Talk:Hepatic encephalopathy

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What other causes of hepatic encephalopathy are there that are not due to liver disease? JFW | T@lk 17:44, 9 November 2005 (UTC)

Uhh, not many - given that it's called hepatic encephalopathy. Right? JFW | T@lk 23:01, 31 March 2007 (UTC)

Addendum

Although this article is tight from a clinic standpoint and should remain as is, it lacks the human aspect of somebody who has suffered the disease and has lived to tell about it.

As far as treatment, lactulose will work to a certain degree, but not how most doctors recomend its dosage. I have found that lactulose works well when confusion and or brain swelling(headache) sets in on an as needed basis. Otherwise, any caloric and vitamin intake that is not readily processed by the weakened liver, will be flushed with the unabsorbed ammonium (NH₄⁺) and will result in unhealthy weight loss and a weakened patient.

When the article speaks of decreasing protien loss to help lessen the effect of ammonia (NH₃) buildup, this is quite true, but it fails to mention that the kind of protien that is most dangerous is animal protiens with beef being the worst offender. From what I understand, even with slight brain damge from seven years of lethal amounts of ammonia (186+) in my bloodstream before my transplant, the animal protiens cannot be broken down by a weakened liver and those protiens are made into the simplest byproduct, ammonia. Unfortunately, the human body cannot do without protien intake at all, so it is usually recomended that the patient find a more readily soluable protiens such as those found in non-animal sources and eggs. Cunsult a nutritionist and your doctor for a solution for a suitable diet plan.

As mentioned in the above article, there is a flapping tremor that is associated with this disease, but it fails to mention how closely this symptom has to be watched. Shaking hands are normal to a degree, but if the arm is fully extended with the fingertips pointing at the ceiling and the hand is flapping like somebody waving, it is a sign that the patient has very little time left as this is what is known in doctor's circles as "the wave good-bye."

Just for the record, I'd like to expand on the different "grades" of this disease, these "grades" can be mixed and matched and a symptom listed in "grade 3" can be present in "grade 2" depending on the person. As far as "amnesia" goes, there will be confusion in the patient as to what place and time they are in, but a patient lives longer with the disease (and that is quite possible), there might be a form of regression as in a 37 year old patient might wake up with the memories from 16+ years temporarily unacessable for a short period of time. This is not a good time to force feed them their true age, because the patient may become scared and violent.

Speaking of these violent "fits of rage," this is due to confusion and is usually not all that dangerous to anyone but the patient as long as the patient doesn't have access to weapons. When I say weapons, I include the patient driving vehicles. A patient with this disease does not respond well to stress since it will increase the confusion and they should NOT be allowed to drive or have access other weapons including kitchen knives. Truthfully, they shouldn't be allowed to operate any cooking appliance without supervision. I say this because a patient with this disease can be easily fixated on a fire and forget how dangerous it is.

As a final note, I'd like o make crystal clear that there are several ways to get liver cirrhosis besides alcoholism and hepatitis and in no way whatsoever should a person assume that a patient with cirrhosis brought it upon themselves. I take offense to these clinical articles always referring to alcoholism based cirrhosis an example of its symptomology. As a matter of fact, there are increasing cases of "cryptogenic" liver cirrhosis. That means that the doctors have no clue as to how or why it happened. Believe me, if it was alcoholism, it would be easily detectable. Please keep that in mind before you pass judgement on somebody fighting for their life.

You should not leave comments on the article page. The page does not in any way pass judgement on the causality of the cirrhosis. Indeed, many new cases are indeed cryptogenic (chronic active hepatitis, NASH, alpha-1 antitrypsin-related etc). I agree that the flapping tremor is used as a marker of mild encephalopathy, and I will move ahead and put this into the article. — Preceding unsigned comment added by Osmodiar (talk • contribs) 15:07, 13 December 2005 (UTC)

As for your other points, the ammonia and lactulose paradigm has been shown to be of doubtful clinical relevance, and as long as constipation is avoided, cirrhotics need not be on stupendous lactulose doses. Indeed, as it is an energy-wasting state, nutrition is of vital importance.

