Wikipedia:Peer review/Traumatic brain injury/archive1

Traumatic brain injury

• A script has been used to generate a semi-automated review of the article for issues relating to grammar and house style; it can be found on the automated peer review page for November 2008.

This peer review discussion has been closed.
I'd like to take this to FAC eventually, and would like any feedback, especially with respect to accuracy and completeness. Thanks much! delldot ∇. 07:36, 8 November 2008 (UTC)

First of all I want to say that a fast look to the article has given a very good impression. I believe that in the short term this article will surely become FA. I am going to try to review from top to bottom, but it will take me quite a long time; so be patient. My interest in the article comes because I worked for 3 years in a Brain damage association where many of the participants had suffered TBI. Right now I do not work with TBI but I do work investigating neuropsychology of neurological pathologies (I am a psychologist). Anyway here goes a comment for the introduction of the classification.

Classification

Introduction

• impairment of brain function without physical damage may also be included in the definition of TBI: First of all: how can we be sure that there has been no physical damage? It would be a good idea to say "apparent", since evidence comes from neuroimaging techniques which are not perfect. Secondly: is the reference the same one than for birth at the end of the sentence?: it is a ref about treatment: it would be probably better to search for a general review similar to the one of lancet and not one centred in treatment.

• Good point on the first issue, done. Second point, yes the ref covers both facts. I'll look for a more general review for the info. delldot ∇. 21:37, 12 November 2008 (UTC)
• Replaced treatment review with more general one. delldot ∇. 05:53, 15 November 2008 (UTC)

• and trauma that takes place during birth is excluded from the definition.: better to add it to the next sentence which talks about the difference between congenital and acquired since it is a perinatal brain injury.

• Couldn't figure out how to add it to that sentence, which was already a little long, but I separated it out and put it right before that one. delldot ∇. 21:37, 12 November 2008 (UTC) Integrated into next sentence. delldot ∇. 03:46, 13 November 2008 (UTC)

• TBI is classified based on severity, location, mechanism of injury, and other injury characteristics.: They are possible classifications: I would say TBI can be classified...

• Done. delldot ∇. 21:37, 12 November 2008 (UTC)

• Only as a way of not repeating skull: How about changing A depressed skull fracture occurs when pieces of the broken skull to when bone pieces...

• Good idea, done. delldot ∇. 21:37, 12 November 2008 (UTC)

• A depressed skull fracture occurs when pieces of the broken skull press into the tissue of the brain.; TBI is one of two subsets of acquired brain injury (brain damage that is not congenital); the other subset is non-traumatic brain injury, which does not involve external mechanical force (examples include stroke, meningitis and insufficient oxygen);and Similarly, brain injuries fall under the classification of neurotrauma and central nervous system (CNS) injuries. need a ref (probably one of the already provided)

• I'm glad you brought this up, it turns out that depressed skull fractures usually or commonly send pieces of bone into the brain but that's not part of the definition. So I removed this sentence as a bit of a tangent (there's a link to skull fracture in the previous sentence). Neurotrauma and CNS are done, still working on done with ABI. delldot ∇. 02:46, 13 November 2008 (UTC)

More to come tomorrow. best regards. --Garrondo (talk) 14:17, 12 November 2008 (UTC)

Thanks so much Garrondo, I'm thrilled to have a review from someone with your experience in the field, especially one so detailed as this. Take your time with the review, I certainly appreciate the time you're putting in. delldot ∇. 21:37, 12 November 2008 (UTC)

I give it another go.

Severity

• A general comment: From my point of view entering into detail about the different scales makes the section a bit confusing and difficult to follow. I would try to simplify it.

• Good point. What do you think now? delldot ∇. 02:25, 14 November 2008 (UTC)

• The Glasgow Coma Scale is a universal system for classifying TBI severity.[2]: After this sentence I would give a sentence explaining what does it measure since people may think that it only measures coma, while it is really a consciousness scale.

• Done delldot ∇. 02:25, 14 November 2008 (UTC)

• In a similar system, the criteria are the same as listed in the table, except that trauma is only severe if unconsciousness and post-traumatic amnesia last for over a week.[14] Other classification systems use PTA or LOC alone or together.[12]: I feel this is too much specific: I would summarize it into something like: Similar variations have also been proposed and give the refs. (Or even simply eliminate the 2 sentences). My rationale is that going into such detail is only of interest for physicians and not for general reader.

• Good point. Reduced the sentences. delldot ∇. 02:25, 14 November 2008 (UTC)

• Findings on the frequency of each level of severity vary based on the definitions and methods used in studies. A World Health Organization study estimated that between 70 and 90% of head injuries that receive treatment are mild,[15] and a US study found that mild and moderate injuries each account for 10% of TBIs, with the rest mild.[16]: This is truly epidemiology. I would create a separate subsection in epedimiology about severity.

• Moved to epidemiology. I didn't want to create a separate section, since the roboreview claims the TOC is already too long. delldot ∇. 02:25, 14 November 2008 (UTC)

• The scales use duration of unconsciousness, post-traumatic amnesia, and other concussion symptoms to gauge severity.: This is an introductory sentence. Should go at the very begining of the section, before GCS. Or does it refer only to concussion? It is not clear. Also Unreferenced.

