Wikipedia:Featured article candidates/Rhabdomyolysis/archive1

The following is an archived discussion of a featured article nomination. Please do not modify it. Subsequent comments should be made on the article's talk page or in Wikipedia talk:Featured article candidates. No further edits should be made to this page.

The article was promoted by SandyGeorgia 16:56, 12 June 2011 [1].

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Rhabdomyolysis

Rhabdomyolysis (edit | talk | history | protect | delete | links | watch | logs | views)

• Featured article candidates/Rhabdomyolysis/archive1

Nominator(s): JFW | T@lk 20:01, 22 May 2011 (UTC)

I am nominating this for featured article because I believe that in its current form it represents a reasonable overview of this interesting medical condition. It may arise in numerous different situations, from drug abuse to being trapped under a collapsed building. It also has interesting historical and aspects. It has been a personal project of mine since 2007, and although it has been a Good Article since 2008 I have recently identified some additional sources that have been very helpful in improving it further. The article has recently undergone Peer Review (link), where some very helpful comments were received and addressed. JFW | T@lk 20:01, 22 May 2011 (UTC)

• Source review - spotchecks not done
  • WP:MOS: we make minor alterations to quotes and titles to adhere to our typographical guidelines. For example, the title of ref 1 should use a dash instead of the final hyphen
  • Ref 11: give editor and publisher information for the larger textbook
  • It's fine to abbreviate journal titles, but you must be consistent in how you do so. For example, you abbreviate the British Medical Journal as both "BMJ" and "Br. Med. J."
  • Sources used seem appropriately scholarly, though I can't speak to source comprehensiveness. Nikkimaria (talk) 15:03, 23 May 2011 (UTC)
    • In your second recommendation, you are proposing that the editors change the citation style from the one that they chose to the one that you prefer.
    • In your third recommendation, you may wish to know that the periodical changed its name, and that therefore the name used in 1941 should not match the name used in 2008. WhatamIdoing (talk) 20:31, 23 May 2011 (UTC)
  • The periodical changed its name in 1988; the current reference list uses "Br. Med. J." for a 1990 issue. Nikkimaria (talk) 20:34, 23 May 2011 (UTC)
    • The publication itself used Br. Med. J. in its recommended citation, as you can on this scanned copy of the first page of the 1990 article (left margin, just above the image). I don't actually care which one is used—the style to follow is up to the editors at the article, and WP:CITE permits them to make up any sensible style they want—but if we follow the source's description of itself, this is arguably correct for the 1990 citation, and even if this one is changed, the article should use both names, because of the 1941 historical source. WhatamIdoing (talk) 22:49, 23 May 2011 (UTC)
    • Response
    • Ref 1 and 11 fixed. I changed the 1990 reference to "BMJ"; if the journal officially changed name in 1988 then we ought to use the new name. The 1941 source should stay the same.
    • As indicated on the talk page, I have done a pretty thorough search for reviews on rhabdomyolysis, and justified my decisions for not including material from all sources (as there is significant overlap). JFW | T@lk 09:11, 25 May 2011 (UTC)
      • Okay. I'm satisfied with the reference formatting, and I'll leave the issue of comprehensiveness to someone more familiar with the literature. Nikkimaria (talk) 16:56, 27 May 2011 (UTC)

