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Wikipedia:Featured article candidates/Thyrotoxic periodic paralysis/archive1

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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 01:35, 4 January 2011 [1].

Thyrotoxic periodic paralysis

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Thyrotoxic periodic paralysis (edit | talk | history | protect | delete | links | watch | logs | views)

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Nominator(s): JFW | T@lk 15:38, 16 December 2010 (UTC)[reply]

Self-nom. I am nominating this for featured article because I think that in its present form it represents the state of knowledge about this rare condition, is not too long for a rare topic, and relies exclusively on high-quality medical sources (apart from a single citation of historical interest). The condition is becoming more common in English-speaking countries and warrants a high-quality Wikipedia resource. JFW | T@lk 15:38, 16 December 2010 (UTC)[reply]

  • Sources comments: The sources all look suitably scholarly and reliable, and are properly cited. My only observation is that I am used to medical articles having a rather wider range of sources than we have here—and nearly half the citations are to a single article. Does this reflect a limitation in the availability of scholarly articles on his topic? Brianboulton (talk) 00:57, 17 December 2010 (UTC)[reply]
    • This is a rare condition. On the talkpage you will find discussion about recent review articles identified by searching Pubmed for any review on TPP. Dpryan (talk · contribs) alerted me to the broader review about channelopathies in Neuron. Are there any sources that I have left out? JFW | T@lk 11:19, 17 December 2010 (UTC)[reply]
  • Oppose 1c. Both the article and the references list look rather short for a disease that is widely covered in the scholarly literature. The list below is just a sampling of recent reviews that haven't been used as sources. Sasata (talk) 15:56, 17 December 2010 (UTC)[reply]
    • :Thyrotoxic periodic paralysis: a case report and literature review. Barahona MJ, Vinagre I, Sojo L, Cubero JM, Pérez A. Clin Med Res. 2009 Sep;7(3):96-8. Review. PMID 19625499
    • Hypokalemic thyrotoxic periodic paralysis with thyrotoxic psychosis and hypercapnic respiratory failure. Abbasi B, Sharif Z, Sprabery LR. Am J Med Sci. 2010 Aug;340(2):147-53. Review. PMID 20581656
    • Hypokalemic periodic paralysis: a case series, review of the literature and update of management. Alkaabi JM, Mushtaq A, Al-Maskari FN, Moussa NA, Gariballa S. Eur J Emerg Med. 2010 Feb;17(1):45-7. Review. PMID 20201128
    • Primary periodic paralyses. Finsterer J. Acta Neurol Scand. 2008 Mar;117(3):145-58. Review. PMID 18031562
    • Thyrotoxic periodic paralysis and anesthesia report of a case and literature review. Diedrich DA, Wedel DJ. J Clin Anesth. 2006 Jun;18(4):286-92. Review. PMID 16797431
    • Fontaine 2008 is a 20-page review article on periodic paralyses, and it is used only once, to cite the statement "TPP is one of a number of conditions that can cause periodic paralysis." ?
    • Thyrotoxic periodic paralysis: an overview. Hsieh CH, Kuo SW, Pei D, Hung YJ, Chyi-Fan S, Wu LI, He CT, Yang TC, Lian WC, Chien-Hsing L. Ann Saudi Med. 2004 Nov-Dec;24(6):418-22. Review. PMID 15646156
    • Thyrotoxic hypokalaemic paralysis in a pregnant Afro-Caribbean woman. A case report and review of the literature. Iheonunekwu NC, Ibrahim TM, Davies D, Pickering K. West Indian Med J. 2004 Jan;53(1):47-9. Review. PMID 15114895
    • The pitfalls of potassium replacement in thyrotoxic periodic paralysis: a case report and review of the literature. Tassone H, Moulin A, Henderson SO. J Emerg Med. 2004 Feb;26(2):157-61. Review. PMID 14980336
    • Electrocardiographic changes in thyrotoxic periodic paralysis. Boccalandro C, Lopez L, Boccalandro F, Lavis V. Am J Cardiol. 2003 Mar 15;91(6):775-7. Review. PMID 12633825
      • Would you suggest that every single one of these are used? Is there a particular detail that I have omitted? I really wish you were more specific. JFW | T@lk 22:17, 18 December 2010 (UTC)[reply]
        • Nope, I'm just suggesting that in my opinion the article does not meet FAC criteria 1c ("well-researched: it is a thorough and representative survey of the relevant literature") because the level of sourcing in the article is not consistent with the availability of good sources available. Your reply to Brian Boulton above and the discussion of the talk page further confirm that the literature search was not sufficient for this to qualify as one of Wikipedia's very best medical articles. I could spend a couple of hours going through these reviews to find specific details that are missed, but that's the job of the nominator. Sasata (talk) 22:36, 18 December 2010 (UTC)[reply]
