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Deep vein thrombosis[edit]

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I've listed this article for peer review because I want to submit this article to FAC. I have some ideas, from a few 2012 review articles, on where to add some things for comprehensiveness, but what else could be addressed?

Thanks, Biosthmors (talk) 20:07, 2 October 2012 (UTC)[reply]

  • I can't be of much help with the scientific/medical aspects of the article, but I can offer some comments in relation to the prose/presentation/manual of style aspects that might come up at FAC. Overall, the article looks very solid.
    • Thanks
  • One issue is repeated wikilinks. For help picking them out, try User:Ucucha/duplinks.
    • Done
  • Overall, there are a lot of wikilinks. It doesn't seem like too many common words are linked, but I'd suggest checking for ones that don't add much to the reader's understanding.
    • Removed some
  • Some of it may be unavoidable, but try to minimize the amount of short sections and subsections if you can.
    • I've tried to bundle, for example like this
  • On a similar note, watch for short sentences next to each other and see if you can combine them.
    • Good point, I've done some combining
  • Purely a preference issue, but I'd consider WP:LDR for readability when editing.
    • Thanks
  • I'd double check the use of italics in Classification, some of them are definitely right, but I'm not sure all of them are needed.
    • Looked at, and another editor did more than me, thanks to them[1]
  • The usage of the serial comma is inconsistent, so it should probably be standardized.
    • Should be consistently used now
  • "When taken together with the risk factors (see below), they are useful in determining the likelihood of DVT," I'm not sure the parenthetical phrase here is helpful, but you could consider linking it to the section you have in mind.
    • Parentheses removed
  • There's a one-sentence paragraph in Signs and symptoms, this should generally be avoided if you can.
    • Removed
  • A couple of the bullet points under inherited Causes aren't cited.
    • They are cited above and more in the category of commonly known (but I can add them if they would be helpful)
  • "Oral contraceptives and hormonal replacement therapy increase the risk through a variety of mechanisms.[8][which?]" The which tag should probably be resolved... but I'm not sure there's anything wrong with the sentence as-is.
    • Clarified which
  • "In 2012, results from the ASPIRE study are expected." You might want to introduce this study or explain it a little more, I think this is the first it's mentioned. Mark Arsten (talk) 15:39, 22 October 2012 (UTC)[reply]
      • Reworded
    • Thanks for pointing out that script. Very helpful. Thanks for the comments I'll address them. Biosthmors (talk) 21:05, 25 October 2012 (UTC)[reply]
    • Thanks again. I didn't cite the old age and the thrombophilias in the risk factors because they are already cited above and they are more well known. I think I've addressed all these points. One downside is I did create a one sentence paragraph after removing the one you mention, because a comment below suggested that the material be trimmed. It is currently the last paragraph in anticoagulation. Biosthmors (talk) 18:51, 7 November 2012 (UTC)[reply]
      • Alright, not a big deal--they're best to avoid if you can, but it isn't a hard and fast rule. Mark Arsten (talk) 19:01, 7 November 2012 (UTC)[reply]


  • Some comments from me:
    • I would not attempt to include splanchnic thromboses under the header of DVT. These are different diseases.
      • Removed and clarified with a note
    • There is no precendent for providing the grading of recommendations in medical articles. I think it might be better not to trouble the reader with this if it's possible to work this into the text. Also, the ACCP does not have the final word in many other health systems. For the sake of systemic bias we should be prepared to include the new guideline by NICE (National Institute for Health and Clinical Excellence. Clinical guideline 144: Venous thromboembolism. London, 2012.)
      • Grades removed. Still need to incorporate NICE
    • I wasn't aware that "ternary" was in widespread use
      • Common language used now
    • I'm not sure if we should discuss the Cochrane review studying NSAIDs for DVT. If there is nothing to say, perhaps we shouldn't say it.
      • Reworded and trimmed to remove details about the n=90 study
    • In "epidemiology", no attempt is made to provide statistics for countries other than the USA.
      • Generalized, clarified where the data comes from, and added England/Asian
    • I have a vague recollection of a previous U.S. president having recurrent PEs and undergoing a caval interruption to stop this from happening. Forgotten where I read it. JFW | T@lk 19:17, 23 October 2012 (UTC)[reply]
      • Thanks. As a temporary reply, this is the second comment I've gotten that expressed skepticism about the value of the strength grades, so I'll just plan on removing them. That way I can remove a table and some text too. And I'll definitely incorporate the NICE guideline. Biosthmors (talk) 20:11, 25 October 2012 (UTC)[reply]
      • Good memory. Maybe I'll put that at PE: "Former Vice President Dan Quayle, who spent long hours in planes, developed a pulmonary embolism in 1994 and again in 1998. The first clot was initially diagnosed as pneumonia, but Quayle returned to his doctor before the blockage turned deadly." Biosthmors (talk) 18:45, 8 November 2012 (UTC)[reply]


