Talk:Dementia with Lewy bodies/Archive 2

Rewrite

I've rewritten most of the article, but there is still more to do. In particular, my prose is not stellar, so I invite @Colin: @Graham Beards: @Anthonyhcole: and @WhatamIdoing: to work on copyediting. SandyGeorgia (Talk) 15:59, 7 April 2018 (UTC)

• Starting version. SandyGeorgia (Talk) 16:36, 7 April 2018 (UTC)

Sandy, I'll read through, editing as I go. I'll try not to change meaning but may change expression for style or clarity. Everybody, please undo or fix me if you whish. If I encounter anything substantial, or have queries, I'll bring them here. --Anthonyhcole (talk · contribs · email) 12:21, 9 April 2018 (UTC)

thx Anthonyhcole could you start a section below like others, that makes it easier for me to follow, especially while sitting in clinic. SandyGeorgia (Talk) 12:54, 9 April 2018 (UTC)

Will do. I'm thinking about the first paragraph at the moment. --Anthonyhcole (talk · contribs · email) 14:58, 9 April 2018 (UTC)

To do

Get this review to resolve citation needed on sialorrhea (hypersalivation):

• Sialorrhea ref name=Palma2018 Palma JA, Kaufmann H (March 2018). "Treatment of autonomic dysfunction in Parkinson disease and other synucleinopathies". Mov. Disord. (Review). 33 (3): 372–90. doi:10.1002/mds.27344. PMID 29508455.

• Got this review, will work it in and address citation needed. SandyGeorgia (Talk) 17:17, 9 April 2018 (UTC)

Beef up History (problem, everything I found was from people writing about themselves)

I am at a stopping place on History, and would appreciate feedback, critique. SandyGeorgia (Talk) 16:37, 10 April 2018 (UTC)

Check:

• "DLB may be more responsive than AD to donepezil." TRY TO FIND THIS IN NEWER SOURCE ... ref name=Neef2006
• Review all wikilinking and acronyms

I had already corrected most of this; review again. SandyGeorgia (Talk) 15:59, 7 April 2018 (UTC)

• Color vision impairment is mentioned in Tousi 2017, but I left it out of the article because it seems that Tousi is the discoverer and Tousi is the only one reporting it. If anyone can find mention of color vision impairment in a non-Tousi review, it could be added. SandyGeorgia (Talk) 17:43, 7 April 2018 (UTC)

• Vascular dementia differential is weak. SandyGeorgia (Talk) 18:11, 7 April 2018 (UTC)

Pathophysiology

Completely rewritten. Figure out if any of this can be saved or is needed for pathophysiology (now rewritten from sources):

These intracellular collections of protein have similar structural features to "classical" Lewy bodies, seen subcortically in Parkinson's disease. Additionally, those affected by DLB experience a loss of dopamine-producing neurons (in the substantia nigra) in a manner similar to that seen in Parkinson's disease.

A loss of acetylcholine-producing neurons (in the basal nucleus of Meynert and elsewhere) similar to that seen in Alzheimer's disease also is known to occur in those with DLB. Cerebral atrophy also occurs as the cerebral cortex degenerates. Autopsy series have revealed the pathology of DLB is often concomitant with the pathology of Alzheimer's disease. That is, when Lewy body inclusions are found in the cortex, they often co-occur with Alzheimer's disease pathology found primarily in the hippocampus, including senile plaques (deposited beta-amyloid protein), and granulovacuolar degeneration (grainy deposits within and a clear zone around hippocampal neurons).

Neurofibrillary tangles (abnormally phosphorylated tau protein) are less common in DLB, although they are known to occur, and astrocyte abnormalities are also known to occur.

SandyGeorgia (Talk) 15:59, 7 April 2018 (UTC)

I found the origin of this text in a previous editor's Sandbox; it was not MEDRS sourced. SandyGeorgia (Talk) 22:25, 7 April 2018 (UTC)

Lead

Substantially rewritten, with some less-than-accurate info replaced with more accurate, updated info from higher quality sources, and some information expanded. Here is a diff to the lead before I started working in case we want to retain any of the old. I removed the inline commented quotes, as they were hard to edit around and were documenting content that is uncontroversial. SandyGeorgia (Talk) 15:59, 7 April 2018 (UTC)

I've just read the new lead, and it is much much better from an prose and article-summary POV. The previous lead wasn't even grammatical in the first sentence. I like how "Together with Parkinson's disease dementia (PDD), it is one of two dementias referred to as the Lewy body dementias (LBD)." is moved down to the last paragraph -- these classification aspects aren't so fascinating for readers as for scientists, and better also after the "lewy body" aspect is explained. Glad also to see the medical jargon "differential diagnosis" and "treatments are supportive" removed from the lead, and better phrased. Also good to see Kenji Kosaka mentioned, as his contribution is key to the disease itself. I didn't, in fact, find anything to copy edit in the lead. I'll read the other sections later. -- Colin°^Talk 16:24, 7 April 2018 (UTC)

Quote boxes

Quote boxes must be used cautiously (for example, care must be taken that they are not used to advance a POV). I added one last month to highlight the severe risk to people with DLB of antipsychotics; this is important enough IMO that it should stand out for readers. I have added one more quote box to highlight the exciting new discoveries of and addition to the consensus diagnostic criteria on RBD, because it is 94 to 98% predictive of a synucleinopathy, and most commonly, a LBD. That a "single question screen" for RBD is so specific highlights the importance of further evaluation of RBD for the need to avoid antipsychotics in this population. SandyGeorgia (Talk) 15:59, 7 April 2018 (UTC)

Comments by Colin

(Will add more as I read)

• Signs and symptoms: "damage in different domains". Not clear to reader what "domains" are. Is this "domains of brain function" or is there a better phrase?
  • Refers to the domains in the Notes section. Those little critters get everywhere and mess up everything. SandyGeorgia (Talk) 17:06, 7 April 2018 (UTC)
    • PS, Colin, I punted on that because figuring out how to paraphrase all that was ... too much. Someone else might take it on. SandyGeorgia (Talk) 17:44, 7 April 2018 (UTC)
      • I hope this fixes that problem. SandyGeorgia (Talk) 20:29, 7 April 2018 (UTC)
• The text "progressive cognitive decline of sufficient magnitude to interfere with normal social or occupational functions, or with usual daily activities" is quoted. I guess this is such a key definition that we should be wary of trying to put it into our own words. Do we need to attribute it in-text? There are more quotes later too, mostly to same consensus consortium. Can we find a way to introduce them as the source of most quotes in this section. They are mentioned already. -- Colin°^Talk 16:57, 7 April 2018 (UTC)
  • I believe it should be attributed in-text, but when I was doing that early on, someone else was removing it.[1] So, I stayed away from in-text attribution in some places. I believe it is needed there-- where I don't worry about in-text attribution is when quoting public domain NIH sources. I guess we can always reference the DLB Consortium? SandyGeorgia (Talk) 17:06, 7 April 2018 (UTC)
    • I'll have a think about how to phrase it. Alternatively User:Graham Beards may have some good ideas.
    • One option might be to use your Notes section, and state that the unattributed quotes in the text come from the consensus document? -- Colin°^Talk 18:35, 7 April 2018 (UTC)
      • I'd be much happier just attributing the quotes ... there aren't too many of them. SandyGeorgia (Talk) 20:01, 7 April 2018 (UTC)
        • I think, with this edit, everything is now attributed. SandyGeorgia (Talk) 20:27, 7 April 2018 (UTC)
• "anxiety affects 27% and depression affects 59% of people with DLB". I'm wondering if this degree of precision is needed or warranted (from a study of 147 subjects). Would it be more readable to see "anxiety affects around one quarter, and depression affects just over half of people with DLB"? -- Colin°^Talk
  • That was my tendency in the past, but then I have seen it challenged as "what do you mean around or just over? I think I had that issue with Eubulides. Since then, I put in exact numbers. I am indifferent should you wish to change it. SandyGeorgia (Talk) 17:41, 7 April 2018 (UTC)
    • Let's see what others think. I agree that changing some precise percentages to approximate ratios isn't always appropriate. Probably the case is stronger for the lead than article body text. -- Colin°^Talk 18:35, 7 April 2018 (UTC)
      • The anxiety 27%, depression 59% is Boot[2] citing ... Boot[3] ... study of 147 subjects. Perhaps we can find a better source or just rephrase. SandyGeorgia (Talk) 22:20, 11 April 2018 (UTC)

• I've changed "large populations of persons with DLB have not been identified, and because typically the disease is not seen in families". The former statement appears to contradict the "third most popular form" statistics from earlier. Looking at the source, it seems the difficulty is "large, homogeneous cohorts of PDD/DLB cases have been difficult to assemble ". Also I think the families aspect needs to be a little more precise. So changed to " it has been hard to study large homogeneous populations of persons with DLB, and because typically the disease is not seen clustered in families". -- Colin°^Talk 17:47, 7 April 2018 (UTC)
  • 'Tis good! SandyGeorgia (Talk) 17:52, 7 April 2018 (UTC)
• "Modafinil and armodafinil are not always covered by insurance" is a US-specific comment. For example, in the UK the equivalent might be NICE approval. -- Colin°^Talk 18:21, 7 April 2018 (UTC)
  • Are you suggesting to clarify (specific to US), or remove? SandyGeorgia (Talk) 18:35, 7 April 2018 (UTC)
  • More that it would be good to see if there is more we can say internationally. On the KD, I mention approval by NICE and by US insurance companies. -- Colin°^Talk 18:36, 7 April 2018 (UTC)
    • I would expect there to be something sourced, considering The Guru is Ian McKeith. Perhaps someone with better journal access than I could try to find something. SandyGeorgia (Talk) 18:41, 7 April 2018 (UTC)
      • Added U.S. anyway. SandyGeorgia (Talk) 20:31, 7 April 2018 (UTC)
        • I can't actually find any NICE guidelines on DLB. There is some brief mention of modafinil for PD. NICE still seem to be clumping all the dementias together, which doesn't seem very useful. The closest to any UK-specific material on DLB is BMJ Best Practice. So I guess most of these drugs are still experimental and lacking good evidence. -- Colin°^Talk 09:40, 8 April 2018 (UTC)
          • That page is still linking to the Third Consensus (not Fourth), so perhaps still in process of being updated? That is all very odd, since Ian McKeith is on your side of the pond, and He Is Mr DLB. I don't have a subscription; is there material in there that should be worked in to the article? SandyGeorgia (Talk) 13:18, 8 April 2018 (UTC)
            • I don't have access either, and suspect the pages are not going to be very detailed (or, it seems, up-to-date). I was actually very disappointed that NICE's guideline pages just had "dementia" as one huge topic. Rather insulting for a condition that affects so many people and clearly has so many different causes, specific symptoms and specific needs and possible treatments. It's a bit like finding "Womens's troubles". -- Colin°^Talk 17:21, 8 April 2018 (UTC)

Causes, genetics

I see the text I revised to "it has been hard to study large homogeneous populations of persons with DLB" (here) has been edited to "because it is difficult to survey the affected homogeneous population" and finally Tryptofish removed the "homogeneous" with reason "because that would make it easier to study, not harder". So I think the sentence has been edited incorrectly (can't find when/who) to become incorrect, then vague, and so now we have a rather weak claim that the population is merely difficult to survey. The point before was that for the role of genetics to be discovered, you need a large homogeneous population group where the minor variations lead to variations in risk of disease. Perhaps we need to go back to the source (and other sources such as the book) for a better rationale for why genetics is not yet well studied. -- Colin°^Talk 07:47, 10 April 2018 (UTC)

The original was:

The genetics are "vastly understudied", because it has been hard to study large homogeneous populations of persons with DLB. Typically the disease is not seen clustered in families, leading to the belief that DLB does not have genetic underpinnings.

We now have:

The genetics are "vastly understudied", because it is difficult to survey the affected population. Typically the disease is not seen clustered in families, although having another family member with DLB is a risk factor, leading to the belief that DLB does not result from simple genetic alterations.

Weil 2017 says:

The genetic underpinnings of PDD/DLB have been vastly understudied. Two main reasons may have contributed to this: first, the fact that large, homogeneous cohorts of PDD/DLB cases have been difficult to assemble and thus large-scale genetic studies have not been possible; second, because we do not tend to see familial aggregation of DLB, as we do in some instances in PD or AD, the general reasoning has been that there is no genetic basis for this disorder. However, the last few years have started to shift this notion, much like the early ’90s did for PD and the early ’70s for AD.

NINDS says:

Genetics— While having a family member with LBD may increase a person’s risk, LBD is not normally considered a genetic disease. A small percentage of families with dementia with Lewy bodies has a genetic association, such as a variant of the GBA gene, but in most cases, the cause is unknown. At this time, no genetic test can accurately predict whether someone will develop LBD. Future genetic research may reveal more information about causes and risk.

SandyGeorgia (Talk) 12:23, 10 April 2018 (UTC)

References

I realize that, by the time that I edited it, the meaning of the original, which was essentially that there is no large and defined patient population, making it difficult to study, had changed to it being difficult to study because the patient population is homogeneous. I was reacting to the latter, which obviously does not make sense. In other words, what the Weil source actually says is that studies have been hampered by the lack of an appropriate study population. I've made this edit: [4], which reorders the sentence so that it makes sense and follows what Weil says. --Tryptofish (talk) 19:31, 10 April 2018 (UTC)

Since it's one of the top three dementias, they probably exist, but they have been, according to Weil, difficult to assemble. How about changing "do not exist" to "have not been gathered"? SandyGeorgia (Talk) 20:27, 10 April 2018 (UTC)

Strictly speaking, "large" populations exist, but "homogeneous" populations do not. The classic example of a homogeneous population might be Huntington's disease. But I'm going to change "do not exist" to "have not been identified". --Tryptofish (talk) 20:42, 10 April 2018 (UTC)

Responding to edits from Doc James

Doc, I am not a fan of piping apathy --> loss of interest. Apathy is a common word, and used correctly here; in fact, IMO it's a better word. Loss of interest in what? ... that leaves the reader hanging. Apathy is loss of interest, concern or emotion, and we don't really want to add all that, do we? Also, in a collaborative spirit, might you allow time for others to work over the prose before chopping up sentences? SandyGeorgia (Talk) 18:51, 7 April 2018 (UTC)

Apathy is not a very common term in English. It is a board lack of interest.

Best not to have a 32 word sentence in the lead when shorter sentence work just as well and are more clear. Doc James (talk · contribs · email) 07:32, 9 April 2018 (UTC)

Also, in the chance that this article can be prepared for FAC, please try to keep citations consistent.[5] SandyGeorgia (Talk) 18:54, 7 April 2018 (UTC)

1. Before your edit, we had: memory loss not always present early --> worsens over time --> to point of diagnosis.
2. That became: worsens over time --> to the point of diagnosis --> not always present early.

The first seems a more logical flow, and it aids the reader who (mistakenly) thinks of DLB like AD, where memory loss is present early on. SandyGeorgia (Talk) 19:03, 7 April 2018 (UTC)

So the disease always worsens over time to the point of diagnosis.

Sometimes memory loss is not present early on.

IMO what is always present is best first followed by what can occasionally occur. While I consider the change in order an improvement not set on it. Doc James (talk · contribs · email) 07:32, 9 April 2018 (UTC)

This edit has several poor aspects. I've restored "apathy" and "relentlessly" to the lead. This is why clumsy dumbing down, for the sake of it, as seen here, is harmful. Words that are carefully chosen, like "apathy", and may indeed be well sourced, are replaced by other words and phrases that mean something else or mean less. Far better for editors to make a comment that they think a word is too difficult for the lead, though one would struggle to get any consensus that "apathy" is too difficult for the lead. Shortening the sentence to just "The exact cause is unknown." meant the following sentence required introducing words to be added to it, and left us with a choppy sentence. The introducing text "the underlying mechanism" is medical jargon. Sometimes jargon is necessary, other times not. I've removed it and joined the sentences.