      • I dispute the claim that all recent reviews (particularly case reports disguised as reviews) should be cited. What you are seeing now is the product of four recent high-quality reviews, because other sources simply repeat the same observations that have already been made in the main reviews. As I stated, this is a rare condition. Bringing in more sources is not the answer. Again please feel free to challenge me with specific omissions. JFW | T@lk 23:21, 18 December 2010 (UTC)[reply]
        • To clarify, I did not claim that all recent reviews should be cited. However, they certainly should have been read as part of the literature review for this article. As for specifics, I'm not a medical doctor, but I'll try:
          • Signs and symptoms:
            • does the paralysis present asymmetrically?
            • does it affect deep tendon reflexes?
            • does it ever present as an upper motor neuron type weakness with respiratory, bulbar, and occular muscle paralysis, leading to ventilatory and pharyngolaryngeal junction failure?
            • does it affect mental function, cranial nerves, sensations, and bladder and bowel functions?
            • does resolution occur in the same or reserve order of initial involvement? Is there any ephemeral myalgia?
            • have any of the following been reported to precipitate paralysis: trauma, stress, cold exposure, menses, infections; medications such as K+ wasting diuretics, insulin, amiodarone, adrenaline, physostigmine, cosyntropin, and pilocarpine?
          • Mechanism
            • One theory suggests that the thyrotoxic state causes a decrease in intestinal absorption of calcium and a high calcium turnover from the bones and kidney, which would explain the increased urine calcium in the face of normal serum calcium. PMID 4855209, PMID 4260573, PMID 2192868 None of these papers, nor the theory is mentioned in the article.
            • Two TPP-presenting Germans had adrenal adenomas. PMID 1635436 How did these cases help explain why TPP is much less prevalent in white patients, why there is lack of correlation between the intensity of paralysis and the severity of hyperthyroidism, and why TPP is predominantly in males?
          • Treatment
            • potassium supplementation at a rate of greater than 40% of IV KCl at a rate of 10 mEq/hr may lead to rebound hyperkalemia; the article does not mention this nor the general recommendation that KCl replacement be slow. PMID 15666258
            • why do only non-selective beta blockers work in treatment? PMID 15666258, PMID 11228188
          • Epidemiology:
            • "… with much lower rates in people of other ethnicities." what value does "much lower" represent?
            • where's the discussion of differential diagnoses (Hyperkalemic Periodic Paralysis, HPP, Paramyotonia Congenital, Anderson-Tawil Syndrome)?
            • Can the history of this disease, known for a century, really be covered adequately in two sentences?
            • you mention above "No, the sources don't mention studies looking into heritability." Please check Ryan et al (2010) PMID 20074522, which does not fully agree with your assessment. Sasata (talk) 00:53, 19 December 2010 (UTC)[reply]
        • Most of the sources you cite are fairly old (e.g. PMID 4260573 from 1972). If a recent review does not mention the findings of older sources, I am acting on the presumption that their findings have been disproven or superseded. This is all stuff that medical contributors have agreed upon in WP:MEDRS. This is a general encyclopedia article and not a summary of all theories that have once been uttered and have now been disproven.
          • Actually, all the points I brought up are from a recent (2010) review, one that was not used in the article, see PMID 20581656; I assume it wasn't looked at because it's "disguised as a case study". All references to primary literature I used above were from this review. Sasata (talk) 07:02, 23 December 2010 (UTC)[reply]
        • Signs and symptoms: some of the points can be covered from the sources that are currently in place, and I am prepared to expand on these points. Others are not even discussed, and it would be NOR to state these negatives explicitly.
        • Mechanism: The calcium theory is not discussed in much detail in recent reviews and seems to have lost currency. The 7 pt case series from 1992 does not shed light on the general question of male predominance, and it is not a MEDRS that would enhance the article.
