Talk:Hemothorax/GA1

GA Review

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Reviewer: PeaBrainC (talk · contribs) 22:20, 4 February 2019 (UTC)

Hi, I'm going to make a start on this review. PeaBrainC (talk) 22:20, 4 February 2019 (UTC)

Initial Review

Here are my initial thoughts:

The article certainly has its good points, but it feels a little thin in places. The prose certainly needs tightening up and there are quite a few typos littered around. Some sections are unreferenced.

Specific points:

Infobox

Speciality - Emergency medicine. Should be Respiratory Medicine or pulmonology if we're going for a US style  Done

Complications - ...hemothorax. Can't be a complication of itself, surely?  Done

Prognosis - usually good. Needs to be more specific Done

Lead

The term is from hemo- + thorax. - explain  Done

Symptoms include chest pain, difficulty breathing, and rapid breathing. Probably doesn't need rapid breathing as well.  Done

If treated, prognosis is usually good, even it complications arise. Even if... and should be more specific Done

Signs and symptoms

Try to avoid bullet lists if the text can be expressed in prose form  Done

Causes

Not sure if the categorisation into traumatic and non-traumatic is really working. How about further mention of other iatrogenic causes such as following pacemaker implantation, or chest drain insertion.  Done

How about looking at Etiology and management of spontaneous haemothorax - PMID:25922734 as an open access secondary source for this section Done

Spontaneous hemothorax or hemopneumothorax may be occur with endometriosis, if endometrial tissue implants on the pleural surface, then bleeds in response to cyclical hormonal changes in menstruating women. May be occur? Explain what endometriosis is first  Done

Mechanism

...are separated by a thin layer serous fluid. …thin layer of...  Done

...resulting in dypsnea and tachypnea. Misspelt. Try to use non-technical terms. "shortness of breath" is better than dyspnoea.  Done

Management

Need to mention fluid resuscitation +/- transfusion. Done

Surgery - citation needed Done

Prognosis

Needs to be more specific. Citations needed.  Done

Complications

Need to mention shock.

Usually they can be treated too. How?

Images

It feels like the gallery contains too many similar CXR images. What is the image of a hemothorax in an animal? What species?

Wikilinks

Overlinking. Remove duplicate links to chest tube, tube thoracostomy, empyema, dyspnea  Done

References

Mainly appropriate secondary sources. #3, #4, #18 are primary and should be removed. I don't think that #19 is the best - surely better peer-reviewed review articles are out there?  Done

Suggest looking at these open access reviews available on PubMed:

• PMID:25922734 - Etiology and management of spontaneous haemothorax, useful for causes wection
• PMID:20817498 - general review of haemothorax
• PMID:25978625 - detailed review of use of VATS for haemothorax

Copyvio Earwig's only flags up wikivividly.com which seems to be a mirror of WP  Done

GA review – see WP:WIAGA for criteria

1. Is it well written?

   A. The prose is clear and concise, and the spelling and grammar are correct:

   See comments above

   B. It complies with the manual of style guidelines for lead sections, layout, words to watch, fiction, and list incorporation:

   List in Symptoms and signs should be prose

2. Is it verifiable with no original research?

   A. It contains a list of all references (sources of information), presented in accordance with the layout style guideline:

   B. All in-line citations are from reliable sources, including those for direct quotations, statistics, published opinion, counter-intuitive or controversial statements that are challenged or likely to be challenged, and contentious material relating to living persons—science-based articles should follow the scientific citation guidelines:

   see comments above

   C. It contains no original research:

   some citations needed to make this compliant - see above

   D. It contains no copyright violations nor plagiarism:

   No copyvio found

3. Is it broad in its coverage?

   A. It addresses the main aspects of the topic:

   B. It stays focused on the topic without going into unnecessary detail (see summary style):

4. Is it neutral?

   It represents viewpoints fairly and without editorial bias, giving due weight to each:

5. Is it stable?

   It does not change significantly from day to day because of an ongoing edit war or content dispute:

6. Is it illustrated, if possible, by images?

   A. Images are tagged with their copyright status, and valid fair use rationales are provided for non-free content:

   B. Images are relevant to the topic, and have suitable captions:

7. Overall:

   Pass or Fail:

Placing on Hold 9th Feb

Hi @Steve Mulch Civic (Pro):, I've adjusted some of the typos and you've made a start by turning the list into prose. There's still quite a bit of work to be done to bring this up to GA standard. Perhaps you could mark as Done the specific action items listed above that you feel have been completed? There are still some areas that require citations from reliable medical sources - I suggest you look at the review articles I've listed above.