• It refers to the concussion scales, I combined the sentences to clarify. It's very basic uncontroversial info ref'd in the concussion grading scales article, so I didn't think a ref was necessary. delldot ∇. 02:25, 14 November 2008 (UTC)

• with at least 16 concussion grading scales in use.: Saying how many too much specific and also prone to change: Maybe in a few years only 1 is used or maybe 30. Probably better to say with different scales.

• Done delldot ∇. 02:25, 14 November 2008 (UTC)

• Can you give a wikilink to "resuscitation"? The medical meaning (at least in spanish) is not the same to the normal use meaning.

• Done. delldot ∇. 02:25, 14 November 2008 (UTC)

• which can be helpful for comparing results of clinical trials or health care: I believe this is also too much specific and at the same time not inclusive enough since I do not think that this is the only purpouse of such scales. I would eliminate this part of the sentence.

• Good call, done. delldot ∇. 02:25, 14 November 2008 (UTC)

• An internal link for prognosis?: Not common knowledge for general reader.

• Done. delldot ∇. 02:25, 14 November 2008 (UTC)

• according to the table at right: Personal preference: I do not like self reference comments such as this one. Is it really needed? I would say it is not.

• I think I need this to reference the example after rearrangements made above, but yeah, the 'at right' was unnecessary so I took it out. I think there's a guideline in MOS somewhere, I'll try to find it. delldot ∇. 02:25, 14 November 2008 (UTC)

More to come in the afternoon or tomorrow. Best regards--Garrondo (talk) 10:18, 13 November 2008 (UTC)

More great stuff Garrondo, thanks much. I think this is really improving the article! delldot ∇. 02:25, 14 November 2008 (UTC)

I do not think that I can finish with focal and diffuse today but I'll try

Focal and diffuse

• While useful, classification based on severity does not give information about the pathology of the injury or how to treat it; systems also exist to classify TBI by its features: Different problems with this sentence: while useful is an unneeded opinion, classification on severity does give info on treatment (at least on the need of chronic care)...: I would simply say: Systems also exist to classify TBI by its pathological features.

• Done. I'm glad you're offering ways to cut down on length, too, this article is too long! delldot ∇. 02:37, 15 November 2008 (UTC)

• confined to one area of the brain or involving a wider area, respectively.: Diffuse does not depend on how big the area is: there can be a focal damage to the almost the whole brain. How about saying confined to specific areas or the brain or affecting it as a whole in an unspecific manner?: My wording is horrible so try to find a better way to say it, but involving area is uncorrect. Also a ref is needed

• Reworded. Still working on ref. delldot ∇. 05:53, 15 November 2008 (UTC)

• Types of injuries considered diffuse include concussion and diffuse axonal injury and shaken baby syndrome commonly manifests as diffuse injury.: I would succinctly explain what is diffuse axonal injury. The sentence on shaken baby syndrome: I believe it is too much specific and I would remove it or move it to the causes section: IT can be seen as a cause for diffuse axonal injury. Also unreferenced

• Definition of DAI added. Ref provided. SBS info moved to mechanism section, ref provided. delldot ∇. 02:37, 15 November 2008 (UTC)

• Diffuse axonal injury is often associated with coma and poor outcome.[2]: this is prognosis

• Moved. delldot ∇. 02:37, 15 November 2008 (UTC)

I have to go. Sorry, but I will have to continue on Monday this section.--Garrondo (talk) 15:31, 14 November 2008 (UTC)

That's fine Garrondo, you're going far above and beyond what I could have asked or hoped for in a reviewer, I really appreciate it. delldot ∇. 02:37, 15 November 2008 (UTC)

I have been involved in a very stressful FAC, and right now I needed to feel useful; and this seemed a wonderful way: a very well written article in one of the themes a like most in a one-to-one talk to a person who does as much as he can to improve the article: feels great... At the same time I crossed with you at the Alzheimers FAC, and your comments were as many and as useful as I want mine to be. :-) Best regards.--Garrondo (talk) 20:37, 16 November 2008 (UTC)

I continue with Pathological features. Only a general note on style: I have seen that the word brain appears hundreds of times: many of them are needed but many others it is not since it is clear that all time we are talking about brain damage and brain location. It would be great if you can reduce its overuse.

Sounds good, I'll do a read-through for repetition and unnecessary wording. Always happy to find ways to cut it down. delldot ∇. 02:11, 18 November 2008 (UTC)

• those that occur in a specific location in the brain: It has already been defined; not needed.

• Done delldot ∇. 02:11, 18 November 2008 (UTC)

• are often associated with symptoms corresponding to the part of the brain that was injured: This might be my neuropsychological bias but I would rather say something like: often produce symptoms related with the functions of the damaged area: the important thing is not directly the area, but the functions it holds.

• Good idea, done. delldot ∇. 02:11, 18 November 2008 (UTC)

• for example manifesting in hemiparesis (partial paralysis on one side of the body) or other focal neurological deficits.: if you are going to say examples say also why they cause it. My proposal: often produce symptoms related with the functions of the damaged area, for example manifesting in hemiparesis or aphasia when motor or language areas are respectively damaged. Also a ref would be needed (I know it is well known facts, but at FAC there is some people prone to ask for them).

