REM sleep behavior disorder subsection should be amalgamated. Also looks a bit contradictory at first glance (though ultimately isn't) Cas Liber (talk · contribs) 11:18, 14 April 2018 (UTC)

• I hope this is better. SandyGeorgia (Talk) 15:22, 14 April 2018 (UTC)

• Yep it is Cas Liber (talk · contribs) 19:28, 14 April 2018 (UTC)

• Not thrilled about the antipsychotic recommendations as they themselves are based on a 15-year old paper that predates the release of aripiprazole, which is (I suspect) what most people would start with if needing an antipsychotic, but whatever. I might even ditch para 2, which could be confusing. Starting with "antipsychotic medications that should be used with great caution,..." after pointing out their grave dangers might lead some readers to think these are the ones to use first rather than last.... Cas Liber (talk · contribs) 11:43, 14 April 2018 (UTC)

• Thanks, Cas, will work on these ... but I have some 2015 and 17 papers on treatment that discuss antipsychotics, so will see what they say about aripiprazole. SandyGeorgia (Talk) 13:50, 14 April 2018 (UTC)

• I am not finding any indication on aripriprazole. Case studies saying good, case studies saying bad. I cannot access this, but the google scholar abstract is: "Pharmacotherapy in Dementia with Lewy Bodies, M Ikeda - Dementia with Lewy Bodies, 2017 - Springer … Dementia with Lewy bodies (DLB) is the second most common type of senile dementia following Alzheimer's disease (AD) [1]. The … Despite an attractive in vitro profile (a partial dopamine agonist), aripiprazole can induce serious extrapyramidal side effects such as parkinsonism … " This review does not say anything more about aripripazole than clozapine or quetiapine. This is not promising either. SandyGeorgia (Talk) 14:46, 14 April 2018 (UTC)

• None of this surprises me. Thing is, at every understaffed and underskilled nursing home around the world...we all know what drugs staff will be using on unruly patients with dementia, don't we...? Cas Liber (talk · contribs) 19:32, 14 April 2018 (UTC)

• Yes ... some of the sources did go in to how to very cautiously approach ... but getting in to that kind of detail feels to HOWTO. Will see what Tryptofish thinks? SandyGeorgia (Talk) 19:35, 14 April 2018 (UTC)

• @Tryptofish: what do you think? On the one hand, I feel that education about antipsychotic use in DLB is reinforced in every journal review, but Cas has a point that they way it is phrased now "might lead some readers to think these are the ones to use first rather than last". SandyGeorgia (Talk) 15:14, 14 April 2018 (UTC)

  Antipsychotic medications that should be used with great caution, if at all, for people with DLB include chlorpromazine, haloperidol, olanzapine, risperidone, and injectable antipsychotics.

• I'll answer below. --Tryptofish (talk) 22:21, 14 April 2018 (UTC)

• Rephrase and dequote The genetics are "vastly understudied"

• Done, but I also rejigged the order a bit, to get risk factors together, and to explain that the genetics are understudied before explaining the issues. [8] OK? SandyGeorgia (Talk) 15:22, 14 April 2018 (UTC)

• The precise mechanisms contributing to DLB are not well understood, and a matter of some dispute. - the material following does not give an indication of a difference of opinion that a statement like this suggests. Needs some explanation.

• How is this? I quoted Weil, SandyGeorgia (Talk) 17:04, 14 April 2018 (UTC)

• Yeah that helps Cas Liber (talk · contribs) 19:27, 14 April 2018 (UTC)

Rest of it looks good. Cas Liber (talk · contribs) 12:06, 14 April 2018 (UTC)

@Casliber: @Tryptofish: re this edit, our article says thioridazine is still available as a generic; would it be OK to reinstate this? SandyGeorgia (Talk) 13:57, 14 April 2018 (UTC)

If you insist I am not too bothered really. One almost never sees it any more though Cas Liber (talk · contribs) 19:26, 14 April 2018 (UTC)

What I think may really be going on here is that first generation neuroleptics (some of which are still used quite a bit and others have largely been supplanted) are contraindicated in DLB, whereas the newer, second generation atypical antipsychotic drugs are (1) increasingly the drugs used for psychosis in general, and (2) may in several cases be safer in DLB because of their (basically) lesser relative specificity for dopamine receptors. It may be better to dispense with listing the names of these drugs entirely, and wording it in terms of drug classes. Casliber, what do you think about that? --Tryptofish (talk) 22:21, 14 April 2018 (UTC)

I encountered somewhere wording about those that act on D2 receptors being the worst. But if taking out the list entirely is the easier way to go, that works. I am not finding any indication that newer antipsychotics are necessarily better, and the news that come out this week about deaths from pimavanserin gives me pause that we should be very careful here ... I am particularly worried, as Cas says, that by including any list at all, we may give the impression others are safe. SandyGeorgia (Talk) 22:54, 14 April 2018 (UTC)

It's possible that it would be better to word it in terms of which receptors they act at, rather than broadly in terms of new and old, but that has the potential to get very complicated, and of course I don't want to do any WP:OR. I'm inclined to go with whatever Casliber would recommend. --Tryptofish (talk) 22:02, 15 April 2018 (UTC)

I think it is a vexed area - for instance, studies not showing quetiapine is effective, yet reviewers recommending it because of low side effects and ignoring the fact that it had not been shown to work. Furthermore the two groups (typicals and atypicals) are more heterogenous wthin themselves than certain member drugs are to each other, rendering the distinction spurious in my opinion. Hence, my concern over lists in general. In vitro affinity doesn't necessarily translate to in vivo EPSE, a la aripiprazole - but if the data is lacking I am loth to make assumptions. Anyway, those are my thoughts. Cas Liber (talk · contribs) 13:38, 16 April 2018 (UTC)

Proposals

@Cas, Tryptofish, and Anthony: thanks! So, I propose we:

• Drop this entirely:

  Antipsychotic medications that should be used with great caution, if at all, for people with DLB include chlorpromazine, haloperidol, olanzapine, risperidone, and injectable antipsychotics.

