This is an archive of past discussions about PANDAS. Do not edit the contents of this page. If you wish to start a new discussion or revive an old one, please do so on the current talk page.
Should it not be the other way around? It seems a little out of sorts to have periods between the abbreviations when most other scientific/medical articles I've seen do not. -- Serephine♠talk - 03:20, 25 April 2007 (UTC)
I actually can't remember coming across any period-separated abbreviations. Any objections to me switching the redirect/talk page across? -- Serephine♠talk - 03:30, 25 April 2007 (UTC)
It's been a long time since I set this up ... and I was new to Wiki when I worked on it ... but I think I thought <grin> I had to put the periods because of the issue with [[Panda]]s and [[PANDAS]] (that is, distinguishing the plural of the bear). If someone can make it all work, I'm not tied to the periods. SandyGeorgia (Talk) 23:26, 26 April 2007 (UTC)
The "Controversy" section seems to only talk about the people who don't believe in existence. While I understand that the theory is shown in the earlier sections, there is a vast amount of statistical information that is unmentioned, and the first sentence is redundant in telling us that it hasn't been proven. I would put the other side up myself, except I cannot remember were I found it. I don't know, maybe I'm the bias one because I had it...JLAF10:16, 25 November 2006 (UTC)
That's why it's a controversy section, which is fully referenced, factual, and based entirely on medical consensus. How is unproven "redundant"? Because someone told you you had PANDAS doesn't change the medical consensus. You've made no case here for POV; only that you disagree with the medical facts. Please make a case for POV, or the tag should be removed. SandyGeorgia (Talk) 00:35, 14 March 2007 (UTC)
Problems with POV tag
A POV tag is not appropriate because one editor disagress with content based on personal anecdote; please give an explanation for alleged POV. Leaving out the fact that there is considerable controversy surrounding the entire hypothesis WOULD be POV; on the contrary, including four sentences about the controversy is necessary to maintain a neutral point of view in face of an unproven and highly contentious hypothesis. In fact, considering the amount of controversy, four sentences is too little, if anything, and undue weight is given to the theory, over the lack of support for the hypothesis. Yes, there is a vast amount of technical information about the theory and about the controversy as well that is not included in this article, simply because no physician has yet come on board to write the article (and since there are very few physicians in the world who understand PANDAS, it's not surprising there is no one on Wiki who can write the article). Because the article is brief is not an argument for POV; you are misunderstanding NPOV. NPOV says that all significant views published by reliable sources should be presented, without giving undue weight to any one view. A group of researchers at NIH have made a name for themselves on the PANDAS hypothesis, which has been promoted on the internet because of desperate parents (not my words, read the journal-published accounts, the statement is from very reliable sources); almost all respected independent researchers continue to have very large problems with the entire hypothesis, which have been the subject of numerous peer-reviewed journal publications. If anything is given short shift in this article, it's the extent of the controversy. If there is POV (which I don't agree), the POV is in favor of the hypothesis, and not in the short controversy section, which is an understated summary of the research and published fact. Please establish a basis for a lack of neutrality in the article. SandyGeorgia (Talk) 14:59, 14 March 2007 (UTC)
I may know nothing about PANDAS but I can clearly see the article attempting to persuade me that there is controversy regarding PANDAS, and that I should believe the viewpoint disputing it, rather than accepting it. WP:NPOV says that if the reader can detect an attempt to persuade him one way or another, the NPOV rule hasn't been followed. Reswobslc17:10, 14 March 2007 (UTC)
Well, there is a massive controversy; that's fact that can't be ignored. Can you give some examples, suggestions of sentences that might be adjusted to fix this perception? SandyGeorgia (Talk) 17:47, 14 March 2007 (UTC)
Hypothesis, not a diagnosis—undisputed fact. Unproven—fact. Controversial—fact. What wording would you change, and still remain factual? SandyGeorgia (Talk) 18:17, 14 March 2007 (UTC)
See WP:NPOV for generic examples. Specifically for this article: The PANDAS theory is a highly controversial, unproven hypothesis would be better stated as The (existence/legitimacy/recognition) of PANDAS is controversial, and is considered an unproven hypothesis by (name or description of group). (Group) alleges that PANDAS has engendered the use of dangerous methodologies for children.... In the introduction, don't qualify PANDAS as hypothetical. Just let the article describe it as whatever the person who thought of it says it is. The opposing side gets its turn in its own section. Have you ever watched Judge Judy and seen a defendant insist "no I didn't" and "that's not true" after every sentence of the plaintiff? It gets annoying. You don't want to do that on Wikipedia. Let the article describe what PANDAS is or claims to be, and then factually (as explained in WP:NPOV) describe the controversy in its own section. Reswobslc05:31, 15 March 2007 (UTC)
I'm well versed in WP:NPOV from other areas of Wiki; the examples you give don't work for this article.
If someone can produce an ICD or DSM code for PANDAS, hypothetical can be removed from the lead. Here's some ICD codes; notice how they mention PANDAS.[1] Please review the enormous body of research that refers to it correctly as the hpothesis that it is. Reporting the referenced facts in the lead does not equate to POV. The lead should accurately reflect that it is, currently a hypothesized condition. That's fact, not controversy. Leaving it out would be POV.
You offer "The PANDAS theory is a highly controversial, unproven hypothesis would be better stated as The (existence/legitimacy/recognition) of PANDAS is controversial, ..." all of the above, take your pick, and then expand the list to name every single aspect of the hypothesis, since it is the entire hypothesis that is controversial. That wouldn't be good writing; it's the entire thing; the hypothesis is controversial. Again, referenced fact to numerous journal reports, just about anything you can read. There is no aspect of the hypothesis that isn't controversial; again, this misunderstanding may be arising because others don't know PANDAS,and the article isn't yet comprehensive, going into all the detail. I have read every medical journal report published on PANDAS in the last 10 years, but I don't feel qualified to write the comprehensive article since it's highly technical territory, and I'm not a physician. We shouldn't label articles POV when we don't understand them or know the condition or the research.
You offer and is considered an unproven hypothesis by (name or description of group). It is not considered an unproven hypothesis by any group; it is an unproven hypothesis, as acknowledged by just about every reference you can find. Listing the groups would again be poor writing. Where's the ICD or DSM code making it a medical condition? Sometimes a general statement that is true, is true, and is best left generalized. Arguing that the article isn't yet comprehensive does not equate to POV.
(Group) alleges that PANDAS has engendered the use of dangerous methodologies for children.... No, this seems to be another issue coming from lack of understanding. No group alleges it; the NIH (which is behind the hypothesis) and the TSA (whose medical board comprises the most of the rest of the researchers working on unraveling the controversy and could be considered "the other side") JOINTLY issued a warning about the methodologies. NO group considers it such; both sides of the controversy issued the warning JOINTLY. It's not a matter of one or another side "alleging"; the different parties to the controversy agree, and the referenced sources document that.
Let the article describe what PANDAS is or claims to be, ... It does. It is a hypothesized condition. Hypothetical is the accurate word, unless you can find a better one. ... and then factually (as explained in WP:NPOV) describe the controversy in its own section. It is. The controversy is confined to the controversy section, which is now labeled POV! The controversy is given less weight here than it merits, based on the research.
You seem to be arguing (accurately) that the article fails in comprehensiveness. It does; it's a hard article to write, very technical, and there is no one on Wikipedia versed in PANDAS. I don't feel qualified to expand the article, but failure in comprehensiveness does not equate to POV. The referenced facts are accurately stated, it is a hypothesized condition, the controversy is confined to the controversy section, and the only side that is not given due weight is the controversy. I'll be traveling for two weeks, so may not be able to respond for a while. I do appreciate that someone is trying to help, and I can see that the article needs to be better spell out some of the medical issues that others might not understand or be aware of, but don't want to change wording based on misunderstanding of the research or the facts—still open to wording that remains accurate. Dropping hypothesis from the lead would be inaccurate and misleading. The controversy section is accurate, albeit brief. To fix the article correctly would require an expert in PANDAS, and Wiki doesn't have a physician who speaks PANDAS. SandyGeorgia (Talk) 14:53, 15 March 2007 (UTC)
As this is not an established medical diagnosis and is instead a proposed mechanism in a sub-set of patients, I think it is entirely accurate to describe it as a hypothesis. It may be a correct hypothesis, or it may be incorrect, however at present it is a proposal that covers an area of research with much contradictory evidence. Describing it as a fact would be POV, describing it as a myth would be POV, but describing it as a hypothesis is simply saying what it is. TimVickers18:13, 15 March 2007 (UTC)
Very nice changes from both Tim and Reswobslc; not a single quibble from me. Thanks so much for the effort ! It would be still be stupendous if we could write the article more comprehensively, but that would be quite an undertaking. SandyGeorgia (Talk) 18:19, 15 March 2007 (UTC)
The main problem I have with the term "hypothesis" is that it is an invalidating term - unless the people who came up with PANDAS are touting it as a hypothesis or theory themselves. It doesn't appear that way. If NIH calls it a "diagnosis", then "controversial diagnosis attributed to the NIH" is factual - anything less is not. Reswobslc01:40, 16 March 2007 (UTC)
To accept the description of one side of this controversy is to attribute their opinions undue weight. I see hypothesis as a neutral and technical term colloquially equivalent to "Idea" and "Theory". From one of the more positive reviews linked on the page "To indicate their shared clinical features (and presumed etiopathogenesis), the subgroup was identified by the acronym PANDAS—Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections." link. TimVickers01:51, 16 March 2007 (UTC)
Hypothesis, Idea, and Theory are not accurate, unless the NIH themselves are calling it that. I could do drugs and say I saw a pig fly, but if I were to seriously insist that as true, it would be a "claim", "assertion", or "statement" (all of which connote that I think I'm for real) rather than a hypothesis, idea, or theory (all of which connote that I'm just tossing out a guess without any serious weight). On the other hand if a pig really was flying, and I speculated that maybe it was shot from a cannon, then that's a hypothesis. It appears to me the NIH thinks this is for real, and "hypothesis" is totally inaccurate because it suggests that they don't think it's real - which appears inconsistent with what they claim on their web site. If NIH thinks it's for real, you can't suggest otherwise - any more than if I were to go and edit the Catholicism or Islam article to call their beliefs "hypotheses" just because the majority of the world doesn't agree with them. Reswobslc02:34, 16 March 2007 (UTC)
I'm in a quandary here, scientific ideas move from hypotheses, through models to theories. As the PANDAS "idea" is not proven we can't describe it as fact and you object, possibly rightly, to us describing it as a hypothesis as although this is the correct scientific term for an idea that is currently being tested through research, it has negative connotations for the non-specialist. I propose we instead substitute the term "model" which is both reasonably accurate and in my eyes quite neutral. What do you think? TimVickers02:46, 16 March 2007 (UTC)
Sure. In fact, it would be helpful to convey the nature of the controversy, so people understand the viewpoints of the two "sides". Clearly the NIH must think of this as more than just a mere "hypothesis" otherwise there wouldn't be a "controversy" about it. Help the reader understand what the NIH thinks, and then help us understand what everyone else thinks. Reswobslc02:59, 16 March 2007 (UTC)
OK, but I'd never describe a hypothesis as "mere" I spend all my working hours testing hypotheses so I know they are powerful things! TimVickers03:31, 16 March 2007 (UTC)
I'm catching a plane; sorry if this is not coherent, just some thoughts. Res seems to be making attributes to the word "hypothesis" that aren't a reflection of what is meant by the use of the word. A hypothesis doesn't imply what you're suggesting, and isn't negative in a medical or scientific sense. No one suggests it's not a valid hypothesis, worthy of testing; in fact, everyone (serious) is working on it. It's a difficult hypothesis to validate because of the controls needed and the fact that both conditions are fairly common (tics and strep). No one is saying that whatever is going on in a subset of kids with tics and OCD isn't "real"; most informed researchers and specialists agree that something may be going on that relates to autoimmunity in up to 20% of children with tics. (I can produce some research statements on that when I return from travel.) The questions revolve around whether the current hypothesis is correctly formulated—no single piece of it has yet to be validated and replicated in controlled studies. In terms of the NIH using the word "diagnosis" in one website, we don't give undue weight to one version or one website—we aren't obliged to parrot a word that is obviously wrongly-used. Factually speaking, it's not a diagnosis—where's the ICD or DSM code? It's a proposal for research purposes. A serious proposal, but not a diagnosis in the correct sense of that word. I can do far more work on conveying the nature of the controversy if someone like Tim is on board to help tweak my wording to keep it medically accurate; as a layperson, I know the controversy inside and out, and where to find all the info (see the Sandbox I set up). I can even help write the article to a more comprehensive state. But I can't work on it for the next two weeks, and I can't do it without help, because it gets into bacterial and buggy territory I don't feel trained to write. Another factor to keep in mind in terms of conflict of interest; the NIH gives buckets of research money to the TSA, and this is their baby, so the TS/OCD folk have to tread very carefully with their criticism. Criticism of the PANDAS hypothesis has been fairly muted, all things considered. Regards, SandyGeorgia (Talk) 09:06, 16 March 2007 (UTC)
Another note—just saw this: "... as some scientists think this sub-set of patients do not differ in any significant way from the remainder of the patient population and that infections do not increase the risk of Tourette syndrome." I have heard the researchers say (seminar) that they agree something may be going on with autoimmunity in a subset of children. When I can dig into my notes and papers, we should convey somewhere that they are examining the idea that a subset of tic/OCD children may have an autoimmune component. Do a PubMed search on Tourette, setting limits to the last 60 days - there was something out of the Yale group (Leckman et al) about t cells, that falls out of this research. SandyGeorgia (Talk) 09:12, 16 March 2007 (UTC)
Biased changes
The article has been rewritten to a version that, in addition to needing significant MoS cleanup, contains a completely WP:UNDUE biased article that reduces, strangely, mainstream medical thinking to a controversy section and mentions dangerous and unproven treatments with no balance. I'm tempted to completely revert and ask the new editor to build a better understanding of Wiki policies and WP:MEDMOS, but there is some content worth saving and I can't work on the article today. SandyGeorgia (Talk) 18:42, 2 December 2008 (UTC)
Noting also that, in this case, PANDAS was promoted by Swedo at the NIMH and the hypothesis is largely unsupported by mainstream private research, so the article should balance NIMH bias with mainstream consensus. ANY of the recent TS reviews highlight the significant problems with the hypothesis as posed; it's not only unproven, some of the treatment implications are dangerous and have really misled parents who are desperate to 1) deny the genetic component of TS and 2) seek a quick cure. Any expansion of this article needs to balance the significant mainstream evidence against the hypothesis as formulated and include mention of the dangerous unproven methodologies being employed by desperate parents who want to believe their child's tics were caused by a bacteria and can be cured by unproven methods. Long after the hypothesis is sorted, the damage to children will remain. SandyGeorgia (Talk) 20:20, 2 December 2008 (UTC)
I second Sandy's concerns, the presentation of PMID15820236 was very misleading, particularly in light of the strong criticisms that were published of the design and interpretation of this study. Tim Vickers (talk) 20:21, 2 December 2008 (UTC)
There is, simply stated, no credible TS researcher who hasn't pointed out the many problems with the hypothesis as currently formulated. I don't believe the PANDAS hypothesis would have ever gained any traction if the NIMH hadn't been behind it: unfortunately, it has gained traction in ways that result in harm to children, both physically and emotionally (via dangerous unproven treatment, overuse of antibiotics, and parental denial of the reality of their diagnoses and the desperate search for a "cure", which is emotionally damaging to children). SandyGeorgia (Talk) 20:23, 2 December 2008 (UTC)
Why is neurodiversity.com in the External links? It's biased and incomplete, presenting only one side of the story. How about instead some links to TSA information about the problems with the hypothesis or some full journal articles that discuss the significant flaws in the hypothesis? SandyGeorgia (Talk) 20:30, 2 December 2008 (UTC)
The treatment section is particularly misleading: the only treatment endorsed by mainstream researchers is antibiotic treatment as usual only when strep throat is proven present. Anything else is research only, several mentioned here carry significant risk. Mainstream recommendation is not included. The current version of this article has flip-flopped mainstream, due weight and controversy; it is almost entirely now unproven controversy, with mainstream consensus relegated to the bottom of the article as contoversy. SandyGeorgia (Talk) 20:51, 2 December 2008 (UTC)
I'm updating this page for a class project and really tried my best to be unbiased and present all the research involved. I did a lot of research, but I am sure those who have been editing the page and researching/studying the disease are better informed. I hoped that I helped add some information and definitely understand that some may need improvement. User:Gtg938w 15:58, 2 December (EST)
Actually, while your text demonstrates medically sound writing, the content you have added is cherry picked to the point of introducing an extreme bias. I suspect you will become a productive Wiki editor once you've had a chance to read up more on policy, but it might be helpful now if you give Tim Vickers and MastCell a chance to clean up and balance the text you've introduced without edit conflicts, while you might invest some time in reading up on some of the links I left on your talk page. Helpful would be expanding your reading horizons beyond NIMH publications to some recent peer-reviewed journal reviews by, for example, Singer Kurlan and the Yale Group. Regards, SandyGeorgia (Talk) 21:05, 2 December 2008 (UTC)
Journal reviews
Noting that this article is quoting the Mell report, in which patients were not actually examined (computer registry); anyone who understands TS can easily poke too many holes in the methodology there; this is the problem when Wiki articles rely on primary sources.