Please offer further views as to how this article can be improved. I will try to include material on the EEG diagnosis of hepatic encephalopathy (when I'm closer to my textbooks) and hopefully some more recent reviews. JFW | T@lk 16:34, 13 December 2005 (UTC)

I've done some fixes. JFW | T@lk 16:37, 13 December

2005 (UTC)

Aftereffects

Another subject for consideration is the "after affects" of the impact. I am a liver transplant receiptant (for "crypotogenic reasons") who had a sustained two week period of major encephalopathy which was overcome by the use of lactalose (4 times a day). I suspect, even though I don't have the confusion issues to deal with, that I do have some dimunition of mental ability -- and maybe it is strictly because of age in combination with the remants of the disease. The changes are not dramatic to the rest of the world -- and maybe not evident to them -- but I can detect a change. Small loses of cognitive ability. I was involved in a research project during my disease to check the relationship of a possible link to "hemocromotosis". It would be interesting to continue the testing now, to see the relationship of my answers now -- to then.75.34.95.100 17:38, 24 January 2007 (UTC)

Hemochromatosis you meant undoubtedly.

I'm not sure if I understand what you mean. Are you suggesting that the episode of encephalopathy caused lasting damage? That is hard to demonstrate, given that HE is a diffuse process. JFW | T@lk 23:01, 31 March 2007 (UTC)

Speaking as another former sufferer who lived with the condition for a year in all degrees of severity from mild befuddlement to coma, I just wanted to note that mental subtraction becomes difficult before addition, not afterwards. It seems obvious, but the article incorrectly states the opposite.

I, too, was on lactulose 4x/day, but it did absolutely nothing for me as far as I could tell; all relief came from antibiotics. Cirrhosis was from far too much acetaminophen during a long bout of the flu coupled with previously undiagnosed hemochromatosis. —Preceding unsigned comment added by 71.219.36.42 (talk) 10:59, 2 December 2009 (UTC)

Early studies

PMID 429564 shows how ammonia is "trapped" in the brain. JFW | T@lk 23:01, 31 March 2007 (UTC)

CHESS score

doi:10.1111/j.1365-2036.2007.03394.x - the new CHESS score (0-9). JFW | T@lk 21:04, 6 June 2007 (UTC)

Cost-effectiveness

doi:10.1111/j.1365-2036.2007.03464.x APT article on cost-effectiveness. Discourages routine use of rifamixin & suggests reserving it for those who fail on lactulose. JFW | T@lk 22:27, 9 August 2007 (UTC)

Herbs of chicory root and milk thistle.

Herbs of chicory root and milk thistle.

Some very good information on this.

Having known someone who suffered from this may I suggest , Herbs of chicory root and milk thistle, that are well known to treat the liver.... ()

--Caesar J. B. Squitti  : Son of Maryann Rosso and Arthur Natale Squitti 20:53, 5 March 2008 (UTC)

— Preceding unsigned comment added by Caesarjbsquitti (talk • contribs) 20:53, 5 March 2008 (UTC)

QJM review

doi:10.1093/qjmed/hcp152 is a nice general review from Ireland that I intend to use to replace numerous primary sources. JFW | T@lk 10:47, 18 February 2010 (UTC)

While using the Cash review as the "backbone" for my current rewrite, I have identified a couple of other sources.

Harrison's 16th edition - chapter 289

Sundaram V, Shaikh OS (2009). "Hepatic encephalopathy: pathophysiology and emerging therapies". Med. Clin. North Am. 93 (4): 819–36, vii. doi:10.1016/j.mcna.2009.03.009. PMID 19577116. {{cite journal}}: Unknown parameter |month= ignored (help)

Randolph C, Hilsabeck R, Kato A; et al. (2009). "Neuropsychological assessment of hepatic encephalopathy: ISHEN practice guidelines". Liver Int. 29 (5): 629–35. doi:10.1111/j.1478-3231.2009.02009.x. PMID 19302444. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link) (mainly about MHE, but worth mentioning)

Will hopefully be finished in the next few days, by which time I will ask for a peer review and submit for GAC. JFW | T@lk 22:19, 21 February 2010 (UTC)