• Change in the lead,:

Now:Antipsychotics, even for hallucinations, should be avoided because people with DLB are sensitive to them, and their use can result in death.

Change to: Antipsychotics, even for hallucinations, are usually avoided because people with DLB are sensitive to them, and their use can result in death.

Separately, I will look for the statement about antipsychotics that act on D2 receptors being the worst offenders, and once I find it, we can discuss adding something. SandyGeorgia (Talk) 13:44, 16 April 2018 (UTC)

• Yes, I strongly support that lead change, per WP:NOTHOWTO.
• I also agree about removing the drug list. Given the source below about D2 receptors, I think something like

Antipsychotic medications with D2 dopamine receptor blocking properties are used only with great caution.

would work. --Tryptofish (talk) 22:49, 16 April 2018 (UTC)

List of antipsychotics avoided removed. SandyGeorgia (Talk) 04:07, 19 April 2018 (UTC)

And replaced with statement about antipsychotics that act on D2 receptors, per Tousi 2017. SandyGeorgia (Talk) 04:11, 19 April 2018 (UTC)

Looks good, thanks. --Tryptofish (talk) 18:13, 19 April 2018 (UTC)

Other antipsychotic feedback

• Can we use this? http://pmj.bmj.com/content/lewy-body-dementia-emergency-department

Even if not usable, what do others think about including it in External links? It is quite good. SandyGeorgia (Talk) 18:14, 16 April 2018 (UTC)

• Tousi 2017 says: "D2 receptor blocking antipsychotics, which can cause severe antipsychotic sensitivity, are now rarely prescribed for treatment."
• I don't know if we can use this? http://www.mededicus.com/downloads/Optimize_Care_Patients_Parkinson_Disease_Psychosis.pdf

SandyGeorgia (Talk) 14:14, 16 April 2018 (UTC)

In my opinion, all three of those are reliable sources, and I think the Tousi one is a good source to say that about D2 receptor block. --Tryptofish (talk) 22:42, 16 April 2018 (UTC)

The letter poses some problems - ideally you'd want the information in a Review Article...and then if it is in a Review Article...it begs the question about why we need the link to the letter. The mededicus link appears to be a Review that we could use yes. Regarding Tousi, I'd dispute his findings (maybe he lives in a nice part of the world with well-funded and managed nursing homes) but what he says is in the article now. My more realistic wording is "antipsychotic use is widely discouraged (with varying degrees of success)" - but that is only my opinion....and his is the source. Cas Liber (talk · contribs) 03:33, 17 April 2018 (UTC)

NB: If antipsychotics were only rarely prescribed all these folks wouldn't be making such a big deal of how bad they are!! Cas Liber (talk · contribs) 03:33, 17 April 2018 (UTC)

Cas, I don't think Tousi meant to say it's no longer a problem; the context of Tousi's sentence is that severe antipsychotic sensitivity is no longer listed as a Core feature, rather a Supporting feature, because some progress had been made on that front, with better recognition about antipsychotics that work on D2 receptors. But others are killing patients as well. Unfortunately, it is the letter that makes that point best (Emergency Department physicians' lack of DLB knowledge kills patients). I will keep looking through reviews. What are opinions about using the letter in External links? SandyGeorgia (Talk) 11:42, 17 April 2018 (UTC)

Added Emergency Dept info to External links. SandyGeorgia (Talk) 04:19, 19 April 2018 (UTC)

About Tousi, I think we can say that antipsychotics are typically avoided, without getting into how well or poorly the problem has been solved to date. Also, the Tousi source appears to be a sort of editorial, rather than a primary source report of findings, so it seems to me to fit with the MEDRS meaning of a review, even though it isn't named as such (sort of what is sometimes called a "mini-review"). But if it looks like the preponderance of sources are saying that most antipsychotics should not be used, and there is no identifiable pattern that identifies the ones that seem safer, then we should simply refer to antipsychotics in general, without getting into the names of individual drugs. In that case, I would say that the sentence about "Antipsychotic medications that should be used with great caution, if at all, for people with..." should be removed. If we have enough sourcing to say that antipsychotics are avoided, except for [specific drug names] that appear to be safe, then we can say that. But no need to give examples of the ones that are avoided. --Tryptofish (talk) 23:17, 17 April 2018 (UTC)

• Very good info, but from advocacy org LBDA: Emergency room treatment of psychosis SandyGeorgia (Talk) 12:11, 17 April 2018 (UTC)

• Interesting, they also have a printable wallet card. SandyGeorgia (Talk) 12:14, 17 April 2018 (UTC)

• Boot 2015 seems to be still the best bet if we want to add more text-- go down to the "Hallucinations and delusions" section. SandyGeorgia (Talk) 12:19, 17 April 2018 (UTC)
• And McKeith Consensus (emphasis mine):

  The use of antipsychotics for the acute management of substantial behavioral disturbance, delusions, or visual hallucinations comes with attendant mortality risks in patients with dementia, and particularly in the case of DLB they should be avoided whenever possible, given the increased risk of a serious sensitivity reaction. Low-dose quetiapine may be relatively safer than other antipsychotics and is widely used, but a small placebo-controlled clinical trial in DLB was negative. There is a positive evidence base for clozapine in PD psychosis, but efficacy and tolerability in DLB have not been established.