I'm going to mark the article as being on hold for now. Do you feel the standard 7 days is a reasonable timeframe to address the unanswered concerns?

Thanks, PeaBrainC (talk) 20:08, 9 February 2019 (UTC)

To give you a hand I've started ticking some of the points that have been addressed. You can edit this page and write Done or use the  Done tag to mark points that you feel have been addressed. Citations need to be from reliable secondary medical sources as per the manual of style - see WP:MEDRS. Case reports like the one you just used to back up the prognosis of aortic rupture do not fulfill this definition. I'd strongly recommend reading the freely available review articles that I've suggested in the references section above. PeaBrainC (talk) 10:49, 11 February 2019 (UTC)

I have fixed some of the issues

More in depth review 27th Feb

Hi @Steve Mulch Civic (Pro):. Well done for fixing some of the issues, the article is starting to look better. I think that most of the breadth required for the article is now covered and the overall section layout is good. However, the structure within each section is a little lacking and the prose is not yet up to scratch. The concerns regarding some of the references are still to be fixed. I will go through each section in detail with points to be addressed. I will do a couple at a time and come to the lead last. PeaBrainC (talk) 18:35, 27 February 2019 (UTC)

Signs and symtpoms

Hemothorax tends to occur following blunt or penetrating trauma to the thorax or thoracoabdominal area. It may also follow thoracic surgery, or may be spontaneous.

This section should include information about signs and symptoms not causes.

The affected side may have no breathing, and that side of the chest may not rise.

May have no breathing? Could be worded better. Consider “Breath sounds may be quieter on the affected side…”

It can be deadly when shock occurs. Done

This sentence refers to prognosis, not symptoms.

Causes

Its cause is usually traumatic Done

Start each new section imagining the reader has started reading from that point and re-identify the subject you are talking about. Consider “Hemothorax is often caused by an injury, referred to as a traumatic hemothorax”.

Blood loss may be massive in people with these conditions, as each side of the thorax can hold 30 to 40% of a person's blood volume or 1.5 to 2 L per side in the average adult Done

This sentence would fit better in the mechanisms section.

An extensive left hemothorax can also be caused by a traumatic aortic rupture, a surgical emergency with a high death rate despite emergency surgery. Done

Again, keep to the point of that section with minimal deviation to prognosis or management – these can be dealt with later. Consider “While the injuries that typically cause a haemothorax lead to bleeding from the small blood vessels that supply the pleura, hemothorax can also be caused by damage to larger blood vessels such as the aorta. In these cases, hemothoraces tend to be extensive."

Spontaneous hemothorax or hemopneumothorax can occur with endometriosis, a condition in which cells similar to those in the endometrium, the layer of tissue that normally covers the inside of the uterus, grows outside of it, if endometrial tissue implants on the pleural surface and then bleeds in response to cyclical hormonal changes in menstruating women. This condition is known as a catamenial henothorax. Rarely, cancer can cause a hemothorax.

Mention these rare-as-hens’-teeth causes at the end of the causes section to highlight how uncommon they are. Done

Hemothorax may occur be a slight injury or a small blood vessel that has spontaneously ruptured. Done

Not sure what you’re getting at with this sentence – is this not just repeating the fact that some hemothoraces are traumatic while others are spontaneous?

It is a vary rare complication, with less than 1% of cases involving hemothorax Done

Make it clear what you are referring to here – I’m not sure what you mean. 1% of those with Ehlers Danlos experience a hemothorax? Done

It can be a complication of heart and lung surgery, for example the rupture of lung arteries caused by the placement of catheters Done

Group this with the traumatic causes mentioned earlier. Consider “Traumatic hemothoraces can occur as a complication of surgery performed on the heart and lungs….” Done

References

Still need to address the unsuitable references that were mentioned in the beginning.