• Good wording, thanks. I expect I'll find a ref for that no problem during the course of working on the article, I'll keep it in mind. delldot ∇. 02:11, 18 November 2008 (UTC)

• The section on hemorrages is very difficult to follow. Here is a reordering proposal, but I am not sure if it is correct. I assume that all hemorrages are hematomas. Is it true? I would also simplify the last sentences on extra-axial, centring the text only in location and not consequences so as to make it more easily readable:Another type of focal injury are hematomas. Hematomas are collections of blood in or around the brain. They are divided in intracranial hemorrhage, which involves bleeding that is not mixed with tissue. and intracerebral hemorrhage, with bleeding in the brain tissue itself. While the former is an extra-axial lesion the latter is intra-axial. Extra-axial lesions include epidural hematoma, subdural hematoma, subarachnoid hemorrhage, and intraventricular hemorrhage. Epidural hematoma involves bleeding into the area between the skull and the dura mater, the outermost of the three membranes surrounding the brain. In subdural hematoma, bleeding occurs between the dura and the arachnoid mater. Subarachnoid hemorrhage, involves bleeding into the space between the arachnoid membrane and the pia mater. Intraventricular hemorrhage occurs when there is bleeding in the ventricles.

Good stuff, I'm using it with some changes. Hematomas are collections of blood that can result from hemorrhages. Intracranial hemorrhage covers all bleeding within the skull. I'll try to clarify, and will find refs for everything that's missing them. delldot ∇. 05:12, 18 November 2008 (UTC)

More later or tomorrow; but after a quick glance at signs and symtoms I believe that the section would have to be expanded: it is centred in the acute or subacute stage, but not much is said about the chronic stage. Maybe it would be a good idea to subdivide the section is these 3 stages and talk about each of them, since the signs and symptoms are quite different. Best regards.

I covered the longer term results in complications. There's so many of them that any section that covers it is going to be vast; in fact a spinoff, complications of traumatic brain injury, has been created. As I understand it symptoms is more for the earlier, clinical bases for diagnosis, and complications covers the later stuff. But I'm glad to reorganize if necessary, let me know what you think should be done when you read it. delldot ∇. 05:12, 18 November 2008 (UTC)

Ok, since this is a peer review and not a FAC proccess there is no time rush and we can always come back to a section. Lets leave it for the moment like this and we'll see later. Just for curiosity, where are you from? I ask it because you edit exactly in the opposite hours I do it :-) Best regards. --Garrondo (talk) 08:02, 18 November 2008 (UTC)

OK, I'll solicit others' input, too. I'm on the east coast of the US, at UTC -5. At least we'll never edit conflict each other! :P delldot ∇. 04:34, 19 November 2008 (UTC)

I have been thinking on the section and I believe that complications should be unified with signs and symptoms. I would do a small introduction and then leave the signs and symptoms as short-term and complications as long-term, or complications. Main reasons are because there is not a complications section is MEDMOS and also because the word complication gives the feeling that something has gone wrong, while the truth is that most patients with moderate or severe will have them. --Garrondo (talk) 16:21, 18 November 2008 (UTC)

Could rename 'complications' to 'long-term effects' or 'consequences' to avoid that connotation (although some things mentioned are definitely complications, e.g. DVT). I'm more interested in producing a high-quality article than on adhering strictly to MoS, even if it means a harder time at FAC, so I'd rather consider the naming of the sections based on what works best in this article. MEDMOS wasn't really written with trauma articles in mind, it seems. I'm reluctant to move long term effects up because the page is at the moment somewhat chronological (e.g. prevention and diagnosis before treatment). It would seem odd to be discussing the long-term effects so early on in the article, before issues like acute treatment are discussed. Also, I don't really think of long-term disability as 'symptoms'; I think of the latter word as meaning 'clinical indicators on which to base a diagnosis'. Discussion on disability could be moved to under prognosis maybe, that's how subarachnoid hemorrhage does it. At any rate, I'll certainly be thinking on what to do about it and we can keep discussing it throughout this review. delldot ∇. 04:34, 19 November 2008 (UTC)

This is probably your decision. Maybe a good name (a bit long anyway would be "consequences and complication", since as you say some are not complications but long-term effects and other are truly complications. Regarding position; if it is left down on the page I would write a few lines in the signs and symptoms, something like a summary. Best regards--Garrondo (talk) 08:20, 19 November 2008 (UTC)

Haven't had much time today but I'll keep working. Thanks again Garrondo, this is great stuff. delldot ∇. 05:12, 18 November 2008 (UTC)

Until we take a decision about the signs and symptoms section I jump to next section.

Causes

• General comment: My main problem with this section is that it gives some figures but it is not said where do they apply. I do not think they are world-wide, (probably US). Other articles on TBI epidemiology-causes in other countries would be needed or even better world wide. I cannot do a more in-depth revision of the section until it is expanded to give a world-wide view or at the very least say where the sentences provided apply. Anyway some minor comments:

• Very good point, I'll work on making it less US-centric. delldot ∇. 04:34, 19 November 2008 (UTC)

• and has been identified as the "signature injury" among wounded soldiers of the current military engagement in Afghanistan and Iraq: it is unneeded and quite US-centric and recentist.

• Done. delldot ∇. 04:34, 19 November 2008 (UTC)

• United States Centers for Disease Control and Prevention: give only the initials to summurise

• Done. delldot ∇. 04:34, 19 November 2008 (UTC)

• Image:the most common is falls, followed by vehicle accidents, then striking or being struck by something: Not needed: info is in the image, main text and ref.