  SandyGeorgia (Talk) 12:28, 17 April 2018 (UTC)

From Kosaka book
The following discussion has been closed. Please do not modify it.
Please pardon typos: p. 215: When using antipsychotics in DLB or PDD, the likely balance of risks vs. benefits requires very careful consideration. p. 216: DLB patients can be exquisitely sensitive to antipsychotic agents for delusions and hallucinations and develop life-threatening sensitivity reactions ... p. 228: These patients are particularly sensitive to developing extrapyramidal symptoms (EPS) and also to the potentially fatal complication of neuroleptic sensitivity, which affects ~50% of DLB patients. p. 229: Analyses of pooled data from RCTs indicate that the use of antipsychotics in older individuals with dementia is associated with an increased risk of cardiovascular disease and mortality. Although clozapine is useful in treating PD psychosis, very few studies have been conducted in patients with DLB or PDD. ... Olanzapine appears to be poorly tolerated in a considerable number of patients, even at low dosages ... Risperidone has been associated with a high risk of neuroleptic malignant syndrome ... aripiprazole can induce serious extrapyramidal side effects such as parkinsonism and tardive dyskinesia. Quetiapine reduces reduces psychiatric manifestations of DLB wihtout casuing neuroleptic sensitivity or increasing EPS ... no siginificant differences in the primary outcome of efficacy ... may be an attractive candidate at this point.

SandyGeorgia (Talk) 12:48, 17 April 2018 (UTC)

"Should" and similar language

What I was trying to get at when I was talking about contraindication above is that we should not be using prescriptive language (i.e., sentences that use words like "can, could, may, might, shall, should, will, would, must, have to, has to, and ought to" to convey obligation or permission) in our articles; those are normative statements and the only exception where it's potentially appropriate for inclusion in an article is when those statements are directly attributed to a source. This article should only contain positive statements because encyclopedia articles are supposed to contain factual statements about the article topic.

Prescriptive statements that pertain to clinical practice also constitute medical advice, so the inclusion of these contradicts our own WP:Medical disclaimer when we write them in Wikipedia's voice (i.e., when we don't explicitly attribute a statement like "XYZ should ..." to the source making the claim within the same sentence). The attribution of that form of language, however, makes it clear that Wikipedia itself is not providing the medical advice in the article text; rather, Wikipedia is simply repeating the advice from the attributed source. Using prescriptive language in a sentence and citing a source from which it originates without in-text attribution to that source isn't sufficient for its attribution for the same reason that this practice is insufficient for the attribution of direct quotes: it's not explicit.

So, just to point out a few instances of where unattributed prescriptive language is used in this article (NB: compare the statements below to the second paragraph of Mild cognitive impairment#Treatment):

• A prior history of violence or injury should be inquired about, as they increase the likelihood of future injurious dream enactment behaviors.
• A multidisciplinary approach should go beyond early and accurate diagnosis to educating and supporting the caregivers.
• To lessen the risk of fractures in individuals with DLB who may be at risk for falls, bone mineral density screening and testing of vitamin D levels can be done,[1] and caregivers should be educated on the importance of preventing falls.
• Driving ability should be assessed regularly, and medical alert bracelets or notices about medication sensitivity "can be life-saving".
• Visual hallucinations associated with DLB create a particular burden on caregivers, so they should be educated on how to distract or change the subject when confronted with hallucinations rather than arguing over the reality of the hallucination.
• Caregivers and people with the condition should be educated about the increased risks of antipsychotics for people with DLB; if evaluation or treatment in an emergency room is needed, they may be able to explain that, in the words of Gomperts "patients with DLB are essentially 'allergic' to haloperidol and other neuroleptics".
• Bed partners may be advised to sleep in another room, and firearms should not be kept in the bedroom.

---

In the bulleted article text above:

• Bold text → prescriptive statements
• Underlined text → uses "may", but expresses possibility, so not prescriptive

The problem with the bolded text can be fixed by attributing the source or by simply rephrasing the statement so that it's a factual/positive one. For example, "antipsychotics shouldn't be used in people with dementia" is a normative statement, but "antipsychotics are contraindicated for dementia" is a positive/factual statement; only the latter one is encyclopedic.

In any event, that's all I have to say on this at the moment. I hope I've made it clear as to why statements like this are problematic. It's not absolutely necessary to fix the language in this article since so many others also have this issue; however, it does need to be addressed if this article is going to be nominated at FAC. Seppi333 (Insert 2¢) 04:39, 18 April 2018 (UTC)

Thank you for sharing this, Seppi333. I am fairly certain that every use of should and such is backed by the cited source, but naturally, once the bigger issues in the text are ironed out, I will be combing through and doublechecking every instance.