There's a brief sampling of some of the most recent reviews, representing hands down the topnotch brains working on this in the TS world. SandyGeorgia (Talk) 21:17, 2 December 2008 (UTC)
PMID15119917 Lack of effect of intravenous immunoglobulins on tics: a double-blind placebo-controlled study.
Sandy, you can take WP:MEDRS and eat it! This article is written mostly from PMID15241433—a featured review in Molecular Psychiatry, the number two psychiatric journal by impact factor, and published by Nature Publishing Group. What could possibly be wrong with it? Perhaps that the review was written by the guys that proposed this hypothesis? Nah, it's been peer reviewed. Any bias would have been eliminated. Seriously, it needs conterbalancing from other reviews, but in its current form it's a good showcase of why you shouldn't read a single review.
In the same vein, see BMJ 2003; 327: 266 for what a (meta)review of type 2 diabetes reviews found. Not so reassuring. Also read Fitzmaurice's commentary that comes right after the article. Quoting for those w/o access: "The point is well made that review articles, particularly those written by specialists, tend to be of dubious value with authors selectively choosing evidence to support their own prejudices. I would argue, however, that most practicing clinicians know this already." Xasodfuih (talk) 11:13, 22 January 2009 (UTC)
Blatant Bias Against PANDAS Theory in General, Misrepresentation of Research
By placing the statement "PANDAS is not recognized as a diagnosis under the International Statistical Classification of Diseases and Related Health Problems" at the beginning of the article, the writer immediately asks the reader to question the legitimacy of the disease. No newly-discovered disease can be "recognized as a diagnosis under the International Statistical Classification of Diseases and Related Health Problems". Anyway, if you're going to mention that at all, you should also mention the large and growing numbers of clinicians who recognize PANDAS.
Saying "PANDAS became popular in the late 1990s" is silly: PANDAS became a popular research topic in the 1990's, but PANDAS itself (or, if you prefer, the symptoms that the PANDAS theory describes) is a debilitating disease; no one likes it, so you can't say that it is "popular."
The assertion "There is controversy in the medical field over the reality of this disease, as studies have failed to prove or disprove its existence" is misleading. Studies have thus-far failed to determine the pathogenesis of the PANDAS, but the fact that a subset of childhood OCD is caused by autoimmune response has been strongly suggested by the results of Swedo's 1999 study, "Therapeutic plasma exchange and intravenous immunoglobulin for obsessive-compulsive disorder and tic disorders in childhood". The Lancet 354: 1153-58. The Lancet is a fairly respectable, peer-reviewed journal, no? Questioning the "reality of the disease" is blatantly biased.
Under Plasmapheresis, the writer insists that "A 2000 study that found that plasma exchange did not provide benefits to PANDAS patients." This is a false statement. May I point out that the title of the study includes the phrase "Without Poststreptococcal Exacerbations"? Perhaps the writer would care to read the study (or at least its title) before he cites it to support his biased assertions.
Under Risks, the observations of the side-effects of IVIG and plasmapheresis that were discussed of Swedo's 1999 study should be presented, and presented honestly. Calling IVIG an "invasive surgical procedure", while perhaps not technically false, is totally biased. I suppose that a tetanus shot is also "an invasive surgical procedure." The phrase "invasive surgical procedure" calls to mind opening the flesh with a scalpel. IVIG involves only the intravenous administration of a blood product. It is done routinely and safely for other conditions.
Also, under Treatment, the Swedo's 1999 study should be described in detail (which I will get to soon). Although the pathogenesis of PANDAS symptoms is unclear and is the subject of current research, the fact that immune modification therapy leads to significant and long-term improvement in PANDAS patients was proven in that study, and cannot be emphasized enough. —Preceding unsigned comment added by Atsaxon (talk • contribs) 17:13, 14 July 2009 (UTC)
Looking at the history of this article, it has been expanded a great deal with some, as you say, questionable content from the last draft that I wrote. If you would prefer, we could revert to this version and try to write a tighter and more balanced version that discusses less primary literature and instead summarises review articles. Tim Vickers (talk) 17:31, 14 July 2009 (UTC)
Atsaxon, please see my message on your talk page. WP:MEDRS will explain the use of primary sources in medical articles. Broader reviews disagree with your interpretation of the primary sources you are introducing. Broader reviews agree with the danger of IVIG for treating PANDAS. Please read peer-reviewed articles on PANDAS rather than primary sources, and discuss your edits here with others and gain consensus for changes you want to introduce. PANDAS has not only not been recognized; its validity as a hypothesis has been questioned by review articles which qualify as reliable sources. I concur with the idea to revert to the last correct version, as suggested by Tim Vickers. It provides a much better starting place for a rewrite, and was accurate. SandyGeorgia (Talk) 17:33, 14 July 2009 (UTC)
That's good! So I suggest giving Tim Vickers time to finish working on the article, and then discuss here any other changes we still want to include. The article was really damaged some time ago, and no one ever got around to repairing it. Please discuss the use of sources you want to use, and refrain from edit warring. Thanks ! SandyGeorgia (Talk) 17:57, 14 July 2009 (UTC)
OK, I've reverted. PMID19242249 is the most recent review that I can access, so I've quoted it in the lead. It would be useful if you could add summaries of some reviews that take the opposite viewpoint, Atsaxon, as you seem to be much more familiar with the literature than I am! Tim Vickers (talk) 18:03, 14 July 2009 (UTC)
The PANDAS hypothesis is questioned by every review, so to say otherwise would be inaccurate. We have to be careful with any of the primary sources available here (I have or have read all of them, to my knowledge), as they have all been questioned in broader reviews. SandyGeorgia (Talk) 18:09, 14 July 2009 (UTC)
I'd be interested in seeing any review that questions Swedo's 1999 finding that IVIG and plasma exchange offer long-term cures to a subset of OCD sufferers, or explains the results of that study as anything other than such OCD being autoimmune-induced. (Atsaxon (talk) 04:08, 15 July 2009 (UTC))
For starters, Shulman 2009 (PMID19242249) discusses Swedo's finding and more recent results, and concludes "That there is an OCD/tic disorder patient group with an autoimmune pathogenesis specific to GAS infection has not been proved and seems increasingly unlikely." A more positive review, Moretti et al. 2008 (PMID18495013), says in its abstract "Nonetheless the contrasting results from numerous studies provide no consensus on whether PANDAS should be considered as a specific nosological entity or simply a useful research framework." That's about as positive as I could find in a recent reliable review. The article shouldn't be citing primary studies directly; there are plenty of reviews to choose from. Eubulides (talk) 05:30, 15 July 2009 (UTC)
Neither of those reviews appear to address my question, are there any reviews that challenge Swedo's 1999 finding that IVIG and plasma exchange offer long-term cures to a subset of OCD sufferers, or explains the results of that study as anything other than such OCD being autoimmune-induced? Shulman's statement seems to say that it seems "increasingly unlikely" that there is an OCD-induced auto-immune disorder specific to strep. His statement does not cast doubt on the hypothesis that there is one or more OCD-induced auto-immune disorder regardless of pathogenesis, or suggest that such OCD-induced auto-immune disorder(s) are not highly responsive to immune modification therapy. That's what Swedo's 1999 study showed. (Atsaxon (talk) 01:07, 16 July 2009 (UTC))
The conclusions I quoted are single sentences that summarize lengthier discussions that do indeed seem to challenge Swedo's 1999 finding. For example, Shulman discusses, in a more-detailed section, "concerns about the previously published plasma exchange and intravenous immunoglobulin (IVIG) treatment study in PANDAS". Other recent reviews give these treatments even shorter shrift; for example, for tic management Shprecher & Kurlan 2009 (PMID19170198) simply say in their PANDAS section that "treatment with chronic antibiotics or immune-modifying therapies like plasma exchange or intravenous immune globulin are not justified based on existing evidence." Again, as per WP:MEDRS we should not be directly citing primary sources like Swedo's 1990s study; we should be relying on recent reliable reviews. Eubulides (talk) 01:34, 16 July 2009 (UTC)
Certainly, let's rely on reliable reviews. I don't have access to Current Opinion in Pediatrics. But "concerns" about the treatment study in PANDAS is pretty vague, wouldn't you agree? What, exactly, are his "concerns," and do they bear on the specific deduction required by that study that there is one or more OCD-induced auto-immune disorder, or suggest that such OCD-induced auto-immune disorder(s) are not highly responsive to immune modification therapy?
I do have access to Shprecher & Kurlan paper, however. That review, "The Management of Tics", published in Movement Disorders, touches on PANDAS only tangentially in a single-paragraph section entitled "Treatment of Tics Associated With Streptococcal Infection". In it, the statement "In our opinion, there is insufficient evidence to conclude that streptococcal infection has a true etiological role in causing tics" is summarily presented without context, discussion or a single supporting reference. Similarly, the statement "treatment with chronic antibiotics or immune-modifying therapies like plasma exchange or intravenous immune globulin are not justified based on existing evidence" is also summarily presented without context, discussion or a single supporting reference. One can't argue with a conclusory statement that doesn't reveal its premise, I guess, but it hardly makes for a "reliable review."
As for positive reliable reviews, we can start with a random 2008 paper I happen to have on my desk, "Challenges in the Identification and Treatment of PANDAS: A Case Series" (2008), Mabrouk AA and Valsamma E, Journal of Tropical Pediatrics 55:46-51, in which the authors state that "Both plasma exchange and intravenous immunoglobulin (IVIG) have been found to be effective in lessening the symptom severity in children with infection triggered OCD and Tic disorders". This review does include supporting references, by the way, including Swedo's original research with NIMH. (Atsaxon (talk) 03:20, 16 July 2009 (UTC))
The "concerns" statement itself summarizes a long discussion. It's not at all vague in toto. However, I cannot reproduce the entire paper here, for obvious reasons. I urge you to find a copy the next time you are near a medical library. The Shprecher & Kurlan paper reflects mainstream opinion about tic management. Certainly we as Wikipedia editors can disagree with expert opinion, but it's our job to present what reliable sources say, not to present our own theories. Mabrouk & Valsamma 2008 (PMID18499734) is a case series, not a review. Case series are one of the lower-quality forms of primary sources. As per WP:MEDRS we should be relying on secondary sources, not primary. Eubulides (talk) 04:24, 16 July 2009 (UTC)
Isn't the proposition that the Shprecher & Kurlan paper "reflects mainstream opinion about tic management" your--how you say--"POV"? In any case, while many sections on the paper seem to be adequately supported by cited research, the authors offer no research or other evidence whatsoever to indicate that their summary opinion about PANDAS treatment--which I think we can all agree is a highly politicized and hotly debated area of medicine--is anything other than their own uninformed bias. Scientists base their published opinions on actual and verifiable facts and data, no? So again, since the authors give us no way to verify the basis of their opinion on the hotly-debated topic of PANDAS, this paper should not be considered a reliable source for the proposition that you assert. With respect to the case series that I mentioned, while the cases themselves may be a primary source, the authors discussion about the current state of PANDAS research is a secondary source and is at least, in fact, supported by primary sources (unlike the opinion about PANDAS in the Shprecher & Kurlany paper).
I still see no credible challenge to Swedo's 1999 finding that IVIG and plasma exchange offer long-term cures to a subset of OCD sufferers, nor have I seen anyone account for the results of that study as anything other than such OCD being autoimmune-mediated. (That's not my own theory, that's my observation.) Anyway, I'm beginning to wonder whether the aversion to primary sources that the anti-PANDAS editors here have is based on their aversion to the facts that those primary sources reveal. (Atsaxon (talk) 05:52, 16 July 2009 (UTC))
Atsaxon, three of us now are trying to explain the same thing to you. With the exception of the newer reviews posted below, I believe I have read every paper written about PANDAS over the last ten or fifteen years. (Some quotes are listed above, at Talk:PANDAS#Journal reviews; have you reviewed that section?) There is simply no medical consensus for the views you express above, nor are they supported by high-quality review articles. PANDAS is an unproven hypothesis. IVIG and plasma exchange are dangerous and unproven treatments. Every credible review states such, and discusses the methodological problems in studies of PANDAS, reflected in the primary sources. The studies you want to cite are not as strong as you believe; that is why review articles dismiss them or put them into proper context. If you have a reliable source that states otherwise, please produce it. To my knowledge, there are none, not because this article is biased, but because the facts are the facts. Multiple reviews of PANDAS, by many different authors, written over many years, are not all "biased". They reflect medical consensus about the shortcomings in the primary studies. For a number of reasons, PANDAS is a difficult topic to study, leading to methodological errors in many studies; that is why we must rely on secondary source interpretations of primary studies. SandyGeorgia (Talk) 06:35, 16 July 2009 (UTC)
You didn't like the first one I offered, "Challenges in the Identification and Treatment of PANDAS: A Case Series" as discussed. How about Obsessive Compulsive Disorder: Current Understandings and Future Directions, National Institute of Mental Health and Neuro Sciences (India)(2007)(A compilation of the proceedings of the International Symposium on Obsessive-Compulsive Disorder (November, 2007)): "To describe such patients, the term pediatric autoimmune neuropsychiatric disorder associated with Streptococcus (PANDAS) was coined. Patients with OCD precipitated by streptococci may initially have increased basal ganglia volume, perhaps with subsequent loss of volume. Also, such patients may respond to specific immunologic interventions, such as plasmapharesis or intravenous immunoglobulin therapy. Of further interest in this regard is a body of work showing that patients who expressed a particular B-lymphocyte antigen, known as D8/17, are more susceptible to poststreptococcal autoimmune sequelae." Don't like that one? How about Dale, RC, "Autoimmunity and the Basal Ganglia: New Insights into Old Diseases" (2003), QJM 96: 183-91: "The only placebo-controlled trial examining the benefit of immunomodulation (plasma exchange and IVIG) demonstrated improvements in the patients treated with active agents compared to patients treated with sham (saline) infusions. Importantly, the treatment improvements were maintained at one year." and "The published findings strongly suggest that SC and PANDAS are autoimmune-mediated brain disorders". (Atsaxon (talk) 06:49, 16 July 2009 (UTC))
I couldn't find "Obsessive Compulsive Disorder: Current Understandings and Future Directions"; do you have a PubMed ID for that? Dale 2003 (PMID12615982) is a reliable review, albeit too dated to cite now. Although it views the PANDAS hypothesis positively, it does use words like "controversial" to describe it, and says "Currently, immune treatments should not be given routinely to SC or PANDAS patients until further controlled trials confirm their benefit." and at the end (as usual) calls for further research. We should be citing newer sources than this, since many newer reviews are available.
I suggest avoiding language like "aversion to the facts that those primary sources reveal" in comments here. I searched for recent PANDAS reviews using standard techniques and did not filter out any of the results. We are committed to the WP:MEDRS guidelines here, and one important guideline is that the article should not use primary sources to dispute the overall picture supplied by reviews.
Sandy, thanks for the link to Talk:PANDAS#Journal reviews. There I note your smug references to "the desperation of internet armed parents." I hope that life won't someday deal you a taste of the "desperation" you so arrogantly dismiss in parents of sick children. But if it does, though (see karma), remember me when you get there! ;-) (Atsaxon (talk) 08:17, 16 July 2009 (UTC))
I appreciate your concern, but it's terminology I picked up from one of the reviews (I believe it was Swerdlow, but I could have forgotten which one by now, since I've read most of them). Also, until/unless you know my personal story, you might consider that your assumptions about what I've experienced as a parent are likely wrong. Also, please be aware of WP:AGF, and it's not our personal stories that matter on Wiki, rather the use of reliable sources. You might find WP:TALK helpful as well; it's wise to keep focused on article content on article talk pages, and avoid personalizing discussions. SandyGeorgia (Talk) 08:27, 16 July 2009 (UTC)
I don't know if "Obsessive Compulsive Disorder: Current Understandings and Future Directions" is online; it's a monograph published by NIMHANS in book form. I have a pdf image of the book, but I don't remember where I got it.