• Review by Axl ¤ [Talk]
  • From "Mechanism", paragraph 4: "Myoglobinuria (the appearance of myoglobin in the urine) occurs when the level in plasma exceeds 0.5–1.5 mg/dl; this becomes visible to the naked eye when the level reaches 100 mg/dl." Where the word "appearance" is used, does this mean that the myoglobin is visibly apparent in urine or does it mean that it is filtered into urine without necessarily being visible? Does the value 100 mg/dl refer to plasma or urine? Axl ¤ [Talk] 20:53, 23 May 2011 (UTC)
    • The visibility in the urine depends on the plasma levels. If they reach 100 mg/dl, it is severe enough to be visible in the urine. Will change this for clarification. JFW | T@lk 09:11, 25 May 2011 (UTC)
  • From "Diagnosis", subsection "General investigations", paragraph 4: "The same phenomenon may happen in hemolysis (destruction of red blood cells); in the latter condition the blood plasma is also discolored, while in rhabdomyolysis it is normal." Two references are provided: Elsayed and Ropper. Elsayed states that the colour difference is in serum, not plasma. I do not have access to Ropper. Axl ¤ [Talk] 22:37, 23 May 2011 (UTC)
    • My mistake, and thanks for spotting that. Have changed it. JFW | T@lk 09:11, 25 May 2011 (UTC)
  • From "Treatment", subsection "Other complications": "The need for fasciotomy may be decreased if mannitol is used (see above)." What does "see above" refer to? Axl ¤ [Talk] 08:20, 26 May 2011 (UTC)
    • It is probably redundant, but it refers back to the use of mannitol as an osmotic diuretic. This is relevant if trying to treat crush syndrome in the absence of RRT facilities. I will remove the "see above". JFW | T@lk 10:06, 26 May 2011 (UTC)
  • From "Prognosis": "People with rhabdomyolysis complicated by acute kidney impairment may have a mortality rate of 20%." Could this be changed to "Rhabdomyolysis complicated by acute kidney impairment may have a mortality rate of 20%."? Axl ¤ [Talk] 08:22, 26 May 2011 (UTC)
    • You're right, that's probably preferable. JFW | T@lk 10:06, 26 May 2011 (UTC)
  • Reluctant oppose. The table in the section "Causes" is derived from an amalgamation of different sources. The headings (Physical, Medications, etc.) seem to have been chosen by the author of the article (i.e. JFW) rather than from a specific secondary source. The choice of which causes to include and which to omit also seems to have been chosen by JFW. I discussed my concerns at the recent peer review and we (JFW & myself) have been hoping to gain consensus from more editors. Axl ¤ [Talk] 16:08, 27 May 2011 (UTC)
    • I am sorry to hear that, especially after I went through quite a lot of effort to address other concerns, and indeed have tried to get more feedback from other editors. Another point: none of the other reviewers on the FAC have expressed particular concern with either the grouping of the causes or the fact that not every cause is individually sourced. Some editorial judgment had to be applied - Warren (Muscle Nerve 2002) has more than one full page of reported causes. It bears remembering that a large proportion of causes reported in the literature made the scene because of isolated case reports. The references for each section do support the causes listed in those sections. With regards to the grouping, this is based on CritCare2005 (as I explained on the Peer Review page), but with separate sections for medication (as this was a very large subgroup) and genetic/heriditary causes. Rewriting the Causes section would require a significant amount of work that I am happy to undertake if there is consensus that for the purposes of WP:WIAFA the current section is not sustainable. JFW | T@lk 16:26, 27 May 2011 (UTC)
    • Axl, I'm not sure that I understand your concern. Surely organizing the list of significant causes—there are 20 major causes, and some of them have six or eight subtypes—according to some sensible scheme is better than presenting them randomly, or alphabetically. How exactly would you have presented this list of ~100 items? WhatamIdoing (talk) 20:11, 29 May 2011 (UTC)
      • I dislike your implication that I am recommending a scheme that is random or alphabetical, or otherwise not "sensible". As I stated above, I discussed my concerns at the recent peer review. (Diffs [2] & [3]) Axl ¤ [Talk] 10:18, 30 May 2011 (UTC)
        • I apologize for appearing to suggest that you supported randomness; I have read your comments at the peer review, and you supported incompleteness. You argued for following the organization used by a good source, and when you learned that (1) every source uses a different organizational system (many of them radically different and mutually incompatible; others only somewhat different), and (2) no source contains the complete list, you argued for presenting a noticeably incomplete list, so that the organizational scheme could be easily copied from the one source whose list was being copied. You presented no possibility of an approach that would allow all of the multiply sourced material to be presented. You also presented no arguments about how to choose which of the multiple high-quality sources should be used and which of the sources' material should be omitted. Fundamentally, deliberate incompleteness, in the name of not making editors use their brains to figure out how to summarize and describe material taken from from multiple high-quality secondary sources (something editors are supposed to do), doesn't seem like appropriate to me. WhatamIdoing (talk) 01:00, 31 May 2011 (UTC)

" when you learned that (1) every source uses a different organizational system (many of them radically different and mutually incompatible; others only somewhat different), and (2) no source contains the complete list, you argued for presenting a noticeably incomplete list "

— WhatamIdoing

You think that I didn't know that different sources have different lists? You are mistaken.