Nitpicks Sasata (talk) 19:28, 25 October 2012 (UTC)[reply]

  • image captions that aren't complete sentences shouldn't have periods (e.g. "The incision for a completed knee replacement surgery, a procedure that can cause DVT.") Those that are, should (e.g. "The ACCP suggested graduated compression stockings for at-risk travelers and some hospital patients".)
    • Done
  • author formats of refs #12 and#31 are different than the rest
    • Should be OK now
  • why is therapy capitalized in ref#7? Also, the first letter after the colon in a title should be capitalized (check refs throughout; there are other instances)
    • Fixed
  • is ref #34 the same as #3 (and if so should they be merged?)
    • No longer cited
  • how about links to: calf, iliac and feral veins, protein C deficiency, and protein S deficiency; factor V Leiden should be linked @ first occurrence
    • Linked
  • would like to know incidence rates for places other than the US
    • Limited data, said so and mentioned people of Asian descent
  • "In 2012, results from the ASPIRE study are expected." Does this not violate WP:CRYSTAL?
    • Results were published, so updated
  • don't like how the last sentence of "Research directions" is phrased; it could imply that the results of the study (reduction in recurrent VTE with aspirin) are similar, when I suspect it's the study methodology that is similar
    • Reworded


more comments

  • The images all have acceptable licenses.
  • We are missing a section on airline response to DVT in flight.
  • Most of this article is from the point of view of Western medicine, however are there any other alternatives such as Chinese traditional medicine, herbal remedies, or even physiotherapy? Is there any law on the topic, particularly for travelers?
    • We would include alternatives to the extent they are discussed in secondary reviews. SandyGeorgia (Talk) 01:28, 19 November 2012 (UTC)[reply]
  • There is no alt= text for the images.
  • In the history section there is an unexplained and unlinked acronym LDUH.
    • Good catch. Added the abbreviation where it belonged.
  • "venous thromboembolism" is later used with abbreviation (VTE) but VTE should be introduced at the first occurrence. Even better if these kinds of jargony abbreviations are not used.
    • Clarified
  • Some acronyms are not needed as they are used in one section only, eg GCS and would be better shortened to stockings for comprehension. But it would not help to spell them in full.
    • Removed acronyms of PTS, IPC and GS
  • References need to be improved in the use of abbreviations for Journal titles. The full title of the journal must be given as our readers are not specialists in the field. For example there is: CMAJ, Semin Respir Crit Care Med, N Engl J Med, Crit Care Med and so on.
  • If the author's first name is unknown then the initials should have a . after them.
  • Page ranges should have the numbers in full eg 265–72 should be 265–272.
    • The three points directly above this are incorrect (said the now-retired FAC delegate). Nor are List-defined references widely used, required or respected. Alt text is no longer required at FAC. SandyGeorgia (Talk) 01:23, 19 November 2012 (UTC)[reply]
  • Journal references with no doi include Conklin P, Kakkos S. Graeme Bartlett (talk) 04:51, 11 November 2012 (UTC)[reply]
    • Added Kaddos. A doi for Conklin is unlikely, I think.
Regarding journal titles, there is no policy that requires the names to be spelt out in full. Perhaps in your opinion it may be preferable to do so (and indeed also in my opinion), but the statement "The full title of the journal must be given as our readers are not specialists in the field" is false.
Regarding the use of a full stop (period) after initials, again I do not believe that there any policy or guideline that requires this. In my opinion, use of full stops here creates unhelpful clutter. Axl ¤ [Talk] 19:19, 15 November 2012 (UTC)[reply]
Similarly, full page ranges are not essential. Axl ¤ [Talk] 19:23, 15 November 2012 (UTC)[reply]
I concur with Axl on these points. Graham Colm (talk) 22:04, 15 November 2012 (UTC)[reply]
For normal articles I would not worry either, but for featured article status the MOS enthusiasts will crack down hard on full stop and ndash use. I suppose "must" is too strong here, but I still recommend expanding journal titles. Graeme Bartlett (talk) 10:51, 16 November 2012 (UTC)[reply]
Are you aware that GrahamColm is one of the FAC delegates? (I.e. he is responsible for determining consensus to promote.) Axl ¤ [Talk] 00:16, 18 November 2012 (UTC)[reply]
  • From "Signs and symptoms", paragraph 1: "... although about half of those with the condition are asymptomatic." I added a wiktionary link to "asymptomatic", but I wonder if it might be better to say "have no symptoms". Axl ¤ [Talk] 18:58, 15 November 2012 (UTC)[reply]