• Done. delldot ∇. 04:34, 19 November 2008 (UTC)

Best regards... More to come following days (I hope you are not in a rush... I have a lot of work these days and I only have less than half an hour a day for wikipedia.).--Garrondo (talk) 16:21, 18 November 2008 (UTC)

No rush at all, take your time. I have plenty to catch up on (I'm not ignoring your earlier comments, just haven't had time to get to them all). I'll work on expanding the causes section to give it a worldwide view. Thanks again, this is really good input. delldot ∇. 04:34, 19 November 2008 (UTC)

This is not a FAC so take those comments that you find useful and do not take those you don't like, and anyway... take your time. Best regards. --Garrondo (talk) 08:20, 19 November 2008 (UTC)

I begin with the mechanism section. Little by little we are approaching the end... :-)

Mechanism

• General comments: I know you have said that you do not want to strictly follow medmos, however I would include mechanism inside the causes section either as a subsection or simply after the causes text. The reason is that I feel that mechanism and causes are very closely related, having each kind of cause an specific kind of mechanism. (And you simplify the firs level structure of the article, which right now is a bit complicated and ease things at FAC)

• I see what you're saying but I don't think causes and mechanism are that closely related; causes is about the history, whereas mechanism focuses on the types of forces involved. However, mechanism and pathophysiology are kind of related, and MEDMOS calls for "Pathophysiology or mechanism". What do you think of combining the two sections to "Mechanism and pathophysiology"? I've done this as a trial thing, not sure if I like it or not. delldot ∇. 02:24, 24 November 2008 (UTC)

• First paragraph: I would simplify it a lot since it is quite difficult to follow. I would leave the paragraph simply like this: The type, direction, intensity, and duration of forces all contribute to the characteristics and severity TBI.[2] Forces that may contribute to TBI include angular, rotational, shear, and translational forces with refs 19 and 37 after it. Rationale is that everything after is too much specific, saying what each kind of force produces. After it I will continue with Even in the absence of an impact...

• Done (except ref 37 didn't cover that content) delldot ∇. 02:24, 24 November 2008 (UTC)

• Shock waves can also destroy tissue along the path of a projectile in penetrating injuries through a cavitation injury mechanism: Ok, this is probably true (I did not know it), however you haver forgotten to say that the the projectile itself causes a direct damage (You probably forgot due to its obviousness... :-)

• Done delldot ∇. 02:24, 24 November 2008 (UTC)

• In impact loading, the force sends shock waves through the skull and brain, resulting in tissue damage.[19] Shock waves can also destroy tissue along the path of a projectile in penetrating injuries through a cavitation injury mechanism.[14] Pressure waves propagate through the tissue, forcing it out of the way and creating a temporary cavity; the tissue quickly moves back into place, but is damaged.: Maybe it could be summarized into something like: Shock waves can also destroy tissue in penetrating injuries, through a cavitation injury mechanism, or after impact loading.

• Reworded, what do you think? delldot ∇. 02:24, 24 November 2008 (UTC)

• The mechanism, especially for contrecoup injuries, is a subject of much debate; potential mechanisms include the effects of inertia on the brain within the skull, movement of the cerebrospinal fluid that surrounds the brain,[39] and inbending of the skull.[19]: I would eliminate this sentence:

the info does not add much very interesting since it is too much specific.

• Image: it is a great image, however right now in most computers it is out of the section due to the causes section image. Until the causes section is expanded it might be a good idea to leave any one of the two in the talk page.

• I'm not happy with the image placement currently either, but I've decided to postpone worrying about it until I have a more final draft; I'm sure so many changes will take place that it'll get worked out in the end. You're right though, this will have to be fixed before taking it to FAC. Of course, suggestions are welcome. delldot ∇. 02:24, 24 November 2008 (UTC)

I have proposed quite a lot of eliminations in this section to ease the following and structure of the section. Since the info is correct and it is a pity to loose it I would post it in the talk page until a secondary article is created (Maybe one about causes and mechanism in the near future?). More to come:

Best regards. --Garrondo (talk) 14:13, 19 November 2008 (UTC)

Hey, hey, hey... Today I have some more time and I am also going to attack the pathophisiology section.

It is the section I know less, but I will still try:

Pathophisiology

• First paragraph sounds great
• changes in the blood flow to the brain; hypotension (low blood pressure) and isquemia,: They should be together since they are all blood-flow related. How about Other factors in secondary injury are changes in the blood flow to the brain such as ischemia (insufficient blood flow) or hypotension (low blood pressure)...

• Good suggestion, done. Got rid of hypotension, because that's systemic and would accompany TBI but not be caused by it. delldot ∇. 02:24, 24 November 2008 (UTC)

• ...intracranial pressure (the pressure within the skull).[45] Intracranial pressure may rise due to swelling or a mass effect from a lesion: A minor simplification could be intracranial pressure (pressure within the skull), which can rise due to swelling or a mass effect from a lesion

• Good suggestion, but I'm not sure how to implement it. In the first sentence, which is already quite long? Or in the second sentence, which would leave the first mention without the definition? delldot ∇. 02:24, 24 November 2008 (UTC)

• is reduced; ischemia (insufficient blood flow to tissues) results: isquemia has already been defined. Info in brackets is not needed.

• Good catch, done. delldot ∇. 02:24, 24 November 2008 (UTC)

• in which parts of the brain are squeezed past structures in the skull: is this sentence correct? What means past here?