I am surprised that you regard the Oxford Textbook of Medicine's table as "noticeably incomplete". On the contrary, I regard the Oxford Textbook's table as fairly comprehensive. There are two main differences between the Oxford Textbook's table and the current table in the article:-

1. The causes are grouped under different names. In particular, the "Genetic" causes are listed in detail in the article. In my opinion, this gives undue weight to these causes. These causes are referenced to Elsayed, which specifically emphasizes paediatrics.

2. Specific causes are added from their own sources without regard for their own weight, such as Haff disease.

Looking at the list of genetic causes, Elsayed is referenced and the article's table includes causes such as carnitine palmitoyltranferase II deficiency and cytochrome c oxidase deficiency. However there is no mention of beta-sarcoglycan or cytochrome b oxidase deficiency. Why is this? WhatamIdoing, perhaps you should be arguing that the current table is "noticeably incomplete".

Ironically, Elsayed separates its long list of genetic causes from its main diagram of causes.

" you argued for presenting a noticeably incomplete list, so that the organizational scheme could be easily copied from the one source whose list was being copied "

— WhatamIdoing

That's not true. I argued for presenting a different table (that you describe as "noticeably incomplete") so that appropriate weight is given to the causes in the table.

" You presented no possibility of an approach that would allow all of the multiply sourced material to be presented. "

— WhatamIdoing

That's true. I am happy to discuss another approach to allow material from different sources to be presented. Indeed Elsayed has used such an approach; it has one main diagram with the full list of major causes, and a separate list of the genetic causes.

" You also presented no arguments about how to choose which of the multiple high-quality sources should be used and which of the sources' material should be omitted. "

— WhatamIdoing

That is not true. I clearly stated that the source used needs to be reliable and authoritative (on a par with the Oxford Textbook), and suited to a general encyclopedia.

" deliberate incompleteness, in the name of not making editors use their brains to figure out how to summarize and describe material taken from from multiple high-quality secondary sources (something editors are supposed to do), doesn't seem like appropriate to me "

— WhatamIdoing

I agree. I am not advocating "deliberate incompleteness, in the name of not making editors use their brains to figure out how to summarize and describe material taken from from multiple high-quality secondary sources". Axl ¤ [Talk] 08:38, 31 May 2011 (UTC)

I now have access to Warren. The new table entitled "Common and important causes" follows the groups (types) used in Warren. This is an improvement over the previous table. Separation of genetic causes is also a good idea; this is done by both Warren and Elsayed. However there remains selective addition of some causes and omission of others. This would certainly be appropriate in, say, a medical journal article, but I don't think that it is the right approach in Wikipedia. Axl ¤ [Talk] 16:45, 8 June 2011 (UTC)

How do you propose I should select causes for inclusion? I have endeavoured to include causes that are consistently mentioned by most sources, and have omitted the ones that are only mentioned by a few (e.g. tularaemia). JFW | T@lk 23:40, 9 June 2011 (UTC)

• Support—My primary concerns were addressed. — Preceding unsigned comment added by RJHall (talk • contribs) 16:24, May 25, 2011

Comment—Overall a good article and it appears comprehensive. The wording is fairly technical in places, and so it's a bit of a challenge for a lay-person like me to read. (But no more than I would expect for a medical article, and most of it made sense.) Here are a few concerns:

• 1. There is perhaps an overuse of parentheses in the text, which usually indicates that the structure of the text needs to be improved. For example: "myoglobin (a heme-containing protein), creatine kinase (an enzyme) and uric acid (a breakdown product of purines from DNA)" could be written "the heme-containing protein myoglobin, the enzyme creatine kinase, and uric acid, which is a breakdown product of purines from DNA". The statement "haptoglobin (a protein in the blood) binds..." could be written "haptoglobin, a protein in the blood, binds..." or "a blood protein haptoglobin..." etc.
  2. The text appears to mix serial commas with the omission of serial commas. Per MOS:SERIAL, the article should be consistent on which form it uses (with certain key exceptions).
  3. There may be some overlinking (ex. myoglobin) and a few obvious terms are linked (earthquakes, bombing, pain, car accident, and lightning).
  4. The table in the 'Causes' section could use a caption that summarizes its purpose. For example: "Root causes for the classes of rhabdomyolysis"
  5. "The persistent contraction of the myocyte..." looks like unexplained jargon.
  6. "In addition, ..."; "...may also cause..."; "...may also further compromise...", &c. use redundant additive terms. See User:Tony1/How to satisfy Criterion 1a#Eliminating redundancy.
  7. "Phosphate precipitates with calcium from the circulation, ..." doesn't quite make sense to me. Nor does "myoglobin forms casts...", because 'casts' is often used as a verb. Perhaps a link or some clarification would help.
  8. "Its detection in blood or urine is associated with a higher risk of renal impairment. Despite this, use of urine myoglobin measurement is not supported by evidence." Huh? Can this be clarified a little?
  9. "...intended to improve acidosis..."; this seems ambiguous to me. Does it mean to reduce the acidosis or increase it? Perhaps 'alleviate'?
  10. I think that some discussion of the incidence of rhabdomyolysis in sports and exercise would make the topic more relevant for many readers. For example, this story was in the news recently.
  11. One more minor issue I just noticed: The image in the Causes section collides with the table. This causes the table to be less wide than it could be, making it look longer and more cluttered. Is there any way to fix this?
  • Thank you. Regards, RJH (talk) 21:23, 23 May 2011 (UTC)
  • Response - thanks for your detailed review from a non-medical perspective!
    1. It is always a challenge to clarify jargon without drowning in parentheses. I have changed a few glaring examples, such as the ones that you pointed out.
       • I'm not fully convinced that this couldn't be further improved.—RJH (talk)
    2. Have removed serial commas where I could find them.
    3. Some overlinking was done by other editors in recent reviews. I think important words (myoglobin) could be linked once every large section. I am mindful of WP:OVERLINK, but given that the obvious terms are all causes or symptoms of rhabdomyolysis, I think I could justify linking them in a limited (i.e. once only) fashion.
    4. I have changed the table caption to "important causes", as I have not listed every cause mentioned in the sources (Warren has more than a page of them)
       • You changed a column header, but did not add a caption (Example: |+ Important causes.)—RJH (talk)
    5. Have changed myocyte to [[myocyte|muscle cell]]
       • Unfortunately this means that the first instance of "muscle cell" in that section is now not linked.—RJH (talk)
    6. Thanks for pointing out redundant terms. I had to keep one instance of "in addition", but rephrased or slashed others. The only instance of "may also cause" was functional.
    7. Have rephrased "precipitates" to "binds"; the calcium and phosphate form crystals that are deposited in tissues, but that's not very important. I have provided a clarification for the concept of urinary casts.
    8. Have clarified why the reviewers felt urine myoglobin estimation is a waste of time.
    9. Have clarified the use of bicarbonate; it does improve acidosis (it increases the pH) and make the urine alkaline, but it doesn't protect the kidneys.
    10. We've had discussions on the talkpage about exertional rhabdomyolysis. This problem is listed amongst the "causes" (under "physical"), and we discuss the fact that recurrent exercise-induced rhabdomyolysis may point to an underlying muscle condition. There is not an awful lot more to say about it. It's ironic how the media makes heavy weather over a couple of sick footballers, but doesn't bat an eyelid when hundreds of earthquake survivors need dialysis (although there was a CNN report about the Haiti earthquake).
        • Well, it is always possible that greater attention brought to the condition among athletes and military trainees may lead to better treatment of other victims, but what do I know. I can relate better to the condition with a statement such as the following: "'If you've ever had stiff and tender muscles after exercising, you've probably had a slight case of rhabdomyolysis,' notes Marc Rogers, Ph. D., an exercise physiologist at the University of Maryland."[4] Thanks. RJH (talk)
    11. Regards. JFW | T@lk 11:12, 25 May 2011 (UTC)
    • Thanks for your further comments. I have moved the "myocyte" link further up. I thought it might be reasonable to add a link to exercise in the introduction, as this clearly seems to be a cause that gets reported on often (see Talk:Rhabdomyolysis about whether to add "Uncle Rhabdo" the vomiting clown, the logo of CrossFit). JFW | T@lk 15:07, 25 May 2011 (UTC)
    • I have also shifted the table to the "signs and symptoms" section to allow the table to fill the full width. JFW | T@lk 15:57, 25 May 2011 (UTC)
      • That looks greatly improved. Thank you.—RJH (talk)