    • Took your suggestion
  • From "Causes", paragraph 2: "... both of which may increase the risk because of tissue factor from outside the vascular system mixing with blood." Perhaps "entering the blood" rather than "mixing with blood"? Axl ¤ [Talk] 19:38, 15 November 2012 (UTC)[reply]
    • Will do
  • From "Causes", paragraph 2: "Oral contraceptives and hormonal replacement therapy increase the risk through a variety of mechanisms." I believe that the combined oral contraceptive pill increases DVT risk, but the progestogen-only pill does not. Axl ¤ [Talk] 19:43, 15 November 2012 (UTC)[reply]
    • Moved the clarifying note up that covers progestogen-only pills
      • Thanks. It is also worth changing this in the lead section, paragraph 2. Axl ¤ [Talk] 19:56, 15 November 2012 (UTC)[reply]
  • From "Causes", paragraph 3: "The disease term venous thromboembolism (VTE) includes the development of both DVT and pulmonary embolism (PE)." This sentence could imply that both features are required for VTE. It may be more accurate to state: "The disease term venous thromboembolism (VTE) includes the development of either DVT or pulmonary embolism (PE)." Axl ¤ [Talk] 00:00, 18 November 2012 (UTC)[reply]
  • From "Causes", subsection "Pathophysiology", paragraph 3: "The blood flow pattern in the valves can cause low oxygen concentrations (hypoxia) in the blood of a valve sinus." Hypoxia refers to low (inadequate) oxygen uptake within a tissue, which has several generic causes. Hypoxemia describes low oxygen content within the blood. Does the blood flow through venous valves really contribute to localized hypoxemia? Or does it simply contribute to local venous stasis? Axl ¤ [Talk] 23:06, 22 November 2012 (UTC)[reply]
    • I will double-check the source, but I say both are related. And yes, I mean hypoxemia (low blood oxygen, changed). A diagram in the source showed two circles of blood flow in the valve sinus side by side. One was clockwise and the other was counterclockwise, resulting in hypoxemia. Thanks. Biosthmors (talk) 04:20, 26 November 2012 (UTC)[reply]
Okay, thanks. Axl ¤ [Talk] 12:37, 26 November 2012 (UTC)[reply]
  • From "Diagnosis", paragraph 1: "In those not highly likely to have DVT, a normal D-dimer test can rule out a diagnosis." I presume that this should be a normal result rather than a test. Axl ¤ [Talk] 20:45, 23 November 2012 (UTC)[reply]
    • Yes yes. Thanks, changed.
  • From "Diagnosis", subsection "Classification", paragraph 2: "A DVT might also be called idiopathic when it "occurs in the absence of a known precipitating factor, such as oral contraceptives, surgery, trauma, or cancer."" Is the quote really necessary? How about "A DVT might also be called idiopathic when it occurs without a clear precipitating risk factor." Axl ¤ [Talk] 20:53, 23 November 2012 (UTC)[reply]
    • Thanks. It's not my favorite sentence but I think it is helpful to readers and representative of the literature. I think "clear precipitating risk factor" might be misinterpreted because there is a long risk factor list but the literature appears to only use the words "provoked" or "idiopathic/unprovoked" when DVT occurs in the presence or absence of only a few of the commonly known risk factors. I'll think about how this might be improved. I think including the terms provoked and unprovoked might be good too. Biosthmors (talk) 04:20, 26 November 2012 (UTC)[reply]
    • Reworded. Biosthmors (talk) 21:14, 1 April 2013 (UTC)[reply]
  • From "Diagnosis", subsection "Probability": "Wells scores of one or two can alternatively be categorised as moderate, low if less than one, or high if greater than two, with likelihoods of having the condition of 17%, 5%, and 53% respectively." Can we have "moderate" in the middle please? Axl ¤ [Talk] 12:48, 26 November 2012 (UTC)[reply]
    • Done.
      • Thanks. I have adjusted the text. Axl ¤ [Talk] 20:01, 2 December 2012 (UTC)[reply]
  • From "Diagnosis", subsection "D-dimer", paragraph 1: "D-dimers are a fibrin degradation product." This should be either singular ("D-dimer is a fibrin degradation product") or plural ("D-dimers are fibrin degradation products"). I recommend the singular form because the plural is not used anywhere else in the article. Axl ¤ [Talk] 12:53, 26 November 2012 (UTC)[reply]
    • I was thinking along these terms: if one degrades protein, one gets amino acids. Thus fibrin degradation yields D-dimers. Biosthmors (talk) 23:11, 26 February 2013 (UTC)[reply]
  • In "Diagnosis", subsection "D-dimer", paragraph 2, are these statements "suggestions" or "recommendations"? Axl ¤ [Talk] 13:05, 26 November 2012 (UTC)[reply]