• How about "parts of the brain are squeezed by structures"? delldot ∇. 02:24, 24 November 2008 (UTC)

• or potentially deadly herniation: Potentially deadly is not needed since most complications commented (hypotension, ischemia...) are also potentially deadly.

• Done. delldot ∇. 02:24, 24 November 2008 (UTC)

• No medication exists to halt the progression of secondary injury,[36] but the variety of pathological events presents opportunities to find treatments that interfere with the damage processes.[2] For example, mechanical ventilation and fluid resuscitation seek to ensure adequate oxygen and fluid levels respectively.[47]: All these is treatment. I think it should be moved

• Moved the first sentence to Research directions, where it creates a nice intro for the relevant idea (We're working on finding ways to interfere with secondary injury processes). The fluid and ventilation is already covered in treatment, so removed. delldot ∇. 02:24, 24 November 2008 (UTC)

Well that's it for today...As you have probably seen in my talk page I am spanish; and here is 8 pm, so as you said we will hardly have edit conflicts. This is the longest peer-review I have done (It is truly only my second peer-review), and I hope you find it useful. Anyway, I promise that as soon as I finish with it I will closely collaborate with you to take it to FA. At the same time if you need, I have access to most medical journals, so if you need access to an specific article you can ask me. Best regards, and see you tomorrow :-)--Garrondo (talk) 18:56, 19 November 2008 (UTC)

That's wonderful, I'm so excited you're willing to work so much on it, and collaborate to take it to FA! Journal access is a terrific resource. These past two installments are more great stuff, I'm sorry I've been tied up lately but this is definitely my top WP priority. I'll tackle it all as soon as I can and am delighted to have your continued help as long as you're willing to give it. delldot ∇. 04:45, 21 November 2008 (UTC)

Next week I have to go to a congress so I doubt I'll have time to do anything. Take your time to think over my proposals. Best regards.--Garrondo (talk) 10:24, 21 November 2008 (UTC)

Sounds good, take your time, I'll work on the points I missed on my first run-through. Thanks again! delldot ∇. 02:24, 24 November 2008 (UTC)

Everything looks better. As I told you I don't have much time this week. I have taken a quick glance at diagnosis; but I will have to read it much more in depth. However two minor comments: Best regards --Garrondo (talk) 19:00, 24 November 2008 (UTC)

diagnosis

• the abbreviation of each technique appears in brackets; however only MRI and CT are used later in text. You can eliminate all others since the complete name and a wikilink is given (EEG, PET, fMRI, SPECT)

• Good call, done. delldot ∇. 22:40, 26 November 2008 (UTC)

• Does not have sense to name neuropsychological tests and neuropsychological evaluation: I would only leave the latter. They can get to the first one from neuropsychological evaluation. On the other hand neuropsychological tests is only a list with MANY MANY red links...

• Sounds good, done. delldot ∇. 22:40, 26 November 2008 (UTC)

Back again. I think this week I will have some more time to review the article. I have reread the diagnosis section and I have multiple issues with it:

• Diagnosis is suspected based on clinical evidence and confirmed using neuroimaging.[3] In addition, medical personnel perform a neurological examination, for example checking whether the pupils constrict normally in response to light and assigning a Glasgow Coma Score: In addition? neurological examination is almost the main method to obtain clinical evidence. I would mention history or description of the lesion; which is not exactly clinical evidence; and combine clinical evidence and neurological examination in some way.

• medical personnel: is probably redundant: most people would assume that a neurological examination is carried out by medical personnel.

• Done. delldot ∇. 16:48, 3 December 2008 (UTC)

• confirmed using...: Is this always true? I would better say usually confirmed: On the one hand in some countries access to neuroimaging is scarce; on the other neuroimaging can not always confirm diagnosis as it has already been stated when speaking about concussion.

• How about "may be confirmed"? This would cover cases where there is no access, CT is deemed unnecessary due to mildness, and cases where no head injury is present. delldot ∇. 16:48, 3 December 2008 (UTC)

• Imaging tests: As I psychologist it sounds very strange to me the word test here. I always assume that a test needs of some cut-off value to classify people. How about "procedures"?

• How about just "imaging helps"? delldot ∇. 16:48, 3 December 2008 (UTC)

• gold standard radiologic imaging test: gold standard is a dangerous expression: it may be the most commonly used; however MRI is more accurate and therefore it can also be termed as the gold-standard.

• Changed to "the preferred". delldot ∇. 22:53, 3 December 2008 (UTC)

• Angiography appears twice: as CT angiography and as cerebral angiography. However the aim of x-ray angiography, computed tomography angiography and magnetic resonance angiography is in all cases the same: detect blood vessel pathology. I will combine all mentions to different kinds of angiography.

• I'm not sure how to do this, but second mention hidden. delldot ∇. 17:31, 3 December 2008 (UTC)

• X-ray may be used to check for fractures, but evidence suggests it is not useful for head trauma evaluation: I am not very sure of the meaning of this section since it seems to contradict itself.

• Expanded the explanation--better? delldot ∇. 22:53, 3 December 2008 (UTC)

• which uses a powerful magnetic field to produce images: This info is not needed: it already appears in the link and it is not given for any of the other methods named

• Done. delldot ∇. 17:31, 3 December 2008 (UTC)

• Magnetic resonance imaging (MRI), which uses a powerful magnetic field to produce images, can show more detail than X-rays or CT, and can add information about expected outcome in the long-term treatment of TBI (...) MRI is more useful than CT for detecting some injury characteristics in the longer term: This two sentences right now are separated; however they are both advantages of MRI. Can they combined in a single sentence or consecutive sentences? Also the second sentence seems vague; I would add some injury characteristics in the longer term such as...