With respect to the idea that each of these word usages must be explicitly attributed inline to a source, I do not see any place in the (helpful) list above that you cite any Wikipedia policy or guideline page that requires same. My responsibility is to make sure I am faithfully and accurately reflecting what high-quality, recent, secondary reviews say.

I am not sure if you are aware that the proposed policy ATTRIBUTE was specifically rejected by a community-wide RFC in 2007 (Wikipedia:Attribution/Poll)? Among the reasons it was rejected was that it would dilute Wikipedia's core policies and lead to the kind of cumbersome editing practice you describe above ... that is, we would be required to inline attribute dozens of clearly cited and accurate statements in this article. That ATT was rejected perhaps explains why we have so many articles that do just as this example does, as you mention.

As one example that I was reviewing just yesterday relative to WIAFA, the lead of dengue fever contains the cited but unattributed statement: "Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen should not be used. While the vaccine section of that article has some very rough prose that might have a problem at FAC or FAR, this is a perfectly acceptable use of "should".

I am also aware that there has been an attempt to get attribution in via a back door in a guideline, and should the issue come up, I am just the person to deal with that.

Another thing is that (historically, at least, although with such a dropoff in participation, it may have changed-- my sense is that FAC just isn't happening anymore), FAC delegates/coordinators have read through hundreds of debates that involve personal preferences and guidelines, and are well aware of the distinction between policy, guideline and personal preference. Objections must be actionable, and when the nominator can show that an objection is grounded not in policy, but in personal preference, the FAC coordinators are empowered to overlook it. That is, if the article comes to FAC with cited but unattributed instances of "should", you would need to produce a policy page that describes the practice you advocate.

I am most appreciative of the reminder to go back and check every instance of prescriptive wording versus the sources, but if you are still determined to force attribution into an article where policy does not require it,[9] I suggest that you would have to revisit a community-wide redo of the ATT RFC, which caused quite an issue at its last outing. SandyGeorgia (Talk) 15:05, 18 April 2018 (UTC)

References

I agree with Seppi about this. For me, this is different than general prescriptive language because we are dealing with medical content, and that is more important than FAC history. I do not think it's sufficient to say something like "X should be avoided.^[1]" Something like that must be: "According to Humperdinck, X should be avoided.^[1]" And generally, I would do that only when it's really the best way to say it. Most of the time, it is better to change it to a non-prescriptive construction. And that is easy to do, so there is no reason to argue the community history about it. If there's a tough passage, just ask me and I'll be very happy to figure it out. --Tryptofish (talk) 17:39, 18 April 2018 (UTC)

Tryptofish, convince me based on the dengue fever example (which uses the word should four or five times, to Parkinson's disease's seven-- both articles recently subject to external peer review). The source says Do not give ... (ibuprofen) and massive bleeding may occur ... How is it wrong to say that sources back the wording "Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen should not be used".

Paraphrasing medical content is already hard enough; why should we introduce a need for wording change that is not supported by Wikipedia policy, anywhere? SandyGeorgia (Talk) 20:10, 18 April 2018 (UTC)

Wikipedia:Manual of Style/Words to watch does not mention this issue. I think a discussion about normative/positive writing for various article topic kinds might be useful, but I'm not aware of any guideline. There is a problem here in that medical care is not physics with hard facts that can be tested, nor is it economics where they haven't worked out that care with writing style doesn't help it be any less of a pseudo-science than astrology :-) To become a treatment really does require value judgement. There is evidence, of course, but it may be sorely lacking, and must also be combined with subjective opinion such as bearable side effects, acceptable cost, and appropriate risk/reward. We aren't writing an academic piece in which we advance arguments to make a case, where certain writing rules help guide to make stronger arguments.

As soon as we list agreed treatments then the reader is advised. Wikipedia can claim it does not offer medical advice all it likes, but it does, and there's not really any way around that if we are at all selective about what we claim to be a treatment, etc. The phrases "indicated for" and "contraindicated in" are merely medical jargon for "should be used to treat" and "should be avoided when". A difficulty with in-text attribution is that the reader may wonder if this is the only body/person holding that opinion, or wonder why this body/person is considered an authority on the matter, rather than someone else. If the advice is undisputed and/or widely offered, then attribution may be misleading. I disagree with some of Seppi's examples -- a couple of them are just statements of fact. I'd prefer to avoid "should" if possible, but concerned we end up with lots of passive statements, which can be boring as well as incongruous wrt serious concerns or needs. If Tryptofish wants to try to rephrase some of the "shoulds/etc" in the article then I'd be interested to see the result. -- Colin°^Talk 20:32, 18 April 2018 (UTC)

I just did this. It is not that hard. I have been pinged for it in bio articles with cultivation/aviculture sections Cas Liber (talk · contribs) 20:40, 18 April 2018 (UTC)

I wish we would/could finish the writing before honing in on issues like this :)  :)

What do people think of the Causes, Pathophysiology, and the History sections? Are they complete? They are the best I can do so far, do I need to dig deeper? I'd really like to see how we stand on content and then be able to move on to combing through every use of the word should (not that I would mind if someone else looked at them, but no, I will not generally use inline attribution when it is not called for by any guideline or policy when it was explicitly rejected by a community-wide RFC). And I agree with Colin that we fool ourselves if we think the language we switch to is any less "medical advice" than the word "should" is. Wikipedia gives medical advice, period, and should have a visible disclaimer on every article. SandyGeorgia (Talk) 21:04, 18 April 2018 (UTC)