  • From "Diagnosis", subsection "D-dimer", paragraph 2: "An elevated D-dimer level means diagnostic imaging is necessary." That's not what an elevated D-dimer level means. Can you clarify this sentence please? Axl ¤ [Talk] 13:09, 26 November 2012 (UTC)[reply]
    • Clarified.
  • In "Diagnosis", subsection "Imaging", only two sentences are used to describe compression ultrasound, despite this being the de facto gold standard, effectively replacing contrast venography. Compare this with the very detailed D-dimer information. (Actually I think that there is a good case for moving the D-dimer text to its own spinout article, while using summary style here.) I think that the information on compression ultrasound should be expanded. Axl ¤ [Talk] 13:16, 26 November 2012 (UTC)[reply]
  • From "Prevention": "Anticoagulation, which increases the risk of bleeding, is typical when the benefits are thought to exceed the risks." Every drug is given when the benefits are thought to exceed the risks. In this case, anticoagulation is rarely used for prevention. The commonest scenario is when a person has had recurrent DVTs (i.e. two or more). In this situation, a thrombophilia screen is typically performed as well. Thrombophilias are rarely detected in the absence of recurrent DVT, because there is usually no indication to test for them. Axl ¤ [Talk] 11:01, 28 November 2012 (UTC)[reply]
    • I've reworded the text based upon this comment, but maybe you were looking for more changes. Biosthmors (talk) 21:14, 1 April 2013 (UTC)[reply]
  • From "Prevention": "Aside from anticoagulation, the anti-platelet drug aspirin appears effective in preventing VTE." Such a statement needs further qualification. In which group of patients/people is this beneficial? Axl ¤ [Talk] 01:21, 30 November 2012 (UTC)[reply]
  • From "Prevention", subsection "Hospital", paragraph 1: "The ACP also drew attention to a lack of support for any performance measures encouraging physicians to apply universal prophylaxis without regard to the risks." I'm not sure that that sentence is helpful for a general encyclopedia article. Perhaps delete it? Axl ¤ [Talk] 20:08, 2 December 2012 (UTC)[reply]
  • From "Prevention", subsection "Hospital", paragraph 2: "Heparin is suggested in outpatients with cancer who have solid tumors and additional risk factors for VTE." Should this be low molecular weight heparin? Axl ¤ [Talk] 20:16, 2 December 2012 (UTC)[reply]
  • I think this is a very well written article and largely accessible to the lay reader. I agree with the comment above wrt the ACCP being over-cited in-text, which makes the article essentially a description of US health best-practice. As the International English version of WP, we should consider other healthcare systems and protocols, especially if their guidelines deviate for some interesting reason. In addition to the NICE guidelines given above, see also the SIGN 129 guidelines. Both are excellent sources for a WP article as they have a firm foundation in evidence based medicine combined with a pragmatic cost-effective approach to treatment/prevention. It would also be interesting to know which treatments/preventions are affordable or widely used in the third world. Are their any reviews/papers discussing this aspect? Colin°Talk 17:45, 18 November 2012 (UTC)[reply]
    • Thanks, I'll check out that guideline. I saw a review article the other day discussing practices in Asia, but it appeared to be primary for that information. I'll keep an eye out for info on developing countries. Biosthmors (talk) 19:23, 19 November 2012 (UTC)[reply]
  • I would drop the "List of deaths" section. It isn't adding anything to the article and per WP:MEDMOS. If there was some famous historical figure who died or was supposed to have died from this then that may be worth noting. -- Colin°Talk 18:15, 18 November 2012 (UTC)[reply]
    • Fine by me. I'll try to start a List of people who developed venous thromboembolism and move the content there. Feel free to give me a tip or two at my talk page on naming/organization if that is apparent to you. I haven't given it much thought. Biosthmors (talk) 19:23, 19 November 2012 (UTC)[reply]
      • Oh I wouldn't create such a list unless the topic of notable/famous people who developed venous thromboembolism was itself notable. A quick Google suggests otherwise. There are diseases and conditions for which health charities publish such lists, where the first chapter of practically every book on the subject name-drops the notable sufferers (or supposed ones), and where speculation on historical figures is the subject of scientific and not so scientific speculation. I don't think that applies here. Colin°Talk 20:15, 19 November 2012 (UTC)[reply]