• done. delldot ∇. 17:31, 3 December 2008 (UTC)

• Xenon-enhanced CT and single photon emission computed tomography can measure cerebral blood flow.[50] Functional magnetic resonance imaging can show activity in specific regions, and Positron emission tomography can show changes in cerebral blood flow and metabolism; these findings can help predict outcome The aim of all these four is similar although the methodology they use is different. Maybe it could be simplified into something like: Xenon-enhanced CT, SPECT fMRI and PET can measure cerebral blood flow or metabolism; inferring neuronal activity in specific regions. These findings can help predict outcome.: Since in this case methods are not as common or important I would only use abreviattions with links instead of full names.

• Done. delldot ∇. 17:31, 3 December 2008 (UTC)

• Although not directly related with this article it would be great if you could create a stub from xenon-enhanced CT: I hate red links; but I now nothing about this technique.

• Baby stub created. delldot ∇. 16:48, 3 December 2008 (UTC)

• Last paragraph: I'll try to rewrite it today or tomorrow since it has some minor conceptual mistakes.

Best regards.--Garrondo (talk) 14:41, 1 December 2008 (UTC)

• Proposal for the last paragraph: Neuropsychological assessment can be performed to evaluate the long-term cognitive effects of the injury and to aid in the planning of the rehabilitation. Measured cognitive domains may include executive functions, attention and processing speed, memory and learning, language, or perceptual and motor skills. Instruments range from short measures of general mental functioning to complete batteries formed of different domain-specific tests.

• Great stuff, used. I'll find a ref for the last sentence. delldot ∇. 17:31, 3 December 2008 (UTC)

Prevention

Today I have read the prevention section. My first impression is that it is a bit disordered and with some redundancies. It could be simplified. I would say there are 3 main directions for prevention: 1-prevention of traffic accidents and reduction of their consequences; 2-Reduction of sports accidents 3-Reduction of house accidents and children brain damage. The section would be better ordered around this 3 themes creating 3 different paragraphs with the information around each theme in a separate paragraph. Maybe it would also be a good idea to specifically search for a review article which treats TBI prevention, prevention measures and their efficacy, instead of generally TBI. Best regards.--Garrondo (talk) 13:47, 3 December 2008 (UTC)

Separated into 3 paras, will look for review article. delldot ∇. 17:31, 3 December 2008 (UTC)

Thanks Garrondo, this is more great stuff! I'm not quite done with this batch, I'll finish later. delldot ∇. 17:31, 3 December 2008 (UTC)

I will do a new pass on these two sections, since I have more new ideas: --Garrondo (talk) 10:37, 4 December 2008 (UTC)

• A proposal for the first paragraph of diagnosis (You can add first sentence of 2nd par since it mostly says the same. I have also added comment on lesion circumstances): Diagnosis is suspected based on lesion circumstances and clinical evidence, most prominently a neurological examination, for example checking whether the pupils constrict normally in response to light and assigning a Glasgow Coma Score. Neuroimaging helps in determining the diagnosis and prognosis and in deciding what treatments to give.

I will continue later

I have reordered and changed a bit the diagnosis section according to my own comments above since it would have taken me much more effort to explain them here than to go on with them: feel free to comment if you don't agree. My aim was both to simplify and give more order to the section.--Garrondo (talk) 16:58, 4 December 2008 (UTC)

Yes, very much improved in terms of order and logic. Definitely feel free to make edits yourself if it's easier for you, I certainly don't mind that. Thanks again for the work you're putting in here. Hopefully I'll get a chance to address the comments I haven't gotten to yet today. delldot ∇. 17:08, 4 December 2008 (UTC)

I a similar way I have a summary proposal for the first paragraph of prevention: I have added an introduction line and reordered most of the information. I have also eliminated the mentions in children, since they are only examples and with the ones already presented I believe its enough: I have not added yet; so do it yourself if you believe its worth, but I am quite happy with the result.: --Garrondo (talk) 14:45, 5 December 2008 (UTC)

• Since a major cause of TBI are vehicle accidents, their prevention or the amelioration of their consequences can both reduce the incidence and gravity of TBI. In case of accident, damage can be reduced with the use of seat belts, child safety seats, and motorcycle helmets, or presence of roll bars and airbags. Education programs exist to lower the number of crashes. In addition, changes to public policy and safety laws can be made to reduce the number of accidents or their sequels, these include speed limits, seat belt and helmet laws, and road engineering practices.

Some more comments with the prevention section (second par):--Garrondo (talk) 14:59, 5 December 2008 (UTC)

• Changes to common practices have also been discussed with regard to prevention of TBI: I would add in sports after common practices; and I would eliminate the comment to army; so the paragraph only talks about sports. It would be easier to follow.

• Is this what you had in mind? delldot ∇. 19:26, 8 December 2008 (UTC)

• for example a reduction in alcohol abuse: The for example is unneeded. It is clear is an example.