There are arguments both ways for the order of the two sentences, but the current ordering has the unfortunately effect of starting both sentences with "dementia" and having the word "dementia" three times in the top line of the lead paragraph. Wrt James' argument, I don't think there is any doubt in the readers mind, on an article called "Dementia with Lewy Bodies" that dementia is a core feature of the condition. Our first sentence confirms this.

Btw, while we're discussing these sentences, I'm not keen on "Memory loss is not always present early in the course of the disease" being changed (by other editors in multiple edits) to "Memory loss does not always present early". The latter is a more difficult use of the word "present" and is a bit close to the medical jargon too. -- Colin°^Talk 08:56, 9 April 2018 (UTC)

The reasoning behind the order and the specific words I chose, after reading more than a dozen reviews, is for the Wikipedia reader most likely to seek out this article. We are not writing for medical students who already have some understanding of topics; we are writing for general readers, who are likely more naive to the topic(s).

DLB is most often confused with AD, and AD is what people are more familiar with. Meaning that readers first seeking information are coming to the topic thinking that memory loss should be present for a dementia diagnosis, when in the case of DLB, it probably is not at the time that people begin to seek out information. When someone seeks info on DLB, it is highly likely that a) RBD is present, and b) memory loss is not. The sentences as I wrote them were:[6]

Memory loss is not always present early in the course of the disease,[6] but dementia relentlessly worsens over time, and the condition is diagnosed when cognitive decline interferes with normal daily functioning.[1][7] A core feature of DLB, called REM sleep behavior disorder (RBD), involves acting out dreams during REM sleep.[1] An early sign, RBD may appear years to decades before other symptoms.[8]

What we have now is not an improvement on memory loss (it is an improvement on RBD); it resulted from chopping sentences with no discussion. For the general reader who comes to the article naive, a) don't expect memory loss to be there, b) it worsens over time, and c) do expect RBD.

By the way, the word relentlessly is used relentlessly in the literature, but I have now cited it in the lead, hoping it won't be removed again. SandyGeorgia (Talk) 11:14, 9 April 2018 (UTC)

And when a word like that is used so frequently in the literature, that's a good signal that it is important. We know that relapsing-remitting MS follows a different path, for example. This is something that comes only from familiarity with the literature to a degree only achieved if one is passionate about the subject. That's why I think that anyone copyediting an article without that familiarity, needs to respect those that have it. -- Colin°^Talk 11:56, 9 April 2018 (UTC)

Feedback from Ceoil

Hello, Ceoil! I am wondering what you intended here?  :) :)

• Memory loss is not always early present .[7]

Thank you for pitching in here, much appreciated. SandyGeorgia (Talk) 19:10, 7 April 2018 (UTC)

Was tightening Memory loss is not always present early in the course of the disease, will rephrase as Memory loss does not always present early. Hi also. Ceoil (talk) 19:14, 7 April 2018 (UTC)

Thank you, Ceoil! Also, on Parkinson's disease, the distinctions here are tricky because we have parkinsonism, Parkinson's disease, and Parkinson's disease dementia. The nomenclature in here is awful! SandyGeorgia (Talk) 19:22, 7 April 2018 (UTC)

Indeed. Editing as saw post on JB's page and its all very close to home (both sides of the family alas). Please feel free to revert, I'm inclined to trust your judgement. Ceoil (talk) 19:41, 7 April 2018 (UTC)

So sorry to hear that, Ceoil :) I will wait 'til you are finished. SandyGeorgia (Talk) 19:46, 7 April 2018 (UTC)

Thanks Sandy. I had hoped to do some light ce'ing here, but now realise meaning can be changed very easily. Think I will leave this to the specialists. Regards from drizzly Ireland. Ceoil (talk) 19:52, 7 April 2018 (UTC)

Per my talk

• In the latter part - latter stages
• Typically, no family history is apparent among those affected. Dont need "among those affected" as its implied.
• Blood tests and medical imaging can be done to rule out other possible causes - "performed" rather than "done"
• that will modify the course of the disease - progression rather than course Ceoil (talk) 14:59, 8 April 2018 (UTC)
• but does not always appear early on with DLB. It is more likely to present as the condition progresses,[1][6] typically after age 55. - For the sake of flow; "does not always appear early on with DLB, and is more likely"

• Done, SandyGeorgia (Talk) 15:10, 8 April 2018 (UTC)

• Memory loss is not always noticeable early on in DLB - end the sentence with early on.
• Same sentence, "verbal memory is better" - 'better' is imprecise, presumably there are degrees that can be described

• Source says:[7]

  Patients with pure Lewy body pathology have better verbal memory skills than those with pure AD or mixed LBD/AD. Patients with pure AD and mixed LBD/AD show equivalent degrees of impairment on verbal memory testing. By contrast, combined AD and Lewy body pathology appears to have an additive effect on visual memory skills.

Suggestions? SandyGeorgia (Talk) 15:24, 8 April 2018 (UTC)

@Eric Corbett: this is something you might know how to better word? SandyGeorgia (Talk) 15:30, 8 April 2018 (UTC)

If the source doest go further than "better", then its fine as stands. Ceoil (talk) 15:38, 8 April 2018 (UTC)

I think it's worth changing this sentence not because of the imprecision of "better", but because it could be interpreted as suggesting that verbal memory actually improves with the onset of this disease. I'd suggest something like "... memory impairment occurs later in the progression of DLB, verbal memory is not as severely affected, and deterioration in memory function is related to retrieval rather than encoding of new memories." Eric Corbett 16:01, 8 April 2018 (UTC)

Got it, thanks Eric! SandyGeorgia (Talk) 16:25, 8 April 2018 (UTC)

• While the specific symptoms in a person with DLB may vary - 'While the specific symptoms may vary
• In other severe cases of dementia (for example, advanced stages of AD), some core features of DLB may also be present: "for example" is a bit informal, and reminiscent of high school; better "including", or some such construct. Ceoil (talk) 15:14, 8 April 2018 (UTC)

• Done, except "better" above, suggestions needed. SandyGeorgia (Talk) 15:25, 8 April 2018 (UTC)

Thank you. Ceoil (talk) 15:39, 8 April 2018 (UTC)

• People with DLB experience impaired attention, executive function, and visuospatial function - Again dont like people with. The symptoms of is more encyclopedic to me.
• In DLB, Karantzoulis and Galvin (2011) say In DBL doesnt seem needed. Write is better than say.
• link executive functions.
• Alzheimer's disease under the Differential section would read better and be more logical as two rather than 3 paras. Ceoil (talk) 15:33, 8 April 2018 (UTC)

• Done, except executive function is linked ... ??? I will be out for a few hours, SandyGeorgia (Talk) 15:40, 8 April 2018 (UTC)

Tks, missed the earlier link. Its been a bitter sweet pleasure to read this rewrite. Ceoil (talk) 15:49, 8 April 2018 (UTC)

It's like living with cancer; carpe diem. SandyGeorgia (Talk) 15:52, 8 April 2018 (UTC)

• The signs of DLB may first appear subtly The first signs are often subtle. Alas.
• Difficulties with visuospatial processing are present in most individuals with DLB - In most inscidences. "Difficulties with" is unclear; spell out here, and maybe use "complications".
• Reduced dopamine transporter uptake (DAT) seen on PET or SPECT imaging is helpful in distinguishing AD and DLB. This is slightly backwards - if I read it right maybe, "PET or SPECT imaging can be used to detect" Ceoil (talk) 15:47, 8 April 2018 (UTC)

• Dont like "helpful", which sounds opaque when the technology is ingeniousness and advanced. Ceoil (talk) 01:07, 9 April 2018 (UTC)

• Better? SandyGeorgia (Talk) 01:12, 9 April 2018 (UTC)

Yup. Ceoil (talk) 01:20, 9 April 2018 (UTC)

• Done, and I looked at my watch and realized I missed church, so still here :) SandyGeorgia (Talk) 16:04, 8 April 2018 (UTC)

• Flow: "screening questionnaire used to measure"
• may be commonly misdiagnosed as delirium or,[13] more rarely, as psychosis two commas could go
• The sentence "Treatment may offer symptomatic benefit, but remains palliative in nature;[12] there are no medications which will modify the course of the disease,[11] and none approved by the U.S. FDA for its treatment as of 2017.[7]" is the most important in the article, and should be picked over accordingly. I'd break it down more, and make it more globally relevant.
• Management of DLB can be challenging - Management can be challenging. Obv we are talking about DBL. Its a trivial point but there is some over writing like this throughout the article. Ceoil (talk) 16:02, 8 April 2018 (UTC)

• Done, except I am not sure how to address your "Treatment may offer ..." concern further. We only have donepezil in Japan? What else might you like to see here? SandyGeorgia (Talk) 16:11, 8 April 2018 (UTC)

I was more thinking about the U.S. FDA approval. maybe a more generalised claim. Ceoil (talk) 16:16, 8 April 2018 (UTC)

You lost me ;) Tell me what you're after, and I'll go back to the sources to find something. SandyGeorgia (Talk) 16:27, 8 April 2018 (UTC)

I mean more has it been approved by similar bodies in other developed countries. I ask supposing from the POV of a person wondering if it may be available to them. Ceoil (talk) 16:36, 8 April 2018 (UTC)

• Severe sensitivity to antipsychotics (neuroleptics) is cautioned for people with DLB[1] because half will have adverse reactions,[10] - reactions, effecting half. As this is also effectively medical advice, I would spell out the effects.

• The spelling out of effects is in the rest of the paragraph? Also, because this is covered in pretty much every recent review about DLB, not sure how to get around the problem that ... it is medical advice ... suggestions? Maybe if I attribute it to the DLB Consortium? SandyGeorgia (Talk) 16:46, 8 April 2018 (UTC)

• Some medications that should be used with great caution. Yes but a bit editorialising if you dont say whose opinion this comes from. Re pharasing...Other medications...'

• Thing is, that caution is in just about every single paper written about DLB-- it is not any one author's opinion-- it is a serious caution put out by anyone and everyone writing about DLB. SandyGeorgia (Talk) 16:39, 8 April 2018 (UTC)

Ok, then 'medical authorities caution', to kick home. Ceoil (talk) 16:42, 8 April 2018 (UTC)

• As in the other synucleinopathies As with Ceoil (talk) 16:36, 8 April 2018 (UTC)
• I'm almost finished, and these are matters of polish rather than substance. Been a pleasure though. Ceoil (talk) 16:38, 8 April 2018 (UTC)

• Partly done, SandyGeorgia (Talk) 16:46, 8 April 2018 (UTC)

• How's this? SandyGeorgia (Talk) 16:54, 8 April 2018 (UTC)

Satisfactory :) Ceoil (talk) 17:04, 8 April 2018 (UTC)

I'd be more frank in areas: but remains palliative in nature implies speculation about the future. Better maybe is more but palliative in nature Ceoil (talk) 16:51, 8 April 2018 (UTC)

I hate that sentence, and did not write it. Sounds like someone wanting to show off their vocabulary. How about a complete re-do? Ideas? SandyGeorgia (Talk) 16:54, 8 April 2018 (UTC)

@Eric Corbett: might be best able to help here. He had obviously had a fine grasp of subtleties. Ceoil (talk) 16:59, 8 April 2018 (UTC)

I think that to improve matters the first three sentences of the Management section should be merged. I started to type out my suggestion here, but it seemed easier just to make the change and let you review my version in the article. If you don't like it than just roll it back (as I'm sure you would do anyway, without my permission). Eric Corbett 00:33, 9 April 2018 (UTC)

I like it, Eric. At first, I was troubled that "no known cure" went away, but we say it in the lead, and it is implied by the way you wrote the rest. SandyGeorgia (Talk) 00:36, 9 April 2018 (UTC)

PS, should we be relieved that you aren't finding a lot ? Or is it so bad that you are just beginning :) ;) SandyGeorgia (Talk) 00:37, 9 April 2018 (UTC)

So far I've only really looked at the two sentences you pointed me towards Sandy, but don't read too much into that. I'll have a look through the whole thing once your team has finished, but I doubt that I'll find much to whinge about. Eric Corbett 00:44, 9 April 2018 (UTC)

Feedback from Johnbod

• Lead pa. 1: I wasn't initially sure what "which involves the acting out of dreams during REM sleep" meant, & had to follow the RBD link. Maybe explain more, even if in a note. When we do explain, a good deal further down, there's:

" and act out their dreams or have other abnormal movements or vocalizations.[6] About 80% of people with DLB have RBD.[8]

RBD vocalizations may include yelling, screaming, laughing, crying, or unintelligible talking.[8] The movements can include non-violent flailing or more violent punching, kicking,[10] choking or scratching." - this doesn't make it unmistakably clear that all the "yelling, screaming, laughing, ..." = acting out. Rearrange. Is crying a vocalization? Maybe.

How's this? SandyGeorgia (Talk) 07:38, 8 April 2018 (UTC)

• "DLB is the third most common cause of dementia after Alzheimer's disease..." type of dementia, no? Does that mean it is the 3rd or 4th most common? 3rd it seems from next section, but "third most common ... after" sets up ambiguity.

• Gah, the terminology in DLB is awful ... is this better? SandyGeorgia (Talk) 07:47, 8 April 2018 (UTC)

• "These impairments present as driving difficulty" - spell out you mean driving a car

  reworded SandyGeorgia (Talk) 07:08, 8 April 2018 (UTC)

• Pipe "prodomal" from a simpler term

  early sign. SandyGeorgia (Talk) 07:18, 8 April 2018 (UTC)

• "Presentation of motor symptoms is variable, but they are usually symmetric" - on both sides of the body presumably - better say so.

• done, SandyGeorgia (Talk) 07:21, 8 April 2018 (UTC)

• "marked dysautonomia (autonomic dysfunction);" in a list didn't convey much to me

• Better? SandyGeorgia (Talk) 07:42, 8 April 2018 (UTC)

• "Weil (2017) says the genetics "have been vastly understudied"" - well, we're not copyediting him, although the phrase is striking.

• Better? SandyGeorgia (Talk) 07:23, 8 April 2018 (UTC)

• "Cause" section - not "Causes"? maybe

• Don't know how that happened! fixed. SandyGeorgia (Talk) 07:24, 8 April 2018 (UTC)

• Ok, done down to there. Now I have to take my restless legs off to bed, wondering who has stolen my shaver.... Johnbod (talk) 01:08, 8 April 2018 (UTC)

Thanks, Johnbod I will finish working on these tomorrow. Please keep going once you're rested your legs :) I kept the parens here because of the colin above, and linked the terms. SandyGeorgia (Talk) 07:10, 8 April 2018 (UTC)

OK, got this much done, thanks to doggie being up in the middle of the night! Thanks, John ... I am not sure I cleared all that up satisfactorily, so please let me know. SandyGeorgia (Talk) 07:50, 8 April 2018 (UTC)

Ok, all good so far, thks Johnbod (talk) 20:41, 10 April 2018 (UTC)

• Continuing:
• "A proposed pathophysiology for RBD implicates the subcoeruleus or magnocellular reticular areas of the brain." Probably ok, but this meant nothing to me. "subcoeruleus" links (pipe) to Locus coeruleus, in which "subcoeruleus" does not actually appear. "magnocellular" pipes to magnocellular pathway, which redirects to Visual system, where "magnocellular pathway" does not appear, but "magnocellular" does, a couple of times, not clearly explained. Meanwhile you could link to Magnocellular cell and Reticular formation as well or instead.
• More later. Johnbod (talk) 20:53, 10 April 2018 (UTC)
  • I fixed that. --Tryptofish (talk) 21:02, 10 April 2018 (UTC)
  • Thanks, Johnbod. It seems important to explain why RBD can appear decades before other symptoms, but I certainly don't know how to word this. Perhaps Tryptofish will give it a go. Here is what the source says:

    RBD arises from pathology in the brainstem circuitry involved in the control of rapid eye movement sleep. Although the pathophysiology of human RBD remains unclear, degeneration of the subcoeruleus region or magnocellular reticular formation (or both) has been proposed to be responsible. These regions are affected by Lewy body disease and, according to the Braak staging, are involved earlier than the substantia nigra, limbic system, and neocortex. This pattern of development of pathology would explain why RBD often precedes the typical motor, cognitive, and neuropsychiatric manifestations of Lewy body dementias by years or decades.