I think that no one is sugesting that there is not controversy surrounding PANDAS. What I'm arguing is that the literature shows little or no credible controversy over the existence of a subset of OCD patients who's OCD is triggered by an auto-immune response, or that a subset of OCD patients respond positively to immune modulation therapy. Anyway, I'll plod on....
"It was proposed that, through a process of molecular mimicry, autoantibodies were generated against the basal ganglia, leading to behavioural disorder. There is a body of evidence to support this hypothesis and there is now also evidence to suggest that some children with ‘typical’ OCD may have antibasal ganglia antibodies" (emphasis supplied). Bartona, R and Heyman I, "Obsessive–compulsive disorder in children and adolescents" Paediatrics and Child Health 19 (2009), pp. 67-72 [2].
Stein J, "Neurobiology of the obsessive–compulsive spectrum disorders." Biological Psychiatry 47 (2000), pp. 296-304 [3]: "[Swedo and colleagues] demonstrated that patients may develop obsessive–compulsive symptoms in the aftermath of streptococcal infection, presumably on the basis of antinuclear antibodies. ... There is ... increasing evidence that a subset of OCD involves specific autoimmune mechanisms. Patients may present with OCD, tics, or perhaps hair pulling. Once again the basal ganglia appear key here."
Lochnera C and Stein J, "Does work on obsessive–compulsive spectrum disorders contribute to understanding the heterogeneity of obsessive–compulsive disorder?" Progress in Neuro-Psychopharmacology and Biological Psychiatry 30 (2006), pp. 353-361: "Obsessive–compulsive symptoms and tics may also be seen in association with Streptococcal infection; so-called paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections or PANDAS. Children with PANDAS may have larger basal ganglia volumes than healthy controls, and their OCD symptoms may respond to immunomodulatory interventions" (citations omitted)(emphasis supplied).
"[A] large constellation of neuropsychiatric conditions, including SC, OCD and tics (termed PANDAS, for pediatric autoimmune neuropsychiatric disorders with streptococcal infections) seems to be mediated by disruption in the basal ganglia, which are particularly vulnerable to antineuronal antibodies (for review, see Swedo and Leonard, 1994; Leckman and Riddle, 2000; Stein, 2000; Arnold, P.D. and Richter, M.A., 2001. This is supported by several observations...." Aouizeratea B, Guehlb D, Cunyc E, Rougierc A, Bioulacb B, Tignola J and Burbaud P. "Pathophysiology of obsessive–compulsive disorder: A necessary link between phenomenology, neuropsychology, imagery and physiology." Progress in Neurobiology 72 (2005), pp. 195-221. [4].
"[A]lthough inconclusive, studies that have focused the treatment of PANDAS with immunomodulatory interventions demonstrated that autoimmunity should be responsible for the pathogenesis of this condition. ... Perlmutter et al. demonstrated that plasma exchange and the administering of intravenous immunoglobulin were both effective in reducing neuropsychiatric symptoms (40% and 55% reductions, respectively) in a group of children with severe PANDAS. ... Systematic, longitudinal observations have demonstrated that the PANDAS subgroup has a distinct clinical presentation and an identifiable course of symptoms; for these children, there is a clear relationship between streptococcal infections and neuropsychiatric symptom exacerbations." Filardi da Rochaa F, Correaa, H and Teixeirac AL, "Obsessive–compulsive disorder and immunology: A review." Progress in Neuro-Psychopharmacology and Biological Psychiatry 32 (2008), pp. 1139-1146.[5] These authors note NIH's caution against routine use of immune modification therapy, but also note that clinicians do use them "in children with debilitating symptoms with compromised quality of life and in whom standard treatments have failed."
By the way, gentlemen, I'm curious as to how the purported expiration date is set on the validity of a particular study or review. By majority vote, perhaps, or does one of you have a special ring or hat? (Atsaxon (talk) 19:17, 16 July 2009 (UTC))
The most recent reviews are given priority unless there's a really good reason they shouldn't be. Now, going off of reliable sources and relating to you what I was told at a Yale TS/OCD symposium ... many researchers do believe that something autoimmune related may be going on with a subset of OCD patients. What is *not* conclusive is that the current PANDAS hypothesis has any validity or that it accurately explains what's happening in that subset of patients. Perhaps that's where you're confused? SandyGeorgia (Talk) 20:24, 16 July 2009 (UTC)
"What I'm arguing is that the literature shows little or no credible controversy over the existence of a subset of OCD patients who's OCD is triggered by an auto-immune response, or that a subset of OCD patients respond positively to immune modulation therapy." Sure there's controversy. That claim is contradicted, for example, by Shulman, who writes of PANDAS that "it is not clear that it represents a unique subset of the larger universe of prepubertal patients with these neuropsychiatric features. That there is an OCD/tic disorder patient group with an autoimmune pathogenesis specific to GAS infection has not been proved and seems increasingly unlikely."
Of the sources recently cited above:
Barton & Heyman 2009 (doi:10.1016/j.paed.2008.10.011) do mention the PANDAS hypothesis and the evidence for it, as mentioned above. However, their lengthy discussion of treatment says nothing about immune modulation therapy, a telling omission that reflects mainstream skepticism about this approach.
Stein 2000 (PMID10686264) is so old I didn't read it. Things have moved on with respect to PANDAS. Let's look for more-recent sources; there are plenty.
The quote from Lochnera & Stein 2006 (doi:10.1016/j.pnpbp.2005.11.004) omitted the crucial next sentence, which concedes some of the controversy surrounding the hypothesis: "Nevertheless, the extent to which OCD is accounted for by earlier PANDAS remains unclear."
I don't have time to check the other citations right now, but to be frank I am starting to lose patience here. It strains credulity to claim that there's no controversy surrounding the existence of a subset of OCD patients. Clearly there is controversy.
Me too--I'm starting to lose patience with the convoluted, self-serving reasoning that grotesquely overstates the quantity, quality, and scope of the skepticism that does exist with respect to PANDAS theory and research. For instance, "their lengthy discussion of treatment says nothing about immune modulation therapy, a telling omission that reflects mainstream skepticism about this approach." Puleez! At most, the omission reflects the authors' skepticism. (Atsaxon (talk) 21:53, 16 July 2009 (UTC))
Now I'm lost. If Barton & Hayman are not in the mainstream, then why bring them up in the first place? But to return to the other sources cited above:
Aouizerate et al. 2004 (PMID15130710) is somewhat dated in this area, as its discussion of PANDAS cites no studies published after 2001. It is a reasonably accurate summary of the excitement about PANDAS circa 2000 but we should be able to come up with more-recent sources.
Da Rocha et al. 2008 (PMID18262706) is a recent and reasonable source, but the above summary doesn't do justice to its discussion. For example, this source doesn't say that the NIH has merely cautioned against routine use: it says that the NIH "recommended that immunotherapy should be reserved for patients participating in controlled double-blind protocols", a much stronger negative stance. Furthermore, da Rocha et al. use careful language like "these results have not been definitive", and go on to note "The majority of negative findings do not exclude the possibility of an autoimmune pathogenesis for OCD in general, or a subset of OCD. A few theories try to justify these findings." which, again, indicates that we are in a controversial area here and that there are no definitive results.
Barton & Heyman, Lochnera & Stein, and da Rocha et al. are the reviews that have been cited as being favorable to the PANDAS hypothesis. Other reviews, as we've seen, are more skeptical. Surely it would not be reasonable, given the skepticism expressed even in these favorable reviews, to present the PANDAS and/or IVIG hypotheses as if they were accepted mainstream opinion.
I agree with TimVickers and SandyGeorgia about the importance of relying on reliable reviews in this area, as opposed to citing primary sources directly. I searched a bit for more reviews and found some that may be useful.
Wolf DS, Singer HS (2008). "Pediatric movement disorders: an update". Curr Opin Neurol. 21 (4): 491–6. doi:10.1097/WCO.0b013e328307bf1c. PMID18607212. Reliable and recent review of related conditions; may help place PANDAS in context.
Shprecher & Kurlan 2009.[1] Overall management context, with a paragraph on PANDAS. Freely readable, which is a plus.
Williams KA, Grant JE, Kim SW (2008). "The PANDAS subgroup of obsessive–compulsive disorder". In Abramowitz JS, McKay D, Taylor S (eds.) (ed.). Clinical Handbook of Obssessive–Compulsive Disorder and Related Problems. Johns Hopkins University Press. pp. 95–???. ISBN080188697X. {{cite book}}: |editor= has generic name (help)CS1 maint: multiple names: authors list (link) Google Books wouldn't let me look at all of it, but the first part seemed quite good.
da Rocha FF, Correa H, Teixeira AL (2008). "Obsessive–compulsive disorder and immunology: a review". Prog Neuropsychopharmacol Biol Psychiatry. 32 (5): 1139–46. doi:10.1016/j.pnpbp.2007.12.026. PMID18262706.{{cite journal}}: CS1 maint: multiple names: authors list (link) From an immunological viewpoint.
Puxley F, Midtsund M, Iosif A, Lask B (2008). "PANDAS anorexia nervosa—endangered, extinct or nonexistent?". Int J Eat Disord. 41 (1): 15–21. doi:10.1002/eat.20462. PMID17922534.{{cite journal}}: CS1 maint: multiple names: authors list (link) Looks like a good review for that subtopic.
Wow, there are sure a lot of reviews in this area! (I'm sure I missed some.) As per WP:MEDRS should be little need for this article to cite any primary sources.
Eubulides (talk) 18:40, 14 July 2009 (UTC)
I've got quite a few more in my file drawer, but your list is more recent. If we discuss proposed additions, I can check the reviews I've got as needed, but I know what most of them say :) A lot of the primary studies have methodological issues. Thanks for the list !! SandyGeorgia (Talk) 19:19, 14 July 2009 (UTC)
Pichichero ME (2009). "The PANDAS syndrome". Adv Exp Med Biol. 634: 205–16. PMID19280860. This one isn't published yet, alas. (I do love those reviews from the future!)
Four more key reviews; these may help with understanding that, while many researchers agree that something autoimmune-related may be going on, the current PANDAS hypothesis might not be it.
I noticed that the current page seems to have focused on whether PANDAS is a subset of Tourettes Syndrome and on Singer[6] and Kurlan's[7] work, rather than on whether PANDAS shares pathogenesis with Sydenham Chorea. The current material can make a great section of an overall article on PANDAS (i.e., a section covering whether PANDAS is a subset of Tourettes), but the July 14th rework of the article seems to have lost all of the PANDAS/OCD work and references as it tightened the material.
In addition the current article is missing the research supporting the pathogenesis such as Kirvan's 2003 Nature article [8] where she isolated the antibody 24.3.1 and showed the cross-reactivity with neuroblastoma cells and the followup in JNI that showed a separation in Cam Kinase II activation between Sydenham Chorea, PANDAS, Tourettes Syndrome and non-PANDAS OCD.[9] I'm starting an update to the article, but before doing so (based on the heated arguments here) wanted to check if there was a reason the article became a discussion about PANDAS/TS rather than an article about PANDAS?
Buster23 (talk) 05:37, 8 September 2009 (UTC)
Thanks for the reference to Pichichero 2009 (PMID19280860) paper. Are you saying it has a review of the Kirvan papers? We can also use Moretti 2008[10] which is a very well reviewed, available, and often cited paper. Buster23 (talk) 06:59, 8 September 2009 (UTC)
I haven't read Pichichero 2009, so I don't know whether it reviews the Kirvan papers, but I'd be surprised if it didn't, just as I'd be surprised if Moretti et al. 2008 didn't. Eubulides (talk) 07:40, 8 September 2009 (UTC)
I'm not sure what distinction Buster23 is trying to make re PANDAS/TS; please read Wikipedia:Wikipedia Signpost/2008-06-30/Dispatches, which should help you understand the kinds of sourcing the article should use. There are numerous primary sources that discuss PANDAS, and just as many reviews that explain the methodological problems with those primary sources. That is why we use reviews. SandyGeorgia (Talk) 12:41, 8 September 2009 (UTC)
Thanks for the reference. I'm perfectly happy to use secondary sources to follow wikipedia guidelines. I'll use edits to make the conversation concrete rather than a general discussion, but have already found your comments helpful as to why the article was rewritten. I plan on using Pavone et al 2006 (PMID16970875) and Moretti et al 2008 (PMID18495013) as additional secondary sources to the ones mentioned in the previous section . Buster23 (talk) 14:50, 8 September 2009 (UTC)
I would suggest more recent and better quality reviews than those; for example, Pavone (2006) calls PANDAS a "well-defined" syndrome, something that is clearly challenged by almost all reliable reviews. Every part of the definition has been challenged !! It is not clear that those are the best reviews for this article. Further, I'm still unclear on the distinction you are drawing in the section heading here, as the line between tics and a subset of OCD is a fuzzy one. SandyGeorgia (Talk) 14:56, 8 September 2009 (UTC)
Hmm, it seems that you have a POV here about which secondary articles are allowed as I've not found a more recent article saying that PANDAS is not 'well-defined'. I'm not quite sure how to resolve that if some secondary sources are allowed but others are not. I could use Fornaro 2009 et al (PMID19450269) which is quite recent. However, before I get people anxious, I'll try to make concrete changes and we can see if we can work it that way. Buster23 (talk) 15:19, 8 September 2009 (UTC)
No, please read WP:UNDUE, weight is given to all sources according to their preponderance, and undue weight shouldn't be given to minority viewpoints. The idea that PANDAS is "well defined" is decidely a minority viewpoint, which makes one wonder about the rest of the content at that source (I don't have the full text). It is important that we give due weight to the *majority* viewpoint, while minority viewpoints may be mentioned in passing. For that, I suggest reading all of the recent reviews (not selective ones) to be sure you have a clear view of the majority viewpoints, before proposing changes here. Further, Fornaro is not a review article; please read the Dispatch link I provided above, and review the list of reviews in the section before this one. SandyGeorgia (Talk) 15:37, 8 September 2009 (UTC)
I agree about WP:UNDUE so is citing Singer as a review would seem out for the same reason as citing Swedo as a review as both of these authors are creating primary research. Buster23 (talk) 16:08, 8 September 2009 (UTC)
You don't appear to have read the links provided; please notice on PubMed which articles are listed as reviews, under the "Review" tab. You are also mixing two different concepts (UNDUE and the use of primary sources); working on a controversial topic can be challenging, and a thorough read of all policy and guideline pages will be helpful in such an undertaking. SandyGeorgia (Talk) 16:31, 8 September 2009 (UTC)
PubMed, although helpful, is not a definitive authority on whether an article is a review. Some reviews (notably the recent ones) are not labeled as a "review" by PubMed, and conversely some articles it labels as "review" are not really reviews. Irani & Lang 2008 (PMID18176865) is certainly a recent and reliable review; I don't see any problem with it. My only qualm is that we have so many reviews now that we may find that we don't need to cite them all, and may need to cite only the best; whether Irani & Lang is one of the best is something that we don't know yet. Eubulides (talk) 18:17, 8 September 2009 (UTC)
I found some more recent reviews and added them to the list in the previous thread. The review by Gerber et al. 2009 (PMID19246689) is particularly authoritative, as it is a scientific statement by several organizations and is endorsed by the AAP. It should carry great weight in our summary of PANDAS. Other reviews that (from the surface; I've not read any of these) look particularly competent include Lombroso & Scahill 2008 (PMID17937978) and Pichichero 2009 (PMID19280860). Shulman 2009 (PMID19242249) is also competently done (this one I have skimmed). Eubulides (talk) 17:47, 8 September 2009 (UTC)
Thanks Eubulides. On another item, the line "However, current data neither disprove nor support this hypothesis, indeed one recent study found no association between streptococcal infections and the risk of PANDAS symptoms.[10]" is not supported by the reference. The reference states "Ill children with GAS infection, treated for their GAS infection, were not at increased risk for developing PANDAS symptoms." This is slightly different. I recommend the revision to say "However, current data neither disprove nor support this hypothesis, indeed one recent study found that children with streptococcal infections who were treated with antibiotics were not at greater risk of PANDAS symptoms.[10]" Certainly the current sentence can't stand given that the conclusion of the paper is not what is written. Buster23 (talk) 07:09, 9 September 2009 (UTC)
Okay, then do we strike the line too or find a better source. I don't have a secondary source that references this primary material. Buster23 (talk) 09:01, 9 September 2009 (UTC)
Okay, agreed, so then we should revise the line to say "However, current data neither disprove nor support this hypothesis, indeed one recent study found that children with streptococcal infections who were treated with antibiotics were not at greater risk of PANDAS symptoms." You don't have to highlight the emphasis, but wanted to show what changed. Buster23 (talk) 17:40, 9 September 2009 (UTC)
I was actually quoting from the current citation to Perrin (PMID15351749) that says "CONCLUSIONS: Ill children with GAS infection, treated for their GAS infection, were not at increased risk for developing PANDAS symptoms or a mild PANDAS variant compared with children with presumed viral illness or well children." (emphasis added). We can of course use the secondary review Moretti 2008 (PMID18495013) which states "Some seemed to confirm the association between GABHS infection and OCD or TD exacerbations [26,27], whereas others failed [28,29]. " Buster23 (talk) 01:03, 10 September 2009 (UTC)
Buster23, I'm still working to understand the question/concern here (and your later statement about definitional issues). From the recent Lombroso/Schaill review, PMID17937978 :
"Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS) is an acronym first coined by Swedo (1998)[18]. It was proposed to capture those cases of TS/OCD that are the result of an immunological response to a prior group A beta hemolytic streptococcal (GABHS) infection. Presumptive evidence for a link between GABHS infection emerged in the early 1990s. Kiessling and colleagues (1993)[19] noticed an increase in tic disorders in a pediatric clinic after a wave of streptococcal infections swept through Providence, Rhodes Island."