• Replaced with e.g. delldot ∇. 19:26, 8 December 2008 (UTC)

• Design of protective equipment can be improved to prevent injuries; research toward this end includes Head Impact Telemetry System technology placed in sports and military helmets to measure and record impacts to the head.[51: I would completely eliminate this sentence: it may be too much specific, the ref is not of good quality, and it is probably still under research (At most it would be more suitable for the research directions section, with a better ref)

• Done. delldot ∇. 19:26, 8 December 2008 (UTC)

• In sports, improved helmet...: if you follow my previous proposals "in sports" would not be needed.

• Done. delldot ∇. 19:26, 8 December 2008 (UTC)

• Sports commented (baseball and I suppose American football): Too much american centred: In Europe both are very rare games. It would be great to change one of them for another sport, such as soccer (or any other). If info on spear tackling is kept it should about which sport are we talking about; I had no idea.

• I'll add more rather than taking info out. I think the soccer idea is a good one, I'll look into that. I've heard of a mild head injury health concern with soccer, but I don't know if that should go on this article or concussion. delldot ∇. 19:26, 8 December 2008 (UTC)

Third paragraph of prevention: sounds Ok. I would only make a search in pubmed to see if enforcement of laws reducing availability of fire arms reduces TBIs (in a country where almost nobody has firearms as mine last sentence sounds a bit strange. :-) Similarly the epidemiology image would be very different in Europe: TBIs by firearms are very very rare. (In my experience out of 200 people I met with TBI only 1 was due to firearm. Next week I'll move on to next sections. Best regards. --Garrondo (talk) 15:17, 5 December 2008 (UTC)

True, another good point about US-centeredness. This statistic is probably only valid in the US. Should I remove the chart and info altogether? I doubt other places will have as detailed statistics. delldot ∇. 19:26, 8 December 2008 (UTC)

I would leave the chart; since it is an example and gives "color". However the text would have to say that epidemiology varies from countries and comment differences between countries that can help somebody to get an image of epidemiology in different countries and zones. As traumatic brain injury moves a lot of money due to insurances I am sure there will be statistics for almost any country: At least for Europe there has to be plenty of them. Insurance companies spend a lot of money investigating TBI; and specially epidemiology.--Garrondo (talk) 13:57, 9 December 2008 (UTC)

It could be of use: PMID 16311842, PMID 18162698, PMID 11783750

As a side comment: the last par on diagnosis (the one on neuropsychological deficits) is one more reason why I believe that long term symptoms (or sequels) should be combined with symtoms: Until this section we have only talked of short-term deficits, but here we give a paragraph on diagnosis of the long term symptoms; only to talk about them in a complications section. We still have time to discuss it; but the more I read of the article the more convinced I am (And we will also go with MEDMOS). Have a good weekend. Monday is holidays here so I doubt I will do anything in the article (I do not have internet at home; too expensive). Best regards. --Garrondo (talk) 18:57, 5 December 2008 (UTC)

Ok, sounds good. I'll bring others into the discussion of what to do with long- and short-term symptoms, and I have plenty to catch up on from this peer review so take your time! delldot ∇. 19:26, 8 December 2008 (UTC)

Treatment

Although the peer-review has been closed; I have decided to continue it here, to ease the following of the proccess. The treatment section is going to be a hard one to review, since its one of the longest; and secondly I do not know as much about treatment as for other sections. I think I have some info at home for families about rehabilitation of TBI depending of the phase. If I find it it may be of use to clarify the section. --Garrondo (talk) 15:02, 10 December 2008 (UTC)

Treatment

Introduction

• I would create a first introductory paragraph. I have made a proposal directly in the article. Tell me what you think. The section is too long and it eases the understanding acting as a summary.--Garrondo (talk) 14:41, 10 December 2008 (UTC)

• It's awesome!  :) delldot ∇. 23:18, 10 December 2008 (UTC)

• people with mild traumatic brain injuries may need nothing more than rest and treatment for symptoms like pain.: Reference needed.

• Rewritten with ref to match. delldot ∇. 15:45, 13 December 2008 (UTC)

• maintaining adequate cerebral blood flow, and controlling blood pressure.: is there a difference between the two?

• Well, BP can get too high or too low, and there are other factors involved in maintaining CBF (e.g. ICP control). But yeah, they're very linked. delldot ∇. 23:18, 10 December 2008 (UTC)

Damage prevention: New section created from what was the first paragraph

• Hypotension (low blood pressure), which has a devastating outcome in TBI: why is it so devastating?

• I assume because not enough blood flow to the brain, but I think the reasons aren't totally clear (see e.g. [1]). It's very strongly correlated with poor outcome though. Should I change 'has' to 'is correlated with'? delldot ∇. 15:45, 13 December 2008 (UTC)

• Other methods to prevent further damage include endotracheal intubation, mechanical ventilation: I would change it to: endotracheal intubation and mechanical ventilation may be used to ensure proper oxygen supply. I would also move to follow the sentence on hypotension. This way we follow the structure proposed in the introduction par.

• Done. delldot ∇. 23:18, 10 December 2008 (UTC)

• Next sentence would remain as: Other methods to prevent further damage include management of other injuries, and prevention of seizures.

• Done. delldot ∇. 23:18, 10 December 2008 (UTC)

• in rare cases paralytic agents, and antipsychotics only if absolutely necessary (because they can prolong recovery).: if they are only used in rare cases I would not mention them. They could be eliminated; since it is entering technicities of interest only for professionals.