Cochrane

In the "treatment" section we need to mention a few Cochrane reviews. Most of them are negative. They're all in this list. It should be clear that Cash shrugs at the Cochrane lactulose review, and states that from experience the stuff works. I don't think we can avoid citing that, but it would be nice if there were other sources also nixing the review. JFW | T@lk 23:03, 21 February 2010 (UTC)

Time for a little list

Having just completed the "diagnosis" section, I thought I should do a little list of things to do:

•  Done Signs and symptoms - could theoretically have more about MHE
•  Done Classification - we could still mention Harry Conn's PSE score but this is a research tool and Ferenci and Cash state that it is no better than other tools
•  Done Pathogenesis - this will come mostly from Cash
•  Done Diagnosis
• Treatment - will come mostly from Cash; a lot of primary research needs to be trimmed; Cochrane reviews where appropriate
  • Previous content on Hepatic encephalopathy/temp while I rewrite this section
  •  Done Acute vs chronic
  •  Done Diet
  •  Done Lactulose/Lactitol
  •  Done Antibiotics - will need to discuss neomycin, metronidazole and rifaximin
  •  Done LOLA - from Cash and others
  •  Done Combination therapy - touched on in the rifaximin and LOLA sections
  • Unsure if we need to mention flumazenil and acarbose and all those other things that are not in widespread use. Cash and Sundaram discuss a number of others too. MARS really belongs in the acute liver failure article, as its use is simply a bridge to transplant.
•  Done Epidemiology/Prognosis - need to mention 70% prevalence of MHE or worse in cirrhotics; need to mention the fact that long-term prognosis is determined by the Child-(Turcotte)-Pugh (or MELD) rather than the severity of the HE - but you need to survive the HE first and furthermore proper HE will nudge up your CTP by a few points - need sources for that bit of wisdom
•  Done History - Weissenborn refers to Hippocrates (yes, who else) as well as studies from the Sheila Sherlock area that first attempted to quantify HE; sounds like a source of sorts

Any help appreciated, as always. JFW | T@lk 01:54, 22 February 2010 (UTC)

History

In all the reading I have not really come across a good historical overview of HE. I've had the temerity to email Prof Harold Conn, whose West Haven work is still relied upon, and am awaiting a reply. Otherwise there's some bits from Weissenborn as described.

I might list some interesting historical sources here, not suggesting that all are included.

• doi:10.1016/S0140-6736(57)91544-1 - Sherlock's team, still at PGMS, introducing neomycin, then very expensive!
• PMID 429564 - listed above, using radiolabeled ammonia to demonstrate how it goes to the brain

JFW | T@lk 00:26, 23 February 2010 (UTC)

Have also emailed a friendly hepatologist for further advice, but tried my best with the sources at hand. JFW | T@lk 12:23, 2 March 2010 (UTC)

Bajaj

Bajaj in his 2010 APT review lists the Critical Flicker Frequency test and the Inhibitory Control Test. I decided not to mention them because the Randolph paper does not recommend them, and because Bajaj concedes that they still need validating. JFW | T@lk 09:58, 2 March 2010 (UTC)

GA while PR

Only Colin (talk · contribs) was good enough to respond to the peer review, but I have incorporated most of his recommendations and am therefore submitting for GA. JFW | T@lk 21:50, 14 March 2010 (UTC)

GA Review

This review is transcluded from Talk:Hepatic encephalopathy/GA1. The edit link for this section can be used to add comments to the review.

Reviewer: Okay, I will start reviewing here and do some copyediting as I go. Please revert any changes I inadvertently make to meaning. Hopefully I will try to give it a bit of a shove to FAC. I will jot queries below. Cheers, Casliber (talk · contribs) 09:24, 10 April 2010 (UTC)

portosystemic encephalopathy - is this name common? I don't recall hearing this name used but then again, alot of my below-head medicine is rusty... :/ But needs to go in body of text somewhere..

In the Signs and symptoms section where it says (flapping) tremor - I'd go a bit more and say a characteristic flapping tremor (known as hepatic flap).