How then do we separate PANDAS from TS? Can you help me understand your concern about the focus on TS, considering the history of the hypothesis? SandyGeorgia (Talk) 08:17, 10 September 2009 (UTC)
Let me see if this picture helps:
.
Kurlan et al had 95% Tourette syndrome subjects in his study (PMID18519489). Singer et al used these same kids, and interestingly so did Morris (PMID18823914). So all the work on TS is great and likely is indicating that TS is exclusionary to PANDAS. So now we move the focus to work by Dale, Church, Kirvan, Swedo, ... which focus on the rest of the bubbles (i.e., around Sydenham chorea, tics and OCD). Buster23 (talk) 04:38, 11 September 2009 (UTC)
Picture is from me (i.e., original image which I've donated to wikipedia). I added the black dots in case we wanted to discuss Kurlan 'et al' (PMID18519489). Kurlan had 95% of the subjects and controls diagnosed with Tourette syndrome or chronic tic disorder. The study also did not address onset (indeed these were older kids with onset 4 years prior, it was also unclear if the children were now post-pubescent). What was interesting was the Kurlan only had YGTSS exacerbations (i.e., no CYBOC exacerbation) in over a 2 year period. That's amazing and quite different from the clinical reports of 20+ point changed in CYBOC scores seen in Swedo, Church, Dale, reports. However, this is not reported in secondary research so I won't dwell on it here.
If useful for the article, I'm happy to provide this diagram (or a modified version of it) to help with the classification section. It got too complicated when I added CYBOC exacerbations to the picture. Buster23 (talk) 23:30, 11 September 2009 (UTC)
I was looking quickly from the plane yesterday, and hadn't realized the image was original research. It does have several errors, and probably should be deleted, as Google might pick up and propogate those errors. It shows Chronic Tic Disorder overlapping with TS, when those two diagoses are either one or the other. It shows PANDAS as possibly occuring in TS or tics, but not with chronic tic disorder, which isn't correct (PANDAS is proposed to occur with tic disorders, and chronic tic disorder is a tic disorder). It shows Syndenham Chorea as a very large subset of OCD; I don't know the SC literature well enough to know if that's true, but I suspect it might not be ... is there a source for that? It's just basically original research, hence might warrant deletion. I'm sorry I didn't look closer the first time, due to travel. SandyGeorgia (Talk) 03:17, 12 September 2009 (UTC)
I'll be happy to update the picture so we have something we agree on. My purpose in the picture was to try to save some typing by trying a picture and see if we agreed on the basic categories. Venn diagrams are used to represent intersections and unions and seldom are the sizes of the bubbles accurate (as otherwise, lots of text becomes unreadable). I'm not wedded to the diagram and will happily correct it like any text we write here on talk.
My goal here is to see if we agree on what is covered and not covered in the article. The article as it stands is representing primarily the research regarding a TS subgroup that meets the PANDAS criteria (i.e., papers by Church, Singer, Kurlan, Leckman and the Yale TS group). It is not representing Chronic Tic Disorder/PANDAS in any appreciable way, nor general tic disorders meeting the PANDAS subgroup, nor sudden onset versus chronic conditions, nor OCD-only children meeting the PANDAS subgroup.
As such, the article as it currently stands comes across to me as providing WP:UNDUE weight to the PANDAS/TS material and as such is not presenting WP:NPOV over the whole PANDAS subject. I think the article is very close to a WP:NPOV on the subject of PANDAS/TS, but do not at all agree that the article is WP:NPOV on the OCD/PANDAS group. I think everyone agrees here that the article is woefully incomplete that incompleteness is what is causing the issue.
I'm trying to figure out how to make progress. Perhaps the new section on the classification will help. Again, I'm very happy to update the diagram if its current format is causing you more concern than the benefit I was hoping for (i.e., alignment).
There's a really good picture in Miguel et al 2005. [11] If you don't follow the OCD literature you might not have this article. It is quite good and I'd recommend it as one of our references.
Can we archive this section? This talk page is unmanageable, it's hard to see what is done and not, and this section seems mostly addressed, and there's a new image in a section below. SandyGeorgia (Talk) 00:05, 14 September 2009 (UTC)
Lead
I added the three main survey positions to section 1 of the page. Please help me represent the three positions if you think they differ. I'm trying for a neutral voice and to follow the wikipedia guideline that an article should describe all major points of view when treating controversial subjectsWikipedia:Describing points of view. Once we close this section I'll move onto next section. Thanks. Buster23 (talk) 03:03, 9 September 2009 (UTC)
There are several problems with your edit, and I suggest it should be reverted. It would be helpful if you proposed changes instead on talk. First, you've presented a numbered argument in the lead; the lead should be a summary of the mainpoints only, not a place for presenting arguments (WP:LEAD). Second, you've presented them as if they all have equal weight, which isn't the case at all. You are presenting primary source, minority viewpoints in the lead of the article. Third, you're using primary sources, not secondary reviews of those sources. And fourth, there are several MOS errors; for example, italics on quotes (WP:ITALICS), footnote placement (WP:FN) and others. Working on a controversial topic can be a hard place to start on Wiki, and I suggest your efforts will be more fruitful if you first propose text on talk. We can't give equal weight to minority viewpoints in the lead. SandyGeorgia (Talk) 03:22, 9 September 2009 (UTC)
I disagree with reverting, but would value your help on editing them to something we can both agree on. I know of no minority opinion in the three presented. All three have positions. I did cite Kurlan as his latest report changed his prior position and there isn't good secondary research on his June paper. What is the minority viewpoint of the three presented and how are you counting minority? Buster23 (talk) 03:27, 9 September 2009 (UTC)
I will be traveling for three weeks, and won't be able to keep up with incorrect edits to the article; on a controversial and difficult topic, you will be better off if you propose changes on talk and wait for others to review your text, rather than creating material that will eventually be deleted or reverted or need extensive modification. Perhaps spending some time in other articles to see how leads should be constructed will be helpful. You have presented an argument in the lead as if all three points summarize the state of PANDAS, and actually none of the three is an accurate summary. Further, you have presented your own interpretation, which is synthesis (combining info from different sources and drawing your own conclusion) and original research, against Wiki's core policies. Unless a reliable source claims those are the three possibilities, for us to state it as such is original research (even if it were correct, and it's not, because they don't all enjoy the same consensus). At any rate, this synthesis doesn't belong in the lead, so I've moved it and tagged it. Also, direct quotes should be in quotes, not italics, and we should avoid cherrypicking text from sources. SandyGeorgia (Talk) 04:15, 9 September 2009 (UTC)
Hmm, I didn't draw a conclusion from the three papers any more than the rest of the paper is making summary statements on each one. Each quote is verifiable as representing the position of the paper (in fact each quote is from the conclusion). How would you restate the positions? I suppose we can use Martino (PMID17430863) that states "However, the issue remains controversial, mainly due to the observations of the Johns Hopkins group who have repeatedly failed to detect ABGAs in patients with Sydenham’s chorea, PANDAS and Tourette’s syndrome." or use Schulman 2009 (PMID19242249) Buster23 (talk) 05:16, 9 September 2009 (UTC)
The statement survey papers represent three distinct positions is distinctly your own conclusion, synthesis and original research-- one that also gives equal (undue) weight to all three positions. Please stick to the conclusions of the most reliable and reputable review articles, of which we have many. Again, please read Wp:SYN and WP:OR. SandyGeorgia (Talk) 05:30, 9 September 2009 (UTC)
We should not take material directly from a source, even a public domain source, without including that material in quotes. [6] The original paraphrasing was fine; now we have a direct quote without quotes (it's poor practice to lift material directly), and several MoS errors (examples, capitalization of Obsessive-compulsive disorder and incorrect wikilinking of terms on first occurrence). Please review Wikipedia:Wikipedia Signpost/2009-04-13/Dispatches. Buster23, if you continue editing without consensus or discussion with other editors, your work is more likely to be removed or reverted. The article before was correct, if incomplete; please don't introduce errors and synthesis, and please discuss your edits. SandyGeorgia (Talk) 05:07, 9 September 2009 (UTC)
Hmm, strangely I do think that I'm trying for consensus but I appreciate all the pointers you are making. Perhaps what I should do is hold on new content and work on the content that is currently there as I can't verify several of the current statements. Would it work better for you if I focused on challenges on verifyability first? Buster23 (talk) 05:16, 9 September 2009 (UTC)
It would work better for yourself, for Wiki, and for all other editors who have to clean up if you discuss your proposed changes on talk, study some other medical articles on Wiki, and read the links you've been provided to Wiki guidelines and policies. SandyGeorgia (Talk) 05:25, 9 September 2009 (UTC)
Three distinct positions
I agree with SandyGeorgia that the newly-inserted material about "three distinct positions" represents original research and we can't have material organized in that way without a reliable source. For now I've moved that material here so that it can be further discussed:
The PANDAS diagnosis remains controversial and survey papers represent three distinct positions:
That PANDAS is a distinct subgroup where children have more GABHS infections than controls
The overall findings from our study suggest that children with PANDAS represent a subgroup of patients with TS or OCD who may be susceptible to GABHS infection as a precipitant of their symptoms.[7]
That PANDAS is a distinct subgroup where children have elevated anti-neuronal antibodies
Recent evidence suggests that specific antibodies targeted to the dominant epitope of GABHS (N-acetyl-beta-D-Glucosamine) might influence neuronal signal transduction thus causing alterations in behavior and movement control.[2]
That anti-neuronal antibodies don’t separate PANDAS from controls
brain autoantibody measures in some laboratories have not been able to differentiate between PANDAS case and control subjects.[7]
Aside from the "three distinct positions" problem, which is a major one, this material heavily relies on a primary source (Kurlan et al. 2008), and the only review that it cites (Moretti et al. 2008) is a weaker one. We should stick with reviews, and preferably the stronger reviews as discussed in #PANDAS reviews and #Is this about PANDAS or about PANDAS/TS above. Eubulides (talk) 06:10, 9 September 2009 (UTC)
I'm fine with discussing it here. I guess I should start with whether there is disagreement that these are the prevailing positions? I'm hard pressed to find another in the survey material or primary research. Pavone et al 2006 (PMID16970875) writes in his review "At this time, the consensus follows Swedo and coworkers' arguments that PANDAS is a distinctive clinicopathologic entity that has potential treatment implications." I suppose we could disagree and suppress this position, but that doesn't seem to follow the wikipedia guidelines of representing all major points of view. So what do we do with Pavone? Lombroso and Scahill also refer to this review. Buster23 (talk) 06:59, 9 September 2009 (UTC)
It doesn't matter whether we agree that these are the prevailing positions. What matters is whether a reliable source says that these are the prevailing positions. Without a reliable source to support the claim that there are three positions, we cannot include the claim. The Pavone et al. comment is contradicted by Shulman 2009, who writes that "much controversy has ensued" since Swedo et al. proposed PANDAS, and concludes the exact opposite of Pavone et al., namely, "it is not clear that it [PANDAS] represents a unique subset of the larger universe of prepubertal patients with these neuropsychiatric features. That there is an OCD/tic disorder patient group with an autoimmune pathogenesis specific to GAS infection has not been proved and seems increasingly unlikely." As to how to present this sort of viewpoint next to Pavone, I suggest that we look to Gerber et al. for the consensus mainstream view, and go with that. Eubulides (talk) 07:31, 9 September 2009 (UTC)
Okay, having read Gerber et al. I've got to agree that it is the most neutral and conservative of all the surveys and given the significant peer review, it should act as one of the definitive sources. It's a bit brief and misses many elements of the other surveys, but certainly represents what is being said to physicians. Buster23 (talk) 08:28, 9 September 2009 (UTC)
So, going back to Gerber as a source, it represents the hypothesis of PANDAS as being similar to Sydenham Chorea and says nothing about Tourettes Syndrome. It seems this article should be similar and reflect the same view. I'm fine adding in conclusions regarding Tourettes Syndrome and PANDAS if that is reflected in a strong secondary source -- it's not in Gerber except by interpretation. Buster23 (talk) 08:36, 9 September 2009 (UTC)
I agree, but are we synthesizing if we change the message from being about "tic disorders" and insert the interpretation that "tic disorders" means only "Tourette syndrome" versus the wider "tic disorders". Perhaps you are representing that the consensus opinion is that PANDAS is not a subset of Tourette syndrome and that the jury is still out on whether PANDAS is a subset of tic disorders. Buster23 (talk) 21:23, 9 September 2009 (UTC)
Numerous recent reviews are specifically about TS, although it's possible some wording may need adjustment, based on a complete review of all recent review. The controversy is not so much about what may be a subset of what, as much as it is over whether the entire PANDAS hypothesis is invalid and unproven and not a subset of anything. SandyGeorgia (Talk) 21:45, 9 September 2009 (UTC)
I expect that any revised wording will mention both tic disorders in general and Tourette syndrome in particular. We can use Gerber et al. to support the former, and other reliable reviews (of which we have plenty) to support the latter. Eubulides (talk) 22:50, 9 September 2009 (UTC)
It seems what we can agree on is that all the references state that PANDAS is controversial. If there were a single concensus position, then it wouldn't be controversial.
Thus we are going to have to represent in the article multiple points of view. As such, I'm good with using Gerber et al. to represent the position of the AHA; however, it seems odd to quote the AHA regarding tics or OCD. I'm fine with using Schulman 2009 to represent the TS position (if someone can get me a copy to read) otherwise please choose an alternate. We might need someone else to represent the tic disorder position. Finally on the OCD position, my choice is Moretti 2008 as this is targeted directly to psychiatrists. Buster23 (talk) 02:29, 12 September 2009 (UTC)
Don't start with the lead
I would strongly recommend you guys don't start by fixing the lead. The lead is the hardest part of an article to get right, and can only be judged as "right" when it is compared against the body. Although the lead is very tempting (it is all that most folk might read, after all) please resist the temptation and be content to fix the lead once you have got the balance of the body right. This isn't a very big article, does the subject warrant a bigger one, with more sections? I note that refs 2 and 3 are only used in the lead: a warning sign that it isn't summarising the body. Colin°Talk19:56, 9 September 2009 (UTC)
Hear, hear. Let's focus on the body first. It's OK to change the lead as part of changing the body, to keep them consistent, but the initial focus should be on the body. And the lead should not cite any sources that are not already cited in the body. Eubulides (talk) 22:50, 9 September 2009 (UTC)
Agreed. Took me one time to realize that was the wrong way to start. My current approach is to walk through each reference and seeing if it is a secondary reference/review. If not, whether there is a secondary reference that supports the statement/position that is cited. Buster23 (talk) 01:08, 10 September 2009 (UTC)
Questions regarding citations and verifiability on current article
The current article references the NIMH website. This does not seem to follow the recommended citation standard as the reference changes and is neither a primary or secondary reference nor a review. I would propose using Mortini (PMID18495013) which is a review article and is not a primary author. Buster23 (talk) 05:53, 9 September 2009 (UTC)
Yes, we're much better off citing reliable reviews rather than government websites. However, Moretti et al. 2008 (PMID18495013) does not appear to be the best review available, and certainly should not be the sole or even the lead source for the definition of PANDAS. Better sources would appear to be Gerber et al. 2009 (PMID19246689; this is by far the most authoritative of the reviews listed on this talk page), Lombroso & Scahill 2008 (PMID17937978) Pichichero 2009 (PMID19280860), and Shulman 2009 (PMID19242249).