        • Treatment: Will clarify why beta blockers work. Will expand on risk of hyperkalaemia, as already discussed in current sources.
        • Epidemiology: The question of differential diagnosis doesn't belong in this article but in the parent article periodic paralysis. We are already discussing the fact that this diagnostic entity is diagnosed with thyroid hormone determination. The difference in rates per ethnicities is discussed one paragraph below.
        • History: There are no other real historical landmarks immediately worth discussing, unless you have any suggestions from your reading. JFW | T@lk 12:23, 19 December 2010 (UTC)[reply]
  • Comments from RexxSSupport:
    • Accessibilty: images have good alt text. The only criticism is that File:Scheme sodium-potassium pump-en.svg is rendered so small that I have difficulty reading the text. You may want to consider using a larger size, as is allowed in the exception "Images containing important detail", documented at MOS:IMAGES. A size of 300+px eliminates the problem for me.
    • In Epidemiology, the phrase "17–70-fold" reads awkwardly. Perhaps "17- to 70-fold" might work better, or even "17-fold to 70-fold"?
    • In History, is there a source for "The link between hyperthyroidism and periodic paralysis was first reported in the early 1900s in Japanese medical journals"? I can only see the abstract for the following cites, but neither of them seem to mention previous Japanese reports. The article would benefit from some expansion to this section: do we have any sources specifying dates when particular treatments became available, for example? If possible, dates such as "mid-20th century" might benefit from changing to a decade or year, if known.
    • Generally, I'd agree that MEDRS has been followed in selecting the most recent reviews as sources, and the abstracts of the other suggested sources seem to imply that they are primarily case studies, rather than systematic reviews. The only extra point of interest that I could see was in PMID 15646156 where it is stated that TPP can sometimes precede hyperthyroidism, although that is a 2004 report. Is that assertion confirmed or refuted in the current literature? --RexxS (talk) 16:08, 19 December 2010 (UTC)[reply]
      • I will set the image size bigger to allow the ion pump process to be displayed correctly. I will rephrase the 17-70 bit to de-awkwardise.
      • It is surprisingly hard to write "history" sections for some diseases without falling foul of WP:NOR, and I have generally made an effort in my article work to write useful history sections. Thankfully I found some (relatively vague) historical notes in Fontaine's and Lin's papers. Even so, the Japanese reports are not cited in Lin's paper, and Fontaine bypasses them completely. None of the reviews actually cite reliably any of the major discoveries in treatment. JFW | T@lk 20:20, 19 December 2010 (UTC)[reply]
      • I have make some interesting discoveries while rising to your challenge to expand the historical content. I found a 1926 report from a Japanese professor in a German journal, and in fact his report is cited in the Mayo report. I also managed to dig up the first report of the use of propranolol (1974). James Black would be pleased.
      • With regards to TPP preceding "hyperthyroidism", I suspect that the authors mean "clinical hyperthyroidism". In other words, the attacks of weakness start before other symptoms develop. JFW | T@lk 22:23, 19 December 2010 (UTC)[reply]
        • Thanks, JFW, the image is very clear now, and I think you've made a useful expansion to the History section. One minor point: I think it should be "17- to" (hyphen), rather than "17– to" (en dash), since the hyphen means "17-fold" rather than a range (which the "to" now takes the place of). You've met all my suggestions and I'm happy to support. --RexxS (talk) 23:21, 19 December 2010 (UTC)[reply]
  • Support. Fulfills all fac criteria. Most of the references suggested above do not add any new information. There is still a little room for improvement in the symptoms section: it is quite full of terms such as 'may', 'usually', 'tend to' and 'potentially' although I wouldn't directly know how to improve the prose. --WS (talk) 20:19, 27 December 2010 (UTC)[reply]