Cas Liber, I don't think that change fixed anything regarding the concern of Seppi. The phrase "is strongly discouraged" is still a value judgement, still a normative statement, and begs the question "by who?". Really these writing concerns are generally for making statements about the economy or advancing philosophical arguments. I do have to laugh at some of the economics websites that give examples of "positive statements" that make claims of being "testable". The best we can do is not be bloody obvious about offering medical advice, and "should" is an easy tell. -- Colin°^Talk 21:17, 18 April 2018 (UTC)

Casliber strongly discouraged is no different than should be avoided. Seppi is saying we need to add inline attribution, even though all sources support either choice of wording, and there is no requirement anywhere on Wikipedia to provide such intext attribution (in fact, it was expressly rejected by community-wide RFC). This is not a trivial matter; there is not a medical FA on the books which meets the personal preference set forth by Seppi333, and extending editing beyond what policy requires should not be done without careful consideration. By Seppi's definition, we have no medical FAs. And we fool ourselves in a non-trivial manner about the level of medical advice Wikipedia most clearly does give if we think swapping out instances of "may" or "should" will solve the problem. In dengue, you take an NSAID, you can die. It is OK to say that. With DLB, you take an antipsychotic, you can die, too. Who are we fooling with these word choices? The sources support the facts. SandyGeorgia (Talk) 22:02, 18 April 2018 (UTC)

So much discussion over something that is so easy to fix! I am basing what I am saying on WP:NOT, which is a fundamental policy. From WP:NOT#Wikipedia is not a manual, guidebook, textbook, or scientific journal, first numbered point: Describing to the reader how people or things use or do something is encyclopedic; instructing the reader in the imperative mood about how to use or do something is not. I've done this: [10]. You're welcome. --Tryptofish (talk) 23:12, 18 April 2018 (UTC)

@SandyGeorgia: WP:NOTHOWTO - I will vehemently oppose promotion of this article at FAC if every single instance of these normative medical statements isn't removed prior to its nomination. Seppi333 (Insert 2¢) 00:33, 19 April 2018 (UTC)

So, would you like to hear that your vehemence has me shaking in my boots, unimpressed, or merely aware of what a wonderfully collaborative editor you are? I am still hoping for a rational discussion of the very appropriate (and fully supported by the sources) use of should in the lead of dengue fever. SandyGeorgia (Talk) 02:55, 19 April 2018 (UTC)

I'm such a wonderful collaborator, aren't I? To be frank, I don't really care about how you feel about it because the article's promotion isn't up to you. It really surprised me that your immediate reaction to my mentioning the use of unencyclopedic language in this article was to argue with me about it though. Given that you were a FAC coordinator at one point, why would you of all people want to lower the quality threshold of featured articles? Seppi333 (Insert 2¢) 02:58, 19 April 2018 (UTC)

@Colin: and @SandyGeorgia:, I feel that "strongly discouraged" has a subtly different emphasis to "should". However, I personally don't see it as a deal-breaker for FA-hood. If at the end of the FAC day Seppi is opposing on that and everyone else is not, then I suspect the coordinators will take that into account. Agree with Sandy that other areas need processing first and leaving this for the time being. Cas Liber (talk · contribs) 00:43, 19 April 2018 (UTC)

PS: I take most secondary sources proposing X as a treatment are by definition acting on general information as they are review articles. There are some exceptions but they can be argued at the time (eg antidepressants in bipolar depression...sigh) Cas Liber (talk · contribs) 00:45, 19 April 2018 (UTC)

@SandyGeorgia: Just to be clear, the purpose of providing in-text attribution is to change a normative statement by Wikipedia into a positive statement about a normative statement made by the source. "XYZ should..." is a normative statement, but "A says that XYZ should..." is a positive statement. Encyclopedias contain facts, not opinions. The latter one, despite expressing an opinion, is a factual assertion about an entity expressing an opinion. In other words, it's factual because it's falsifiable (i.e., either that entity did or did not make that assertion). Seppi333 (Insert 2¢) 00:57, 19 April 2018 (UTC)

Does anyone have a problem with [11]? --Tryptofish (talk) 00:58, 19 April 2018 (UTC)

Perfectly fine with me. Seppi333 (Insert 2¢) 01:00, 19 April 2018 (UTC)

Yes, there is a serious problem, Tryptofish, which is that the statement is not true and there is probably not a source that supports it (as Cas points out, the problem is that antipsychotics are still prescribed all the time). What is rarely prescribed anymore are specifically the D2 receptor antipsychotics, but that is not the point to made in the lead. The point to be made in the lead is about the severe sensitivity to all antipsychotics, of any type. This is why there is a section above to help us sort out how to address this particular issue con calma, rather than as a reaction to bright yellow highlighting on the page. The statement that we now have in the article is inaccurate. Could we please go back to calmly discussing text, as collaborators, rather than with vehemance? It usually gives much better results. SandyGeorgia (Talk) 03:33, 19 April 2018 (UTC)

Hi Sandy, I think that when I made this change: [12], it was an improvement. And when you made this further edit: [13], that was a significant further improvement, and I fully agree with it. I hope you understand that I am entirely calm and happy to collaborate. Whoever may be vehement, it is not me. --Tryptofish (talk) 17:38, 19 April 2018 (UTC)