• Image review: Some corrections needed, but the licenses and copyright status of all images in this article checks out okay to me. Jappalang (talk) 05:43, 24 May 2011 (UTC)
  • Could you tell me which corrections? JFW | T@lk 19:31, 24 May 2011 (UTC)
    • The corrections were already done by me;[5] I was just pointing out that there were issues with the declarations of the copyright status but it was not actionable (since it was readily apparent to me why it was wrong and easily changed without opposition). Jappalang (talk) 01:07, 26 May 2011 (UTC)
      • Thanks very much! JFW | T@lk 06:00, 26 May 2011 (UTC)

• A fine article. Well done JFW. My thoughts:
  • I'd remove the Oklahoma City bombing picture -- it is peripheral to the article and is still an image that unsettles people. Maybe add ragged red fibers (see right) or some other image relevant to causes instead?

    

  • I may be mistaken but I thought that furosemide was only used if ECFV was high and urine could still be produced. The conversion of anuric to oliguric renal failure in critically ill patients is still specious per this JAMA article among others). Reference 1 is cited, but reviews this with older literature from 1993-1996.
  • Doesn't myoglobin only precipitate in the tubule when it comes into contact with Tamm-Horsfall mucoprotein? I would rephrase: "As the kidneys reabsorb more water from the filtrate, myoglobin forms casts (solid aggregates) that obstruct the normal flow of fluid through the nephron; the condition is worsened further by high levels of uric acid and acidification of the filtrate. Under acidic conditions, myoglobin also interacts with Tamm–Horsfall protein, increasing precipitation."
  • Enjoyed the read a lot. Hope this is helpful. Natural hat trick 21:58, 25 May 2011 (UTC)
    • Just in case, it is decided to use the above picture, it is appropriately licensed. Jappalang (talk) 01:08, 26 May 2011 (UTC)
    • Response - thanks NHT for the comments!
      1. I agree that the London Blitz image is sufficiently illustrative. We also don't know whether any cases of rhabdo actually happened after the Oklahoma bombing. The 1999 earthquake in Turkey may be more illustrative. Is File:Izmit eart6.jpg acceptable? The trouble with the muscle biopsy image is the fact that it would need a very detailed image description for the four different stains - possibly a tad too detailed.
      2. I have added a negative meta-analysis from the BMJ that casts doubt on loop diuretics in AKI. In practice, I have still seen plenty of diuretic use in the setting of oliguric AKI. In the case of rhabdomyolysis, it appears that loop diuretics are intended to "flush out" the toxins, for better or for worse.
      3. I can't see the difference between the rephrased sentence and the current version! I will have another look at Bosch to make absolutely sure that this is correct. JFW | T@lk 06:00, 26 May 2011 (UTC)
      • IMO the possibility that an image of a bombed-out building "unsettles people" is exactly what WP:NOTCENSORED is intended to protect (a far more important situation than, say, the single, young, white males who persistently demand that Pregnancy not include any images of a fully dressed pregnant woman), but as I can find no sources directly discussing rhabdomyolysis in that particular incident, then I have no objection to its removal. WhatamIdoing (talk) 17:03, 26 May 2011 (UTC)
• Support Excellent article. Learned a fair bit reading through it.Doc James (talk · contribs · email) 02:40, 26 May 2011 (UTC)
  • Thanks for the tightening of the headers. I am mindful of the fact that the "prognosis" section is now only one paragraph, but I would not like to merge it with "epidemiology" unless absolutely necessary. JFW | T@lk 06:00, 26 May 2011 (UTC)