See WP:MOSLINK and WP:OVERLINK-- there is still some overlinking (aspirin, for example). Ask yourself if the reader is likely to click on a link (methinks a reader of this article knows what aspirin is), if the link is a common term, or if the link is needed for understanding of the article. SandyGeorgia (Talk) 01:32, 19 November 2012 (UTC)[reply]

  • I went through and removed some links I thought were to more common and less important words to understand the concepts, including X-rays, MRI, and aspirin. Biosthmors (talk) 08:25, 20 November 2012 (UTC)[reply]

Comments

Are the lists of causes in any particular order, e.g. frequency? And did I miss cardiac disease and neurological disease? In Lazarus, Hillard M.; Schmaier, Alvin H. (2011). Concise Guide to Hematology. Wiley-Blackwell. pp. 181–182. ISBN 1-4051-9666-1. it says: "Neurological disease Individuals who have strokes often have thrombosis in the paretic limb, but not in the limb that is functioning. Cardiac disease An uncomplicated myocardial infarction has a low risk for thrombosis. However, a patient with heart failure associated with myocardial infarction has a 25% greater risk for deep venous thrombosis of which 25% will have a pulmonary embolus." Graham Colm (talk) 19:05, 19 November 2012 (UTC)[reply]

I haven't seen a source discuss frequency. A friend told me they diagnosed a DVT the other day that had edema but no redness, warmness, or distended veins, and I wished I would find a source that could help us clarify this. Those conditions should be included. Good points. Biosthmors (talk) 19:15, 19 November 2012 (UTC)[reply]
I too am slightly concerned by the nature of the list. It seems to be an indiscriminate collection from any secondary sources that mention VTE risk factors. It is unclear if the order of the list has any significance. My personal preference is to use a list from a single high-quality secondary source. Ideally, the source would include relative risk or odds ratio values alongside the factors. However I don't think that should be done when listing factors sourced from many different references. This reference has a nice list. (This is just my opinion, and not necessarily "better" than the article's current format.) Axl ¤ [Talk] 11:52, 20 November 2012 (UTC)[reply]
Oops I misinterpreted the first comment and read "causes" as "symptoms". Table I of Lijfering (ordered by risk factor magnitude) has been the most influential in how I ordered it. I largely follow that convention. Thus, while one might argue that due to the ubiquity of non-O blood type, it has a larger impact on causing VTE than the rare deficiency of antithrombin, it remains on the bottom of the inherited list. I will look at the reference you provided Axl, thanks. It might make me switch the order around of something. Biosthmors (talk) 17:11, 20 November 2012 (UTC)[reply]
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