    Perhaps we can avoid mention of specific brain regions and find a way to just explain that it is because of this that RBD precedes ... SandyGeorgia (Talk) 21:04, 10 April 2018 (UTC)
    • I rewrote it based on that (basically just the reticular formation, which is different than what it seemed to say before). I think it's clearer now. --Tryptofish (talk) 21:16, 10 April 2018 (UTC)
      • I like that much better (we aren't a textbook -- I just didn't know how to phrase it). SandyGeorgia (Talk) 21:30, 10 April 2018 (UTC)

• "preserved medial temporal lobe;" - what does preserved mean here?
  • Fixed by Tryptofish. SandyGeorgia (Talk) 20:31, 11 April 2018 (UTC)
• The Criteria section must have a reading age of about 150, kept down only by all the initials.
  • Will work on acronyms all at once. SandyGeorgia (Talk) 20:31, 11 April 2018 (UTC)
• Does parkinsonism not have a cap P?
  • I do not believe so ... SandyGeorgia (Talk) 20:31, 11 April 2018 (UTC)
  • It is lower case, per its page here. --Tryptofish (talk) 20:36, 11 April 2018 (UTC)
• "the synucleinopathies Parkinson's disease dementia" ? hard to parse - anything missing? Synucleinopathy was linked way back, but could be repeated.
  • fixed by Tryptofish. SandyGeorgia (Talk) 20:31, 11 April 2018 (UTC)
• "Differential" section could link Differential diagnosis, and perhaps use that in the title. Not everybody knows about these.
  • Did this, SandyGeorgia (Talk) 20:34, 11 April 2018 (UTC)
• Is the pharma section too long and detailed, especially given they are all palliative?
  • Johnbod because pharmaceutical treatment of DLB is so challenging, and there are so many medications people with DLB must avoid, and there is the situation that what helps one symptom may worsen another, I felt like it was OK to go slightly more into detail than other articles. We could still look case by case, and see if we need to improve prose? But I feel like readers who don't need medication info would skip that section, while those who do wonder will be happy to have the detail. What do others think? SandyGeorgia (Talk) 20:38, 11 April 2018 (UTC)
    • I've been thinking about it, and I've come to the same conclusion that Sandy did. --Tryptofish (talk) 20:41, 11 April 2018 (UTC)
• "increasing table salt for orthostatic hypotension, and increasing fluids or dietary fiber for constipation" - spell out "to prevent"?
  • Fixed by Tryptofish. SandyGeorgia (Talk) 20:31, 11 April 2018 (UTC)
• "the caregiver burden" - plainer English would be good here, and elsewhere: "the demands on carers are higher than with AD"? "Caregiver" isn't really vernacular British English.
  • Fixed by Tryptofish. SandyGeorgia (Talk) 20:31, 11 April 2018 (UTC)
• That's it. In general there are vast numbers of abbreviations, which it would be good to reduce. Not an easy read, but no doubt this is inevitable. Johnbod (talk) 20:53, 10 April 2018 (UTC)

• Thank you ever so much, John! I want to hold off on swapping out the acronyms until everyone is on board (I pinged below, in Trypto section). On the rest, I may not be able to get to this list until much later, as I have to go out this pm, and tomorrow is a very full day at clinic. Others might chip away at it? If so, please diff back to here so we'll all know what is done. Then I will summarize where we stand on everything, what is left to do on the page, hope to archive all the done work, and then settle in to look at the lead and the notable people, once Jytdog has processed a bit of autonomic dysfunction. Bst, SandyGeorgia (Talk) 21:38, 10 April 2018 (UTC)
• I've done this much: [8]. Carer is a redirect to caregiver. --Tryptofish (talk) 22:07, 10 April 2018 (UTC)

Feedback from Tryptofish

Thanks, Tryptofish—some pretty basic things we've missed! SandyGeorgia (Talk) 20:07, 8 April 2018 (UTC)

Happy to do it. Please ping me if there are other things in particular that you would like me to take a close look at. --Tryptofish (talk) 20:09, 8 April 2018 (UTC)

Tryptofish I am at a stage now of waiting for further copyedits, and trying to get hold of Historical reviews to beef up the History section. And waiting for, hopefully, LeadSongDog and Looie496, and a pharm person, to go through. Bst, SandyGeorgia (Talk) 20:12, 8 April 2018 (UTC)

Just so you know, I'm a pharm person. --Tryptofish (talk) 20:16, 8 April 2018 (UTC)

I did not know that! I am worried that I may have linked some general terms incorrectly; were you able to check them? Once I get beyond anticholinergic and antidepressant, it all runs together. SandyGeorgia (Talk) 20:17, 8 April 2018 (UTC)

(Yes, a former Professor of Pharmacology, in fact.) Sure, just tell me which page section(s), and I'll go through them. --Tryptofish (talk) 20:28, 8 April 2018 (UTC)

I am particularly worried about everything I linked that starts with "dopa ... " and that I got every use of aCHEI correct ... would you be able to just plug those into a search on the page and check those links? Also, how do you feel about the place where I use the brand name Benadryl? I think it helps our readers, but not sure if I should do that ... SandyGeorgia (Talk) 20:39, 8 April 2018 (UTC)

I've already checked every link it the Pharmaceuticals section, and they are fine. I would change that to diphenhydramine (Benadryl). --Tryptofish (talk) 20:42, 8 April 2018 (UTC)

I am also still looking for a newer source for this:

• "DLB may be more responsive than AD to donepezil." TRY TO FIND THIS IN NEWER SOURCE ... ref name=Neef2006

And, in the antipsychotic sensitivity section, I left in chlorpromazine because according to our article, it is still used in some other countries ... does that seem right? SandyGeorgia (Talk) 20:44, 8 April 2018 (UTC)

Yes, I would leave chlorpromazine in. I'm not sure about donepezil. --Tryptofish (talk) 21:01, 8 April 2018 (UTC)

I've checked the revised passage about benzodiazepines, and that's much better. --Tryptofish (talk) 20:49, 9 April 2018 (UTC)

Tryptofish I am pretty sure these are two different beasts. In fact, I was considering writing the article on the single-screen since it is such a game-changer. SandyGeorgia (Talk) 21:38, 9 April 2018 (UTC)

OK, fixed. --Tryptofish (talk) 21:41, 9 April 2018 (UTC)

Abbreviations

Trypto, here we get into the dreadful terminology of dementia with Lewy bodies being one of the Lewy body dementias. In this case, the source was specifically referring to LBD not DLB. I suppose we could find a global way to fix that ... ?? SandyGeorgia (Talk) 21:41, 9 April 2018 (UTC)

Sure, that's fine. --Tryptofish (talk) 21:42, 9 April 2018 (UTC)

But if it confused you, it will also confuse others. Do you feel like it is OK to say DLB when the source said LBD, since DLB is an LBD, or do we need to re-phrase? I don't think we should leave it as is, since it will confuse others as well. SandyGeorgia (Talk) 21:47, 9 April 2018 (UTC)

Yeah, it is confusing. How about using DLB when it's really DLB, but spelling out Lewy body dementias for the more general cases? (Overall, the page is rather heavy on abbreviations.) --Tryptofish (talk) 21:53, 9 April 2018 (UTC)

The acronyms are horrible and the nomenclature makes no sense. Let's see what everyone thinks about changing every case of LBD to "the Lewy body dementias". SandyGeorgia (Talk) 21:59, 9 April 2018 (UTC)

Went ahead and did it,[9] SandyGeorgia (Talk) 12:43, 10 April 2018 (UTC)

Good, thanks. One fish's opinion is that it would be good to further decrease the use of abbreviations and acronyms. Personally, I would get rid of and spell out all of the following: RBD, PDD, MSA, VH, DAT, MID, PSP, CBD, and CBS, although I could be talked into keeping RBD. I think it is easier for general readers to see the terms spelled out, even if the terms are rather technical, than to have to keep track of all the letters. --Tryptofish (talk) 20:12, 10 April 2018 (UTC)

@Colin, Tryptofish, Ceoil, Johnbod, Jytdog, LeadSongDog, DocJames, Anthonyhcole, Outriggr, and Eric Corbett: could everyone opine on this before I do it? I could first convert the less commonly used acronyms (MSA and such), we could have another look, and then convert more commonly used if there are still too many (eg RBD PDD could be left til last). SandyGeorgia (Talk) 21:23, 10 April 2018 (UTC)

I agree - I've just been edit-conflicting saying that above. Johnbod (talk) 21:38, 10 April 2018 (UTC)

I'm all in favour of removing all initialisms except DLB ... even RBD and PDD. I hate them when I'm trying to get my head around an unfamiliar topic - constantly having to search for the first instance to find out what they stand for. --Anthonyhcole (talk · contribs · email) 11:13, 11 April 2018 (UTC)

I think it may be hard to get rid of them all (or nearly all) as some parts of the text would explode in size and reading complexity. The symptoms bit would be hard if every RBD was spelled out (why is the S missing?). Certainly some that are only used a few times like those in the differential diagnosis should go. Perhaps some like RBD need kept at times but not at other times, and perhaps writing them out at the start of a long paragraph or set of short paragraphs would help. -- Colin°^Talk 13:48, 11 April 2018 (UTC)

I agree with expanding as many as is feasible. I would probably expand AD--there is only one paragraph where it's used heavily, oh well. I hate "aChEIs" but I don't have a suggestion. A poorer reader might even think it's a simpler medical word (that is, "aches"). I think "SSRI" and the scans are common enough to leave as is. (I keep wanting to turn RBD into a bowel disorder--rabid, rapid, rusty, runny? The options are endless really, no pun intended.) Outriggr (talk) 22:52, 11 April 2018 (UTC)

Although I've said that I want to keep the drug abbreviations, I do agree somewhat about AChEIs. I could go either way on that one. Perhaps "AChE inhibitors"? --Tryptofish (talk) 22:59, 11 April 2018 (UTC)

In use again

Unless anyone is planning to actively edit for the next half hour or so, I will put the article {{inuse}} and work on the lesser abbreviations, and we can look at the others on a second pass (RBD, PDD, things more closely related to DLB). After abbreviations are fixed, then to address the rest of LeadSongDog's comments ... SandyGeorgia (Talk) 20:46, 11 April 2018 (UTC)

Still working through this, once I cleared out PD, there were only 8 instances of PDD, so I did them too. RBD occurs 29 times, so should probably stay. Still working. SandyGeorgia (Talk) 21:13, 11 April 2018 (UTC)

I did a lot, but now it's the drugs that are heavy going (aCHeI, SSRI, etc), and imaging (PET, SPECT, CT, MRI). SandyGeorgia (Talk) 21:26, 11 April 2018 (UTC)

When I made the list of abbreviations above, I was specifically trying to include all those I would want to delete, and leave out all those that I would choose to keep. So I actually am fine with keeping AD and PD (as opposed to PDD). In my opinion, the drug and imaging abbreviations should stay: SSRI, PET, MRI and so forth are commonly used abbreviations that are often more familiar than the full names. --Tryptofish (talk) 21:33, 11 April 2018 (UTC)

Tryptofish There were very few PDs and a boatload of ADs (since DLB is most confused with and compared to AD); do you want me to re-instate the PDs (not the PDDs)? Or should we see how it feels once we complete the next pass? Whatever you want ... I am not tied to anything on that one way or the other. SandyGeorgia (Talk) 22:03, 11 April 2018 (UTC)

That makes two of us who do not feel strongly. I'm fine with seeing how it feels later on. I do feel strongly about the drug and imaging ones. --Tryptofish (talk) 22:34, 11 April 2018 (UTC)

Comments from Anthonyhcole

From the lede:

Antipsychotics, even for hallucinations, should be avoided because people with DLB are sensitive to them,[1] and their use can result in death.

The source says

The use of antipsychotics ... should be avoided whenever possible, given the increased risk of a serious sensitivity reaction.

There are instances where using antipsychotics is the least worst option, so I'd recommend changing the lede sentence to

Antipsychotics, even for hallucinations, should be avoided where possible because people with DLB are sensitive to them,[1] and their use can result in death.

Anthonyhcole (talk · contribs · email) 02:30, 10 April 2018 (UTC)

This is a great example of what happens when we force citations into leads, which should be instead a summary of the article. We have to attach one citation to the summary in the lead, and you looked at that one source, naturally, when in fact, the issue of antipsychotics and DLB is covered in every review listed in the article, and the lead is just a summarizing sentence. We could debate whether the words where possible should be added, but that would be based on all reviews, and the entire text, not just the one citation I was obliged to add to the lead, because that is the new trend in medical articles. I would say there is a very strong case in every article for trying to almost never use them. Have a look at the entire article, and every review, and not just the one citation I was forced to use in the lead. Then we can all decide how to write that part, and what to do about the new trend in citing leads.

One thing I always did when reviewing at FAC was to start reviewing from the bottom, and do the lead last. There is stuff at the bottom of this article that needs attention, and by the time people get there, they're pooped. The lead should be last (does it summarize the article :) SandyGeorgia (Talk) 02:52, 10 April 2018 (UTC)

We might consider Boot 2013 or Walker 2015 to help us hone the wording-- there are more options in those two. Tousi 2017 says simply "should be avoided". SandyGeorgia (Talk) 03:09, 10 April 2018 (UTC)

I read this commentary last night and it was that that prompted me to see what McKeith had to say on the matter. I'll skip the lede. --Anthonyhcole (talk · contribs · email) 03:32, 10 April 2018 (UTC)

We'll come back to the lead :) Right after we come back to Society and culture  :) Thanks, Anthony ... the commentary is provocative, but does he address the fact that there is not evidence that they work? SandyGeorgia (Talk) 03:42, 10 April 2018 (UTC

They address the weakness of the evidence and are talking about dangerous cases where there are no other options - with fully-informed patient/family. --Anthonyhcole (talk · contribs · email) 04:24, 10 April 2018 (UTC)

Pharmacology feedback

I pinged FVasconcellos and WP Pharmacology for med review. I am particularly concerned that I didn't link any medication incorrectly. SandyGeorgia (Talk) 17:20, 8 April 2018 (UTC)

I've checked most of them, and they are OK. --Tryptofish (talk) 20:56, 9 April 2018 (UTC)

Image review

Thank you, Nikkimaria. [10] SandyGeorgia (Talk) 17:23, 8 April 2018 (UTC)

Source review

I pinged Brianboulton for a source review. Will check with Ealdgyth if Brian is worn out. SandyGeorgia (Talk) 17:21, 8 April 2018 (UTC)

Archive

In only one week since the rewrite, amazing progress was made here because of so many who pitched in. The article is not yet FAC ready, but it's pretty darn close, and a fine article with or without FAC. Thanks to all! Editing has slowed down, so I would like to archive this (Rewrite) section, so we can begin the next pass of fine-tuning, settling on the lead, deciding on Notable cases, etc. @LeadSongDog: I am at an impasse with what to do with some of your concerns, and not sure I have addressed them. Might you re-post a new section at the bottom of the talk page with anything outstanding, because I think then everything in the Rewrite section is done, and we can clear it from the page? Best, SandyGeorgia (Talk) 01:23, 14 April 2018 (UTC)

Image

About File:Lewy_bodies_(alpha_synuclein_inclusions).svg this is (apparently) from a person with PD. I've emailed the person who uploaded it asking them to clarify. Am guessing it is from autopsied brain not a living person.... Jytdog (talk) 17:02, 9 April 2018 (UTC)

I think they have to be from a dead brain. Dumb question: do we have any reason to believe or know that immunostained Lewies in a PD brain look different than those in a DLB brain? SandyGeorgia (Talk) 21:26, 9 April 2018 (UTC)

That kind of image typically comes from autopsy samples, but there is a very small possibility that a biopsy sample was taken from a living person. There probably isn't much difference in the Lewy bodies themselves, but there could be a noticeable difference in how they are distributed, and we should be precise about the image in any case. --Tryptofish (talk) 21:35, 9 April 2018 (UTC)

Got it, SandyGeorgia (Talk) 22:06, 9 April 2018 (UTC)

@Jytdog: that image has been in since 2012! Instead of hoping for a reply to your email, why don't we just swap it out? We already have immunostaining in the lead infobox. SandyGeorgia (Talk) 13:01, 10 April 2018 (UTC)

How about File:Immunostaining_(brown)_of_alpha-synuclein_in_Lewy_Bodies_and_Lewy_Neurites_in_the_neocortex_of_a_patient_with_Lewy_Body_Disease.jpg? I can run it by Nikki. SandyGeorgia (Talk) 13:06, 10 April 2018 (UTC)

I agree that this alternative image is a better choice, because we can be confident that it actually shows cells from someone with DLB. I'd say go with the swap. This new image shows accumulation of Lewy bodies in the cortex, that give rise to dementia, as opposed to accumulation in the substantia nigra (much "lower" in the brain), that give rise to dopamine cell loss, which I think is fine. --Tryptofish (talk) 19:42, 10 April 2018 (UTC)

Queried Nikkimaria (she does image reviews at FAC and FAR). SandyGeorgia (Talk) 20:06, 10 April 2018 (UTC)

Nikki found no problems with that image, so I swapped it. I was going to fix the dab problem at agitation before I get on with my day, but it would be thoughtless of me to remove an edit summary from the peerless Yomangani from the top of your watchlists! (Thanks for the chuckles, Yoman.) SandyGeorgia (Talk) 12:45, 11 April 2018 (UTC)

Kosaka

Can anyone get their hands on this book?