  • (edit conflict with nominator) Comment – There are several issues that have made me feel concerned with this FAC. First, the article seems to be being held to a higher standard than other FACs, mainly with regard to the extent of sources used and cited. Perhaps for medical articles this is important and should be encouraged. But it does seem a little unfair. If a few recent, review papers cover all the salient points, then I see no value in digging back into the literature to be seen as being "comprehensive". Second, and in no particular order, this is a FAC, and although an article can be a very valuable contribution, and is generally well-written and reliably sourced, this is not de facto grounds for promotion. (I acknowledge the contradiction with my first point.) Third, this is not a subject in which I have expertise, but it is worrying to see so few citations, (again I acknowledge the contradiction). Third, I am concerned by the lack of input from the editors from the WP:Med. I have great respect for the nominator's long-term commitment to the project, but I think this nomination has been a little rushed. (Which I have been equally guilty of.) Last, the request for support on an editor's Talk Page was a grave mistake, which I think the nominator probably regrets now. I suggest that this nomination be withdrawn to allow time for the issues to be fully resolved. Both Brian and Sasata have raised valid concerns, which, in my very humble opinion, have been too quickly dismissed. Perhaps, the article is perfectly sourced and is complete, but now I have doubts. I know I am in danger of losing a wiki friend by writing this, but please don't shoot the messenger. Graham Colm (talk) 21:17, 27 December 2010 (UTC)[reply]
    • I am not in the business of shooting messengers and prefer a frank opinion. If this FAC indeed fails I shall have to locate other sources (probably textbooks, as all reviews of decent quality are already cited). It is difficult to say whether that will actually enhance the article, as all recent reviews make very similar points based on very similar primary source material. JFW | T@lk 22:03, 27 December 2010 (UTC)[reply]
Note to Graham: There was no request for support on any editor's talk page that I can find. If there was, please supply the diff, or if not, please refactor your comment. The request alluded to by Sasata was made on the article talk page in the section immediately following Working towards FA, in a response to Wouterstomp's remark that "The current version looks good to me". Requesting that WS's opinion (made on the article talk page) be reflected in the FAC surely cannot be seen as improper?
Note to delegate: FAC is meant to be a collaborative process, and I am concerned at the combative attitude being expressed here. It is important that articles be thoroughly reviewed, but no nominator should have to "expect the Spanish Inquisition". --RexxS (talk) 08:46, 28 December 2010 (UTC)[reply]
Thanks for pointing out my mistake for which I sincerely apologise. I have withdrawn the comment. Graham Colm (talk) 09:06, 28 December 2010 (UTC)[reply]
You keep returning to this defence ("all reviews of decent quality are already cited"; "all recent reviews make very similar points"), but I still maintain that over-reliance on a small subset of reviews will lead to important or interesting information being left out. So, let's try again: I hope we can agree that UpToDate is a reliable resource that produces scholarly reviews worthy of the WP:MEDRS qualification. Their review on TPP was updated on May 28, 2010, with the last literature review on Sept 2010. I carefully read through their article and compared it to the Wiki article, and found several things there that could be included here. Apologies in advance if I've included something in the list here that actually is in the article, due to my misunderstanding of the medical terminology:
      • Wiki article does not mention higher incidence in Polynesians
      • Wiki article does not mention 95% (i.e., specific %) of TPP cases occur in men
      • does not mention incidence is 8.7-13% among Asian men with thyrotoxicosis
      • does not mention insulin resistance with compensatory hyperinsulinemia is suspected to have a role in the pathogenesis of TPP
      • The Wiki article says: "Of people with TPP, 33% from various populations were demonstrated to have mutations in KCNJ18, the gene coding for Kir2.6" What is "various populations"? The Uptodate review elaborates more about this, noting that one study showed 26/26 of TPP patients from Singapore to have the mutation, compared with 1/114 from Hong Kong or Thailand.
      • does not mention that there is a possible association of TPP patients with a single nucleotide polymorphism in intron 3 of the alpha3 subunit of the GABA receptor.
      • no mention of the possible role of testosterone in the pathogenesis of TPP