Ref #24 to Wikipedia page Fibrothorax – can’t use another Wiki page as a source Done

Ref #22 from Verywell.com - unsuitable as not a reliable secondary source as per WP:MEDRS Done

Ref #21 Datta 2004 – case report, unsuitable as not a reliable secondary source as per WP:MEDRS Done

Ref #6 – from radiopaedia.org – unsuitable as not a reliable secondary source as per WP:MEDRS  Done

Ref #5 Misthos 2004 – primary source, unsuitable as not a reliable secondary source as per WP:MEDRS Done

Images

Still too many similar CXRs. How about replacing some of these with images of other diagnostic modalities, or a picture depicting what VATS is. Done

Keep up the good work and we'll get this to GA! I'll do detailed reviews of the remaining sections on another evening. PeaBrainC (talk) 18:35, 27 February 2019 (UTC)

Mechanism

…it begins to interfere with the normal movement of the lungs, resulting in dyspnea, poor ventilation, and abnormal oxygenation.

Would be more logical to state the mechanical consequences first followed by the symptom. Suggest “…movement of the lungs which decreases ventilation, reducing oxygenation, subsequently leading to breathlessness. Done

…a small hemothorax may lead to a bloody pleural effusion.

Make it clear that this effusion is additional fluid beyond the blood that is already there. Consider “…a small hemothorax may cause additional fluid to seep from the pleura, leading to a bloodstained pleural effusion.” Done

Blood that is in the pleural cavity is constantly exposed to the moving lung and diaphragm. Hours after the bleeding stopped and the clot has formed, the clot starts to disintegrate. However, is the disintegration is not complete or there was a lot of bleeding, it is unavoidable that a clot will be formed. Once the clot has organized, it will stick to the pleura and the lung.

The significance of this paragraph is unclear and should be made explicit as per the source. Explain why clotting is important – it makes it harder to evacuate and residual clot leads to fibrosis, potentially leading the complication of fibrothorax.  Done

Diagnosis

 DoneConsider starting this section with a one sentence summary of what is to come – (that hemothorax is most often diagnosed using plain X-ray but other imaging modalities such as CT or ultrasound may be more sensitive).

There should be some mention of differentiating between hemothorax and a bloodstained effusion – specifically that a hemothorax is defined as being fluid with a haematocrit of >50% of that person’s blood Done

Surely there should be some mention in the X-ray section that the features of a hemothorax are the same as those of any other pleural effusion (unless I’m mistaken and there is a way to differentiate the two on X-ray – this should be stated if so) Done

Tube thoracostomy may be done prior to imaging when people have sustained blunt or penetrating thoracic trauma and display unstable hemodynamics, have respiratory failure with absent or decreased breath sounds, show tracheal deviation, or have serious penetrating injuries.

This sentence belongs in the management rather than the diagnosis section. Done

However, as much as one liter can be missed in a supine X-ray. In people that are supine, signs of hemothorax may also be subtle on radiographic film, because the blood will layer in the pleural space, and can be seen as a haziness in one half of the thorax relative to the other side.

Maybe put these sentences the other way round – explain the subtlety and then quantify how much can be missed. Consdider “Radiographic signs of hemothorax may be subtle when X-rays have been taken in a supine position as blood can layer in the pleural space, being visible only as a haziness in one half of the thorax relative to the other side. Because of this, a hemothorax containing as much as one litre of blood can be missed on a supine film Done

I'll get round to the remaining sections ASAP. PeaBrainC (talk) 12:23, 1 March 2019 (UTC)

Management

The Management section feels a little unstructured – the text flits back and forth between tube thoracostomy, then thoracotomy, then management of bleeding, then back to chest ubes and how to prevent clogging, then retained hemothropax, then back to clogging, then back to thoracotomy, then VATS. This makes it quite hard to read.

Consdider re-ordering the text that is already there to fit into the following subsections: Done

Initial paragraph describing the general measures – resuscitation, correction of coagulation, drainage of the hemothorax with chest tube , potentially surgery to find and fix the bleeding point. Done

Subseection: tube thoracostomy. Information related to when and how to insert, prevention of clogging etc. Done

Subsection: surgery. Describe indications for surgery and role of VATS. Done

New section – complications  Partly done I think that complications should be a subsection of Prognosis. It is WAY too small to be a section of its own. Done

Move text in 'Management' concerning retained haemothorax to new complications section. Done

Move last line of text in 'Prognosis' describing empyema and fibrothorax to the new complications section. Do you have some figures for the incidence of fibrothorax and empyema?  Done

General comments

Well done for improving the variety of images. Now consider changing how they are placed - putting a single representative image next to the relevant text (as is the case for the ultrasound image) would be better than having them all in a gallery. The pathological specimen is a nice image - could the caption be expanded to explain what it is a little better?