• I have previously crawled through sources on this article, so I skipped the source review today. Here are my notes:
  • Commas
    • Under ==Causes==, Should there be a comma before "such" in the sentence that ends "...and when statins are used in combination with particular other medicines such as ciclosporin."?
    • Under ==Diagnosis==, I'm not sure whether there should be a comma added before "although" in this sentence: "The incidence of actual acute liver injury is 25% in people with non-traumatic rhabdomyolysis although the mechanism for this is uncertain."
  • Clarifications
    • Under ==Causes==, are the "Infections" listed a reasonably complete list? If not, should they be labeled as examples? (If it's a reasonably complete list, then I would not add weasel words like 'includes but is not limited to'; if it's a seriously incomplete list (=pretty much any infection could cause this), then it might be worthwhile. In between those two extremes, I might start the list with "such as", or leave it as is.)
    • Under ==Diagnosis==, DIC dx is described thusly: "The diagnosis can be confirmed with particular blood tests, such as D-dimer." Is this part of a standard DIC diagnostic workup? If so, I might say "can be confirmed with standard blood tests for DIC, such as D-dimer", rather than "particular blood tests"
    • Under ==Treatment==, the sentence runs, "Its advantage over continuous hemofiltration is that one machine can be used multiple times a day..." Is this an advantage from the perspective of the hospital, i.e., that you buy one machine, and four patients can use each day? Or is it an advantage from the perspective of the patient, e.g., maybe you can get more thorough filtration with multiple sessions with this machine than with one 24-hour session with the other?
  • Content
    • In the category of 'providing what the reader expects', I think that readers will expect to see more about exercise-induced rhabdomyolysis. Normally I'd be happy to put this in a ==Society and culture== section, but I haven't ever found any good sources for it. Jokes about "Uncle Rhabdo" can be demonstrated to exist, but there don't seem to be any sources describing or analyzing the phenomenon of exercise enthusiasts glorifying this serious medical condition (as a sort of badge of honor to demonstrate your dedication to exercise). So I'm inclined to leave it out, but I expect to get (more) complaints about that.
  • Support. Overall, I support listing this as a FAC. WhatamIdoing (talk) 23:29, 26 May 2011 (UTC)
    • Response - thank you for your comments and for your support
      • Commas: have added a comma to the first instance. In the second, I thought the word "although" was not justified, and have liberally applied a semicolon to separate the two parts of the sentence.
      • Clarifications:
        • Causes: he list of infections was lifted almost entirely from CritCare2005. Warren gives a much longer list that includes many more pathogens but, for instance, not tularemia. I get the impression that both lists are built on case reports sprinkled throughout the medical literature, and there is certainly not a study that says what proportion of rhabdomyolysis is due to particular infections. Elsayed gives a total of 5%, and mainly lists viruses, but without a breakdown. I have now removed tularemia (because it is not in all sources and probably not an important cause), and added "such as" as you suggested.
        • Diagnosis: DIC is essentially a clinical diagnosis, although there are scoring systems endorsed by ISTH. D-dimer, fibrinogen, other coagulation parameters and platelet count are all included in the assessment. I have followed your advice and rephrased the sentence.
        • Treatment: there are little data to suggest that CVVH (hemofiltration) is better than haemodialysis, but in resource-constrained circumstances (such as an earthquake) it might be possible to treat more people with the same equipment. In most Western countries I would imagine people being treated for rhabdomyolysis to be initially treated with haemofiltration, and converted to haemodialysis if the renal function does not recover after a period of time but the patient is otherwise well. I have not put this in the article because the sources don't say so outright.
      • Content: there is really not an awful lot more to say about exercise-induced rhabdomyolysis, other than that it can... well... happen after exercise, and we are already saying that repeated exercise-induced rhabdomyolysis might point towards an underlying muscle disorder. There are a few secondary sources that focus specifically on exercise-induced rhabdomyolysis, but none offer much by way of additional perspective. Paying attention to anecdotal reports detracts from the "big picture" view that we are trying to take. JFW | T@lk 02:18, 29 May 2011 (UTC)

• Comments beginning a (second) read-through now...I'll jot notes below...Casliber (talk · contribs) 12:32, 3 June 2011 (UTC)

Okay, I'd rejig the lead. In a nutshell, the syndrome is the muscle breakdown and the resulting release of all the crap in the bloodstream. Hence sentence #2 (a cause) is inserted between a nutshell description. I'd move it down to be the second last sentence (i.e. just before treatment.) I'd move the sentence on treatment from last setence first para to first sentence second para.

The Signs and symptoms begs for an opening sentence along the lines of "The symptoms vary markedly depending on the severity of the condition." This then segues into the first sentence nicely - as is, section just "jumps into" current-first sentence.