Other waste products implicated in hepatic encephalopathy include mercaptans (substances containing a thiol group), short-chain fatty acids and phenol - how do phenol and come into the picture here?

The prevalence of minimal hepatic encephalopathy detectable on formal neuropsychological testing is 60–80%; this increases the likelihood of developing overt encephalopathy in the future. - interesting, but makes me think that some might have previous alcohol-related brain damage. Do any sources discuss differentiating these?

Otherwise lookin' good. Casliber (talk · contribs) 00:34, 11 April 2010 (UTC)

Thanks Casliber, and thanks too for fixing my grammar and other mistakes.

The name "portosystemic encephalopathy" is mainly used in older publications (e.g. Sherlock 1954) but there is still current use, e.g. by the Germans who described the PSE-Syndrom-test.

I have taken your advice on the "liver flap".

The mention of phenol and SCFAs is only because I wanted to discuss other players rather than just ammonia, and the Harrisson's source mentioned them. I'll happily take them out if you think that is better because there is really very little discussion on these in any of the other sources.

Truthfully, the sources make little attempt to distinguish MHE from alcoholic encephalopathies, Wernicke's and so on. If you are aware of anything, please let me know! JFW | T@lk 01:01, 11 April 2010 (UTC)

(1) No no, mentioning them is good - I was wondering how/where they come from (i..e unwelcome metabolites from where?) (2) Given that technically everything in the lead should be in the body of the text, then mentioning portosystemic encephalopathy as an older (but also current) term should appear, maybe in the history section, or if you are keen, a small etymology section at the top. (3) will maybe look up to see if there is anything distinguishing ARBD from mild encephalogpathy. Casliber (talk · contribs) 02:45, 11 April 2010 (UTC)

Will work the terminology into the article body. The Harrison's source doesn't say where the other substances come from. JFW | T@lk 23:49, 12 April 2010 (UTC)

Okay, if they can't be sourced they can't be sourced then. Don't worry too much about them. Casliber (talk · contribs) 01:29, 13 April 2010 (UTC)

May as well haul out the green '+' icons then...

1. Well written?:

Prose quality:

Manual of Style compliance:

2. Factually accurate and verifiable?:

References to sources:

Citations to reliable sources, where required:

No original research:

3. Broad in coverage?:

Major aspects:

Focused:

4. Reflects a neutral point of view?:

Fair representation without bias:

5. Reasonably stable?

No edit wars, etc. (Vandalism does not count against GA):

6. Illustrated by images, when possible and appropriate?:

Images are copyright tagged, and non-free images have fair use rationales:

Images are provided where possible and appropriate, with suitable captions:

• Images need WP:ALT text but not a deal-breaker....

Overall:

Pass or Fail: i.e. I think we're over the GA line here/congrats (again)  :) Casliber (talk · contribs) 06:32, 13 April 2010 (UTC)

Thanks much! JFW | T@lk 21:23, 14 April 2010 (UTC)

Warfarin

In addition to BNZs, oral anticoagulants such as coumarins (warfarin) may also cause hepatic encephalopathy. —Preceding unsigned comment added by 92.28.33.151 (talk) 16:29, 9 May 2010 (UTC)

And the evidence for your claim is... JFW | T@lk 20:37, 14 July 2010 (UTC)

Trials

doi:10.1111/j.1365-2036.2011.04590.x - consensus statement on the design of clinical trials. This is hopeful. Perhaps we'll get some more hard data on the various treatments soon. JFW | T@lk 22:06, 1 October 2011 (UTC)

Best test for MHE?

Small trial, not for inclusion but interesting in case secondary sources appear: doi:10.1136/gutjnl-2012-303262 (PHE score comes out best). JFW | T@lk 20:39, 14 September 2013 (UTC)

NEJM review

Wijdicks doi:10.1056/NEJMra1600561 JFW | T@lk 08:10, 27 October 2016 (UTC)

External link COI

I added the following links in External Links section

• Hepatic Encephalopathy: Pathogenesis, Biochemistry, and Pharmacology
• Hepatic Encephalopathy (HE)

These links were removed. After a discussion with user:Doc James I became aware of Wiki’s conflict of interest policy. I hope to navigate that policy carefully.