• [14], [15], [16], and [17]. I think that covers everything on the list. --Tryptofish (talk) 01:37, 19 April 2018 (UTC)
  • Keep in mind that the only sentences that I included in that list were the ones which used the term should and didn't mention antipsychotics, since the antipsychotic sentences were already under discussion. Searching for related terms in the list I provided (i.e., the use of can, could, may, might, shall, should, will, would, must, have to, has to, and ought to" to convey obligation or permission) will need to be done to ensure that all of the unattributed prescriptive statements are removed. Most clinical practice guidelines I've read make frequent use of the terms that I've bolded to prescribe a specific approach to clinical care. The words "can" and "may" are often used to convey possibility as opposed to permission, so one needs to consider the usage of these terms when they're encountered. I can look later and supply a list of sentences that use prescriptive language as I did in the list above, but I'm not inclined to do it right now. Seppi333 (Insert 2¢) 01:48, 19 April 2018 (UTC)

I'm happy to do these, and I'd actually prefer a pointer to which section instead of a list. Of course, it would be great if other editors would make these kinds of edits too. --Tryptofish (talk) 02:09, 19 April 2018 (UTC)

I'll indicate where they are by tomorrow then. The only other issue that stood out to me when I went through this article pertains to the alignment of some of the images (see below). Seppi333 (Insert 2¢) 02:58, 19 April 2018 (UTC)

Thanks, Tryptofish. There is one unintended change of meaning at:[18]

• Regular assessment of driving ability, and medical alert bracelets or notices about medication sensitivity "can be life-saving".

By combining the two sentences, we ended up with regular assessment of driving ability can be life saving, which is not what the source says ... it was two different thoughts. I will come back and figure out how to remove the one attribution that snuck in, because it's what all sources say, and we don't want to leave the impression it is only the opinion of one reviewer. Thanks again, SandyGeorgia (Talk) 02:46, 19 April 2018 (UTC)

Does this wording suffice: [19]? Seppi333 (Insert 2¢) 03:42, 19 April 2018 (UTC)

Tryptofish, I revised to this. The sentence was already quoting Boot directly, so quoting those three more words and attributing the entire sentence to him should solve both problems without introducing too much more verbiage. I am at a loss for a good way to rephrase, "Regular driving assessment should be conducted." Thanks again, SandyGeorgia (Talk) 04:28, 19 April 2018 (UTC)

That's fine, I think attributing it to Boot is entirely OK, no problem. --Tryptofish (talk) 17:48, 19 April 2018 (UTC)

In the interest of removing instances of should, inaccuracies (now three) are being introduced. We now have:

Regular assessment of driving ability is a common practice.

Seppi, do you have a source for this? The cited source says no such thing. Would you mind, please, not making text changes without consulting sources? SandyGeorgia (Talk) 03:44, 19 April 2018 (UTC)

As you'll notice, I reverted the edit after I committed it because my intention was to link to a diff with the use of the proposed language in the article given that I didn't WP:V-check what I wrote. I'm on a crappy wifi right now. I'm not going to not use example diffs if my intention is to merely revert my editing and link to the diff. Seppi333 (Insert 2¢) 03:48, 19 April 2018 (UTC)

OK. And I missed your revert in my reply; I follow every edit to make sure we don't get any unintended changes. There is no need to rush here; slow and steady wins the race. We have had a very collaborative, and deliberative pace until today. I suggest we go back to that mode of operation. We have a discussion above about how to address the antipsychotic issue. We haven't even heard from most editors, and suddenly changes back and forth, resulting in three successive errors being introduced ... please strive for stability and collaboration-- there is no hurry. SandyGeorgia (Talk) 03:56, 19 April 2018 (UTC)

If I understand correctly, [20] is the current version, and that's fine with me. --Tryptofish (talk) 17:52, 19 April 2018 (UTC)

Ok, I think Seppi's argument about normative/positive language is a total red herring and has no place here. I think he's got confused that statements that provide instruction that are loaded with an implied reason for following them, are both normative and "providing instruction". We want to avoid the latter, or at least being rather obvious about it. I'm no grammar expert, but I think he's got these two aspects of language mixed up. I would currently support reverting the attempts to avoid "should" because most that I have looked at change the meaning, make claims our sources don't, and are pretty awful passive English.

Tryptofish's example of "The use of antipsychotics, even for hallucinations, is strongly discouraged" to "Antipsychotics are rarely prescribed" and the joint change of "Driving ability should be assessed regularly "Regular assessment of driving ability is a common practice" both change meaning and also make claims our sources don't. Guys it is really really important you don't do this. Most of the sources of this article are available to read, though of course Sandy has the benefit of access to multiple sources on each point, which makes it much easier to put words into our own language. I saw this problem when we had students mass editing medical articles, who were told: find a journal article and add a factoid to the wiki article. It was very very hard for them to avoid plagiarising while at the same time writing something that was correct and supported by the source -- they didn't really understand the subject well enough, of have access to enough literature, to do a good job of finding original text.

Copyediting is surprisingly hard, and despite Tryptofish's claim that rewording these is easy, he hasn't managed it. What you have done is the difference between "You should avoid obesity, keeping your waist measurement below half your height" to "People are generally slim". You've assumed that the advice is actually followed. And at the same time, removed any imperative for following the advice, so it becomes a meaningless factoid carrying no weight.