If you're dead set on keeping lots of similar CXR images then these could stay in a gallery at the bottom.

Please tick off the items that have been addressed using  Done - if you disagree with the suggestions please tag the item as  Not done and explain why you disagree.

Once all the text in the body of the article is in line then the lead can be tackled.

Thanks, PeaBrainC (talk) 13:22, 3 March 2019 (UTC)

Transcluded from User Talk Page

What do I still need to do? — Preceding unsigned comment added by Steve Mulch Civic (Pro) (talk • contribs) 20:11, 20 February 2019 (UTC)

I have finished the problens that you have mentioned on the review page. Is it ready now? — Preceding unsigned comment added by Steve Mulch Civic (Pro) (talk • contribs) 18:59, 23 February 2019 (UTC)

@Steve Mulch Civic (Pro): Sorry for the slow response - have been away. The article is looking better after your efforts but there is still more to do to get it to GA - some sections are good but the prose in other sections remains disorganised e.g. Diagnosis. Some sources do not meet WP:MEDRS criteria. There are still too many similar images. I will make detailed suggestions when I'm home next week. PeaBrainC (talk) 21:30, 23 February 2019 (UTC)

Hi PeaBrain, I have fixed everything you have left on the Hemothorax talk page. What more needs to be done to get this to GA?

@Steve Mulch Civic (Pro): Well done for all your hard work. Please could you tag all the specific items I suggested as  Done or  Not done with a rationale - I'm not sure if all have been addressed. I have added some suggestions for the Management and the Prognosis sections. PeaBrainC (talk) 13:32, 3 March 2019 (UTC)

Hi Peabrain, What more do I need to do? I have finished everything you said — Preceding unsigned comment added by Steve Mulch Civic (Pro) (talk • contribs) 23:37, 6 March 2019 (UTC)

Hi @Steve Mulch Civic (Pro):. There are still a couple of points that have not been checked on the review page - e.g. the Datta reference still needs replacing. One of the images you have added doesn't show a hemothorax at all (the hamartoma image). The prose can still be improved a lot but I will tackle this. When you've ticked off all the suggestions one way or another and when I've tidied up the prose I intend to get a 2nd opinion to make sure that I haven't lost perspective on the article (it's my first GA review and after quite a few weeks of changes I think that's probably good practice. Hope that's ok PeaBrainC (talk) 12:59, 8 March 2019 (UTC)

Now that I removed the reference you said to remove, is it best to wait until you polish the prose in the rest of the article? Steve Mulch Civic (Pro) 13:37, 9 March 2019 (UTC)

I'm working through the sections slowly - 3 down, 4 to go! I think you've done a good job adding content, once I've been through the remaining sections I'll send out a request for a 2nd opinion. PeaBrainC (talk) 15:17, 11 March 2019 (UTC)

Reference duplication

As of March 12, refs 6 & 29 same, refs 8 & 9 same, and refs 24, 25 and 28 same. Also, ref 21 (Miller) is from 1987 - can a newer ref be found? David notMD (talk) 11:49, 12 March 2019 (UTC)  Done I deleted the duplicate refs. Steve Mulch Civic 23:11, 12 March 2019 (UTC)

Time for a second opinion

So after a bit of a gap (sorry), I've been through the remaining sections to adjust the prose - it was just easier to do it myself rather than generate a long list of suggestions that would all have been relatively trivial in themselves. As a result, whilst I feel that the article is now GA-worthy, I have become a significant contributor to the article and so it would be worth having an impartial editor take a look as a second opinion. @David notMD: - thanks for identifying the duplicate references above, as you've had a read through the article already would you mind giving a 2nd opinion regarding a GA verdict? PeaBrainC (talk) 13:59, 27 March 2019 (UTC)

Will do so by Friday noon (USA east coast time). David notMD (talk) 20:06, 27 March 2019 (UTC)

Thanks David. PeaBrainC (talk) 20:16, 27 March 2019 (UTC)

I did some minor ref editing, including chapter name and chapter author for #19. All references are live, i.e., link to what is being cited, although I have reservations about the ref format being used, and may come back to this.