      • Wiki article: "The average age of onset is 20–40." For what percentage of patients? And can a 20-year range be considered an "average"?
      • "Decreased muscle tone with hyporeflexia or areflexia is typical" areflexia is not mentioned in the Wiki article
      • no mention of sinus arrest, second degree atrioventricular [AV] block, ventricular fibrillation as possible clinical outcomes
      • regarding the potassium levels, the Wiki article says "levels below 3.0 mmol/l are typically encountered"; this is true, but the UpToDate review gives better detail, and mentions the incidence of extremely low (>1.5 mM) potassium levels
      • Wiki article doesn't mention that some patients have the combination of elevated T3 and normal T4
      • doesn't mention that mild hypophosphatemia and hypomagnesemia are "common laboratory findings", and these can help distinguish TPP from familial hypokalemic PP
      • "a urine calcium to phosphate ratio of higher than 1.7 was a sensitive and specific test to distinguishing thyrotoxic PP from familial hypokalemic PP" not mentioned
      • the brief discussion on ECG changes in TPP does not mention ST depression, sinus tachycardia, higher QRS voltage, or first degree AV block
      • the article makes no specific mention of several other forms of periodic paralysis which must be ruled out in acute attacks: acute quadriparesis, such as myasthenic crisis, acute myelopathy (eg, transverse myelitis), tick paralysis, and botulism.
      • other minor things I noticed: adrenaline should be wikilinked, not everyone knows it's the same as epinephrine; is heartbeat one word or two? (both versions are in the article) Sasata (talk) 01:05, 28 December 2010 (UTC)[reply]
        • UpToDate is very comprehensive, but it places emphasis on single case reports and small studies, something I wish to avoid. For this reason I have never regarded it as a particularly useful source when writing an encyclopedia article. We are not attempting a full academic review of the subject in this article. You are mentioning a number of things from UpToDate that are already mentioned (e.g. male predominance of 17-70 to one translates roughly to the figure you have given, the role of testosterone is mentioned in the "mechanism" section, decrease in phosphate and magnesium). I am deliberately not mentioning a differential diagnosis, because that is the role of a medical textbook. The urine Ca/PO4 ratio is not important if hyperthyroidism is easily confirmed by biochemical analysis, it makes familial hypokalaemic paralysis less likely than TPP; I think the reviews still mention it out of academic interest. T3 toxicosis is a form of hyperthyroidism, and not really something that needs elaborating here. Different sources mention different ECG abnormalities; I have mentioned the ones mentioned in one source.JFW | T@lk 07:23, 28 December 2010 (UTC)[reply]
  • "UpToDate is very comprehensive, but it places emphasis on single case reports and small studies, something I wish to avoid."
  • Of the 69 references cited in the review article used most frequently as a source for the Wiki article, about 75% of them are single case reports or case studies. Does this then render this review invalid as a reliable source?
  • "We are not attempting a full academic review of the subject in this article."
  • No, if we were, we wouldn't be limiting ourself to using reviews as sources. We are, however, attempting to "neglect no major facts or details" and we are also providing a "thorough and representative survey of the relevant literature", according to the FA criteria.
  • "You are mentioning a number of things from UpToDate that are already mentioned (e.g. male predominance of 17-70 to one translates roughly to the figure you have given"
  • 17- to 70-fold is the same as 95%?
  • "… the role of testosterone is mentioned in the "mechanism" section, decrease in phosphate and magnesium)."
  • Ok. I was misled by the later statement in the Wiki article "It is unknown why males are predominantly affected".
  • "I am deliberately not mentioning a differential diagnosis, because that is the role of a medical textbook."
From WP:Manual_of_Style_(medicine-related_articles)
"Diagnosis: Includes characteristic biopsy findings and differential diagnosis."
  • "The urine Ca/PO4 ratio is not important if hyperthyroidism is easily confirmed by biochemical analysis, it makes familial hypokalaemic paralysis less likely than TPP; I think the reviews still mention it out of academic interest."
  • Yes, several reviews mention it, but the wiki article does not.
  • "Different sources mention different ECG abnormalities; I have mentioned the ones mentioned in one source."