Anything that damages muscle tissue can cause rhabdomyolysis -ooooh (sharp intake of breath) - I love plain English but the first word to me veers a little to far into casual-speak...but I can't think of an alternative that fits better. This is not a deal-breaker but maybe some round-tabling here might come up with a better way of saying it.

(sigh) I think I agree with Axl on the table of causes. I have problems with each on fine-tuning and omissions (eg. Oxford doesn't have prolonged immobility (such as in drug overdose) which would slot in well after overactivity - I am a psychiatrist, so the two conditions I see related to rhabdomyolysis are NMS and drug ODs) but it is more orthodox and in line with lots of other multi-cause layouts I've seen......the other is weird - the physical/non-physical split needs defining, but the source doesn't and it is a rather clumsy (and somewhat arbitrary) split to say the least (why is NMS physical? I always thought it was mediated by the dopamine blocking activity...) - I'd use the oxford table, unless we find another one similar but better, sorry.

The bottom half is good.

I hate see also sections - I'd make an In other animals section and have a few words on Equine exertional rhabdomyolysis there. Are there any other issues specific to other animals worth listing? Outside of medicine, some areas have very lean pickings and one might need to use some primary sources. Casliber (talk · contribs) 04:18, 5 June 2011 (UTC)

Overall, I do think the finishing line is in sight, but we do have a big deal-breaker to sort out. Casliber (talk · contribs) 14:22, 3 June 2011 (UTC)

• • Response - thanks for your ongoing input Casliber; your comments at PR were very helpful and I can always use help with my grammar!
    • Intro rejigged to get a better flow.
    • Done an opening sentence for "signs and symptoms" - agree completely that this improves things a lot
    • I have had a go at improving the opening sentence of "causes" - hope this seems good
    • The table of causes will need a revamp, and I will work on this tomorrow night.
    • Turning the "see also" into a section means that I had to do some research on non-human rhabdomyolysis. Most non-human rhabdomyolysis I can find on PubMed and Google Scholar has been reported in horses, so I have written a few lines about this. Unfortunately most of the sources are difficult to access. Strangely, it is difficult to find secondary sources on Equine exertional rhabdomyolysis (which was the only article linked in "see also"); I'm not entirely sure how to resolve this.
    • I will alert you when I've done the final work on the table of causes, and hopefully win your support with that. JFW | T@lk 15:15, 3 June 2011 (UTC)

Lead is good. After a brief review of the article's lead section, the details of which can be found on the FAC talk page, I am happy to report that the lead is satisfactory. --Cryptic C62 · Talk 01:24, 9 June 2011 (UTC)

• I do not have access to Warren, "Rhabdomyolysis: a review". I see that many of the individual causes within the table have their own references. Axl ¤ [Talk] 11:47, 5 June 2011 (UTC)
  • Yes, I've followed Warren with regards to the classification of the causes, as you suggested. With regards to the individual causes listed I have applied editorial judgement. For instance, statin myopathy is one of the best researched types of rhabdomyolysis, and some expansion was therefore necessary in this area. I don't think we can lift an entire list of causes from one single source and ignore the others. JFW | T@lk

TCO comments. I did a quick skim of the article and of the discussion here.

1. I think the causes table is fine, to be a synthesized version of several sources. Think just copying one list in items and in layout would not be ideal (verges on copying and also is not comprehensive). Prefer that we have thought out the arrangement here, nothing wrong with that (we do it with content all the time). I would feel better if we sourced each cause (allows someone to rapidly see which source predominates and decide which reviews to look at (if one endnote number "dominates"). Also think it may be possible to pretty up that table and just make it look a little crisper (ask RexxS to take a look at it).
2. The two pictures of proteins look very similar and don't give that much information other than being a complicated bunch of colored tape. I would just do one of them. (Since you are really not getting deep into some structural discussion of how the conformation affects function.)
3. If you had a picture of a suffering patient that would be good.
4. I have seen a lot of stuff in the popular press about Crossfit and rhabdo. Should it be mentioned in article? See for instance: [6]
5. Net/net: looks decent and fascinating topic. Haven't looked at article close enough to support or oppose. TCO (talk) 15:54, 5 June 2011 (UTC)