• Done. delldot ∇. 03:51, 13 December 2008 (UTC)

• Certain facilities are equipped to handle TBI better than others are; care involves bringing the patient to such specialist facilities: I feel this is important; but it breaks the "flow of the paragraph". It seems like a pastiche; but I do not where could we move it. Maybe to the introduction paragraph?

• Yeah, it's kind of the odd thing out. What do you think about this? delldot ∇. 23:18, 10 December 2008 (UTC)

• deteriorating condition: could be simplified with only the word deterioration

• Done. delldot ∇. 23:18, 10 December 2008 (UTC)

Control of intracranial pressure

• I would initiate the par with a line explaining why raised ICP is dangerous

• Done, but I'm sure I'll find a better ref in the course of working on the article. delldot ∇. 17:33, 16 December 2008 (UTC)

• it may require ventriculostomy, a procedure that drains cerebrospinal fluid from the ventricles: I would add surgical before procedure for more explanation.

• Done. delldot ∇. 23:18, 10 December 2008 (UTC)

• Mannitol, an osmotic diuretic, moves water across the blood–brain barrier and improves cerebral blood flow to the injured area.[2] However it appears likely that studies suggesting that mannitol was of use[60][61][62] were falsified.[63] Studies have found insufficient evidence to make recommendations about its use and have found that hypertonic saline may be more effective.[46]: This may be too much complicated. A possible simplification: Mannitol, an osmotic diuretic, was also studied for this use, but such studies have been heavily questioned. Hypertonic saline may be more effective.

• Done. delldot ∇. 03:51, 13 December 2008 (UTC)

• If simplified as proposed I would combine the 3 pars into only 1.

• Done. delldot ∇. 03:51, 13 December 2008 (UTC)

A general comment about all the article: For example is used too many times along the article, and many of them could simply be eliminated. In the following par: Craniotomy, in which part of the skull is removed, is required in about a third of severe TBIs. For example it may be needed to remove pieces of fractured skull or other objects that have become imbedded in the brain. Nothing happens if you eliminate the "for example".

I've done a purge! These are great suggestions, always happy to find new ways to remove fluff. Thanks again Garrondo, I'll finish up with your suggestions as soon as I can. Peace, delldot ∇. 03:51, 13 December 2008 (UTC)

Some more comments on treatment

• Firstly a comment that I made in the treatment section that you have not followed: I am sure if I was not clear enough, you do not feel they are needed, or simply you did not have time: I think that a sentence on both the hypotension and ICP saying why they are dangerous would be most welcomed.

• Done now, sorry for the delay. There are several points I'm not caught up on just because I haven't had a lot of time for editing lately. I hope to catch up on them when I get time. delldot ∇. 17:33, 16 December 2008 (UTC)

Surgery section

• It would also be great if you could create a mini-stub for mass lesions: creating stubs instead of red links is a great way of improving the encyclopedia.

• I redirected it to mass effect (medicine) because they're basically two aspects of the same thing (i.e. a mass lesion causes a mass effect). delldot ∇. 17:33, 16 December 2008 (UTC)

• Wikilinks for suction (medical) (I do not know if it exists), and for forceps?

• Done. delldot ∇. 17:33, 16 December 2008 (UTC)

• This procedure, termed "primary DC", is relatively uncontroversial.[67] When DC is performed hours or days after TBI in order to control high intracranial pressures, it is termed secondary DC.[67] A controversial procedure under ongoing study, it has not been shown to improve outcome in all trials and may be associated with severe side effects.[2] Could be simplified into: during operations to treat hematomas; part of the skull is removed temporarily (primary DC).[67] When DC is performed hours or days after TBI in order to control high intracranial pressures, it is termed secondary DC.[67] Secondary DC has not been shown to improve outcome in some trials and may be associated with severe side effects.[2]

• Sounds good, done. Simplified a bit further. delldot ∇. 17:33, 16 December 2008 (UTC)

Rehabilitation

During the acute stage of rehabilitation: I would change rehabilitation with recovery, since rehabilition implies some short of programmed action; which is not the case. I would leave rehabilitation for the sub-acute stage.

• Done. delldot ∇. 17:33, 16 December 2008 (UTC)

Some more later...--Garrondo (talk) 14:13, 16 December 2008 (UTC)

• My following proposal is mostly copied verbatim from Treatment of multiple sclerosis; an article that some time ago I took to FA, but I think that it applies perfectly: Rehabilitation aims to improve independent function at home and in society and to adapt to disabilities or change living conditions to accommodate impairments. and has demostrated its general effectiveness, when conducted by a team of specialists, in head trauma. As for any patient with neurologic deficits, a multidisciplinary approach is key to limiting and overcoming disability. Neurologists will be the main physicians involved, but depending on the symptom, doctors of other medical specialties may also be helpful. Allied treatments such as physiotherapy, speech and language therapy or occupational therapy can also help to manage some symptoms and maintain quality of life. Treatment of neuropsychiatric symptoms such as emotional distress and clinical depression should involve mental health professionals such as therapists, psychologists, and psychiatrists, while neuropsychologists can help to evaluate and manage cognitive deficits.

• Looks great, but I wasn't sure where to put it. Feel free to move it if you had a better place in mind. Also always feel free to edit the article yourself if you want! You're always on point anyway. delldot ∇. 17:33, 16 December 2008 (UTC)

• I think I am going to try to rewritte the full section: Give me a few days.

• Sounds great! Take your time. delldot ∇. 17:33, 16 December 2008 (UTC)