• Kenji Kosaka (Editor). Dementia with Lewy Bodies: Clinical and Biological Aspects, 1st ed. Springer, 2017. 978-4431559467

It's $170, and I could not get it at the library today. Because Kosaka named DLB, I fear we will not be adequately global if we don't check this source. I have tried to work him into History, but he keeps writing about himself, which makes it hard. SandyGeorgia (Talk) 19:06, 9 April 2018 (UTC)

pls see your email. Jytdog (talk) 19:26, 9 April 2018 (UTC)

wow ... SandyGeorgia (Talk) 19:32, 9 April 2018 (UTC)

Contradiction

Kosaka, p. v (preface) says:

• "Dementia with Lewy bodies (DLB) is now well known to be the second most frequent dementia following Alzheimer disease (AD). Of all types of dementia, AD is known to account for about 50%, DLB about 20% and vascular dementia (VD) about 15%. Thus, AD, DLB, and VD are now considered to be the three major dementias.

But the article says (sourced to US NIH):

• DLB itself is the third most common type of dementia, following AD and vascular dementia.

And (sourced to Walker 2015- older than book Kosaka book):

• An estimated 10 to 15% of diagnosed dementias are Lewy body type, but estimates range as high as 24%.

On page 3, Kosaka clearly distinguishes between DLB and LBD (in fact, he says he proposed this dreadful terminology in 1980), so this doesn't seem to be a nomenclature problem. It would not surprise me to find that the NIH is wrong (they often are behind), but this needs to be sorted. Is DLB now more common than vascular dementia? If it can't be sorted, perhaps we could just say something like:

• AD, DLB and VD are the three most common types of dementia, with AD making up half of all cases.

SandyGeorgia (Talk) 22:59, 9 April 2018 (UTC)

References

I addressed all of this by adding sourced info to a footnote: [11] But the problem here is that the NINDS is wrong (note they use LBD not DLB, so that is demonstrably wrong). This is not atypical. SandyGeorgia (Talk) 13:34, 10 April 2018 (UTC)

Here's another indication that NINDS is out of step; unfortunately, not MEDRS. SandyGeorgia (Talk) 18:14, 10 April 2018 (UTC)

I looked at each of those sources, and I think that Kosaka is the most reliable, with both NINDS and Mayo being a bit less reliable. (I think the ideal way to choose among them would be to look up the primary sources that they cite, and compare those in order to try to account for the differing conclusions, and base what the page says on whoever bases their percentages on the most recent and extensive data.) But I think that it is reasonable to go with "AD, DLB, and VD are the three most common types of dementia, with AD making up about half of all cases." (Please note: "half" → "about half".) That way, we cover all bases, and it really does not matter for our purposes to parse 2nd and 3rd places. --Tryptofish (talk) 19:55, 10 April 2018 (UTC)

Got it, I think? SandyGeorgia (Talk) 21:29, 10 April 2018 (UTC)

Comments from O'r

• Hey this is like a FAC.
• This needs fixing: "Caffeine and other drugs that may worsen RBD include antidepressants (SSRIs, SSNRIs, tricyclics, and MAOIs), AChEIs, beta blockers, and tramadol.[5]"
• This is hard to parse, partially because we aren't sure where the "parallel word" starts (e.g. "Lacking is an advancement" or "Lacking is an understanding of advancement...") but also it should probably be more than one sentence. "Lacking is an understanding of mechanisms that contribute to cell death, advancement of the disease through the brain, and timing of cognitive decline, as well as a model to understand the neurons and brain regions involved.[7]" Outriggr (talk) 22:45, 11 April 2018 (UTC)

I don't think FAC has ever before seen a collaboration between the art cabal and the medicine project! I am too tired for any more work today; others may still have energy to dig in! SandyGeorgia (Talk) 23:01, 11 April 2018 (UTC)

I did this: [12], and this: [13]. --Tryptofish (talk) 23:17, 11 April 2018 (UTC)

• Thanks so much, Yomangani, it is always so much easier to work with inlines than to have to go back and forth from talk to article. Especially when you leave me laughing! But you haven't hit my worst blooper yet :) I will make sure to get to these when I have more energy. SandyGeorgia (Talk) 00:37, 12 April 2018 (UTC)
  • Done by Jytdog, SandyGeorgia (Talk) 03:20, 12 April 2018 (UTC)

Famous cases

If this is going for FAC the famous cases should go; we do not favor these per MEDMOS. Jytdog (talk) 15:05, 9 April 2018 (UTC)

I don't entirely agree - the first two, posthumously diagnosed, might be kept as indicative of the growth of understanding, long period before symptoms appear, etc. But not the rest, who are all American & only locally known anyway. Johnbod (talk) 15:18, 9 April 2018 (UTC)

WP:MEDCASE does not say "the famous cases should go". How, specifically, do you think this could be improved, according to guidelines? Although this disease is not rare, it does seem to be under diagnosed, and so perhaps the number of notable "famous cases" is very low. If that assumption is wrong, or the number of cases grows, then MEDMOS encourages considering more restrictive criteria, and making that explicit, or splitting off to another article. It doesn't, anywhere, say "they should go". -- Colin°^Talk 15:22, 9 April 2018 (UTC)

People often want to include such lists to "raise awareness" - this is not what we are here for. They generally devolve into celebrity gossip. What I wrote was "does not favor". We can see how this discussion plays out; we can bring it to an RfC if we fail to reach consensus locally here. Jytdog (talk) 17:07, 9 April 2018 (UTC)

Jytdog, please don't make bad faith assumptions about why people include such lists. It really helps collaborative editing if you assume others are here to help improve Wikipedia. Notable cases appear in the literature for medical conditions. You'd expect it in popular "for general reader" writing, of course, but also in "for professionals" writing too. From my experience with epilepsy literature, professionals can't help but name-drop historical figures who may have had epilepsy. One way to make an abstract thing, a medical condition, become real to the reader, is to offer examples. If you watched a TV program on a medical condition, it would interview people with it, or film them in medical care. Since we can't go mentioning our own grandparents on Wikipedia, notable cases are an option for us. Readers can, if they want, go read more about that person. There are other reasons for inclusion too, and generally a handful of well known individuals is in keeping with WP:WEIGHT for the disease-article topic.

Your two statements that "for FAC the famous cases should go" and "we do not favor these per MEDMOS" are both false. MEDMOS is totally neutral on the issue. I know because I wrote the text in that section of MEDMOS, which was a result of discussion on talk (1st archive), and still features as examples, Sandy's Sociological and cultural aspects of Tourette syndrome#Notable individuals and my List of people with epilepsy, which is a featured list. When I worked on List of poliomyelitis survivors (another Featured List), this really brought home the life changing aspects of surviving polio, in a way that the Prognosis section of Polio (a Featured Article I helped with) never can. There's also List of people with hepatitis C, another Featured List. These lists (whether in-article or stand-alone) are all per MEDMOS.

I think your opinion on these is a result of misreading what MEDMOS actually says, bad faith assumptions about why those lists are created, and is at odds with the evidence of abundant featured content on this aspect. -- Colin°^Talk 17:56, 9 April 2018 (UTC)

Please discuss content not contributors. Please. Jytdog (talk) 18:01, 9 April 2018 (UTC)

Jytdog, I'm discussing talk page content you added, where you made a bad faith comment about contributors. You were clear about what you thought MEDMOS favoured and featured content required, and you were clearly wrong. Let's move on. -- Colin°^Talk 19:18, 9 April 2018 (UTC)

We don't agree about these sections and how they are used and the arguments people use in practice to justify additions. That is clear. Jytdog (talk) 19:23, 9 April 2018 (UTC)

Every case/article is different, my views on this article. The first two are significant and should surely stay (for reasons elaborated above). Robin Williams affected public perception of the condition, and Peake presents an interesting journal case of potentially the earliest notable case, as well as the problems of misdiagnosis. After that, we have two very small paragraphs (deliberately and quite seriously pruned down from the crufty verbose list that was in the article when I started editing it). This is a little-recognized condition, and those two small paragraphs aren't taking up a lot of real estate or right now presented in a crufty way (as in the other articles with better known conditions where the lists are ridiculous). My suggestion is that we keep those two paragraphs for now, knowing that as the baby boomers age, DLB is better recognized, and the list may grow, it will be spun off to a Sociological and cultural aspects article, to keep the cruft over there. I don't see it as too crufty at this stage, but this is not a hill I plan to die on either :) SandyGeorgia (Talk) 18:07, 9 April 2018 (UTC)

Back for the day and catching up ... got the Palma article. Jyt, the example given at MEDMOS (which was pretty well written by folks in this discussion :) is Tourette syndrome; I think I know how to write that part for FAC, and I have done that (that is, cut down all the crap :) (PS, Johnbod, they are not all American ... there are at least two Canadians.) SandyGeorgia (Talk) 17:11, 9 April 2018 (UTC)

Dear everyone :) Notable cases amounts to a few small paras at the bottom of the article. We will sort it before approaching FAC. All will have time to weigh in.

Meanwhile, it is not something to lose focus over. I would love Love LOVE for this article to be a collaborative effort of all involved, and one that could be presented to FAC as a collaboration of many authors, rather than one person's work. To get an article FA-ready, we must work according to priorities. The notable folks are a small issue and one that can be sorted as people weigh in and the article progresses.

In terms of priorities, we have 1b, 1c, 1d, and 1e, comprehensive and well-researched, neutral and stable (make sure everything that needs to be covered is covered, neutrally, without major disagreements leading to stability problem), followed by 1a (smooth the prose after all content issues resolved, but we are well along on that already), and then go back and get the technicalities (MOS, links, consistent citations, etc.) Media and length will be easy-- there are plenty of images to choose from, and the article is right now tightly focused, we should be able to keep it that way. So, in the areas of substance (eg, see the dysautonomia discussion above, and History has to be written), I hope we can focus on whether we have everything covered. Bst, SandyGeorgia (Talk) 18:31, 9 April 2018 (UTC)

My quick reaction is that it might be better to integrate the most historically significant cases into the History section, and to leave out most of the persons who are mentioned only briefly. --Tryptofish (talk) 20:54, 9 April 2018 (UTC)

• I see that there is Category:Deaths from dementia with Lewy bodies. The pages in the category do not track the examples here. I think a case could be made to treat the persons who did not significantly affect DLB history as category members, rather than listing on this page. --Tryptofish (talk) 22:36, 9 April 2018 (UTC)

I am going to firmly resist the temptation to worry about either this section or the lead until the substantial parts of the article have progressed :) SandyGeorgia (Talk) 03:30, 10 April 2018 (UTC)

but when I do think about it ... I propose that we combine the sociological and cultural aspects of both LBDs (PDD AND DLB) at Sociological and cultural aspects of Lewy body dementia. @Colin:, how would you feel about moving the last two paras over there? Curiously, there was no article on PDD when I started working here ... SandyGeorgia (Talk) 12:54, 10 April 2018 (UTC)

Combining them might make sense, particularly if there is difficulty distinguishing the two at times. What I don't currently see, is any need at present for the daughter article, or to move material out. If I look at Tourette syndrome and the Sociological and cultural aspects of Tourette syndrome I see that the equivalent sections in this article are smaller than at TS and there doesn't appear to be any expansion going on here. If you have > 2x as much material you would like to add, then perhaps. Tryptofish, categories for people-with-medical-condition (or who have died from one) have always been problematic. Sourcing a category is difficult and there is no place to indicate any doubt over the diagnosis. For example, there is a good case that most of the historical figures "diagnosed" with epilepsy did not in fact have epilepsy. So IMO I would not encourage the use of such categories. The description on this article about Robin Williams is a good case for why prose beats categories every time. -- Colin°^Talk 13:37, 11 April 2018 (UTC)

I was initially queasy about Robin Williams (the image in particular), but having stepped back from the article for a week and read it through again this afternoon on lunch, it may offer some level of shared comfort to invested readers, after a pretty harrowing and heavy read of the page. Ceoil (talk) 22:16, 13 April 2018 (UTC)

I agree that an article like this can be a hard read. And fact after fact is a difficult way to learn for some people, who need a face or story to hang the information off of. For example, being told when someone got diagnosed, how they coped, what support they got, etc, can make those facts stick better than just abstract diagnostic techniques and prognosis figures. An illustration or photo can also help facts stick by linking to visual memory. I'm not sure Williams' story is a comfort, though, but is highly notable. He's a highly recognisable face, and there will be people who remember this article topic solely because of the Williams link. -- Colin°^Talk 07:58, 16 April 2018 (UTC)

Proposal for Society and culture

From this version, keep Robin Williams and Mervyn Peake in this article. Cut the final two paragraphs. Create Sociological and cultural aspects of Lewy body dementia, which can then be linked from all three LBD articles (Lewy body dementia, dementia with Lewy bodies, and Parkinson's disease dementia), solving the other problem that the media is not always clear which LBD the person had/has. SandyGeorgia (Talk) 14:24, 16 April 2018 (UTC)

Done. SandyGeorgia (Talk) 04:50, 19 April 2018 (UTC)

Further comments by Seppi333

Besides the use of unattributed prescriptive statements, the only other issue I saw when I went through the article was the placement of two images. See the screenshots, accompanying explanations, and proposed fixes below.

1. This violates MOS:SANDWICH & MOS:SANDWICHING: [14] (see the first 4 lines of text under "Pathophysiology" in this screenshot). The issue with text sandwiching in this part of the article can be fixed by right-aligning both thumbnails or with the use of {{Multiple image}} and right alignment with vertical direction (| align=right | direction=vertical).
   • Fixing this is not optional for FAC (criterion 2).
2. This doesn't violate the MOS, although I think the placement of the image on the left side looks terrible because it forces all of the text to appear to the right of the image instead of along the left margin: [15]; keep in mind that the MOS explicitly states that in most cases, images should be right-aligned unless there's a reason that warrants the use of left-alignment.
   • Fixing this is optional for FAC.