• Recommend that ref #8 (Morgan 2015) be deleted, as it is a case study report on a cancer patient, and thus does not appear to me to be relevant to the text, which is adequately supported by ref #9 (Rousset 2014).  Done
• Mechanism and Prognosis sections need more citations.  Done
• Diagnosis section: do not repeat Wikilinks that are already established in the Lead. Same for not repeating abbreviations. Done
• Delete the Diagnosis MRI scan image. Not done Why? if there is 1 MRI image, that is helpful to the article
• Thoracostomy subsection: "If a chest tube becomes obstructed, the tube can be cleared using an open or closed technique.[22] Manual manipulation of chest tubes (also referred to as milking, stripping, or tapping) is commonly performed to maintain an open tube, but no conclusive evidence has demonstrated that this improves chest tube drainage.[23][7]" Reference #22 is from 1987 - can any newer ref be found. Ref #23 (Wallen) is about pericardial drains, not pleural, and does not apply - delete it.  Done

That's it for now, but may have more comments pending closer reading. David notMD (talk) 03:29, 28 March 2019 (UTC)

• Thoracostomy subsection: With the Wallen ref now removed, there is no support for the sentence "Manual manipulation of chest tubes (also referred to as milking, stripping, or tapping) is commonly performed to maintain an open tube, but no conclusive evidence has demonstrated that this improves chest tube drainage." as that is not covered in the remaining Patrini ref. David notMD (talk) 13:19, 28 March 2019 (UTC)
• I thought to invite someone from the Pulmonary Task Force to also eyeball this article, but no one listed there has been active since 2014. So it's one cardio MD and on nutritional biochem PhD vetting this nomination. David notMD (talk) 18:05, 28 March 2019 (UTC)

I have asked User:Axl who I believe is a respiratory physician (and is certainly still active) if he would mind casting an eye. PeaBrainC (talk) 19:20, 28 March 2019 (UTC)

Not sure why, but sometimes when I view this "Time for a second opinion" section I see at the bottom two statements by S that date back to February. David notMD (talk) 17:41, 28 March 2019 (UTC)

I got confused by that too! I think it's because Steve left his comments at the bottom of the article's talk page rather than on the GA review document, so whenever the talk page is viewed the comments from February always appear under the transcription from this page.

By the way, I note your comment above regarding not re-linking to pages that have already been linked to in the lead. My interpretation of MOS:DUPLINK was that repeated links to a page that all occurred in the body of the article was against MOS, but that it was acceptable for a link that appeared in the lead to then reappear in the body of the article. Your thoughts? PeaBrainC (talk) 18:41, 28 March 2019 (UTC)

Not hard core about my opposition. Most of what I saw was in lead and in body, so I will defer. David notMD (talk) 21:43, 28 March 2019 (UTC)

PeaBrainC, David notMD, that was always my understanding, that links could occur in the lead and then also once in the body. More is overlink, but I've never had a problem with linking once in each place. BlueMoonset (talk) 03:49, 29 March 2019 (UTC)

Another opinion

As requested, I shall give a second (third?) opinion. Axl ¤ [Talk] 10:04, 29 March 2019 (UTC)

• The opening sentence is "A hemothorax is an abnormal accumulation of blood within the pleural cavity." Technically, this is correct. However an accumulation of blood in the pleural cavity is always abnormal. This makes the use of the word "abnormal" in the definition redundant. On the other hand, a hemothorax is abnormal, so simply removing the word might make this less obvious. Axl ¤ [Talk] 10:07, 29 March 2019 (UTC)

It looks like you did simply remove the word. I am not sure that this is the best solution, but it is okay for GA status. Axl ¤ [Talk] 12:31, 30 March 2019 (UTC)

• In the infobox, it would be helpful to add an arrow to the x-ray image to show the position of the hemothorax, but this is not essential for GA status. Axl ¤ [Talk] 11:48, 29 March 2019 (UTC)

Thanks. Axl ¤ [Talk] 12:32, 30 March 2019 (UTC)