Thanks, Gerber doesn't seem to have anything to do with PANDAS, certainly not enough to pull the main lead message. Lombroso & Scahill 2008 look possible. I can't get to Pichichero, and unfortunately Shulman isn't free. Buster23 (talk) 06:26, 9 September 2009 (UTC)
Gerber et al. (PMID19246689) has a subsection entitled "Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections". Perhaps you missed it? The subsection is short, but balancing that is the fact that the review is an authoritative consensus document. I have Shulman and will see if I can get a copy of Pichichero. Eubulides (talk) 06:49, 9 September 2009 (UTC)
Also on reference Hoekstra PMID15119917 reference. This study was on teens/adults (i.e., post-pubertal) and thus should not be referenced when refering to PANDAS. A better reference would be PMID11026187 which shows that IVIG was ineffective on non-PANDAS OCD for children whose exacerbations didn't associate with strep infections. The reference to Hoekstra should be replaced. Buster23 (talk) 06:26, 9 September 2009 (UTC)
I agree that Hoekstra is a bad source and should be removed. But its replacement should be a recent review, not a circa-2000 primary study. Eubulides (talk) 06:49, 9 September 2009 (UTC)
On the line "As the clinical spectrum of PANDAS appears to resemble that of Tourette's syndrome, some researchers hypothesize that PANDAS and Tourette's may be associated." what is the reference for this statement? Buster23 (talk) 06:34, 9 September 2009 (UTC)
I see a more productive work approach evolving now; if that line is still tagged when I return from travel, I'll work on it. I don't expect it to be hard to cite, although the wording may need adjustment, and I may need to get into my extensive file drawer of PANDAS articles, which I don't have time to do now. By the way, somewhere this article should mention the joint TSA/NIH statement about the dangers of experimental treatments wrt PANDAS (which I also can't locate right this minute, I'll be better able to locate those once I return from travel). SandyGeorgia (Talk) 14:02, 9 September 2009 (UTC)
Per SandyGeorgia's comments refering to Wikipedia:Wikipedia Signpost/2008-06-30/Dispatches and the commentary around PubMed and Wikipedia:Reliable sources (medicine-related articles) #Definitions... I wanted to review the references and see if we're following the desired policy of using only reliable secondary research -- with preference for those listed in PubMed and those that are fixed published events (i.e., not websites), inclusive of recent work/research, and in balance those that are freely available (i.e., verifiable by others). Sorry if my pasting of this isn't right. Not sure how refer to each of these.
website ^ a b c d e NIH. PANDAS. Retrieved 7 September 2009.
listed as review ^ Kirvan CA, Swedo SE, Kurahara D, Cunningham MW (2006). "Streptococcal mimicry and antibody-mediated cell signaling in the pathogenesis of Sydenham's chorea.". Autoimmunity 39 (1): 21-9. PMID16455579.
primary research^ a b c Luo F, Leckman J, Katsovich L, Findley D, Grantz H, Tucker D, Lombroso P, King R, Bessen D (2004). "Prospective longitudinal study of children with tic disorders and/or obsessive-compulsive disorder: relationship of symptom exacerbations to newly acquired streptococcal infections". Pediatrics 113 (6): e578–85. doi:10.1542/peds.113.6.e578. PMID15173540. http://pediatrics.aappublications.org/cgi/content/full/113/6/e578.
primary research ^ Singer HS, Hong JJ, Yoon DY, Williams PN. Serum autoantibodies do not differentiate PANDAS and Tourette syndrome from controls. Neurology. 2005 Dec 13;65(11):1701–7. PMID16207842
primary research * Loiselle CR, Wendlandt JT, Rohde CA, et al. Antistreptococcal, neuronal, and nuclear antibodies in Tourette syndrome. Pediatr Neurol. 2003 Feb;28(2):119-25. PMID12699862
primary research * Loiselle CR, Lee O, Moran TH, Singer HS. Striatal microinfusion of Tourette syndrome and PANDAS sera: failure to induce behavioral changes. Mov Disord. 2004 Apr;19(4):390-6. PMID15077236
web site ^ Moyer, Paula. PANDAS May Be Overdiagnosed, Contributing to Overuse of Antibiotics. Medscape Medical News, from AACAP 53rd Annual Meeting: Abstract C21. Presented October 26, 2006. Retrieved March 13, 2007
primary research ^ a b Swedo S (2002). "Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS)" (PDF). Mol Psychiatry 7 Suppl 2: S24–5. doi:10.1038/sj.mp.4001170. PMID12142939. http://www.nature.com/mp/journal/v7/n2s/pdf/4001170a.pdf.
review ^ Rullan E, Sigal L (2001). "Rheumatic fever". Curr Rheumatol Rep 3 (5): 445–52. doi:10.1007/s11926-996-0016-4. PMID11564377.
review ^ Bonthius D, Karacay B (2003). "Sydenham's chorea: not gone and not forgotten". Semin Pediatr Neurol 10 (1): 11–9. doi:10.1016/S1071-9091(02)00004-9. PMID12785743.
primary research^ Perrin E, Murphy M, Casey J, Pichichero M, Runyan D, Miller W, Snider L, Swedo S (2004). "Does group A beta-hemolytic streptococcal infection increase risk for behavioral and neuropsychiatric symptoms in children?". Arch Pediatr Adolesc Med 158 (9): 848–56. doi:10.1001/archpedi.158.9.848. PMID15351749. http://archpedi.ama-assn.org/cgi/content/full/158/9/848.
commentary, not peer reviewed^ Singer HS, Loiselle C. PANDAS: a commentary. J Psychosom Res. 2003 Jul;55(1):31-9. PMID12842229
not sure how to characterize * Kurlan R, Kaplan EL. The pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) etiology for tics and obsessive-compulsive symptoms: hypothesis or entity? Practical considerations for the clinician. Pediatrics. 2004 Apr;113(4):883-6. PMID15060240 Full-text, Retrieved March 14, 2007
review * Dale RC. Post-streptococcal autoimmune disorders of the central nervous system. Dev Med Child Neurol. 2005 Nov;47(11):785-91. Review. PMID16225745
??' Johns Hopkins Medicine. A Strep - Tourette Connection? Brain Waves Fall 2004 Volume 16, Number 4. Retrieved 25 November 2006
website ^ Franklin, Deeanna. Warning About Two Therapies for Tourette's, OCD - obsessive-compulsive disorder. Family Practice News, September 15, 2000. Retrieved 25 November 2006.
primary research, not PANDAS Hoekstra PJ, Minderaa RB, Kallenberg CG. Lack of effect of intravenous immunoglobulins on tics: a double-blind placebo-controlled study. J Clin Psychiatry. 2004 Apr;65(4):537-42. PMID15119917
primary research Garvey M, Perlmutter S, Allen A, Hamburger S, Lougee L, Leonard H, Witowski M, Dubbert B, Swedo S (1999). "A pilot study of penicillin prophylaxis for neuropsychiatric exacerbations triggered by streptococcal infections". Biol Psychiatry 45 (12): 1564–71. doi:10.1016/S0006-3223(99)00020-7. PMID10376116.
primary research Snider L, Lougee L, Slattery M, Grant P, Swedo S (2005). "Antibiotic prophylaxis with azithromycin or penicillin for childhood-onset neuropsychiatric disorders". Biol Psychiatry 57 (7): 788–92. doi:10.1016/j.biopsych.2004.12.035. PMID15820236.
review? not free Gilbert D, Gerber M (2005). "Regarding "antibiotic prophylaxis with azithromycin or penicillin for childhood-onset neuropsychiatric disorders"". Biol Psychiatry 58 (11): 916. doi:10.1016/j.biopsych.2005.08.004. PMID16242119.
Do you agree with the characterization of the references? Can we replace those marked as primary research with appropriate reviews? Buster23 (talk) 18:31, 9 September 2009 (UTC)
Thanks for checking the current sources. This looks mostly right, with the following exceptions:
Singer & Loiselle 2003 (PMID12842229) appears to be a peer-reviewed review (even if it has "commentary" in its title).
Kurlan & Kaplan 2004 (PMID15060240) is clearly a review; it says so in the abstract.
The two above (Singer and Kurlan) are key; they both contain lengthy discussions of the methodological issues and problems plaguing the PANDAS research. I can't recall which, but one of them analyzes the problems in every piece of the PANDAS definition. Everyone working on this article should find these two helpful, unless newer reviews cover the same territory. SandyGeorgia (Talk) 07:09, 10 September 2009 (UTC)
I can't retrieve A Strep-Tourette Connection? but if it is the same as this copy then it's a press release and should not be used as a reliable source (though it'd be OK as a laysummary= parameter to {{cite journal}}).
Also, of interest in that article is Singer's statement, that shows what has fueled this unproven hypothesis: "People are drawn to simple explanations for complex neuropsychiatric problems," he says. "In Tourette syndrome, most parents would rather you say that their child's disease is due to infection than to inheritance." (emphasis added). Such thinking assuages the infamous "parental guilt" and gives (false) hope for a "cure". SandyGeorgia (Talk) 00:00, 13 September 2009 (UTC)
Franklin 2000 is a press article (from Family Practice News), not a random website.
That is a copy of the warning put out jointly by the TSA/NIH about PANDAS treatments; it is a good example of when we *don't* need to use a review article, and when another source is appropriate to the text being cited. SandyGeorgia (Talk) 07:12, 10 September 2009 (UTC)
Shouldn't we cite the TSA/NIH warning directly? That would be more authoritative than citing a brief summary of it in a non-peer reviewed source, especially when (as is the case here) the brief summary doesn't contain a working URL to the actual warning. Eubulides (talk) 07:54, 11 September 2009 (UTC)
Some uses of primary sources and other websites are appropriate; please read Wp:V and WP:MEDRS. When they can be replaced by reviews, they should be, but the issue is correct use of primary sources. Whether a source is appropriate depends on the text being cited. Since some of Wiki's most expert medical editors have worked on this article, I would suggest review with them before replacing sources. The logical next step would be to read the best and newest reviews (listed above by Eubulides) to see how much can be sourced to them, since everything currently in this article reflects easily sourced medical consensus; I won't have time to print and review the newest reviews while I'm traveling, but I know there is nothing in this article now that doesn't reflect peer-reviewed consensus. SandyGeorgia (Talk) 18:37, 9 September 2009 (UTC)
This area is so well-reviewed that I expect and hope that we can replace all the primary studies referenced with reviews. We won't know this until we do the reading and writing, though. Similarly, I expect that the web sites and press articles can be replaced as well. Eubulides (talk) 22:50, 9 September 2009 (UTC)
There sure are a lot of changing rules here. We started our discussion regarding the appropriate use of references. I'll most certainly go back and re-read WP:MEDRS again. I'm trying to figure out if you are disputing that primary sources were used, that they were used correctly, or that there aren't secondary sources, or that you are out of time...
I'm happy to then use the secondary sources and check whether the statements reflect accurately what the secondary sources say.
So right now, the facts I'm concerned about are:
"where antibodies attack the brain and cause neuropsychiatric conditions." (emphasis added). I find references to "interfere with neuronal tissue" but don't find any reference to attack. Recommend changing attack to interfere.
"In PANDAS, it is believed that Tourette syndrome is produced in a similar manner." The PANDAS critieria states about a subset of tics and OCD. What reference states that in PANDAS it is believed that Tourette syndrome is produced in a similar manner. citation needed.
"Thus, the antibodies damage the brain to cause the tics and OCD that characterize Tourette syndrome" citation needed. What reference states that damage is occuring versus interference as is the case with Sydenham Chorea? The pathogenisis is postulated to be about Sydenham Chorea (a sequela in 30% of Acute Rheumatic Fever) and not about Tourette syndrome.
"However, current data neither disprove nor support this hypothesis, indeed one recent study found no association between streptococcal infections and the risk of PANDAS symptoms." This is not what that study shows and misrepresents that study.
"anti-infective treatments for Tourette syndrome are experimental" needs citation about Tourettes Syndrom and probably should be about PANDAS and not Tourette sydrome.
"However, the methods in the latter study have been criticized." I don't have the reference and am trying to get it. Can you highlight the basic criticism?
"At present, whether the group of patients diagnosed with PANDAS have developed tics and OCD through a different mechanism (pathophysiology) than seen in other people diagnosed with Tourette syndrome is unclear." Is this the question or is the question whether pathophysiology is similar to Sydenham Chorea. I find lots of reference about pathophysiology related to Sydenham Chorea but not a reference on pathophysiology of Tourette syndrome. A reference is needed and possibly a second line about Sydenham Chorea.
On a final note, I think the paper makes a great argument that the mainstream view is that PANDAS is likely not a subset of Tourette syndrome. However, that is a very narrow area of OCD and tic disorders. A point of view is that PANDAS is a subset of other tic and OCD disorders and has similar pathogenesis to Sydenham Chorea. I like the summary regarding Tourette syndrome, but I don't think we have the summary about Sydenham Chorea. Buster23 (talk) 19:52, 9 September 2009 (UTC)
Because of time constraints, I havent' checked them individually. I do know that there is currently nothing in this article that can't be sourced to secondary reviews, as I had read almost everything written about PANDAS until the most recent reviews posted by Eubulides, which I won't be able to access until I return. The rules are not changing: I suggest a careful read of policies and guidelines, and other medical featured articles (linked above). It is unclear why you are trying to eliminate TS from this article, and that alone suggests you haven't thoroughly reviewed all of the PANDAS medical history and literature. Some of your small wording changes could certainly be discussed, but the article is currently accurate, although incomplete. Let's not sacrifice accuracy in the (needed) rewrite. A few of your statements above are misguided to inaccurate (perhaps only semantic, or related to an incompelte understanding of the research and the relationship between tics and OCD?), so please take care to read many PANDAS reviews before introducing changes to the article. SandyGeorgia (Talk) 20:04, 9 September 2009 (UTC)
Please don't try to characterize my intentions, I don't think you know me well enough for that :-). I'm asking to check statements for verifiable facts and citations which support positions. I am absolutely not trying to remove Tourette syndrome, but PANDAS critieria is about being a subset of OCD and tic disorders. Tourette syndrome is itself a subset of the OCD and tic disorder group. The article should reflect the position on OCD and tic disorder -- the actual definition of PANDAS per the clinical criteria -- and not only be comparing two subgroups for overlap. I'm happy to take a citation to a paper if you think there is one that has a different defintion of PANDAS. Buster23 (talk) 20:21, 9 September 2009 (UTC)
Do you have full text on any or all of the recent reviews? Have you read most of them? That wil help with a complete understanding of the topic. On what are you basing the statement that "TS is itself a subset of the OCD ... group"? I'm not aware of a medical consensus that TS is a subset of OCD, although some research supports the notion that a subset of OCD may be etiologically linked to TS. Plenty of the most reliable sources specifically discuss TS, so sourcing those statements will not be difficult; I regret that I can't help with specific details now because of my travel. SandyGeorgia (Talk) 21:43, 9 September 2009 (UTC)
My error above, I should have said, "Tourette syndrome is itself a subset of tic disorder with possible comorbid OCD". Thanks for the catch. I sort of like the graphic in Fornaro 2009 (PMID19450269). Buster23 (talk) 01:20, 10 September 2009 (UTC)
That's unfortunate, because that graph is incorrect (noting that isn't a review article, btw). TS exists without OCD, and that graph implies that only tics disorders are outside of the OCD circle. Further, obsessive-compulsive spectrum isn't a well-defined, accepted term ... I'm not sure why you're using that article at all. Again, I suggest that the best way to approach the needed rewrite of this article is to begin by re-reading all of the recent reviews (thru mid-2008, I had read every one of them) to develop a thorough knowledge of PANDAS. Particularly, for example, the numerous reviews that demonstrate that every single part of the definition of PANDAS has been disputred, disproven, refuted, or shown useless. The rewrite will need to reflect how solidly the hypothesis has been questioned by numerous reliable reviews. Fixing what is here won't be particularly helpful; what is here is correct, it just needs better sourcing and the article needs to be completed. As Eubulides suggests below, that work should commence section by section, focusing on recent reliable reviews, not cherrypicking concepts for inclusion. SandyGeorgia (Talk) 02:09, 10 September 2009 (UTC)
Outrageous claims require outrageous proof. I think you need to support your statement that "the numerous reviews that demonstrate that every single part of the definition of PANDAS has been disputred, disproven, refuted, or shown useless" or retract the comment. To keep this simple, let's start with one. Please show the review that refutes Kirvan 2006 PMID16875742 demonstrating that CaM Kinase II activation was elevated in the PANDAS subgroup and in children with Sydenham Chorea. Buster23 (talk) 08:04, 12 September 2009 (UTC)
Can we archive this section? I believe I've summarized all of the reviews in one section above, and don't see that we still need this lengthy section. SandyGeorgia (Talk) 00:06, 14 September 2009 (UTC)
Classification
"So right now, the facts I'm concerned about are:" This comment in the previous section raises valid concerns about what's in the article. The next step is to propose specific changes to address these concerns. These changes should be based on (and should cite) the best sources we have, namely the reliable reviews discussed above.