Seppi333 (Insert 2¢) 02:58, 19 April 2018 (UTC)

On the first, theoretically, the Causes and Pathophysiology sections are still going to grow, and there will not be a sandwiching issue. Assuming we are going to find time to deal with actual content here. On the second, the very page you cite says: Mul­ti­ple im­ages can be stag­gered right and left. Which is what is often requested at FAC. SandyGeorgia (Talk) 03:08, 19 April 2018 (UTC)

Hence why I said optional. Systematic right-alignment is a personal preference and it irritates the fuck out of me when a reviewer requires compliance with his/her personal preferences in a FAC review. If, prior to the FAC nomination, the sections from the first screenshot grow at some point and that expansion resolves the text sandwiching I mentioned above, I'll be fine with their current alignment. Seppi333 (Insert 2¢) 03:23, 19 April 2018 (UTC)

They used to ask for staggering r-l at FAC, which made sense when you could more of less assume most people were using desktop pcs of roughly similar screen size. Now all that's gone, & you don't get that asked any more. I used to stagger, but switched to normally putting things right years ago, as a concession to those using tiny screens. But no facing out of course. See Wikipedia_talk:Manual_of_Style#MOS_wording:_images_that_"look_toward"_the_text for a current discussion (more views would be good), where some truly wierd views are expressed as to the "difficulty" in left-placing anything. Needless to say, MOS has not really adapted to reflect the new situation. Johnbod (talk) 13:05, 19 April 2018 (UTC)

Thanks for this info, Johnbod; once the text is more finalized, I will run through the images again. SandyGeorgia (Talk) 15:35, 19 April 2018 (UTC)

Well, it irritated the heck out of Awadewit when people had eyes or images facing off the page, and since she was a seriously good FAC reviewer and FA writer, you might imagine that we delegates/coordinators tended to pay attention to her reasoning for alternating images. We also had views on reviewers and nominators filling up FAC pages with color and excess markup, and hoped people would leave their crayolas at home. SandyGeorgia (Talk) 03:40, 19 April 2018 (UTC)

But I like crayons. Seppi333 (Insert 2¢) 03:54, 19 April 2018 (UTC)

So do I, sometimes! But when you're a FAC coordinator reading through hundreds of pages a day, it can be quite exhausting to have to sort through excess markup—highlighting, bolding, emphasizing is not going to influence a coordinator as much as irritate them :) SandyGeorgia (Talk) 03:59, 19 April 2018 (UTC)

Cannot find anything else to add to Causes (most frustrating), so I have implemented the Multiple images to avoid sandwiched text between Causes and Pathophysiology. SandyGeorgia (Talk) 00:17, 21 April 2018 (UTC)

Fri Apr 20

Done for a bit, headed off for radiation, in case people want to comb through the prose on my recent additions. SandyGeorgia (Talk) 18:28, 20 April 2018 (UTC)

Best wishes! --Tryptofish (talk) 20:37, 20 April 2018 (UTC)

Thanks, I'm back (with more journal reports to chunk in!) SandyGeorgia (Talk) 22:00, 20 April 2018 (UTC)

One more to work in, and then would be most grateful if others would go through prose, but I am very disappointed that I am not yet finding more sources on Causes. SandyGeorgia (Talk) 23:58, 20 April 2018 (UTC)

Hypersalivation

I have the Palma review now. The article had:

Botulinum toxin injections in the parotid glands may help with hypersalivation.

which could be written and sourced as:

Botulinum toxin injections in the parotid glands have been shown to help with hypersalivation in persons with PD.

References

I will be adding other text per the Palma review, but am unsure/indifferent as to whether we keep the hypersalivation text. On the one hand, I have not come across this in any other review specific to DLB, and Palma mentions it in the context of Parkinson's disease. On the other hand, the article is about autonomic dysfunction in Parkinson's disease and other synucleinopathies. What do others think? SandyGeorgia (Talk) 17:39, 9 April 2018 (UTC)

@Jytdog: I suspect all of this can be sorted and sourced better to one article, Palma. I am reading it now, so perhaps hold off on improvements to autonomic stuff for now. SandyGeorgia (Talk) 17:51, 9 April 2018 (UTC)

On the other hand, if you can also get hold of Palma, perhaps you want to write and beef up the entire para on dysautonomia? Let me know so I can stop reading :) SandyGeorgia (Talk) 17:54, 9 April 2018 (UTC)

Sure, that would be fine. btw that section is kind of "signs and symptoms"ish, isn't it? Those two sections often drift together and I think they have somewhat here... Jytdog (talk) 18:11, 9 April 2018 (UTC)

@Jytdog: how about this plan? I am looking over all of the articles I picked up today, and I still have my hands full with History stuff to complete. And now Palma is another handful. Not sure what you are asking re: signs & symptoms, because the dysautonomia section is in signs & symptoms ...? All of Essential, Core and Supportive features are in Signs & symptoms. If you are interested in using Palma to beef up all other areas of dysautonomia (like that it is 2018, but don't like that it is not freely available as so many of our good sources here are), I will work on the non-pharmaceutical management and caregiving aspects-- there is a lot to be mined from Palma, but you have to take care that the text applies equally to DLB as to PD, and it's not easy reading. If you take on beefing up the Signs & symptoms and pharmaceutical treatment portions of dysautonomia, I will work in non-pharmaceutical and caregiving. Deal? SandyGeorgia (Talk) 18:18, 9 April 2018 (UTC)

ooo i am sleepy. :( struck. Jytdog (talk) 18:21, 9 April 2018 (UTC)

Palma is done. SandyGeorgia (Talk) 23:54, 20 April 2018 (UTC)

Checklist for next pass

Starting point. SandyGeorgia (Talk) 13:16, 16 April 2018 (UTC)

Done items moved to Talk:Dementia with Lewy bodies/Archive 2. SandyGeorgia (Talk) 13:30, 16 April 2018 (UTC)

Recognizing that there is still a LeadSongDog section to work on (above), but working towards being in position to archive everything that is done. If anyone else has anything else unresolved above, please let me know, so I can start archiving done stuff. Putting here a checklist for our next pass (not yet!  :) SandyGeorgia (Talk) 21:51, 11 April 2018 (UTC)

• Vascular dementia differential is weak. I am pretty sure it is ruled out based on imaging, but can't find a source that says that.
  • OK now, I think? SandyGeorgia (Talk) 01:47, 14 April 2018 (UTC)
• Pending decision about notable cases.
  • Done. SandyGeorgia (Talk) 04:51, 19 April 2018 (UTC)
• Pending decision about which expert(s) to approach for external review.
• Drug abbreviations.
  • Ok now, I think? SandyGeorgia (Talk) 01:47, 14 April 2018 (UTC)
• Precision in percentages raised by Colin (eg say 59% or say "more than half")
  • I removed those percentages because they were a Boot review reporting on a Boot study, and we can make the same point without the specifics. SandyGeorgia (Talk) 20:52, 12 April 2018 (UTC)
• Incorporation of more autonomic dysfunction items using Palma and Kosaka (ed) Jytdog
  • Done. SandyGeorgia (Talk) 00:01, 21 April 2018 (UTC)
• How is History looking?
  • I am happy with History now (no one else has opined ;) SandyGeorgia (Talk) 14:44, 20 April 2018 (UTC)
• Causes and Pathophysiology seem weak.
• Epidemiology looks really weak ... perhaps Kosaka has more, but that is all I could mine from sources.
  • Added more geographic regions. SandyGeorgia (Talk) 17:16, 20 April 2018 (UTC)
• Eric Corbett copyedit pass once text is more settled.
• Does anyone maintain email contact with Looie496 to pull him in?
  • I emailed Looie496, no response. SandyGeorgia (Talk) 14:44, 20 April 2018 (UTC)
• Ask Graham Beards to look in.

• Have not figured out wikilink for visuospatial function.
  • Visuospatial function does not exist on Wikipedia; I will have to write it. Today. SandyGeorgia (Talk) 14:58, 14 April 2018 (UTC)
    • There is Visual spatial attention, not tagged for MED project, but should be. Visual agnosia, Spatial memory, Visual system, Sensory nervous system and so on. As usual, we probably have too many nearly over-lapping half or 3/4-baked articles & ideally some should be swept up into a new article. Not that I've looked in detail, or know anything about the subject of course. Johnbod (talk) 15:14, 14 April 2018 (UTC)
      • Visual spatial attention is classic student editing[16] ... will need a copyvio and RS check. Best to ignore it and start over? SandyGeorgia (Talk) 15:51, 14 April 2018 (UTC)
        • Quickest certainly - gets about 30 views a day. Johnbod (talk) 16:09, 14 April 2018 (UTC)
• DLB may be more responsive than AD to donepezil. ... still sourced to Neef2006, have not found newer source
  • Not useful as a source, but appears this is still true, from Section 5. Treatment at LBDA.org. SandyGeorgia (Talk) 17:18, 12 April 2018 (UTC)

• Color vision impairment is mentioned in Tousi 2017, but I left it out of the article because it seems that Tousi is the discoverer and Tousi is the only one reporting it. If anyone can find mention of color vision impairment in a non-Tousi review, it could be added. SandyGeorgia (Talk) 13:17, 16 April 2018 (UTC)

Lead suggestions

• SG wants to unsplit the lead sentences, and go back to:

Now: Dementia relentlessly worsens over time, and is diagnosed when cognitive decline interferes with normal daily functioning. Memory loss does not always present early.

Back to: Memory loss does not always present early, but dementia relentlessly worsens over time, and the condition is diagnosed when cognitive decline interferes with normal daily functioning.

• SG wants to change:

Now:Antipsychotics, even for hallucinations, should be avoided because people with DLB are sensitive to them, and their use can result in death.

Change to: Antipsychotics, even for hallucinations, are usually avoided because people with DLB are sensitive to them, and their use can result in death.

• LeadSongDog Major points:
  • Suggest opening with "Dementia with Lewy bodies (DLB) is one of two types of Lewy body dementia (the other being Parkinson's disease)..."
  • The 'difficult-to-diagnose while alive' and 'only palliative treatments' factoids are rather buried. Consider moving them up in the lede.

Others done, but LSD's two suggestions have not yet been discussed. SandyGeorgia (Talk) 05:00, 19 April 2018 (UTC)

That one that you did looks good, thanks. --Tryptofish (talk) 18:11, 19 April 2018 (UTC)

• Anthonyhcole wants:

  Antipsychotics, even for hallucinations, should be avoided where possible because people with DLB are sensitive to them,[1] and their use can result in death.

Isn't that medical advice? "It is recommended ...", "Top men suggest ..." (Which men? Top men). Though perhaps we've moved on while I've been away and we can dish out prescriptions now - I'll have what she's having. Also, when would it not be possible? "This will probably kill you but there is also a chance you will stop having hallucinations. What? Yes, that's right, dead people don't have hallucinations as far as we are aware. Well done you for spotting how this works, now open wide." Yomangani^talk 00:41, 12 April 2018 (UTC)

Contraindication is a standard section in WP:MEDMOS and WP:PHARMMOS and in articles about diseases/conditions we deal with similar matter. It does border on WP:NOTHOWTO but is also important description; a lot depends on wording. This could be better stated as "guidelines avoiding..." or the like. Jytdog (talk) 00:50, 12 April 2018 (UTC)

How about

Antipsychotics, even for hallucinations, are usually avoided because people with DLB are sensitive to them,[1] and their use can result in death.

SandyGeorgia (Talk) 01:52, 14 April 2018 (UTC)

Stating that something is contraindicated isn't a statement about something that doctors generally do as a "common/best practice"; rather, it's largely a regulatory claim of significant medical consequence. A medical indication is a use for a drug which has received the approval of a national drug-regulating entity (e.g., the USFDA); those are listed in a drug's prescribing information and are essentially just the conditions/tests for which a drug should normally (not: can) be prescribed. Contraindications contrast with a a drug's indications in the sense that if a drug has no medical indications, it necessarily has no contraindications. Drug regulatory agencies decide on those simultaneously. Contraindications for which the use of a drug can result in a serious negative outcome (E.G., THIS SENTENCE: Antipsychotics, even for hallucinations, should be avoided because people with DLB are sensitive to them, and their use can result in death. – that underlined part sounds like this is an absolute contraindication) are normally included in a boxed warning in the prescribing information of FDA-approved drugs. Seppi333 (Insert 2¢) 13:51, 17 April 2018 (UTC)

Not surprisingly, all antipsychotics appear to carry a boxed warning about using the antipsychotic for dementia: [17][18][19]. Seppi333 (Insert 2¢) 13:55, 17 April 2018 (UTC)

Yes, both typical and atypical, for about 10 years now. But, as Cas points out, they are still used. So we have to find a balance for what to say in this article. SandyGeorgia (Talk) 14:04, 17 April 2018 (UTC)

Well, you could do the following:

• use language that sounds like medical advice: Antipsychotics should be avoided...
• use language that states a frequency: Antipsychotics are seldom/sometimes/never used for...
• use language that correctly describes the relationship between antipsychotics and dementia: Antipsychotics are contraindicated...

I suppose an equally acceptable but more verbose alternative would be to explicitly state the FDA's boxed warning in the article and attribute that warning to the FDA; after all, that boxed warning is the contraindication. Seppi333 (Insert 2¢) 14:41, 17 April 2018 (UTC)

See next section. SandyGeorgia (Talk) 14:48, 17 April 2018 (UTC)

I'm OK with language based either on frequency or contraindication (or even that they are contraindicated and therefore almost never used, or something like that). But not with how-to or "should" language. --Tryptofish (talk) 23:21, 17 April 2018 (UTC)

refs

if anybody needs refs please feel free to email me; i can send them to you. Jytdog (talk) 18:11, 9 April 2018 (UTC)

Clinical trials

@Tryptofish: I think you mentioned somewhere that you wanted info on Research directions about what trials are in progress, etc. I don't know that much about how clinical drug trials work. Are you able to get a copy of this article, and look at Table 2?

• ref name=Velayudhan2017 ... Velayudhan L, Ffytche D, Ballard C, Aarsland D (September 2017). "New therapeutic strategies for Lewy body dementias". Curr Neurol Neurosci Rep (Review). 17 (9): 68. doi:10.1007/s11910-017-0778-2. PMID 28741230.

SandyGeorgia (Talk) 20:01, 21 April 2018 (UTC)

And page 68, last para ... and actually, the whole article mentions what trials are at what stage. I don't really know how to write about that stuff. SandyGeorgia (Talk) 20:06, 21 April 2018 (UTC)

If I remember properly, I was saying that we could make editorial decisions about what to include based on completed trials, but that I'd prefer not to have information on the page about trials that are in progress but not yet completed. WP:CRYSTAL and "don't raise false hopes", that kind of thing. --Tryptofish (talk) 20:09, 21 April 2018 (UTC)

ah, ha, much better ! SandyGeorgia (Talk) 20:24, 21 April 2018 (UTC)

And I don't have to pay for the full article! --Tryptofish (talk) 20:26, 21 April 2018 (UTC)

More from Ceoil

• dementia is diagnosed - alliteration

• I still don't like at all what has happened to the first three sentences of the lead, and want to go back to: SandyGeorgia (Talk) 14:05, 14 April 2018 (UTC)

  Memory loss does not always present early, but dementia relentlessly worsens over time, and the condition is diagnosed when cognitive decline interferes with normal daily functioning.