The change "A prior history of violence or injury should be inquired about, as they increase the likelihood of future injurious dream enactment behaviors" to "A prior history of violence or injury may increase the likelihood of future injurious dream enactment behaviors." Is wrong, Tryptofish, this is not the "Prognosis" section, but the "Clinical history and testing" section. So we need to describe what history (i.e. the medical practice of enquiring about the patient's life, course of disease, not the abstract concept of previous events) the doctors will take and what tests they are advised to carry out. Similarly in the Caregiving section, we need to describe what advice is given to patients.

A statement "keeping firearms in the bedroom is considered to be dangerous" is a bland statement that most people outside of North America would respond with "Well, doh!" and wonder why it belongs in this article rather than as a banner advert shown to all readers logged in from the US ;-). The former text gave the reader the understanding that this was advice given to patients and caregivers. So can we find a way to keep the fact, and these are facts, that this advice is given, because we're writing a "Treatment - caregiving" section, and avoid making irrelevant obvious statements like "guns are dangerous".

I agree we should try to avoid explicitly instructional language. But it is hard, and harder than I think some editors here think. Attributing is one possibility but can have issues I raised above. Perhaps there is an authority we can cite for some of the claims, but I would like to avoid name dropping random physicians. Is there a patient charity who have a set of recommendations? Perhaps we can introduce a set of statements to make them clear they are the sort of advice offered to patients/caregivers (or earlier, the advice given to doctors when taking history, or when considering prescribing drugs). Because advice is a fact, is encyclopaedic: this is the advice, the recommendations. When we remove the advice, we make those sections meaningless. -- Colin°^Talk 08:12, 19 April 2018 (UTC)

That was not helpful. You are free to make edits that correct any edits that I have made. --Tryptofish (talk) 17:54, 19 April 2018 (UTC)

The type of language that is used in this article to "provide instruction", as you put it, is normative, but not all normative statements are prescriptive (NB: a command like "do this" is a form of instruction an instructional statement - that's neither fact/positive nor opinion/normative; commands clearly do not belong in an encyclopedia either though). The only reason I used the term "normative" instead of a more specific one is that the opposite of a normative statement is a positive statement - i.e., a fact - which is the only type of statement that belongs in an encyclopedia. FWIW, I prefer to just say "According to the authors of [number] reviews(s)," when attributing a claim, as opposed to name drop, but there's obviously other ways to do this.

I'm well aware of how tedious it can be to rephrase prescriptive medical statements from reviews and medical guidelines because I've had to do it in other articles on many previous occasions. Sometimes it's simple, sometimes not so much - depends upon the statement and context. Seppi333 (Insert 2¢) 08:56, 19 April 2018 (UTC)

The simplest way to make any normative statement - prescriptive or otherwise - encyclopedic is to attribute the statement to the source; as I said above, adding attribution to these yields a factual statement. Rephrasing these statements, as opposed to attributing them, isn't actually necessary and can be detrimental in some cases (e.g., your examples). Seppi333 (Insert 2¢) 09:38, 19 April 2018 (UTC)

Colin, the last 24 hours of editing were most unfortunate. I have been at clinic for three days, and just wanted last night to keep up with the errors. Once I am home, I will step back through the whole thing, re-check everything, and re-do anything if necessary (I hadn't noticed some of what you mentioned, and that will be easier from a real computer at home).

Seppi, I might suggest keeping in mind that the goal is to have the best information available on the Internet about DLB-- not a bronze star. Your brightly colored threat to vehemently oppose at FAC for this article if your personal preferences are not instated was at best immature and uncollaborative, and at worst malicious and battleground-ish. I hope you understand that to a FAC coordinator, an oppose is an oppose is an oppose, and it matters not how strongly, brightly or vehemently you place it. It will be evaluated on its merit, of which yours has little, and FAC coordinators are well empowered to disregard invalid opposes. So please try to realize that such behavior will only make things more unpleasant for other editors, with little change to the article.

We can progress faster towards an excellent article by discussing and collaborating, rather than rushing to introduce changes that result in errors, as happened over the last 24 hours. If the article doesn't get a star, I really don't care-- there's some satisfaction in still holding the record at FAC, and knowing what an FA is and is not whether or not it holds a little icon in the corner. Let's please have a return to collaborative discussion. In spite of Tryptofish's statements that all of this discussion was over a simple matter that was easy to solve, deciding how to best handle the language about the fact that antipsychotics kill people with DLB is not a trivial matter, and why we have to get the language right. I hope the last 24 hours serve to exemplify why we should be discussing, not vehemently forcing our personal preferences into an article by threats against a meaningless bronze star.