With the possible exception of some minor semantic issues, I actually don't see much of concern highlighted above. Perhaps Tim the Biology Man can explain the difference between "attack" and "interfere", but antibodies "attacking" the basal ganglia is the terminology frequenty found in the TS/PANDAS literature. The rest of the list seems to be either misunderstanding or highlighting the point that the article does need better and updated sourcing, and is incomplete, but the information highlighted is not incorrect. The article has developed incompletely because we've had to (more than once) deal with tendentious editing that inserted incorrect text, and we've not been able to more completely develop the article, but what is here is now is not incorrect, unless something has changed in 2009 reviews. Buster23, is your complaint mostly that Syndenham is underdiscussed here? That is correct, because we're always fighting incorrect TS additions, and the rest of the article never got developed. SandyGeorgia (Talk) 07:55, 10 September 2009 (UTC)
I wouldn't worry too much about commenting on or preserving the exact wording currently used, which cites older sources or primary sources or whatnot: the goal ought to be to use wording which accurately summarizes what our best sources say now.
I suggest doing this one step at a time rather than trying to rewrite everything all at once; I realize this may impose a bit of a hardship, at least at first, but it will save time overall.
How about something like the following (I'm not sure I got all the wikipedia capitalization, italics, punctuation correct). I'm willing to put it in the article (or ask one of you to) and edit it there if that's more efficient. Please check content before criticising my punctuation :-) :
OCD is an anxiety disorder involving obsessions (ideas, images, or impulses that repeatedly enter a person's mind) causing anxiety and a compulsion (repetitive stereotyped behaviors or mental acts driven by rules that must be applied rigidly). Executing the compulsion provides temporary relief. The compulsions are not inherently enjoyable and do not result in the completion of any useful task. Failure to complete the ritual results in considerable stress. To qualify for a diagnosis, the symptoms must be disabling. [12]
Tics are sudden, involuntary, repetitive, stereotyped movements (motor tics) or sounds (vocal tics) that are frequently preceded by sensations or urges.[13]
Tourette syndrome is a tic disorder where a person exhibits both multiple motor and at least one vocal tic (although these do not need to be concurrent) over the period of a year, with no more than three consecutive tic-free months. [14] Over half of people with Tourette syndrome have obsessive-compulsive symptoms and more than 30% have symptoms severe enough to be diagnosed with OCD[14]
Sydenham chorea is characterized by complex irregular involuntary movements and neuropsychiatric disturbances including obsessive-compulsive symptoms, hyperactivity and emotional lability. Sydenham chorea can develop in 10%-30% of Acute_rheumatic_fever cases and may be the only manifestation presenting as late as 6 months after the initiating streptococcal pharyngitis. [8]
PANDAS is an acronym describing a subgroup of pre-pubescent onset OCD and/or tic disorders that exhibit dramatic episodic symptom exacerbations following group A Beta-hemolytic streptococcal infections. [10] Episodic is defined as a relapsing–remitting course that appears as a sawtooth pattern distinct from the gradual onset and persistent symptoms typically seen in childhood onset OCD and also differs substantially from the waxing and waning course of tic disorders. [15] The PANDAS subgroup appears to overlap with symptoms of Sydenham Chorea without the precursor of acute rheumatic fever and without full chorea. [16]
For examples of the kinds of things to cover in the "Classification" section, see nosology or other medical articles. We don't have to redefine (entirely) every term for the purposes of this article; the links generally suffice (I agree with Eubulides that a paragraph should do it, and this text doesn't make "Classification" clear, it's more of a list of definitions). So, while it's moot, I'll point out that, on a quick glance, the Tourette syndrome paragraph, at least, is incorrect. I don't even have to access the article to know that Lombroso and the Yale Group would not state that "Over half of people with Tourette syndrome have obsessive-compulsive symptoms and more than 30% have symptoms severe enough to be diagnosed ... ", because they are always *very* careful to clarify that such data pertains only to clinical populations or those who come to the attention of tertiary specialty clinics, recognizing that most people with TS are undiagnosed, and those with comorbid conditions are more likely to come to clinical or tertiary specialty clinic attention and to be diagnosed, while those with "TS only" or "pure TS" (no comorbids) are less likely to come to clinical attention or receive a diagnosis. I'm sure if you review the Lombroso article, you'll find such wording. The methodological difficulties in studying the PANDAS hypothesis are so great that it is important to be aware of distinctions such as this one; they provide examples of the kinds of methodological issues that plague much of the PANDAS primary research, and the sorts of things that make it hard for persons not well versed in PANDAS and TS research to sort the problems in the primary research. For those reasons, this will be a challenging article to complete, and the reason that discussing text on talk before making changes will be helpful. I pulled out a few of my articles to take with me on my trip <sigh>, and on quick glance, I see they all contain a simple paragraph on the classification of PANDAS, but since they are full-text, hard copies, I don't have time just now to look each one of them up to determine which are reviews, but we should be able to pull Classification information from one recent review. SandyGeorgia (Talk) 05:55, 10 September 2009 (UTC)
I'd like to keep these separate definitions with links until we agree on the terms (since that is probably tripping us up), then we can see if the Wikipedia pages are sufficient. I found, for example, Sydenham Chorea was quite a challenge to get a great definition on. Also separating PANDAS from Sydenham Chorea took a while to find a survey article. My finding while doing this particular exercise was that the other wikipedia pages were not very complete. I'd rather not try to fix those just to try to get agreement amongst us on a short description that defines our terms. On your second point, here's the quote from Lombroso :
As noted above, TS is often associated with other disorders. In clinic populations, approximately 65% of children with TS meet the diagnostic criteria for Attention Deficit with Hyperactivity Disorder [10]. In addition, over half also have significant obsessive-compulsive symptoms, and approximately 30% meet the diagnostic criteria for obsessive-compulsive disorder (OCD). Finally, some reports from clinically ascertained cases have shown an increase in aggressiveness, anxiety disorders, depression and learning difficulties in TS patients. Whether these co-occurring conditions reflect ascertainment bias is not completely clear. More recently, however, community-based surveys have found that ADHD and disruptive behavior do occur with higher than expected frequency in children with TS [5].
Looks like I missed the "In clinic populations". I'll change that to:
Tourette syndrome is a tic disorder where a person exhibits both multiple motor and at least one vocal tic (although these do not need to be concurrent) over the period of a year, with no more than three consecutive tic-free months. [14] In clinic populations, over half of people with Tourette syndrome have obsessive-compulsive symptoms and approximately 30% have symptoms severe enough to be diagnosed with OCD[14]Buster23 (talk) 06:51, 10 September 2009 (UTC)
That's better; I was certain Lombroso and Scahill would never misstate that (that's what makes the Yale Group good :) You've made a good start here, but I don't think this article has to work quite so hard to define basic terms, and the papers I have hard copies of all have very consise, even precise, classification sections. We should be able to pull from one of them to avoid the listiness, and to create one basic paragraph from one or two sources. I don't think we've quite hit on the "Classification" yet, at least relative to the papers I just read (again, I'm not sure which of them are reviews, and will have to check when I get settled, but the newer reviews surely cover the same territory as these papers I just glanced at.) SandyGeorgia (Talk) 06:57, 10 September 2009 (UTC)
Perhaps what you folks wanted was a template like the following. I'm not positive I got this right. Essentially, PANDAS itself is a subgroup, so it's two parent conditions OCD and/or tic disorder have to be listed.
No, I'm actually thinking of a one paragraph description of PANDAS, such as can be found in all of the articles I've perused. I'm unclear why you say we're having definitional confusion; with the exception of PANDAS, all of the other conditions are medically defined by standardized bodies like the DSM, and we don't need to redefine them. What is confusion you refer to over definitions-- can you help me understand what you mean? TS and OCD are defined in DSM, and as long as we stick to reliable sources, we don't need to be overly re-defining them here. Also, I would rather stridently oppose the introduction of an Infobox that might mislead readers into thinking that PANDAS is defined in the DSM or ICD, when it's not. It's not a recognized diagnosis, so the infobox would be incorrect and misleading. SandyGeorgia (Talk) 07:57, 10 September 2009 (UTC)
I'm okay either way on the infobox. PANDAS is defined as a subset and thus its parentage is defined in the DSM-IV.
On the definitions, I found it helpful (maybe just for me) to see all the elements together (i.e., what distinguished one from another). I find that hard through links. But if brevity is the goal, I'm okay with just referring to them. So from a definition stand point, are you okay with:
PANDAS is an acronym describing a subgroup of pre-pubescent onset OCD and/or tic disorders that exhibit dramatic episodic symptom exacerbations following group A Beta-hemolytic streptococcal infections. [10] Episodic is defined as a relapsing–remitting course that appears as a sawtooth pattern distinct from the gradual onset and persistent symptoms typically seen in childhood onset OCD and also differs substantially from the waxing and waning course of tic disorders. [15] The PANDAS subgroup appears to overlap with symptoms of Sydenham Chorea without the precursor of acute rheumatic fever and without full chorea. [16]
That is much better than the list of definitions ... once I get settled, I'll try to post excerpts from some of the papers I have, to see if you can use them to beef this up a bit more. SandyGeorgia (Talk) 08:33, 10 September 2009 (UTC)
By the way, (I know original research -- but I'm just talking here) I am finding it interesting that the only distinguishing item of PANDAS versus Sydenham's chorea is the precursor of acute rheumatic fever. We certainly don't know whether the antibody that is attacking heart muscle is the same as the antibody causing brain dysfunction, nor do we know how it crosses blood brain barrier. Right? So what really distinguishes the disease Sydenham's chorea from the PANDAS subset? Is it just the appearance of intense chorea? I know, I know ... not really helping the article... but anyone got a reference that ARF is found in all Sydenham's chorea? Buster23 (talk) 08:26, 10 September 2009 (UTC)
When we start talking about molecular mimicry and blood brain barriers, I throw up my hands and call Tim Vickers. And that is why I've never been able to write this article alone. I can spot things that are wrong, because I know the research well, but the neurobiology is a tough topic, and spotting problems is easier than creating new content on a difficult topic. SandyGeorgia (Talk) 08:33, 10 September 2009 (UTC)
Yes, expert help from Tim would be amazingly useful. I still have not laid my hands on a copy of Pichichero 2009 (PMID19280860), which I think will also be very useful. I agree with SandyGeorgia that the latest draft is by far the best and I'm optimistic that we'll get a good section soon. Some comments on it:
The goal of Classification is both (a) to establish the boundaries between PANDAS and related syndromes, i.e., "how PANDAS fits in", and (b) to establish any boundaries between subtypes of PANDAS, i.e., "how PANDAS is split up". Of course this sort of classification is easier to do with well-studied syndromes, but Autism #Classification should give you an idea of what we're looking for (its main fault is that it's too long).
For (a) "how PANDAS fits in", it may be important to say how it fits in with other CNS disorders hypothesized to be autoimmune-related, for example, opsoclonus myoclonus syndrome. See Irani & Lang 2008 (PMID18176865).
For (b) "how PANDAS is split up" the obvious candidates are OCD and TS, but there is also Sydenham chorea (more controversial), and anorexia nervosa (more controversial yet; see Puxley et al. 2008, PMID17922534). And perhaps other subcategories. I wish I had that Pichichero!
And a couple more comments about this talk page:
That diagram above was so large that my web browser exploded. Hope you don't mind if I ratcheted the size down a bit.
I've created a new section #References to catch all the refs in the drafts we're generated. The idea is to keep it at the bottom of the talk page. This collides with the "create section" tab at the top of this page, but that's life.
Eubulides thank you for shrinking the picture, I wasn't sure how to do that. I hope it helped to explain the current overlaps and why talking only about children with Tourette syndrome who fit the published critieria for PANDAS is a small subset of what the criteria covers.
The work by Singer (PMID16207842) and Kurlan (PMID18519489) in addition to Martino, Dale and Church (PMID17516471) are certainly helpful at determining whether TS is exclusionary to PANDAS and whether TS has a pathogenesis from anti-neuronal antibodies, but that is just one section of what this article about PANDAS needs to be.
Swedo in her initial work chose to make a confirmed diagnosis of Sydenham chorea exclusionary to her clinical study (but not to the definition) see Swedo et al (PMID9464208) . Work by Kirvan is indicating similar elevation on Cam Kinase II and anti-lysogangliosides when studying the pathogenesis of PANDAS and Sydenham chorea. Primary: Kirvan et al. 2006 (PMID16455579) secondary: Moretti 2008 (PMID18495013)
Kirvan's articles as referenced in Moretti, stand unrefuted and are the current best evidence of an anti-neuronal antibody pathogenesis during an acute exacerbation in some children fitting the PANDAS critieria. Guase, Morris and Singer (PMID19628285) note that they have not studied Tubulin or lysoganglioside GM1. Buster23 (talk) 16:19, 11 September 2009 (UTC)
So just checking with others... I proposed the initial text:
PANDAS is an acronym describing a subgroup of pre-pubescent onset OCD and/or tic disorders that exhibit dramatic episodic symptom exacerbations following group A Beta-hemolytic streptococcal infections. [10] Episodic is defined as a relapsing–remitting course that appears as a sawtooth pattern distinct from the gradual onset and persistent symptoms typically seen in childhood onset OCD and also differs substantially from the waxing and waning course of tic disorders. [15] The PANDAS subgroup appears to overlap with symptoms of Sydenham Chorea without the precursor of acute rheumatic fever and without full chorea. [16]
Is this our working definition? I recommend including the venn diagram (without the small black circles and with CYBOCS exacerbation) as a means of visually describing the classification.
I suppose then we can add the symptoms, pathogenesis, and treatment sections. Is that the structure of the article you are encouraging?
I think it is time we start working on the actual document. It is getting impossible to know what we've closed in this talk session without updating the working deck.
Not quite; we're not looking for a definition, we're looking for a classification section. Also, several studies and reviews dispute the symptom exacerbation portion with respect to tics, so the text needs to be balanced to incorporate that info. As I said, I'll pull up some excerpts from other papers when I have time, to show what classification might cover. Since our current text is not incorrect, we should take care not to introduce text until it is correct, and the dramatic symptom exacerbation of tics has been questioned. Also, I'm not concerened about the length of talk; what still has to happen is that recent reviews have to be read and the article has to be rewritten from them. Nothing else has really resulted from these conversations, and until that is done, it will be hard to advance the article accurately. Wiki articles are written from reliable sources; the first step is to access all of the important reviews, and begin writing from there. Have you accessed yet the articles I indicated in the list of reviews above as being key to an understanding of the methodological issues? SandyGeorgia (Talk) 03:33, 12 September 2009 (UTC)
I know you were looking for a classification, but before we get there, I want to see if we agree on the definition. It seems we haven't been (i.e., that a DSM IV diagnosis of OCD can occur without tics, that the onset is pre-pubescent, that the clinical presentation differs, ... from this I can create a symptoms section or an pathogenesis section.
By the way, you seem to keep asking people if they've read the papers cited in talk. Yes, I have read all the articles except Pichichero 2009 (PMID19280860) and Shulman 2009 (PMID19242249) (so please make it more constructive by asking me about a particular paragraph, section, or finding you want to discuss). In terms of Pichichero, it isn't available so I doubt you have read it. In terms of Shulman, I'll accelerate getting a copy if there is a particular finding or section you want me to read.