• • Response - thanks for your comments
    1. I have yet to come across an article of this kind where every single cause is individually sourced. This would place a burden on the reader (a reference every 1-2 words) and on the referencing apparatus (30 additional references to a source like NEJM or Warren alone?) As I stated above, most causes listed in the secondary sources are actually based on small case series or case reports; only the evergreens such as crush injury, statin myopathy and malignant hyperthermia have a representative body of literature behind it.
    2. I agree that the protein pictures are not particularly informative beyond saying "this is how it looks when drawn by a computer programme on the basis of some crystallographic data". There are not many other images available that could be used to replace either of them. In the case of creatine kinase, I have used the image caption to provide a little bit more offline information about the enzyme.
    3. To my knowledge, there is no free image on Commons of a patient. To be honest, it might be difficult to get advance consent from someone with a "proper" case of rhabdomyolysis.
    4. We've had long discussions about Crossfit on the article's talkpage. I have made several concessions: we now place more emphasis than before on rhabdomyolysis induced by heavy exercise. A bunch of tough blokes overdoing it a bit makes for marvellous headlines. In real terms, for all the hype, no scientist has bothered to write about CrossFit in the medical literature (Pubmed search), which I find a pretty good indication that this should not receive more coverage than, say, earthquakes with 1000s of victims.
  • JFW | T@lk 20:43, 5 June 2011 (UTC)
• I wouldn't give up so fast on the referencing. If you are really compiling the list from different sources, this would make sense to show where they came from. I would not expect you to show every reference that lists every cause. (IOW, every listed cause should have at least one reference, but not every study or review). Probably just use the best one or two review articles that hit most of the causes, first, then fill in the oddballs with the study that supports them. IOW, I am fine that you are showing a synthesized product, just show where the components come from. I don't think it is that painful to read, since the stuff is in a table anyway. Or maybe you could just have a references column like in state reptile.
• On the Crossfit, leave it out of here. It is mentioned in the Crossfit article, which is a better place for it.TCO (talk) 21:04, 5 June 2011 (UTC)
• Yeah, I just looked on Flickr and Google and there is not much free stuff available. However there are several copyrighted images that show damaged tissue (think would be encyclopedic and kind of cool and better than another protein conformation picture). If you know of a prominent researcher or something like that who has good images on the web or in publications, we could write and ask for a donation. (Half the images in painted turtle were donations...you get more better stuff that way.) I'm pretty good at it and used to it, so if you know a good source (best thing is an academic, not a journal), let me know and I can write for permission. Not sure if the patient really has to give permission (not sure our Wiki rules), especially if their face is not shown, but obviously there are images going into journal articles of patients bodies all the time. No one has yet told me that the turtles needed to sign waivers.  ;) TCO (talk) 21:18, 5 June 2011 (UTC)
  • Having just completely rejigged the table of causes in response to two other editors, I am going to await their responses before making further major changes.
  • The trouble with most rhabdomyolysis is that you can't see much on the outside; you would see an ill-looking human being in a hospital bed, perhaps connected to a dialysis machine. That is, unless there is extensive injury or the surgeons have been along to do fasciotomies. File:Fasciotomy leg.jpg is fairly illustrative for one complication (compartment syndrome). JFW | T@lk 21:29, 5 June 2011 (UTC)

Nominator comment - I am very grateful for all the support votes so far. I don't think there are any concerns outstanding. I have asked Natural Hat Trick offline whether their comment implies Support. I have asked Axl if he will revise his Oppose vote now that I have substantially rejigged the "Causes" section; a copy of Warren has been emailed for review. I have also asked Casliber if the rejigged "Causes" section satisfies his concerns. I will be offline for the next 48 hours or so, because some things are still more important than an FAC. I will make sure to address any further comments on my return. JFW | T@lk 19:30, 7 June 2011 (UTC)

FWIW, I think we're definitely on the right track. I was sitting down comparing Warren to the article and musing on how I felt when other things intervened. I will rejoin the debate anon....and eat plenty of cheesecake (sounds like some nice food is on order over next 48h) Casliber (talk · contribs) 04:21, 8 June 2011 (UTC)

Back on wiki and cheesecake duly consumed. JFW | T@lk 23:40, 9 June 2011 (UTC)

The above discussion is preserved as an archive. Please do not modify it. No further edits should be made to this page.