• In "Causes", subsection "Non-traumatic", the editors seem to have chosen a random selection from those listed in the source (Patrini). Patrini does not indicate any particular ranking incidence. I shall try to find a source that discusses incidence. Axl ¤ [Talk] 12:52, 30 March 2019 (UTC)

Thanks for taking a look Axl, very useful to have a subject expert's views. Do you feel it would be better to list all causes mentioned in Patrini? I agree that the current selection doesn't haven't a particularly solid logic behind it, but how about identifying the most common causes, the most dangerous, and potentially the most interesting (endometriosis as a cause for hemothorax, even if rare, is a really interesting factoid - if properly worded would make a great Did You Know for the mainpage)? PeaBrainC (talk) 15:31, 30 March 2019 (UTC)

Fishman's Pulmonary Diseases and Disorders has a table of causes similar to those listed by Patrini. Unfortunately no incidences are included. I shall keep looking. Axl ¤ [Talk] 14:04, 1 April 2019 (UTC)

Light's Pleural Diseases has good information at hemothorax. Although incidences of non-traumatic hemothorax causes are not explicitly mentioned, Light states that the commonest causes are tumours, anticoagulants, and catamenial, in that order. Axl ¤ [Talk] 14:13, 1 April 2019 (UTC)

I am surprised that no-one has replied to this. Are the primary editors not interested in using Light's Pleural Diseases to improve the article? Axl ¤ [Talk] 10:27, 6 April 2019 (UTC)

Sorry for the delay Axl, it's been a busy week. I appreciate your input and have amended the order in which the causes of spontaneous hemothorax have been mentioned as per your summary of Light's (unfortunately I don't have immediate access to that textbook so am relying on your word!). Light's contrasts with the Patrini reference which states that spontaneous hemopneumothorax is the most common cause - my guess is the discrepancy arises from definitions, I'd imagine that a tiny volume of blood can be detected frequently in a spontaneous pneumothorax but that this is considered relatively trivial by Light. As a compromise I have listed neoplasia, coagulopathy and catamenial first, then mentioned spontaneous HPT, then listed the remainder of the rare causes mentioned in Patrini. Does that sound ok to you? PeaBrainC (talk) 20:03, 8 April 2019 (UTC)

I just used that source - ❄️Steve ^talk? 14:53, 7 April 2019 (UTC)

Axl, now that your problems with the article are solved, should it be GA? - ❄️Steve ^talk? 22:55, 30 March 2019 (UTC)

Er, I have barely started my review. I expect that it will take me about two weeks. Axl ¤ [Talk] 14:04, 1 April 2019 (UTC)

No, we are not inactive - ❄️Steve ^talk? 13:48, 6 April 2019 (UTC)
For a preview, look here https://books.google.com/books?id=vHEpRHQXaKUC&pg=PA340&dq=hemothorax&hl=en&sa=X&ved=0ahUKEwjDxZD1zbvhAhXK3YMKHQqOBywQ6AEIKDAA#v=onepage&q=hemothorax&f=false - ❄️Steve ^talk? 13:51, 6 April 2019 (UTC)

I am in the process of updating the fifth edition Light references (2007) to the sixth edition. I have also separated out iatrogenic causes from traumatic—mainly because the epidemiological data does so. (Light also separates the categories.) I need to go through the spontaneous section and make some adjustments. Axl ¤ [Talk] 15:29, 10 April 2019 (UTC)

Thanks for your help with this Axl and David notMD. From my point of view I feel that while of course more could be done to make the article even better, it now hits the GA targets. If you agree then I'll sign it off. PeaBrainC (talk) 16:48, 17 April 2019 (UTC)

I agree. David notMD (talk) 16:50, 17 April 2019 (UTC)

Me too - ❄️Steve ^talk? 22:38, 17 April 2019 (UTC)

As it's been a week and there haven't been any further concerns I'm going to pass the article. Well done Steve, thanks Axl and David notMD for your help with my first GA review. PeaBrainC (talk) 16:45, 25 April 2019 (UTC)

Thoracostomy

You did not strike off as Done, but it appears the added ref Salmon et al supports handling/'milking' chest tube as practice. David notMD (talk) 02:30, 31 March 2019 (UTC)