Can we archive this section, so we can start using a standardized ref naming scheme and work on rewriting the article from reviews? The talk page is too much to follow now. SandyGeorgia (Talk) 00:21, 14 September 2009 (UTC)
Admin request
Tim, next time you happen this way, would you use your adminly tools to resurrect User:SandyGeorgia/PANDAS? Eons ago, when I had hopes we could write this article, I began gathering material there, but I long ago deleted it. I have no idea what was there, how good it still is or isn't, and which were review sources (MEDRS was beefed up after I did that work), but I'm curious to see if anything I had there is still helpful. Since I'll be traveling, you all may be able to find something useful there. Or maybe not ! SandyGeorgia (Talk) 08:01, 10 September 2009 (UTC)
Although I now see we've been down this road before :) I posted mutliple excerpts above, in Talk:PANDAS#Journal_reviews, which combined with the new sources from Eubulides, should be more than enough reviews from which to complete this article. SandyGeorgia (Talk) 08:21, 10 September 2009 (UTC)
Since we're adding a references page to our talk page (gosh, sounds like the talk page is becoming an article :-)) Should we use a common naming convention so they all show up and are consolidated in the reference section. I'm not sure if policy would recommend us going back and cleaning up references in the talk page or just adopting a convention from now on? Recommendations? Buster23 (talk) 16:47, 11 September 2009 (UTC)
I only have a quick moment today ... thanks for gathering the refs into one place, Eubulides ... that will help me get back up to speed once I find the time ... may I ask a favor, can you also add links to the full text in the cases when we have them, or are those all available thru the PMID link? SandyGeorgia (Talk) 16:56, 11 September 2009 (UTC)
I tried to modify the Cite error: A <ref> tag is missing the closing </ref> (see the help page).
There are numerous sources supporting that statement, so I'm again concerneced that you might not have accessed the full text of the full body of recent PANDAS literature, and it will be very hard to develop this article without having done so.
Instead of questioning what I have read. Provide the paper that supports your position and lets discuss that paper. If you think many papers support the position, cite one of them. Buster23 (talk) 05:11, 12 September 2009 (UTC)
That the pathogenesis of TS is unproven doesn't exclude that infections don't increase the risk of TS, so I'm not sure why you're mixing those two. SandyGeorgia (Talk) 03:24, 12 September 2009 (UTC)
I'm asking you for the citation because I could easily read 100 articles and not run across the one that you have used that you think supports the strength of the statement. There's a big difference between saying that there is no concensus evidence that infection causes Tourette syndrome and to say that infections don't cause Tourette syndrome. Please insert your favorite citation.Buster23 (talk) 05:11, 12 September 2009 (UTC)
I suppose we could say,
While it is accepted that infection is a precursor to Sydenham chorea, [5] many scientists studying Tourette syndrome have not found evidence that infection increases the risk of Tourette syndrome. [citation needed].
I'm not disputing that you have a citation. The statement I wrote is also true and I provided the citation. I am stating that mine is a more accurate reflection of the sources. I am, however, open to other editors' opinions as we may need one or more 3rd parties to help. Buster23 (talk) 04:26, 12 September 2009 (UTC)
This one should be updated to reflect the four A/N reviews, suggesting that another autoimmmune process may be involved in TS. Just fixing this one sentence won't be correct ... the A/N sources get into other (non-PANDAS) infectious processes that may be suspect, and explain why the PANDAS hypothesis may be insufficient. I have those sources in hard copy, not electronic format, and no, I don't plan to spend my vacation time typing up the excerpts, so please access them. SandyGeorgia (Talk) 21:53, 12 September 2009 (UTC)
We haven't closed Item 1 yet, but hoping a 3rd party can help with that. The current text says:
However, current data neither disprove nor support this hypothesis, indeed one recent study found no association between streptococcal infections and the risk of PANDAS symptoms.[17]
The actual conclusion from that paper reads:
"Ill children with GAS infection, treated for their GAS infection, were not at increased risk for developing PANDAS symptoms or a mild PANDAS variant compared with children with presumed viral illness or well children." (emphasis added)
The cited study does not support the statement as claimed. The statement should be modified to:
However, current data neither disprove nor support this hypothesis, indeed one recent study found no association between streptococcal infections and the risk of PANDAS symptoms when the children were treated for the streptococcal infection.[18]
Here, I am not seeing what you're after. Obviously, active strep infections should be treated. I see no difference in the statements, nor is the original incorrect, so I guess I'm missing your point. SandyGeorgia (Talk) 21:50, 12 September 2009 (UTC)
I'm glad that you agree about treating strep, but that is exactly the point of the paper and the edit. Just like untreated strep may lead to acute rheumatic fever, untreated strep may lead to PANDAS. The finding in the paper was that treated strep did not seem to lead to exacerbations. You can't say anything about untreated strep. So why are you objecting to the edit if you see them as the same? I don't and think the proposed change is superior and more accurate as the omission is technically broader than the finding. Buster23 (talk) 23:13, 12 September 2009 (UTC)
The problem is that your wording is leaving the implication that untreated strep does lead to PANDAS, when that is unproven. Your fix isn't fixing the sentence completely or accurately; it's potentially misleading the reader. If you can address that with a more complete statement, you'll probaby get consensus for the change. SandyGeorgia (Talk) 23:26, 12 September 2009 (UTC)
I object to this change; it's misleading. Once we get into the new sources, the entire thing will be rewritten anyway, so this isn't worth spending time on ... it's currently accurate. SandyGeorgia (Talk) 04:07, 14 September 2009 (UTC)
Item 3 : Inaccuracy in quote from NIMH stating PANDAS is similar to ARF. Should be SC.
In the current article it states:
"However, researchers at the NIMH are pursuing a hypothesis that the mechanism is similar to that of rheumatic fever,"
This is not accurate compared to the citation provided. The citation provided states:
"In PANDAS, it is believed that something very similar to Sydenham’s Chorea occurs."
The line should be changed to properly reflect the actual stated position as well as that supported by the survey and primary research. [19] I recommend the wording:
"However, researchers at the NIMH are pursuing a hypothesis that the mechanism is similar to that of Sydenham chorea,"
This is an example of where we could waste a lot of time on semantic nitpicking, rather than just rewriting the article from scratch. The rheumatic fever statement is not incorrect, see for example this, there are many other examples. I'm not finding the approach of making this article look grossly inaccurate, when it's not, an effective use of our (limited) time. That sentence would need a much broader fix, but what's there is not inaccurate. SandyGeorgia (Talk) 21:48, 12 September 2009 (UTC)
The paper you cite is about D8/17 lymphocyte markers that were found to be higher in ARF and SC. The correct statement is about sydenham chorea. There is no assertion that PANDAS causes heart carditis.
May I inquire why you are objecting to the change if you think the two statements are equivalent? I want the current article to be as accurate as possible until such time as we rewrite it. At this point, I argue my statement is more accurate than the current one and the current one incorrectly represents the position of the cited text. Buster23 (talk) 23:19, 12 September 2009 (UTC)
I did not object; I just don't think semantic nitpicking is the best use of our time here. If others agree with this change, and if you cite it, I don't object. But please wait for others to weigh in. By the way, on citations, they go after punctuation, with no space (I don't mind fixing them, but you might as well learn :) And as mentioned in the Dispatches I linked you to earlier, the format used in medical articles is the Diberri template filler.) SandyGeorgia (Talk) 23:24, 12 September 2009 (UTC)
I don't see the point in making this change; once we write a complete Classification section, the relationship and use of rheumatic fever vs. SC will be clarified, as it is in all the abstracts I've got in front of me and haven't had time to type up. This sort of agony over one word, in an article that needs an entire rewrite, isn't productive. SandyGeorgia (Talk) 04:06, 14 September 2009 (UTC)
Item 4 : Incorrect assertion that motor symptoms are necessary
In the current article it states:
In addition to the motor symptoms, it is also thought that children may have psychiatric manifestations, becoming moody, irritable or show concerns about separating from parents or loved ones.[1]
This is not accurate compared to the citation provided. The citation states:
The children usually have dramatic, "overnight" onset of symptoms, including motor or vocal tics, obsessions, and/or compulsions. In addition to these symptoms, children may also become moody, irritable or show concerns about separating from parents or loved ones.
vocal tics, obsessions, and/or compulsions need to be added to clarify that motor tics are not required to meet the PANDAS criteria. Therefore the statement should be reworded to:
In addition to the required OCD diagnosis and/or tic diagnosis, children may have psychiatric manifestations, becoming moody, irritable or show concerns about separating from parents or loved ones.
This looks good, except please avoid the use of and/or since and/or is the same as or. "In addition to an OCD or tic diagnosis, children may have ... " There is new literature about other conditions, like anorexia, which is why I continue to think a rewrite will be more effective than this line by line analysis of what's there now, but I don't object to this change. SandyGeorgia (Talk) 21:41, 12 September 2009 (UTC)
Sandy, and/or is distinct from or. The term 'or' may be exclusive (as in you can have A or B but not both) or may be inclusive "you may have A or B or both". In order to avoid confusion, and/or is used to indicate that the choice is the inclusive type. Buster23 (talk) 23:24, 12 September 2009 (UTC)
This is dealt with somewhere in MOS and and/or is considered poor writing on Wiki. If you'd prefer, we can ask Tony1 (talk·contribs), but most of us can already tell you he will scream at and/or. It's poor writing. I've made this change, and consider this item done, hopefully. SandyGeorgia (Talk) 04:04, 14 September 2009 (UTC)
I've responded on your talk, as the volume on this talk page is making it increasingly unlikely that progress will be made with this approach. I'm sorry to repeat myself, but the way forward on this article is to read all of the recent reviews and rewrite the article from them (as Eubulides suggested, by starting with Classification, which hasn't yet been done). Focusing on individual semantic differences (over which we could argue for a long time) currently on the page won't accomplish the global rewrite needed. SandyGeorgia (Talk) 15:40, 12 September 2009 (UTC)
We need a new, consolidated review section, to put all of the suggested reading in one place, with complete citations. When I was quickly reading from the plane, I thought that had been done, I now see it's just a reflist. We may make better progress if we archive this page and get up a list of the material everyone should read in order to move forward on this article; we have now a talk page that has little productive material. SandyGeorgia (Talk) 15:42, 12 September 2009 (UTC)
Sandy, you were the person requesting this style of edit. Rather than just WP:Be_bold I'm not changing the main text without discussing here in chat. I appreciate that this is tortuous and you and I are both feeling the pain, but I'm honoring your explicit request.
I'm trying to make the current article accurate since it is currently published. You asked me not to add new content until you got back from vacation (you said it a different way, but I think that's what you meant). Therefore, I've focused on the current article. I agree that the whole article needs rewriting and will be glad to help on the classification, but I want what is currently published to be accurate. I've made very specific arguments in this section why the current statements are inaccurate, I've made suggestions as to how to fix them. Please vote on the changes. If they are trivial and you're troubled I'm wasting your time -- terrific, we'll agree quickly and we'll put the change in. If you don't agree to the change, I'd like to hear your argument as I've provided mine with supported citations. I don't accept that the article is accurate in its current form.
If you really don't think you'll agree to any change, let's get a 3rd party in here to help. This is a very specialized area but statements must be verifiable by any editor.
Hi folks, any objections to splitting each of these items out as their own section? I'm finding it hard to edit this way? Buster23 (talk) 19:53, 12 September 2009 (UTC)
Several third parties are here helping, and Eubulides made a very good suggestion about not concerning ourselves too much with what's here, and starting to rewrite the article. I agree; everyone should get hold of *all* of the reviews, so we can do this right. SandyGeorgia (Talk) 21:44, 12 September 2009 (UTC)
I have to concern myself with what's here until a new article is ready. I strongly encourage you to step back, see if my point has any merit, and if so let these through -- this is fact checking and the core of WP:V. When I tried to verify the facts, they are not supported by the literature or have created ambiguity around an actual finding. The ommision of all the literature on clinical findings and immunologic findings around PANDAS/OCD and SC is of course a bigger issue. Help me out here. Are you welcoming improvements or stating that the current article should be left untouched until the new article is ready. Buster23 (talk) 23:32, 12 September 2009 (UTC)
Whenever you have proposed a correct and citable change, I've agreed to it (I believe that's two out of four). I can't agree or disagree on OCD/SC literature until I've read it. I don't see disagreement with sources in every case you point out, although some just haven't been correctly cited yet. If others, once they catch up, don't disagree with your proposals, then add them. As others get more comfortable with your knowledge of Wiki and we all get through the new literature, this will become easier. SandyGeorgia (Talk) 23:38, 12 September 2009 (UTC)
Hi Sandy, in an attempt to close this, I made three what will seem trivial edits to the article. Please see if these are acceptable. If so, we can close all the above. I know, it's likely you'll say "all that effort for those 3 changes" and that's how I felt too :-) Buster23 (talk) 07:39, 14 September 2009 (UTC)
One final question, I see in the article, we refer to Tourette syndrome as "Tourette's", "Tourette's syndrome" and Tourette syndrome". Seems we should choose one of them. Any one know which one? Oh, and I'm done on the nitpicking -- isn't that what editors do :-)
Buster23 (talk) 07:46, 14 September 2009 (UTC)
Good, uncontroversial improvements. So we can archive this old business now? All of them are common names, used in all the literature, but for Wiki naming convetions, it's Tourette syndrome. To make this article writing easier, I defined the acronym TS in the lead, and we can now just refer to TS or OCD on future occurrences. SandyGeorgia (Talk) 14:50, 14 September 2009 (UTC)
Cleanup
This talk page is unmanageable. I'm going to begin working in my sandbox, gathering our sources there, reviewing what has been done, and then archiving the talk page sections as I get through them. After I gather an alphabetical list of the sources in one place, I'll also begin work on Classification and typing up needed excerpts. I have a few hours tonight. SandyGeorgia (Talk) 21:28, 13 September 2009 (UTC)
I think I have all of the reviews consolidated at the top now. That took way too much time, and I'll continue working later tonight. Can someone please review my work and clean up any that may need cleanup? I can't make Diberri work today. I'll also continue trying to archive portions of the talk page that we're done with later. I also added a standardized ref naming scheme, since they are all over the map on this page (several of us hate using PMIDs). SandyGeorgia (Talk) 23:52, 13 September 2009 (UTC)
Can we please stop this thing that got started of using inline citations on the talk page; they will create quite a problem when sections are archived. I'm trying to standardize them all, but what a mess. SandyGeorgia (Talk) 00:02, 14 September 2009 (UTC)
It's true that they don't work well as threads are archived one by one, and I don't object to doing it another way. Also, I think it's time to archive the older discussions. This talk page is now so unwieldy that I am having trouble following it, and I suspect that's true for everybody who's reading it. Eubulides (talk) 00:31, 14 September 2009 (UTC)
Sandy, I'm uncomfortable archiving a document that has content only 3 days old. Just so I don't start undoing work, can we "seal" sections and mark them for archive with a date (like 3 days from now). This will give me a chance to see if the items getting moved to archive have been closed.
For example, I see that my annotation of the various references in the current article are getting archived, but I thought we were going back in to fix those references to not be citing press-releases. Buster23 (talk) 02:41, 14 September 2009 (UTC)
It's unlikely we're going to close "open" issues when the page is cluttered with nitpicking; in fact, other than removing primary sources, I don't see any open issues, and think we can move forward much faster if we clean out this page. We need to start generating new text from current reviews; there's little else of use on this page, other than the list of reviews. SandyGeorgia (Talk) 04:02, 14 September 2009 (UTC)
I won't archive if you're uncomfortable, but archiving something doesn't mean it's "done" or "closed"; it just means it's off of this page and on to an archive page. Yes, we still need to remove all the primary sources from the article; we all agree on that. That is ongoing work. If it will make it easier for you to keep track, we can add a todo box here, but the length of this page assures that few other editors will wade through it. We really need to focus less on what's in the article now, and more on generating new content, and this page is full of nitpicks, when we need a complete rewrite. Let me know; if you don't want me to archive those sections, I won't. SandyGeorgia (Talk) 03:07, 14 September 2009 (UTC)
Sandy, I specifically asked you not to archive the sections for a few days. I realize that archiving doesn't lose content, but it does mean I have to check that it survived and I wasn't quite done with several items in there. Does this mean I bring all the context back here to close or cross reference to the discussion in archive?
Is there a reason you couldn't honor my request to hold off on archiving the very recent content for 3 days? I had no problem with many of the areas, but this process has removed visibility of the this week's discussion from other editors. "Decisions about when to archive, and what may be the optimal length for a talk page, are made according to the Wikipedia policy of consensus for each case. If possible, archive talk pages during a lull in discussion, thus maintaining the context of a discussion by not cutting it off in progress." from How to archive a talk pageBuster23 (talk) 16:43, 14 September 2009 (UTC)
Tough to take a breadth around here... I've checked the threads and I'm okay with the sections being moved to archive. But I may have to resurrect some content... I just think it is odd that we moved them so fast rather than waiting for a lull.