… and therefore missed abnormalities mentioned in other sources ("neglect no major facts or details")

  • I have applied editorial judgement in a number of situations, e.g. whether to delve into the urinary Ca/PO4 ratio or every single ECG abnormality described in people with TPP, which will make minimal contribution to the diagnosis or management. A large number of other facts could be added about the condition, which would turn the Wikipedia article into UpToDate. I grant you that Kung's article also uses case reports; I was referrring more generally to the approach taken by UpToDate. Again, which medical articles actually provide a differential diagnosis?
  • I'm not sure whether a prolonged discussion about our views here is going to be helpful, given that we have opposing perspectives on the level of detail required. JFW | T@lk 17:01, 28 December 2010 (UTC)[reply]
On the points raised so far, I've reviewed UpToDate in the area I'm most familiar with (Tourette's), and its summary had one issue that was lacking, and while it was written by a good TS researcher, it wasn't written by the best, so I understand the reluctance to rely on it too much. I also know that in medical articles, we have to use consensus about which reviews are best and most accurate, and sometimes that's a function of us knowing who the top people in the field are, and who is controversial or promoting their own research, so some judgment applies here. On the talk page request for support, it was on article talk as part of an FA drive, and I work with and know these guys, so it doesn't concern me too much. Still reading. SandyGeorgia (Talk) 01:08, 4 January 2011 (UTC)[reply]
  • Comment - beginning a look-over now. Casliber (talk · contribs) 21:21, 27 December 2010 (UTC)[reply]
    • Thyrotoxic periodic paralysis (TPP) is the occurrence of attacks of muscle weakness in the presence of hyperthyroidism (an overactive thyroid gland)... - first sentence. This one is tricky as I wonder whether it is worth rewording as "Thyrotoxic periodic paralysis (TPP) is a condition' typified by attacks of muscle weakness in the presence of hyperthyroidism (an overactive thyroid gland)." - i.e I am musing on whether we have to note in the first sentence that it is a "syndrome" or "condition" (and we can link syndrome). I do concede it makes the first sentence more unwieldy though. Casliber (talk ·' contribs) 21:25, 27 December 2010 (UTC)[reply]
  • Support, with a minor question about whether the Sternberg source actually needs a "retrieved on" date, and whether the first sentence under ==Epidemiology== could have both of its inline citations presented (only) at the end of the sentence, rather than scattered about.
    I am particularly happy to see a FAC that has so few primary sources (and most of those few historical documents rather than references that the article was built on). Half a dozen top-quality reviews are IMO better than half a hundred primary sources of the sort that infest Schizophrenia, and it represents the ideal of "based largely upon reliable secondary sources".
    As for Sasata's issues above, I think the correct choices generally were made here, e.g., to omit the information on how to work up a patient presenting with these symptoms. Even FAs are supposed to be encyclopedia articles, and that means leaving out trivial details and how-to information. WhatamIdoing (talk) 02:45, 31 December 2010 (UTC)[reply]
    • Thanks for pointing out the Sternberg source. I added a retrieval date reflexively as it uses the {{cite web}} citation template, but it has enough unique identifiers already. JFW | T@lk 08:56, 31 December 2010 (UTC)[reply]
    • I should have kept reading; WhatamIdoing says what I was trying to say, and case reports disguised as reviews are avoided by most good medical editors, in favor of the broadest possible reviews, published by the highest quality journals. SandyGeorgia (Talk) 01:23, 4 January 2011 (UTC)[reply]

Looks good, and very digestible. I see a statement about prognosis in the Lead:

  • Treatment of the hypokalemia, followed by correction of the hyperthyroidism, leads to complete resolution of the attacks.

which is covered under treatment. I assume that means we don't have any additional information on prognosis to warrant a "Prognosis" section, per WP:MEDMOS, since treatment commonly resolves the condition? If that's not the case, the article would need a Prognosis section. SandyGeorgia (Talk) 01:19, 4 January 2011 (UTC)[reply]


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