Because real people read our articles. SandyGeorgia (Talk) 13:05, 19 April 2018 (UTC)

Here's another one (fatal gun incident). SandyGeorgia (Talk) 14:36, 19 April 2018 (UTC)

Again, I am not being vehement, and I urge editors not to personalize these things. I'm sorry you've had a tough couple of days, really. I am trying to help. --Tryptofish (talk) 17:59, 19 April 2018 (UTC)

Yes, you have been helpful! Thanks so much, @Tryptofish: Just that yesterday, with me away at clinic for two nights over, there was a bit of us all stumbling over each other :) I will catch up this weekend. I appreciate that you move forward and make edits, because it seems that we are stalled at times. Thanks again. SandyGeorgia (Talk) 18:15, 19 April 2018 (UTC)

OK then, good! --Tryptofish (talk) 18:18, 19 April 2018 (UTC)

And, GOOD news and BAD news. The good news is, I stopped and picked up three books. The bad news is, there is almost nothing useful in them, so I wasted my money. The best news is that this article is already so far beyond what is available to readers at their bookstore, that I was pretty amazed at how bad the books were relative to the ground we have covered. I do have some things to tweak as I get to them... can do so much better on Causes and Pathophysiology, and now know where to look, but no help on the "should" issues from the books. That we have been able to update to the newest diagnostic criterion and pull in the most recent journal reviews, puts us well ahead of anything I can find in any books! Cool beans, SandyGeorgia (Talk) 18:16, 19 April 2018 (UTC)

Proposed solution

I am averse to attributing "should" text to a specific review because the only kind of should text in this article can be sourced to multiple secondary reviews-- it is generally accepted advice, such as the dengue fever information that NSAIDs should not be given, which is well sourced.

In searching for a way to attribute such text, I have looked into using one of Colin's ideas. What do others think of this proposal?

1. We have a secondary review that recommends the Lewy Body Dementia Association (LBDA).
2. We have multiple secondary reviews that mention the subjects that we are discussing above, so attributing them to any one review seems misleading to our readers (they are information that is broadly supported).
3. So how about if we switch some of these instances to the voice of the LBDA, as long as and only when the information can also be cited to a MEDRS secondary review. That is (example),

   The LBDA says Joe Bloe should not eat worms.(cited to LBDA)(cited also to secondary review about eating worms).

Would that work for everyone? SandyGeorgia (Talk) 14:55, 19 April 2018 (UTC)

I'm fine with attributing views in the form of "the LBDA says". --Tryptofish (talk) 18:16, 19 April 2018 (UTC)

Further comments by Seppi333

Besides the use of unattributed prescriptive statements, the only other issue I saw when I went through the article was the placement of two images. See the screenshots, accompanying explanations, and proposed fixes below.

1. This violates MOS:SANDWICH & MOS:SANDWICHING: [21] (see the first 4 lines of text under "Pathophysiology" in this screenshot). The issue with text sandwiching in this part of the article can be fixed by right-aligning both thumbnails or with the use of {{Multiple image}} and right alignment with vertical direction (| align=right | direction=vertical).
   • Fixing this is not optional for FAC (criterion 2).
2. This doesn't violate the MOS, although I think the placement of the image on the left side looks terrible because it forces all of the text to appear to the right of the image instead of along the left margin: [22]; keep in mind that the MOS explicitly states that in most cases, images should be right-aligned unless there's a reason that warrants the use of left-alignment.
   • Fixing this is optional for FAC.

Seppi333 (Insert 2¢) 02:58, 19 April 2018 (UTC)

On the first, theoretically, the Causes and Pathophysiology sections are still going to grow, and there will not be a sandwiching issue. Assuming we are going to find time to deal with actual content here. On the second, the very page you cite says: Mul­ti­ple im­ages can be stag­gered right and left. Which is what is often requested at FAC. SandyGeorgia (Talk) 03:08, 19 April 2018 (UTC)

Hence why I said optional. Systematic right-alignment is a personal preference and it irritates the fuck out of me when a reviewer requires compliance with his/her personal preferences in a FAC review. If, prior to the FAC nomination, the sections from the first screenshot grow at some point and that expansion resolves the text sandwiching I mentioned above, I'll be fine with their current alignment. Seppi333 (Insert 2¢) 03:23, 19 April 2018 (UTC)

They used to ask for staggering r-l at FAC, which made sense when you could more of less assume most people were using desktop pcs of roughly similar screen size. Now all that's gone, & you don't get that asked any more. I used to stagger, but switched to normally putting things right years ago, as a concession to those using tiny screens. But no facing out of course. See Wikipedia_talk:Manual_of_Style#MOS_wording:_images_that_"look_toward"_the_text for a current discussion (more views would be good), where some truly wierd views are expressed as to the "difficulty" in left-placing anything. Needless to say, MOS has not really adapted to reflect the new situation. Johnbod (talk) 13:05, 19 April 2018 (UTC)

Thanks for this info, Johnbod; once the text is more finalized, I will run through the images again. SandyGeorgia (Talk) 15:35, 19 April 2018 (UTC)

Well, it irritated the heck out of Awadewit when people had eyes or images facing off the page, and since she was a seriously good FAC reviewer and FA writer, you might imagine that we delegates/coordinators tended to pay attention to her reasoning for alternating images. We also had views on reviewers and nominators filling up FAC pages with color and excess markup, and hoped people would leave their crayolas at home. SandyGeorgia (Talk) 03:40, 19 April 2018 (UTC)

But I like crayons. Seppi333 (Insert 2¢) 03:54, 19 April 2018 (UTC)

So do I, sometimes! But when you're a FAC coordinator reading through hundreds of pages a day, it can be quite exhausting to have to sort through excess markup—highlighting, bolding, emphasizing is not going to influence a coordinator as much as irritate them :) SandyGeorgia (Talk) 03:59, 19 April 2018 (UTC)