Buster23 (talk) 17:26, 14 September 2009 (UTC)
So, just checking, on our current process, would I then add my references to the top and then move the prior section to archive? Buster23 (talk) 17:26, 14 September 2009 (UTC)
I'm sorry, then I misread your last statement, where you said we had closed these sections out. Tell me what you want brought back, it's no problem. Archiving doesn't mean something is "done", "closed", just clearing out the page where I thought we had agreement, and you can still access anything in archive. Tell me what sections you want brought back. I wouldn't worry about visibility for other editors; the ones who will read this page know how to read archives, and Eubulides already indicated it had become too hard to follow, but we can bring back anything you want. I apologize for misreading your last message as a go-ahead to archive. SandyGeorgia (Talk) 17:30, 14 September 2009 (UTC)
My comment just above with "Tough to take a breadth" was a go ahead. My comment at 16:43 was a what's going on. You actually did make the right call, it was just a shock to see a bunch of content disappear and then I had to go and check all of it to see if there were still outstanding issues in the mix. At this point, we're fine and we'll restart.
ref name = Martino2007: Martino D, Defazio G, Church AJ; et al. (2007). "Antineuronal antibody status and phenotype analysis in Tourette's syndrome". Mov Disord. 22 (10): 1424–9. doi:10.1002/mds.21454. PMID17516471. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
Still primary sources. Since we've agreed to replace them, and since we have more than ample reviews, I'm still unclear why these primary sources are requested? SandyGeorgia (Talk) 18:36, 14 September 2009 (UTC)
ref name="Snider2004" Snider LA, Swedo SE (2004). "PANDAS: current status and directions for research". Mol Psychiatry. 9 (10): 900–7. doi:10.1038/sj.mp.4001542. PMID15241433.
ref name="Wild2007" Wild EJ, Tabrizi SJ (2007). "The differential diagnosis of chorea". Pract Neurol. 7 (6): 360–73. doi:10.1136/pn.2007.134585. PMID18024776.
ref name="Murphy2000" -- a little old but good Murphy TK, Goodman WK, Ayoub EM, Voeller KK (2000). "On defining Sydenham's chorea: where do we draw the line?". Biol Psychiatry. 47 (10): 851–7. PMID10807957.{{cite journal}}: CS1 maint: multiple names: authors list (link)
Okay. I do like the review as it was an interesting positioning relative to SC where as most of the other reviews are dealing with TS. But you are right, it is older. I'll look for more recent.Buster23 (talk) 17:02, 14 September 2009 (UTC)
ref name="Kirvan2007" -- more primary research, but has good lit review in front Kirvan CA, Cox CJ, Swedo SE, Cunningham MW (2007). "Tubulin is a neuronal target of autoantibodies in Sydenham's chorea". J Immunol. 178 (11): 7412–21. PMID17513792.{{cite journal}}: CS1 maint: multiple names: authors list (link)
ref name="Bronze1993" -- a secondary summary Bronze MS, Dale JB (1993). "Epitopes of streptococcal M proteins that evoke antibodies that cross-react with human brain". J Immunol. 151 (5): 2820–8. PMID7689617.
Primary ref name="Perlmutter1999" Perlmutter SJ, Leitman SF, Garvey MA, Hamburger S, Feldman E, Leonard HL; et al. (1999). "Therapeutic plasma exchange and intravenous immunoglobulin for obsessive-compulsive disorder and tic disorders in childhood". Lancet. 354 (9185): 1153–8. doi:10.1016/S0140-6736(98)12297-3. PMID10513708. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
Because it is a landmark paper. Who is disputing the results -- a reference please. As far as I know there has been no followup to this paper. Buster23 (talk) 17:02, 14 September 2009 (UTC)
Primary ref name="Yannadup2009" -- very, very recent work on passive transfer Yaddanapudi K, Hornig M, Serge R, De Miranda J, Baghban A, Villar G; et al. (2009). "Passive transfer of streptococcus-induced antibodies reproduces behavioral disturbances in a mouse model of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection". Mol Psychiatry. doi:10.1038/mp.2009.77. PMID19668249. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
We specifically don't include "very very recent work" to avoid RECENTISM. I'm confused about why you put this list up; we need to get busy writing the article from reviews, not primary sources. SandyGeorgia (Talk) 05:05, 14 September 2009 (UTC)
I have to get to sleep, but put additional references here. Need to sort them into primary/secondary. Suggest we make those into sections. It seems that landmark/seminal papers are exempt from the primary research if we are to draw attention to them. Seems given the theory, we may need to refernce Husby 1977 paper.
I tried to clean this up, but wasn't able to, so moved it to the bottom of talk for discussion. Several of these are primary sources and several are duplicates of reviews already listed above. If we are in agreement to rewrite the article from reviews, why are you adding primary sources to the article and talk page list of reviews? If there are reviews here that we all agree to use, we can alphabetize them and them to the review list above. SandyGeorgia (Talk) 04:58, 14 September 2009 (UTC)
First, we have two independent tasks. We have a desire to write new paper, I'm all for it, but it will take us a while to get there. The energy you see from me and the haste is similar to your concern about the inaccurate picture, a concern that people are getting incorrect information from the current page. So, instead of having an unreferenced section, I cited the best reference I could, then I'm happy to update it again with a good secondary reference. Bottom line, there are small things I want to fix on the current page while we all get set up for a more leisurely rewrite.
For me, what you call semantics, are important. The NIMH doesn't think that PANDAS is similar to ARF, they think it is similar to Sydenham chorea, a sequelea to ARF that occurs in 30% of ARF folks. One is correct and a fact, and one is not. The NIMH does not think that PANDAS is similar to ARF, they think it is similar to a sequelae of ARF -- thus the statement that is there now is false.
SandyGeorgia -- I'll make the changes to the main article (and I swear they will be small), you can then see if you agree or disagree to the very minor wording changes. I will avoid adding new content. If you disagree with the changes, I'd like to discuss them with you. If you feel it is trivial semantics, then just leave the change and lets close. In this way, we can move on to the new article. Buster23 (talk) 05:32, 14 September 2009 (UTC)
Please go ahead and fix the ARF/SC if you'd like, but realize that the whole thing may end up rewritten, as it's muddled now, and can easily be cleared up with a correct and concise Classification section. SandyGeorgia (Talk) 05:35, 14 September 2009 (UTC)
MY question here is a different one; I spent all day trying to clean up the talk page and hone in on what reviews we have, and you added a list of primary sources to our reviews at the top of the page, from which I thought we were going to begin working. Why new primary sources? If there are any new reviews here that we need to use, we can discuss them and add them to the list we've all reviewed and discussed. But in the interest of cleaning up this talk page and getting down to work, I'm unsure why you've added a lengthy list of primary and duplicate and old sources. SandyGeorgia (Talk) 05:37, 14 September 2009 (UTC)
Hi Sandy, I appreciate how many hours that must have taken you to collect the articles. I didn't see the overlaps, but will go back and remove them. This may have been both of us working on the list at the same time. You've been busy and the list changed several times today. I tried to check off each article before I expanded it.
However, with that said, I most certainly wasn't closed on which 'secondary' sources to use, which is why I provided ADEM, Sydenham chorea, and OCD review. Also in re-reading policies, it appears that primary sources should be referenced if they represent seminal papers or landmark papers. It would be odd in the rewrite to not mention Swedo (even if we do so in the History section -- which we will add). So I'm providing Husby, Swedo, and one of Snider's papers. Snider is a tricky one. I found several good secondary articles on Snider about OCD CYBOC exacerbations being > 19 pts (which I think is the only definition of "significant exacerbation" I've found. However, the secondary is in a book.
So to make this clear, I think I'm closed on the secondary list if we include the ones I list (which are a combination of OCD papers, a set of Sydenham chorea papers, and a set of ADEM and immunologist papers).
I expect we'll only use primary papers if we are refering to specific facts that aren't easily found in the secondary source. I expect as we get into the article we'll have to unseal the list or will drop some contentious reviews from the list. Buster23 (talk) 06:11, 14 September 2009 (UTC)
We may be misunderstanding each other, but what you're proposing is exactly what we don't do; we don't include recent research or facts that secondary sources don't find worthy of mention, so I'm confused about what you're suggesting. SandyGeorgia (Talk) 06:18, 14 September 2009 (UTC)
I wasn't refering to recent research (aside from the Yaddapud paper that I do recommend you read as it is just too recent for a review). I was saying that there are a few original papers that are cited by almost all secondary sources, but as we add a history section (which this paper desparately needs), we'll likely want to refer to the seminal papers. Are there other papers above that are bothering you? I actually thought I was putting in only good reviews from the OCD-only perspective as most of the others dealt with neurology and TS. Buster23 (talk) 15:50, 14 September 2009 (UTC)
Yes, I agree in a History section that we refer to seminal papers that reviews cite ... I was concerned that you were wanting to add in recent research or primary sources not mentioned by reviews. Looks like we're on the same page? SandyGeorgia (Talk) 16:00, 14 September 2009 (UTC)
ref name="Murphy2006b" Murphy TK, Sajid MW, Goodman WK (2006). "Immunology of obsessive-compulsive disorder". Psychiatr Clin North Am. 29 (2): 445–69. doi:10.1016/j.psc.2006.02.003. PMID16650717.{{cite journal}}: CS1 maint: multiple names: authors list (link)
For Chorea:
ref name="Wild2007" Wild EJ, Tabrizi SJ (2007). "The differential diagnosis of chorea". Pract Neurol. 7 (6): 360–73. doi:10.1136/pn.2007.134585. PMID18024776.
ref name="Kirvan2007" -- more primary research, but has good lit review in front Kirvan CA, Cox CJ, Swedo SE, Cunningham MW (2007). "Tubulin is a neuronal target of autoantibodies in Sydenham's chorea". J Immunol. 178 (11): 7412–21. PMID17513792.{{cite journal}}: CS1 maint: multiple names: authors list (link)
Primary ref name="Yannadup2009" -- very, very recent work on passive transfer Yaddanapudi K, Hornig M, Serge R, De Miranda J, Baghban A, Villar G; et al. (2009). "Passive transfer of streptococcus-induced antibodies reproduces behavioral disturbances in a mouse model of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection". Mol Psychiatry. doi:10.1038/mp.2009.77. PMID19668249. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
History:
ref name="Swedo2002" -- sort of the basic review Swedo SE (2002). "Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS)". Mol Psychiatry. 7 Suppl 2: S24-5. doi:10.1038/sj.mp.4001170. PMID12142939.
ref name="Bronze1993" -- a secondary summary Bronze MS, Dale JB (1993). "Epitopes of streptococcal M proteins that evoke antibodies that cross-react with human brain". J Immunol. 151 (5): 2820–8. PMID7689617.
Primary ref name="Perlmutter1999" Perlmutter SJ, Leitman SF, Garvey MA; et al. (1999). "Therapeutic plasma exchange and intravenous immunoglobulin for obsessive-compulsive disorder and tic disorders in childhood". Lancet. 354 (9185): 1153–8. doi:10.1016/S0140-6736(98)12297-3. PMID10513708. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
Thanks Eubulides, I missed one of your posts where you highlighted what you were looking for. Lots of posts recently and it looks like two overlapped. Please see if this helps. Sorry the refs aren't right format... figured content then format.
How PANDAS fits in
PANDAS identifies a subgroup of children who are diagnosed with tics or Obsessive Compulsive disorder (OCD), or both tics and OCD. While the exact causes of tics and Obsessive Compulsive disorders are not known, the basal ganglia has been implicated in both disorders. [20][21]
From a disease standpoint, the PANDAS subgroup is thought to be categorized as an auto-immune disease that impacts the Basal Ganglia.[22]
In the literature, PANDAS is often compared with:
Sydenham chorea
acute disseminated encephalomyelitis
obsessive compulsive disorders
and tic disorders (such as Tourette syndrome) [23][19]
PANDAS is separated from Sydenham chorea by not having acute rheumatic fever, carditis, or full chorea[5]
PANDAS is separated from acute disseminated encephalomyelitis (ADEM) by clinical history and through diagnostic tools. PANDAS is defined by a relapsing-remitting course as opposed to the single event in ADEM. [24] In MRI exams, white matter lesions can be detected in ADEM. While there is mixed reports of enlarged basal ganglias, no demylination lesions have been found in PANDAS.
The PANDAS subgroup is identified within the obsessive-compulsive disorder by the clinical progression and onset of the disease. [19] Children in the PANDAS subgroup clinically present with severe onset of symptoms associated with a preceding GABHS infection and a sawtooth episodic course that emerges over time. [19] This episodic course differs from the slow-onset and the relatively constant nature of traditional OCD compulsions or obsessions. Some scientists have also found that children in the PANDAS subgroup are distinguished from controls due to elevated anti-lysogangliosides and CaM Kinase II activation. [19]
The ability to distinguish the PANDAS subgroup within the tic disorder is less clear particularly in the absence of co-morbid OCD. Tics that are relatively always present would not constitute a relapsing/remitting course. To some, this has meant that a diagnosis of Tourette syndrome or chronic tic disorder should be exclusionary to the PANDAS subset. [25]
How PANDAS is split up
Several different categories of PANDAS have emerged[26]
OCD-only PANDAS
Tic-only PANDAS
Tic+OCD PANDAS
Comments? This can wait a bit and I need to think on it more, but I think it lays the foundation for the set while keeping the basic framework for the work that is showing TS isn't coming up PANDAS. Buster23 (talk) 07:12, 13 September 2009 (UTC)
This is more than needed, and not clear. I have just (again) read through multiple papers with clear, concise paragraphs on Classification. The problem is that I don't have them in electronic format, I have hard copy, so I will have to type them up here manually. I'll do that as soon as I can; I am a houseguest, and the router was down here for several hours. In the meantime, I do hope everyone will get hold of the four A/N articles I listed above. Somewhere else on this page is a discussion that the article gives UNDUE attention to TS/PANDAS; this is a misinterpretation of UNDUE. We must give due weight according to reliable sources, and most research about tic disorders and PANDAS focuses on TS, much more than other tic disorders. It's probably a simple matter of what populations show up for the studies. Again, the way forward here is simple; get the recent reviews and start writing -- that will bring in more OCD and SC and rheumatic fever, which still isn't explained here. I will type up samples of the concise paragraphs I've seen as soon as I get access again. I'm also concerned about some of the tone in the sample above ... PANDAS is ... as opposed to wording like the PANDAS hypothesis is, or PANDAS hypothesizes, or whatever. PANDAS is all very murky, but the tone above conveys more certainty than the literature warrants. The Classification of the PANDAS hypothesis is doable in one or two paragraphs, all at once explaining the hypothesis and the relationship to tics, OCD, SC and rheumatic fever ... I just read it about a dozen times, but typing it up will require time. SandyGeorgia (Talk) 19:00, 13 September 2009 (UTC)
Hi Sandy, I agree that the TS literature is more than the Tic literature, but the OCD literature (particularly OCD-only) is about equal in number, level of journal, and citation. I think this is because we have two camps, the psychiatric group and the neurology group -- they don't seem to talk or read each other's papers :-)
There are plenty of good primary and secondary sources on OCD version of PANDAS in reliable sources. We've cited them throughout including papers from Nature and JNI. Indeed in the paragraphs above, we have them cited.
Just as a warning to others, the image I used earlier has been updated. Thus a different thumbnail is showing. I could link to the old image, but that didn't seem the right thing to do. Hope the new image helps.
Happy to start using secondary sources here. It still is taking me a while to rely on secondary sources since my training as a research scientist always caused me to go back to primary sources and then check if secondary sources got it right. So I listed the primary sources for each position figuring we'd relax to secondary. I can list both and then once we agree, remove the primaries. Again, I'd like to check on content first and then citation -- if you have a secondary that disagrees, then by all means let's switch.
^ abc{{cite journal| author=Pavone P, Parano E, Rizzo R, Trifiletti RR| title=Autoimmune neuropsychiatric disorders associated with streptococcal infection: Sydenham chorea, PANDAS, and PANDAS variants. | journal=J Child Neurol | year= 2006 | volume= 21 | issue= 9 | pages= 727-36 | pmid=16970875 Cite error: The named reference "pmid16970875" was defined multiple times with different content (see the help page).
^Cite error: The named reference Shprecher2009 was invoked but never defined (see the help page).
^ abcdeCite error: The named reference Lombroso2008 was invoked but never defined (see the help page).
^ abcSnider LA, Swedo SE (2004). "PANDAS: current status and directions for research". Mol Psychiatry. 9 (10): 900–7. doi:10.1038/sj.mp.4001542. PMID15241433.
^ abcPavone P, Parano E, Rizzo R, Trifiletti RR (2006). "Autoimmune neuropsychiatric disorders associated with streptococcal infection: Sydenham chorea, PANDAS, and PANDAS variants". J Child Neurol. 21 (9): 727–36. doi:10.1177/08830738060210091401. PMID16970875.{{cite journal}}: CS1 maint: multiple names: authors list (link)