The first link is a video that I created, and is therefore a conflict of interest for me to post. I would ask that a third party look into the video and decide it’s worthiness.

I receive advertisement fees for videos. This is one of my top videos—and is not likely to see an significant increase in traffic from posting here. I am not allowed to disclose earnings from YouTube, but suffice to say, even if views on this video were to double annually for the next 10 years, I’d still have made less in those years than I would in a week at a part time job. Tmbirkhead (talk) 05:27, 11 December 2017 (UTC)

 Declined per: WP:NOTLINK

While there is no blanket ban on linking to YouTube or other user-submitted video sites, all external links to video sites still must abide by the External Links guidelines. (See § Restrictions on linking and § Links normally to be avoided.) Those guidelines state that when considering external links, proposed videos such as yours should be evaluated for inclusion with due care on a case-by-case basis, in order to ensure that the videos hosted on YouTube meet the standards for inclusion. In my opinion, the subject matter surrounding hepatic encephalopathy warrants additional vigilance above and beyond that which would normally be the case, in that many readers of that article who have gone there in search of medical information deserve the utmost care and respect by ensuring they receive the most accurate information possible. While this is not meant to impugn the hard work that you've put into your videos, I'm sure you'll understand that the possibility of yours or anyone else's videos inadvertently providing information that could be misinterpreted by those individuals watching them, causing them harm, is much too great a risk to entertain. Spintendo  ᔦᔭ  13:00, 11 December 2017 (UTC)

You are Correct to state that the subject matter deserves consideration. Have you considered the content that is linked? Have you considered the value added to the medical community, and the medical student? Are you implying that something within the linked pages is inaccurate? Please point out exactly what makes these links different from a myriad of other YouTube videos that are linked on other medical wiki-articles that deserve equal or more vigilance? Thanks for your time and I invite you to reconsider. I did not make my video carelessly. I made it for partial credit toward my degree in medicine (Medical Doctor, candidate class of 2019). Tmbirkhead (talk) 22:48, 12 December 2017 (UTC)

Are you aware of any actual problems, or are you just nervous about linking to anything that talks about medical conditions? WhatamIdoing (talk) 19:25, 11 December 2017 (UTC)

• Oppose addition. We are not here to drive traffic to closed sourced content to raise money for their creators. Doc James (talk · contribs · email) 15:58, 11 December 2017 (UTC)
  • Please read the official guideline at WP:EL#ADV: "Wikipedia uses the same standards for evaluating links to websites owned by for-profit and (real or purported) non-profit organizations. Links to potentially revenue-generating web pages are not prohibited, even though the website owner might earn money through advertisements, sales, or (in the case of non-profit organizations) donations. Choose which pages to link based on the immediate benefit to Wikipedia readers that click on the link, not based on the organization's tax status or your guess at whether the website's owner might earn money from the link."
    If you have objections based on "the immediate benefit to Wikipedia readers", as opposed to the chance that the maker might earn an extra US $3 every now and again (=the average YouTuber's revenue for 1,000 views) then it would be helpful to share them. WhatamIdoing (talk) 19:21, 11 December 2017 (UTC)
    • I have a very high bar for ELs since they are so often used for spamming. I am sure Osmosis will eventually make us a video under an open license for this article. Doc James (talk · contribs · email) 06:36, 13 December 2017 (UTC)
• oppose this is not appropriate--Ozzie10aaaa (talk) 18:05, 11 December 2017 (UTC)
  • User:Ozzie10aaaa, what's not appropriate about them? If your concern is about the fully disclosed conflict of interest by the editor, then do you have any objection to the second link, which belongs to the Texas Liver Institute rather than the editor? WhatamIdoing (talk) 19:33, 11 December 2017 (UTC)