• deterioration in memory function is related to retrieval - not sure if "related" is the right word, as a reader I honed in on this sentence, but it confirmed experience rather than explained cause

• and new memories may be encoded but not retrieved? SandyGeorgia (Talk) 14:11, 14 April 2018 (UTC)

• Is there something we could say here about the underlying type of damage? Ceoil (talk)

• Are we there yet? SandyGeorgia (Talk) 17:59, 14 April 2018 (UTC)

• This is very helpful. Ceoil (talk) 03:48, 15 April 2018 (UTC)

• While the specific symptoms may vary - While specific
• In "Core features", why is "spontaneous cardinal features of parkinsonism" in quotes
• The individual with RBD may not be aware that they - An individual, or the patient
• bed partner: coy - sleeping partner
• As a reader, I didn't know what epidemiology means, so "dementia with Lewy bodies is under-recognized,[11]" is more than a little confusing. And maybe merge this section into one para. Ceoil (talk) 12:44, 14 April 2018 (UTC)

• Do these suffice? SandyGeorgia (Talk) 14:34, 14 April 2018 (UTC)

Yes overall. Good improvement on linking epidemiology (effective), but am still not getting "under-recognized". If we could go into why "not retrieved", that would be great. Ceoil (talk) 14:38, 14 April 2018 (UTC)

In case its not clear my criteria here is accessibility; reasonably intelligent family members may read this, and I believe it should be aimed at them rather than qualified professionals. In this regard, now consider the article as a success, to be further verified by the qualified professionals I see at work here. Ceoil (talk) 12:54, 14 April 2018 (UTC)

Sandy: can you also see if "Severe sensitivity" is the best way to put it. It doesn't read well, but may be necessarily precise, so leaving it with you. Ceoil (talk) 22:56, 15 April 2018 (UTC)

Yes, awkward. The intent of severe is like, can cause death. @Ceoil: your prose is (infinitely) better than mine, and you have been through the article so thoroughly now that I kinda think it's fine for you to tackle my sucky prose in instances like this one :) Bst, SandyGeorgia (Talk) 23:09, 15 April 2018 (UTC)

now "Severe reaction". Re prose, haha not quite, you talking to one who had to make over 700 edits to a 16kb article :) :) Ceoil (talk) 00:00, 16 April 2018 (UTC)

• Last from me but "Relentlessly worsening over time"; "relentlessly worsening" sounds overwritten and needless when progressive is far more familiar. Ceoil (talk) 22:05, 15 April 2018 (UTC)

I agree with that. I found "relentlessly" excessive when I saw it, but I forgot until now to point that out. --Tryptofish (talk) 22:08, 15 April 2018 (UTC)

• @Ceoil: As it's written now, I think it's a tongue twister (relentlessly worsening and a convoluted order). If we went back to:

  • Memory loss does not always present early, but dementia relentlessly worsens over time, and the condition is diagnosed when cognitive decline interferes with normal daily functioning.

  would you still dislike the "relentlessly"? Also, Ceoil and Tryptofish, I am still not happy with the flow of the part about Memory (encoding v retrieval) that I reworked yesterday, in case you can improve. SandyGeorgia (Talk) 22:11, 15 April 2018 (UTC)

About "relentlessly", I think that sentence, as you show it just above, would work well if we simply changed "relentlessly" to "steadily". I'll take a look at the memory part now. --Tryptofish (talk) 22:15, 15 April 2018 (UTC)

That works for me. SandyGeorgia (Talk) 23:09, 15 April 2018 (UTC)

Done, SandyGeorgia (Talk) 04:58, 19 April 2018 (UTC)

Good, thanks. --Tryptofish (talk) 18:04, 19 April 2018 (UTC)

This is a better formulation but would still drop relentlessly. However you now have three timelines (early, over time, when cognitive decline interferes). Are these defined stages? Ceoil (talk) 22:18, 15 April 2018 (UTC)

Not necessarily (if you mean, as in the defined stages of Alzheimer's). SandyGeorgia (Talk) 23:09, 15 April 2018 (UTC)

I'm fine with the above resolutions. We are there, far as i am concerned. Ceoil (talk) 23:28, 26 April 2018 (UTC)

Memory relative to AD

Memory loss is not always noticeable early on. In contrast to AD, where the hippocampus is among the first brain structures affected and episodic memory loss related to encoding of memories is typically the earliest symptom, memory impairment occurs later in DLB. Deterioration in memory function occurs because new memories may be encoded but not retrieved. DLB memory loss has a different progression than AD because frontal structures are involved early on, with later involvement of temporoparietal brain structures. Verbal memory is not as severely affected as in AD.

References

I started looking at the memory material, and am getting bogged down in the details, so perhaps a more medically or psychologically oriented editor would be better able than me to sort it out. (Also, I think what it says about memory and AD in "Essential features" seems different from what it says in "Differential diagnosis".) But, as I was looking at this source: [20], something brought me up short. The authors place a lot of emphasis on the fact that AD and DLB often co-occur in the same persons, so DLB cases that are completely free of AD are in the minority. In the 6th paragraph of the Memory section, they say: LBD tends to co-occur with AD in 80% of cases, with only 20% having pure LBD. (I realize that's LBD, but I would assume that DLB is a subset.) As of now, the page makes it sound like AD and DLB are two completely separable diagnoses, and I think that may be wrong. --Tryptofish (talk) 22:41, 15 April 2018 (UTC)

@Doc James: could you take a look at what I just said about AD versus DLB? Thanks. --Tryptofish (talk) 22:46, 15 April 2018 (UTC)

That's a 2011 source, Tryptofish; we need to compare that to all of the more current sources. SandyGeorgia (Talk) 23:11, 15 April 2018 (UTC)

Dang computer. @Tryptofish: I just went through every newer source to compile what they said on the matter, and my computer hung and lost the whole post. Summary being that they all mention in passing that AD and DLB can co-occur, but I can find no recent source that mentions anything on the level mentioned by Karantz 2011.

Weil 2017 (Current concepts and controversies) says, "Taken together, these studies show that the synergistic relationship between AD pathology and α-synuclein is bidirectional and that each protein synergises the other." NIH says only that, " LBD can occur alone or along with Alzheimer’s or Parkinson’s disease." Weil also mentions "a higher prevalence of Alzheimer’s-like pathology in DLB than PDD" citing PMID 27516115 McKeith Consensus 2017 is silent. Gomperts 2016 says, "with a variable degree of coexisting Alzheimer pathology", and "Because of the frequent coexistence of Alzheimer pathology in DLB, however, the AD CSF pattern does not exclude DLB", that's it. I can't remember all the rest I looked up, but cannot find any other source saying what karantz said in 2011. SandyGeorgia (Talk) 23:41, 15 April 2018 (UTC)

Walker 2015 spends a lot of time on the problems with diagnosis and confusion with AD because of the old criteria. And one place where we can see some real data-- albeit primary source-- is the oft-quoted autopsy results that showed 98% of RBD had synucleinopathy, here. It found (LBD)(n = 77), combined LBD and AD (n = 59), so again, nothing like this older 80%. SandyGeorgia (Talk) 23:48, 15 April 2018 (UTC)

Tryptofish I am not seeing the contradiction you mention memory issues in Essential features and Differential diagnosis ... ??? SandyGeorgia (Talk) 00:33, 16 April 2018 (UTC)

I think the main thing that looks contradictory to me is where the Differential section talks about "visuospatial processing", whereas I don't see anything about that in Essential features. I want to say, however, that I think that I'm the wrong editor to be advising you about memory classification and about differential diagnosis. I just don't know enough about those things, and I can easily be wrong. I do think, however, that since I am confused about how the medical consensus has changed over the past several years, then the page needs to be clearer about it. --Tryptofish (talk) 22:57, 16 April 2018 (UTC)

Visuospatial processing problems are in Core features (essential feature is dementia). SandyGeorgia (Talk) 11:45, 17 April 2018 (UTC)

Well, I find all of the stuff about different kinds of mental impairment and their diagnostic implications confusing. In part, I don't really understand the different kinds of memory. So again, I may be a sort of barometer of how understandable those parts of the page are, but I'm clearly the wrong editor to give advice about it. --Tryptofish (talk) 22:57, 17 April 2018 (UTC)

This was in the article before, but long uncited: SandyGeorgia (Talk) 13:20, 16 April 2018 (UTC)

A loss of acetylcholine-producing neurons (in the basal nucleus of Meynert and elsewhere) similar to that seen in Alzheimer's disease also is known to occur in those with DLB. Cerebral atrophy also occurs as the cerebral cortex degenerates. Autopsy series have revealed the pathology of DLB is often concomitant with the pathology of Alzheimer's disease. That is, when Lewy body inclusions are found in the cortex, they often co-occur with Alzheimer's disease pathology found primarily in the hippocampus, including senile plaques (deposited beta-amyloid protein), and granulovacuolar degeneration (grainy deposits within and a clear zone around hippocampal neurons). Neurofibrillary tangles (abnormally phosphorylated tau protein) are less common in DLB, although they are known to occur, and astrocyte abnormalities are also known to occur.

Fine tuning the lead

I adjusted the lead:

• Mentioning "rule out other conditions" gives little info to our readers, and is true of every disease, and we now have tests to "rule in" with DLB.[21]
• We randomly included constipation, together with neuropsychiatric symptoms, without explaining that the entire autonomic nervous system is affected (which gives context to constipation, and sets the reader up to understand why we have a cardiac biomarker).[22]
• We used the word "core" twice in two sentences, and using the word core might confuse new readers since symptoms of parkinsonism are not always present early on, only one cardinal feature is needed, and parkinsonism may not be noticeable at the time a new reader is seeking info.[23]
• Ceoil expressed concerned that one sentence covered three different time frames.[24]
• This needs to be reworded:
  • Acetylcholinesterase inhibitors (AChEI), such as donepezil, may provide some benefit ...

• as an example of a meaningless statement in the lead ("may provide some benefit" ... there is strong evidence in support of AChEIs, and donepezil is even licensed to treat DLB in Japan). Need help with better wording.

SandyGeorgia (Talk) 16:49, 21 April 2018 (UTC)

I like all of those changes. About donepezil, does this [25] work? --Tryptofish (talk) 19:46, 21 April 2018 (UTC)

Does for me, thanks! SandyGeorgia (Talk) 19:54, 21 April 2018 (UTC)

Stating the efficacy and the affected outcome is the ideal way to describe a drug's treatment effect. So, that wording is ideal provided that it accurately reflects the sources. Seppi333 (Insert 2¢) 19:58, 21 April 2018 (UTC)

Good! --Tryptofish (talk) 20:04, 21 April 2018 (UTC)

@Tryptofish and Seppi333: I think McKeithConsensus2017 has the best wording, in case you want to further tweak: "Meta-analyses of Class I clinical trials of rivastigmine and donepezil support the use of cholinesterase inhibitors (CHEIs) in DLB for improving cognition, global function, and activities of living, with evidence that even if patients do not improve with CHEIs they are less likely to deteriorate while taking them." SandyGeorgia (Talk) 20:29, 21 April 2018 (UTC)

I've also added to the article text about rivastigmine having the broadest evidence base, and I have never known why we are singling out one (donepezil) rather than both or neither in the lead and the infobox (that was there when I started editing). See pharmaceutical management section on Cognitive. SandyGeorgia (Talk) 20:31, 21 April 2018 (UTC)

Sorry for the late reply. Was getting stop errors and had to reinstall my operating system. Assuming "Class I clinical trials" refers to phase I clinical trials, I'd probably change that wording and add a wikilink to "phase I clinical trials". In any event, that wording is fine with me. Seppi333 (Insert 2¢) 03:12, 23 April 2018 (UTC)

I am done for a while ... have at it on prose-refining! SandyGeorgia (Talk) 20:07, 21 April 2018 (UTC)

Feedback from LeadSongDog

Major points:

• Suggest opening with "Dementia with Lewy bodies (DLB) is one of two types of Lewy body dementia (the other being Parkinson's disease)..."
• The 'difficult-to-diagnose while alive' and 'only palliative treatments' factoids are rather buried. Consider moving them up in the lede.

Some trivial points:

• The usages "Lewy body disease" or "Lewy body dementia" both are pretty common, should likely disambiguate in a hatnote or in line one.
• Under Society and culture, the listings appear to be based simply on personal celebrity rather than a particular connection to LBD beyond having it. Comparing Alzheimer's disease#Media, it shows individuals who wrote or talked about the disease, organized fundraisers for it, etc. and were separately noted for doing so.

• Oh, my. I just looked at Alzheimer's disease for the first time in years, hoping to find a page of people with dementia (eg Ronald Reagan) that we could piggy-back on to. Promoted in 2008, not reviewed in more than 10 years, NOT up to Featured article standard by any stretch. Maintenance tags, very outdated text, rambling TOC, one-sentence sections ... WP:OTHERSTUFFEXISTS, but nothing useful there :( I wish I had not looked. SandyGeorgia (Talk) 01:27, 10 April 2018 (UTC)

• Refs use a mix of title- and sentence cases for article titles. Journal names should be consistent, either abbreviated or full. LeadSongDog come howl! 16:53, 9 April 2018 (UTC)

Home for the day, catching up; thanks LeadSongDog. I will hold off on any changes to the lead while we get bigger wrinkles out. The criteria in Society in culture is people who meet Wikipedia notability. I will add hatnote. And I will convert all citations to sentence case ... for some reason, I though Boghog was already doing that, but apparently not (??). Thanks again! SandyGeorgia (Talk) 17:15, 9 April 2018 (UTC)

PS, to avoid edit conflicts with people who are combing over the prose, I will fix these items at a time when folks are done, so please let me know when you're in and out :) SandyGeorgia (Talk) 17:16, 9 April 2018 (UTC)

Wikipedia notability sure, but we don't want to be treating celebrity gossip rags as RS in medical articles. We know where that leads.LeadSongDog come howl! 18:48, 9 April 2018 (UTC)

Do we have those? I don't speak French, so I'm not sure what we have there ... anyone? SandyGeorgia (Talk) 18:50, 9 April 2018 (UTC)

I read French, if there are any you'd like to point me to. --Tryptofish (talk) 20:57, 9 April 2018 (UTC)

Hang on @Tryptofish: I am about to add a new source, and then you can check them both. By the way, could you prettify the second quote box the same way you did the first? I am not entirely sure what you did, but it looks good. SandyGeorgia (Talk) 21:32, 9 April 2018 (UTC)

Done for the second box. When you have both sources, please indicate to me which two sources they are, so I know where to look, and I'll check them. --Tryptofish (talk) 21:39, 9 April 2018 (UTC)

Weird. I could have sworn that earlier today I saw Entertainment Tonight cited, but there's no trace I can find in the history. Sorry for the runaround. Still, these sections do tend to attract that sort of thing. LeadSongDog come howl! 22:01, 9 April 2018 (UTC)

Here are the French sources ... SandyGeorgia (Talk) 22:02, 9 April 2018 (UTC)

... and Canadian singer Pierre Lalonde.