We are not here to drive traffic to closed sourced content to raise money for their creators (by Doc James above) says it best...IMO--Ozzie10aaaa (talk) 20:34, 11 December 2017 (UTC)

the official Wikipedia policy states that links are not to be judged based on perceived monetary gain. They are only judged by the value or benefits to readers. I respect all opinions with regard to the content and presentation. But the reason for declining is in stark contrast to the actual guidelines WP:EL#ADV. It is also in contrast with many other links posted on other pages of medical significance. I Respectfully invite you to reconsider. Many YouTube videos are linked in the section for external links. Thanks for your time. Tmbirkhead (talk) 22:48, 12 December 2017 (UTC)

Ozzie10aaaa, what's Doc James' objection got to do with the second video link, which is not made by this editor? Or do you have a blanket objection to any and all YouTube videos, regardless of the content or creator, because all of them could be earning the uploader about 0.3¢ per view? WhatamIdoing (talk) 01:50, 13 December 2017 (UTC)

WAID...i'll go w/ blanket objection--Ozzie10aaaa (talk) 01:58, 13 December 2017 (UTC)

You’d have to delete ALOT of links throughout wikipedia, with that objections. However, that objection is invalid by official guidelines. I’m sooo completely baffled. I have given Wikipedia way more in donations than I’d ever make on that video; and because it has helped me soo much. Some of that help has come from external links. I’m only one person, but I see nothing wrong. And I went through appropriate channels. Tmbirkhead (talk) 02:26, 13 December 2017 (UTC)

peritonitis is the 12th-most visited medical article on Wikipedia Wikipedia:WikiProject Medicine/Popular pages. It’s external link goes directly to a textbook which allows each chapter to be downloaded for the low low price of $30.00. Several pages within the top 10 medical articles have links to DMOZ, which is no better than a link to the results of a google search (an actual violation of Wikipedia’s external links guidelines). In the page Wikipedia:Getting to Philosophy the first external link is a youtube video. I appreciate the diligence, but I invite the same level of diligence to be applied uniformly.Tmbirkhead (talk) 23:09, 12 December 2017 (UTC)

Have removed the textbook from peritonitis. Thanks for pointing it out. We often use DMOZ as they are an independent organization that releases their content under an open license.

If you see further issues I am happy to address them. That Wikipedia has issues is not a reason to create more of them. Doc James (talk · contribs · email) 06:34, 13 December 2017 (UTC)

Doc James - hyperthermic intraperitoneal chemotherapy has EL to a website of links to YouTub; Axillary artery has youtube EL; Mouse models of breast cancer metastasis has EL to youtube (which is 99% unrelated to the wiki article); vesicular transport adaptor protein has, not one, but four ELs to youTube; That took me 10-minutes using a very poor “advance search” on google. I believe that you are concerned about spam, like you stated above, so I invite you to go after the Much lower hanging fruit, which is YouTube videos used as primary references (which might apply for current events, but hardly at all for medical articles). And I ask you to use that “High bar” to actually evaluate the video that I posted. Did I create spam?! Is that what this is, spam? The fact that you make that assertion is evidence that you haven’t evaluated the source that you are scrutinizing.

futhermore, the Wikipedia users have addressed this very issue a number of times. You are to evaluate YouTube links based on content and copyright, AND NOTHING ELSE. This has been addressed in several talk pages and on several pages in general.

And here you are asserting that my video link would be an issue. I’m asserting that it would make Wikipedia better, overall. But can you be bothered to spend 25-minutes watching the video on 2X before you make an evaluation?

lastly, denying an external link is not based on what someone else might do. Osmosis videos are actually pretty low quality in my opinion. I’d prefer onlinemeded over osmosis any day of the week, and yet neither of them will make a video as comprehensive as the one that I made, at least not anytime soon. Please reconsider. I’ll send you a private link to download the video (under the agreement that it won’t be shared or uploaded to any server, if you prefer to evaluate the video without pinging the YouTube server with your “view”. This would be done under the assumption that you’d evaluate only content and copyright. And that you’d ask yourself, “would his benefit current readers of this article? My hope is to gain your trust. If I thought this was a trrrible spam-video, the last thing I would do is to make my username hit the radar of those who have been editing for 10+ years. I hope you notice that the links that I posted were done so in good faith and with forethought, and that my judgment to do so was not unscrupulous.