References

The two sources are very similar. They are obits from publications that are basically the pop culture sections of newspapers. The first is an obit that focuses on his entertainment career, and states that it was the cause of death, but does not treat it as something that otherwise was a prominent part of his life (as in speaking as a patient etc.). The second is a brief report that his wife said that he died after courageously living with the disease(s). The first says that he "suffered since 2010 from Parkinson's disease and also from Lewy body dementia". The second says that his wife "revealed that, in addition to Parkinson's, he also suffered from Lewy body dementia, the same disease that afflicted Robin Williams". I can't really tell whether they mean LBD or DLB. --Tryptofish (talk) 22:24, 9 April 2018 (UTC)

In use

Yea, now it's bugging me :) Unless anyone is actively copyediting, I will put the article in use to correct all journal titles to sentence case ... please speak up if doing this shortly would cause edit conflicts! SandyGeorgia (Talk) 19:21, 9 April 2018 (UTC)

 Done SandyGeorgia (Talk) 20:03, 9 April 2018 (UTC)

Further comments

• "abnormal myocardial MIBG scintigraphy" means what? A scan of the myocardium using MIBG radioactive markers?
  • Will use this to beef up that section: SandyGeorgia (Talk) 18:40, 12 April 2018 (UTC)
    • Chung EJ, Kim SJ (May 2015). "(123)I-Metaiodobenzylguanidine Myocardial Scintigraphy in Lewy Body-Related Disorders: A Literature Review". J Mov Disord (Review). 8 (2): 55–66. doi:10.14802/jmd.15015. PMC 4460541. PMID 26090077.
      • Whew. Does this address that? Scroll down to scintigraphy stuff (past other edits made by Tryptofish in the interim). SandyGeorgia (Talk) 21:11, 12 April 2018 (UTC)

Pending from LeadSongDog

• "REM sleep without atonia evidenced on polysomnography" is indicative how? How can polysomnography show that atonia is absent during REM phase sleep, and why does that matter? Is it the same thing later discussed in the Clinical history and testing section under RBD? Perhaps it should just say that "muscle movement during REM sleep is termed RBD".

• @LeadSongDog: I am not sure how to unravel this, because I'm not understanding yet what is not clear. RBD can be diagnosed in one of two ways: by sleep study, or by clinical history. Polysomnography records when REM sleep is occurring, and when there are movements during REM sleep (loss of atonia). History, questionniare, involves reports of dream enactment behavior. Yes, it is the same thing discussed later, because if RBD cannot be confirmed by questionnaire (for example no bed partner report, subject is not aware, etc) the loss of atonia can be captured on polysomnography. And vica versa. The reason it matters is that DLB cannot be diagnosed only on biomarkers, so if polysomnography is all they've got, no diagnosis. I suspect I am not clear what the question is? (Going to the Kosaka book for some of your other questions.) SandyGeorgia (Talk) 03:41, 12 April 2018 (UTC)

• @SandyGeorgia:If I'm understanding correctly, the indicative factor is the anomolous muscle movement seen during REM, and polysomnography simply discerns when REM occurs. A camera in a sleep study bedroom could substitute for a bed partner (at least as regards this aspect of diagnostics).LeadSongDog come howl! 16:17, 12 April 2018 (UTC)

• Under Epidemiology, "DLB affects more than one million individuals in the United States", but is this representative of global prevalence?

• Possible sourcing at [26] p.29 for a statement about how uncertain the global prevalence is and why. LeadSongDog come howl! 16:17, 12 April 2018 (UTC)

• I am not sure what to add there, LeadSongDog. The Hogan source on epidemiology that was added by Doc James seems to include a lot of non-US studies and represent as thorough of a survey as possible. While the WHO source is 2012-ish, and is not specific to LBD. Could you suggest what we might add? SandyGeorgia (Talk) 20:59, 12 April 2018 (UTC)

• @LeadSongDog: I worked in more geographic regions with these edits, but am still unsure how to use the WHO report. While it makes good points about lower income countries, my concern is that the studies they cite are a) very old, and b) not specific to Lewy body dementia. Please let me know if you have other suggestions. SandyGeorgia (Talk) 17:13, 20 April 2018 (UTC)

• Not to worry, it was just a suggestion. PMID 29448953, PMID 27307129, or PMID 23521899 may be alternatives. LeadSongDog come howl! 19:17, 20 April 2018 (UTC)

• Thanks, worked in some more. And found an important problem (not so clear there is a gender difference). SandyGeorgia (Talk) 23:55, 20 April 2018 (UTC)

• Under Management, the first sentence runs on. It would be better split.
  • Sure was! Chopped in two, SandyGeorgia (Talk) 22:32, 11 April 2018 (UTC)
• Under Research directions, perhaps some sense of how advanced each direction of investigation is? What phase of clinical trial? Each statement made in the section seems to be backhanded: Rather than "Pimavanserin is approved by the U.S. FDA for treating psychosis in PD, and "holds promise"[15] in DLB, but as of 2017, there were no controlled studies of its use for psychosis in DLB.[9][12]" I would suggest "As of 2017, there were no controlled studies of Pimavanserin use for psychosis in DLB,[9][12] but it "holds promise"[15] in DLB and its use for treating psychosis in PD has been approved by the U.S. FDA."
  • In trying to find info about what phase of trials might be going on for pimavanserin, this bad news is all I could come up with: [27] SandyGeorgia (Talk) 01:03, 13 April 2018 (UTC)
    • Oddly, the manufacturer has not published those negative results on the trial. There was an earlier Ph2 trial (for Alzheimer's) with published results at PMID 29452684 and correction at PMID 29496302. Its finding was essentially the same as placebo (at N=90 vs. 91). LeadSongDog come howl! 15:29, 17 April 2018 (UTC)
      • Considering the deaths mentioned above, I am wondering how others feel about completely removing mention of pimavanserin from Research directions? All we say is that there are no controlled studies for DLB, and with the deaths, one wonders if there ever will be. SandyGeorgia (Talk) 15:33, 17 April 2018 (UTC)
        • I think we should only cover something in Research if it is clearly seen by sources as promising, so it sounds to me like pimavanserin should not be mentioned at all. --Tryptofish (talk) 23:24, 17 April 2018 (UTC)

LeadSongDog come howl! 13:54, 11 April 2018 (UTC)

I should be able to find some Japanese epidemiology in Kosaka, and I think I've seen French somewhere. And I should find more on myocardial scintigraphy in Kosaka as well, since it's used in Japan. My reading over the next week ... SandyGeorgia (Talk) 03:44, 12 April 2018 (UTC)

• Shall we delete the part about pimavanserin? I think that we should. --Tryptofish (talk) 22:53, 19 April 2018 (UTC)

• @Tryptofish: it has been so widely advertised as being promising, that I was hoping we would get something official ... FDA or something? ... so that we could put that officially to bed. If that's not likely, yes, I go with delete altogether. SandyGeorgia (Talk) 23:02, 19 April 2018 (UTC)

• That works for me. I just want to make sure that we do not include speculative research unless there is clear evidence that it is going to be productive. Otherwise, we risk creating false hopes. --Tryptofish (talk) 23:07, 19 April 2018 (UTC)

• Agree, but the CNN report only came out April 9. Do you think we are likely to see something in a journal or from a gov't agency, should we wait, or should we go ahead and delete now? SandyGeorgia (Talk) 23:16, 19 April 2018 (UTC)

• I just went looking for source information about that. There is currently a Phase 3 clinical trial that has just started, testing it in people with DLB and related disorders: [28]. It will take a while before they have results, and it's entirely possible that the results will be negative. Agencies like the FDA won't touch anything about putting it "on label" until they have clear clinical data support. The current FDA status is a "Breakthrough Therapy Designation", which only allows the trial to proceed, but does not approve use beyond the trial: [29]. And, according to LBDA, Ian McKeith says that he is skeptical that it will prove safe: [30]. Taking those things together, I would say delete. Especially with McKeith saying it might prove harmful. That can be reconsidered after the Phase 3 trial is over, but I think that will be maybe a year from now. --Tryptofish (talk) 23:39, 19 April 2018 (UTC)

Abbreviations in imaging terminology

• The criteria section seems to have Imaging Terminology Easter Egg Syndrome (ITEES). Readers shouldn't need to hunt to learn that SPECT, PET, CT, and MRI are imaging techniques while EEG is not. LeadSongDog come howl! 13:54, 11 April 2018 (UTC)
  • Does this solve that? SandyGeorgia (Talk) 03:26, 12 April 2018 (UTC)
    • Not really, though it is an improvement. Initialisms should be spelled out at their first appearance, not just pipe-tricked. Some readers are seeing these things on paper, so hovertext doesn't help them.LeadSongDog come howl! 14:27, 17 April 2018 (UTC)
      • ah, ha, I think I see what you want now :) You would like to see spelled out

        PET, SPECT, CT, MRI and EEG as ...

        positron emission tomography, single-photon emission computed tomography, CT scan, magnetic resonance imaging, and electroencephalography.

      • Is that correct? I wonder how others feel about that, as this will result in quite a chunk of text, and I am unsure if those can be viewed as common terms? SandyGeorgia (Talk) 14:39, 17 April 2018 (UTC)
        • They should not be spelled out. Unlike terms like AD and PD, which seem to be initials used only by workers in this field, PET, SPECT, CT, MRI, EEG are all initials by which the scan/procedure is called. It would be like spelling out GIF, NATO, FAQ. The doctor does not send you for a single-photon emission computed tomography scan, and nor would you have any more clue about what it is if he did. -- Colin°^Talk 15:08, 17 April 2018 (UTC)
          • @Colin: Please see Wikipedia:Manual_of_Style/Abbreviations#Exceptions. If the initials truly are "what the scan/procedure is called" then are those target articles mistitled? To a significant section of our readership there's a difference between wearing a special skullcap vs. being injected with radioactive chemicals or put into a tiny space inside a huge magnet. It's not that hard to change the first use from "[[single-photon emission computed tomography|SPECT]] scan" to "[[single-photon emission computed tomography]](SPECT) scan" and it will serve some readers better.LeadSongDog come howl! 16:25, 17 April 2018 (UTC)
            • MOS is a guideline, hence its application here (particularly wrt FAC) will be applied based on consensus. It would be helpful to hear if others want those abbreviations spelled out. If so, I can do it easily enough, but IMO it's going to complicate an already complex paragraph. (But yes, they may be mistitled ... note for example that the Wikipedia article is CT scan, because that's what it is usually called, rather than computed tomography scan ... so if we follow convention here, we will end up with an inconsistent list. It's not our problem on this article to deal with misnamed articles outside of here ... here, we should decide based on this article.) And then, to make the Wikipedia inconsistency even better, why is it computed tomography scan but not single-photon emission computed tomography scan? We can't go by what Wikipedia does, because ... it's a wiki. Additionally, the very source this text is taken from (McKeith Consensus 2017) uses the abbreviations. (Among the sources written since the new guidelines, using biomarkers, were issued, Tousi 2017 is not available online, but he doesn't spell out the abbreviations either. Weil 2017 does spell them out.) I am not trying to talk you out of it LSD, so much as ask that others weigh in so we can build consensus. SandyGeorgia (Talk) 17:08, 17 April 2018 (UTC)
              • We're interested in the clinical aspect of these terms rather than the physical and technological aspects. Nobody is ever referred for a single-photon emission computed tomography scan. Nor for a magnetic resonance imagery scan with T1-weighted-fluid-attenuated inversion recovery sequence. Knowing what the letters stand for does not actually provide any meaning, and will not in fact help our readership know if one requires injection with radioactive chemicals, or being put inside a huge magnet with a force greater than the earth's own gravitational pull. As far as this article is concerned, these are just "names of medical procedures". It is quite irrelevant if one involves big magnets and the other x-rays. If they want to know more about the procedure, they can follow the link to the article. The names are more concerned with the physics than with the clinical procedure from the patient's point of view. If it was the latter, it would be a "Huge doughnut-shaped loud-banging mega-magnet scan". -- Colin°^Talk 17:32, 17 April 2018 (UTC)

Feedback on imaging abbreviations

• Option 1: abbreviations for imaging techniques, like this version.
• Option 2: spell out abbreviations for imaging techniques, like this version.

Could others please weigh in? SandyGeorgia (Talk) 17:46, 17 April 2018 (UTC)

• Option 1. I still do not think these need to be spelled out, especially if they are blue-linked at the first mention. But if we go instead with option 2, I would probably leave out the abbreviations that are in parentheses: just spell the words out. --Tryptofish (talk) 23:01, 17 April 2018 (UTC)
• I am beginning to be indifferent to these two, so if anyone has a strong argument for one or the other, please speak up :) SandyGeorgia (Talk) 00:01, 21 April 2018 (UTC)

If there are no strong feelings, I'd go with Option 1. --Tryptofish (talk) 19:39, 21 April 2018 (UTC)

Expert review

Once the current editors are happy with the accuracy and comprehensiveness of this article, would you like me to arrange for the world's top DLB experts to review it? --Anthonyhcole (talk · contribs · email) 10:58, 9 April 2018 (UTC)

Brief response from ipad at clinic ... I am already on that ... which of them did you have in mind? SandyGeorgia (Talk) 12:52, 9 April 2018 (UTC)

I would approach BMJ. When I asked them to review Parkinsons disease they recruited five researchers including a (the?) leading contributor to the last set of diagnostic criteria and a leading contributor to the new diagnostic criteria. The latter is also the most published author of peer-reviewed journal articles on the topic. But if you've got it under control, I'll leave it with you. --Anthonyhcole (talk · contribs · email) 23:56, 9 April 2018 (UTC)

Anthonyhcole if you can get Ian McKeith via the BMJ, that would take the cake. I am aiming at the top tier, but he's the one. SandyGeorgia (Talk) 23:59, 9 April 2018 (UTC)

I would certainly suggest McKeith but ultimately the choice would be BMJ's. They didn't let me down with Parkinsons disease. What I like about doing this via BMJ is the reviewers are chosen by an entity independent of the Wikipedia authors. I know it's not the case here but I can envision a future case where Wikipedia editors select reviewers who represent just one side of a controversy. In the case if PD, for instance, BMJ put the main proponent (I think) of the old criteria together with a leader in the design of a new set of criteria. Things were a little tense at times but we got a neutral result. Let me know if you'd like me to kick this off. --Anthonyhcole (talk · contribs · email) 00:46, 10 April 2018 (UTC)

My approach was going to be to call in a favor; yours might be a more neutral approach? And it sounds like you already have some irons in the fire, which could be good, while I would be just starting. So, question is, how close are we to ready? Is it best to have them look sooner rather than later, so we can work in suggestions? SandyGeorgia (Talk) 01:09, 10 April 2018 (UTC)

Go ahead and try to get help/advice, while you're rewriting the article, from any experts you can - up to and including McKeith - and then, once you are all satisfied with what you have - I guess that means when it has passed FAC - I'll bring in BMJ for an independent review. One of the problems with the PD review was there was way too much wrong with the article, and the "reviewers" ended up becoming the writers.

Wikipedia needs experts contributing to the writing of its articles as well as different, independent experts reviewing its articles. --Anthonyhcole (talk · contribs · email) 01:38, 10 April 2018 (UTC)

And the problem with having the reviewers have to re-write the article is that ours are not supposed to be journal articles-- they are supposed to be encyclopedic, for general readers. I am curious to hear from Colin how his external review process went, because I was thinking of something like what I understood to be what he had. Get one of the top 5 DLB guys in the world to look it over, tell us if it is comprehensive and accurate, but not turn it into a journal article. SandyGeorgia (Talk) 01:55, 10 April 2018 (UTC)

OK. If you change your mind, let me know. I'd like to talk to you about making Wikipedia articles WP:RSs (not journal articles, but reliable encyclopedia articles) one day, but now's not the time. --Anthonyhcole (talk · contribs · email) 02:34, 10 April 2018 (UTC)

I just looked at the Parkinson's FAC ... and remembered that I was off skiing at Whistler-Blackcomb most of the time it was at FAC and when it was promoted. 'Twas not I ! SandyGeorgia (Talk) 02:07, 10 April 2018 (UTC)

For the record, at Ketogenic diet, I chose someone who appeared to the an authority on the subject (many papers, member of consensus panel, experience of large KD clinic, etc). Sent them a short email explaining the article was receiving 800 hits a day and I was aiming for it to be reviewed for Featured Article status. If it was good enough, it would appear on the main page of Wikipedia and get millions of eyes. I asked if he (or a colleague) could do an expert review. He agreed readily and I sent him some more info. He suggested I format the article into a Word document, which he would review and tweak with the Track Changes feature, and this also allows sections of text to be highlighted and a note added. This worked well: we had a stable version and it used technology he was familiar with, rather than Wiki markup. Generally the suggestions were easy to apply, though a couple of points I couldn't add because there were no sources for it. When I made changes to the article, I noted in the summary that this was from expert review. The textual revisions suggested were very minor, so there was no problem with attribution that their might be if a lot of text had been written by the expert. Although this expert was a fan of reading Wikipedia, they had never edited it. I would definitely recommend doing this last, when the text is very stable. Although the copyediting we've seen in the last few days is very helpful, it runs a big risk of changing meaning/emphasis and deviating from sources: because most folk copyediting are doing so without reading the sources, without deep knowledge of the subject. So once it stabilises I recommend comparing the before/after revisions and check that what is said now really is what was meant. Of course, when it goes to FAC, an whole new bunch of folk will hack at it, but Sandy knows all about that. -- Colin°^Talk 16:10, 11 April 2018 (UTC)

Regarding procedure: I tried to get the Parkinsons reviewers on-wiki but they just wouldn't and the review began only when one of them copied it into Word. They passed it in sequence from one to another, using "track changes", and they discussed it in an email chain. Wikitext was a hurdle but, mainly, most of them do peer review while they're flying between conferences offline, and Word is ideal for that. With requests and prompting from me, they suggested sources for about half of their proposed changes but I had to find sources for the remainder. I incorporated their changes in the article, announcing in the first edit summary and on the talk page what I was doing, with a link to their proposed changes and annotations, which I had transcribed from the Word doc into wikitext and moved onwiki. It might be best to save the field-leaders for the final review when the article is quite stable, after FAC (if only because these are very busy people), and try to involve other authors and researchers during this writing/re-writing stage - if you have a choice in the matter. --Anthonyhcole (talk · contribs · email) 19:32, 11 April 2018 (UTC)

Ok to all ... we still aren't quite finished, ready, stable enough. I ditched the idea of calling in a favor for avoidance of COI. I may (when I get a free moment) go ahead and email Boeve instead to ask if he or a member of his team might be interested, and if so, that we would be in contact later and work out technicalities then. I am hoping they will be interested because of this, but worry about having an advocacy organization (LBDA) want to take over ... what do others think of approaching Boeve? Or would people feel better about McKeith, because he may be less tied to an advocacy group? Boeve is head of LBDA scientific advisory board as well as this new Research Centers of Excellence initiative. SandyGeorgia (Talk) 20:21, 11 April 2018 (UTC)

Feedback from Cas Liber

• Material from paras 1 and 3 of REM sleep behavior disorder subsection should be amalgamated. Also looks a bit contradictory at first glance (though ultimately isn't) Cas Liber (talk · contribs) 11:18, 14 April 2018 (UTC)

• I hope this is better. SandyGeorgia (Talk) 15:22, 14 April 2018 (UTC)

• Yep it is Cas Liber (talk · contribs) 19:28, 14 April 2018 (UTC)

• Not thrilled about the antipsychotic recommendations as they themselves are based on a 15-year old paper that predates the release of aripiprazole, which is (I suspect) what most people would start with if needing an antipsychotic, but whatever. I might even ditch para 2, which could be confusing. Starting with "antipsychotic medications that should be used with great caution,..." after pointing out their grave dangers might lead some readers to think these are the ones to use first rather than last.... Cas Liber (talk · contribs) 11:43, 14 April 2018 (UTC)

• Thanks, Cas, will work on these ... but I have some 2015 and 17 papers on treatment that discuss antipsychotics, so will see what they say about aripiprazole. SandyGeorgia (Talk) 13:50, 14 April 2018 (UTC)

• I am not finding any indication on aripriprazole. Case studies saying good, case studies saying bad. I cannot access this, but the google scholar abstract is: "Pharmacotherapy in Dementia with Lewy Bodies, M Ikeda - Dementia with Lewy Bodies, 2017 - Springer … Dementia with Lewy bodies (DLB) is the second most common type of senile dementia following Alzheimer's disease (AD) [1]. The … Despite an attractive in vitro profile (a partial dopamine agonist), aripiprazole can induce serious extrapyramidal side effects such as parkinsonism … " This review does not say anything more about aripripazole than clozapine or quetiapine. This is not promising either. SandyGeorgia (Talk) 14:46, 14 April 2018 (UTC)

• None of this surprises me. Thing is, at every understaffed and underskilled nursing home around the world...we all know what drugs staff will be using on unruly patients with dementia, don't we...? Cas Liber (talk · contribs) 19:32, 14 April 2018 (UTC)

• Yes ... some of the sources did go in to how to very cautiously approach ... but getting in to that kind of detail feels to HOWTO. Will see what Tryptofish thinks? SandyGeorgia (Talk) 19:35, 14 April 2018 (UTC)

• @Tryptofish: what do you think? On the one hand, I feel that education about antipsychotic use in DLB is reinforced in every journal review, but Cas has a point that they way it is phrased now "might lead some readers to think these are the ones to use first rather than last". SandyGeorgia (Talk) 15:14, 14 April 2018 (UTC)

  Antipsychotic medications that should be used with great caution, if at all, for people with DLB include chlorpromazine, haloperidol, olanzapine, risperidone, and injectable antipsychotics.

• I'll answer below. --Tryptofish (talk) 22:21, 14 April 2018 (UTC)

• Rephrase and dequote The genetics are "vastly understudied"

• Done, but I also rejigged the order a bit, to get risk factors together, and to explain that the genetics are understudied before explaining the issues. [31] OK? SandyGeorgia (Talk) 15:22, 14 April 2018 (UTC)

• The precise mechanisms contributing to DLB are not well understood, and a matter of some dispute. - the material following does not give an indication of a difference of opinion that a statement like this suggests. Needs some explanation.

• How is this? I quoted Weil, SandyGeorgia (Talk) 17:04, 14 April 2018 (UTC)

• Yeah that helps Cas Liber (talk · contribs) 19:27, 14 April 2018 (UTC)

Rest of it looks good. Cas Liber (talk · contribs) 12:06, 14 April 2018 (UTC)

@Casliber: @Tryptofish: re this edit, our article says thioridazine is still available as a generic; would it be OK to reinstate this? SandyGeorgia (Talk) 13:57, 14 April 2018 (UTC)

If you insist I am not too bothered really. One almost never sees it any more though Cas Liber (talk · contribs) 19:26, 14 April 2018 (UTC)

What I think may really be going on here is that first generation neuroleptics (some of which are still used quite a bit and others have largely been supplanted) are contraindicated in DLB, whereas the newer, second generation atypical antipsychotic drugs are (1) increasingly the drugs used for psychosis in general, and (2) may in several cases be safer in DLB because of their (basically) lesser relative specificity for dopamine receptors. It may be better to dispense with listing the names of these drugs entirely, and wording it in terms of drug classes. Casliber, what do you think about that? --Tryptofish (talk) 22:21, 14 April 2018 (UTC)

I encountered somewhere wording about those that act on D2 receptors being the worst. But if taking out the list entirely is the easier way to go, that works. I am not finding any indication that newer antipsychotics are necessarily better, and the news that come out this week about deaths from pimavanserin gives me pause that we should be very careful here ... I am particularly worried, as Cas says, that by including any list at all, we may give the impression others are safe. SandyGeorgia (Talk) 22:54, 14 April 2018 (UTC)

It's possible that it would be better to word it in terms of which receptors they act at, rather than broadly in terms of new and old, but that has the potential to get very complicated, and of course I don't want to do any WP:OR. I'm inclined to go with whatever Casliber would recommend. --Tryptofish (talk) 22:02, 15 April 2018 (UTC)

I think it is a vexed area - for instance, studies not showing quetiapine is effective, yet reviewers recommending it because of low side effects and ignoring the fact that it had not been shown to work. Furthermore the two groups (typicals and atypicals) are more heterogenous wthin themselves than certain member drugs are to each other, rendering the distinction spurious in my opinion. Hence, my concern over lists in general. In vitro affinity doesn't necessarily translate to in vivo EPSE, a la aripiprazole - but if the data is lacking I am loth to make assumptions. Anyway, those are my thoughts. Cas Liber (talk · contribs) 13:38, 16 April 2018 (UTC)

Proposals

@Cas, Tryptofish, and Anthony: thanks! So, I propose we:

• Drop this entirely:

  Antipsychotic medications that should be used with great caution, if at all, for people with DLB include chlorpromazine, haloperidol, olanzapine, risperidone, and injectable antipsychotics.

• Change in the lead,:

Now:Antipsychotics, even for hallucinations, should be avoided because people with DLB are sensitive to them, and their use can result in death.

Change to: Antipsychotics, even for hallucinations, are usually avoided because people with DLB are sensitive to them, and their use can result in death.

Separately, I will look for the statement about antipsychotics that act on D2 receptors being the worst offenders, and once I find it, we can discuss adding something. SandyGeorgia (Talk) 13:44, 16 April 2018 (UTC)

• Yes, I strongly support that lead change, per WP:NOTHOWTO.
• I also agree about removing the drug list. Given the source below about D2 receptors, I think something like

Antipsychotic medications with D2 dopamine receptor blocking properties are used only with great caution.

would work. --Tryptofish (talk) 22:49, 16 April 2018 (UTC)

List of antipsychotics avoided removed. SandyGeorgia (Talk) 04:07, 19 April 2018 (UTC)

And replaced with statement about antipsychotics that act on D2 receptors, per Tousi 2017. SandyGeorgia (Talk) 04:11, 19 April 2018 (UTC)

Looks good, thanks. --Tryptofish (talk) 18:13, 19 April 2018 (UTC)

Setback

I thought we were almost there. But when I noticed that this text from the original lead was not adequately paraphrased from the source[32] and needed to be rephrased, I started checking that source, and realized that since March 24 (and earlier), [33][34] the article has used sources for Lewy body dementia, not Dementia with Lewy bodies. That is, some of the text applies to Parkinson's disease dementia but not dementia with Lewy bodies. I should have noticed sooner :( :( So, now I am going back through checking every statement sourced to these NIH sources, which are all LBD, not DLB. I am finding errors, removing some things, resourcing what I can, finding some that are still OK because they are general rather than specific to DLB ... anyway, sigh ... back to the drawing board, just when I thought we were just about done. I am going to try to resource as much as I can ... I am finding so many issues that I have no confidence in any sourcing to NIH, NIA or NINDS. There are a number of things sourced to them that I have not seen in any secondary review. Do not feel comfortable approaching FAC at this stage. SandyGeorgia (Talk) 04:06, 22 April 2018 (UTC)

I think I fixed it all. The remaining text cited to NIH, NINDS and NIA sources on LBD is now contextually appropriate, and I've switched to DLB sources where specifics were needed. That was discouraging. SandyGeorgia (Talk) 07:25, 22 April 2018 (UTC)

Paraphrasing can occur but is not required as these sources are public domain as produced by the US government. This tag however should be used if not fully paraphrased {{PD-notice}} Doc James (talk · contribs · email) 01:01, 26 April 2018 (UTC)

Doc James, yes, I know ... I wasn't so worried about that other than it could set off red flags at FAC. I was more set back by realizing the sources were LBD not DLB, needing to go back and check everything, and the muse has not yet returned. I appreciate the list below and will get on it in a few days (some are intentional, I will need to explain, hoping to get another source), but for today, just too tired. (Curiously, after a bad week, I found we have no article on radiation colitis, it is a redirect to radiation proctitis, which is not the same thing.) Will address the list below by the weekend. Thanks again, SandyGeorgia (Talk) 01:35, 26 April 2018 (UTC)

Merge proposal

As a reward for two long days of work, and spinning off Notable cases as discussed here, please see the merge proposal at Talk:Lewy body dementia. That does me in for the day. Done for a while, would appreciate others going through prose ! SandyGeorgia (Talk) 01:03, 21 April 2018 (UTC)

Issues

• "The autonomic nervous system is usually affected, and can result in symptoms like changes in blood pressure, heart and gastrointestinal function, and constipation"

Constipation is a change in gastrointestinal function thus this sentence reads strangely. Doc James (talk · contribs · email)

Ugh. Constipation is a very common symptom, and one that presents early and may be present before other symptoms, so my intent was to specifically highlight it. How is this?

• The autonomic nervous system is usually affected, resulting in changes in blood pressure, heart and gastrointestinal function, with constipation as a common symptom.

SandyGeorgia (Talk) 03:54, 26 April 2018 (UTC)

Yes better thanks. Doc James (talk · contribs · email) 00:25, 29 April 2018 (UTC)

• "specific biomarkers, blood tests, neuropsychological tests, medical imaging, and polysomnography."

The biomarkers are "polysomnography" and certain types of medical imaging.

Neuropsychological testing is how dementia is diagnosed and is summed up within "based on symptoms". It is a core part of diagnosis not a supportive feature.

How is this?

• A probable diagnosis is made based on symptoms and biomarkers; the diagnostic workup may include blood tests, neuropsychological tests, medical imaging, and polysomnography.

SandyGeorgia (Talk) 04:00, 26 April 2018 (UTC)

Looks good. Thanks Doc James (talk · contribs · email) 00:25, 29 April 2018 (UTC)

• Would summarize "Average survival 5.5–7.7 years from disease onset" to "Average survival 6.5 years from disease onset". This is an overview and taking the middle point of the range is perfectly appropriate in the infobox.

This is a place holder; I am waiting for a new source. The numbers are all over the map, and I need to see what another source says. SandyGeorgia (Talk) 03:54, 26 April 2018 (UTC)

Got the third source, it was not helpful in sorting the differences, went back to simpler NINDS data. SandyGeorgia (Talk) 03:17, 27 April 2018 (UTC)

Thanks. Doc James (talk · contribs · email) 00:25, 29 April 2018 (UTC)

• These "Other frequent symptoms include visual hallucinations; marked fluctuations in attention or alertness; and sometimes slowness of movement, trouble walking, or rigidity." are also core features. They appear to be given less weight than REM. Why the "sometimes" for the motor symptoms?

Yes, the wording is awkward. Here is what I wanted to convey (but didn't).

First, only one of the cardinal features of parkinsonism need be present, not all three. Second, the symptoms of parkinsonism are usually much less severe than in Parkinson's. Third, the symptoms of parkinsonism are not always present early in the course of the disease (which I see I read in a source but failed to add to the article ... tomorrow).

On the other hand, the other three core symptoms (RBD, visual hallucinations, and fluctuating cognition) are either present early on, or may be prodomal. I was attempting to draw a distinction between those three and parkinsonism, and "sometimes" isn't cutting it. I will need to find the quote in the source about parkinsonism not always being noticed early on. I was concerned that the word "core" would mislead the reader to think all of those signs of parkinsonism had to be present and noticeable early on, as the others are. Not sure yet how to fix this. Ideas ? SandyGeorgia (Talk) 04:15, 26 April 2018 (UTC)

Cannot figure out how to solve this in terms simple enough for the lead, so took out "sometimes". SandyGeorgia (Talk) 03:20, 27 April 2018 (UTC)

Yes the removal of "sometimes" sufficiently resolves my concern. Doc James (talk · contribs · email) 00:25, 29 April 2018 (UTC)

Doc James (talk · contribs · email) 01:01, 26 April 2018 (UTC)

@Doc James:, I have been through these if you would like to take a fresh look at the lead. SandyGeorgia (Talk) 03:20, 27 April 2018 (UTC)

@SandyGeorgia: I personally think the lead reads well now. It balances concerns of easy to understand language with that of being medical accurate. Thank you for your work on this. Best Doc James (talk · contribs · email) 00:25, 29 April 2018 (UTC)

@Doc James: thanks Doc! I am at a point now where I've worked in all the material I have, and have done as much prose smoothing as I can. As soon as we resolve this impasse over opinion v. fact, assertion v attribution, I would like to call in Eric Corbett for a copyedit. Should you be interested in combing through the entire article, now is a good time! SandyGeorgia (Talk) 00:36, 29 April 2018 (UTC)