thanks for (re)considering. Tmbirkhead (talk) 07:32, 13 December 2017 (UTC)

• Oppose - this article is flagged as a good article, which at least means that it tells broadly what it should tell (though there are still additions and improvements possible). I do not believe that a youtube video (however popular and correct) will necessarily really add a lot over that content (and what it adds could possibly be included anyway). Moreover, I do think that on this type of articles material should be of high quality, and properly vetted, preferably issued by official organisations. If this video is linked/transcluded on a website of an organisation regarding the subject, then I would consider that page on that website a better possibility. --Dirk Beetstra ^{T C} 08:06, 13 December 2017 (UTC)

Dirk Beetstra, Guidelines State to judge an external link based solely on content and copyright. There is no guideline stating (to my knowledge) that you can’t be opposed to the link without cause, but the causes that you’ve listed are simply out of line with Wikipedia’s own policy on external links. Even Doc James has stated (elsewhere) that he’d be more open to the video if it were uploaded to wikimedia commons. This indicates a bias against the YouTube platform. You state that your primary reason for opposition is that you “don’t believe” a YouTube link would add much to this article. The reason you don’t believe that is because you haven’t viewed the video. I am not saying that because I want to drive you to YouTube. I will provide you an MP4 copy of the video if you’d be willing to actually view it (and respect that I am not licensing you with any other use besides private viewing). If you watch the video, you’ll see that this article does a terrible job at explaining the pathophysiology and the proposed biochemistry (with the several theories of pathological mechanisms). You’d also find that the YouTube platform is a very helpful didactic tool that is hard to overcome in print. Tmbirkhead (talk) 08:19, 13 December 2017 (UTC)

Have you read WP:NOT#REPOSITORY and WP:EL? "If the website or page to which you want to link includes information that is not yet a part of the article, consider using it as a source for the article, and citing it. Guidelines for sourcing, which include external links used as citations, are discussed at Wikipedia:Reliable sources and Wikipedia:Citing sources.", "Any site that does not provide a unique resource beyond what the article would contain if it became a featured article. In other words, the site should not merely repeat information that is already or should be in the article. Links for future improvement of the page can be placed on the article's talk page." --Dirk Beetstra ^{T C} 08:27, 13 December 2017 (UTC)

Dirk Beetstra, I have read all of those guidelines in the last 24 hours. Your response includes these elements: 1) if the video is simply better due to more information, just add the info and cite. 2) The video might not be considered valuable if the page was complete-enough to be featured. I can only convince you that neither of those apply if you watch the video. This video has averaged 50-100 views per day. Your view won’t significantly change anything. However, if you’d like to view it as an MP4, I’d be willing to send it to you. Thanks for an honest response, and thanks in advance for an honest assessment. Tmbirkhead (talk) 08:52, 13 December 2017 (UTC)

50-100 views per day? So what, there are videos on YouTube that top that in a handful of minutes. Popularity is not a reason to include (and at worst, it just shows how well a video is advertised). --Dirk Beetstra ^{T C} 09:46, 13 December 2017 (UTC)

, I believe you missed the point. It’s not popular (studying advanced topics in medicine are typically unpopular online—-as those who have the condition tend to be less sophisticated with IT (in general) due to their advanced age. The point was that your single view would be statistically insignificant on the page. So, encouraging you to actually assess the content is NOT a conflict of interest, but there is a definite conflict when disapproving a link without examining the content therein. However, even with my assertion that there is NO conflict of interest, I’d even be willing to send you an MP4 copy to ease your mind, if that’s a concern.— Preceding unsigned comment added by Tmbirkhead (talk • contribs)

No, I did not miss the point .. Our inclusion standards are described, and 'this is a video that everyone wants/needs to see' is not an inclusion standard. We are writing an encyclopedia here, not a linkfarm. --Dirk Beetstra ^{T C} 10:42, 13 December 2017 (UTC)

Yes, you did miss the point (at least originally). The point I made about the view count was to point out any absurdity in the fact that you did not (and still haven’t) viewed the source content. And nobody has given any inclusion criteria that is unmatched by the content being suggested. This is an honest COI edit request, not a show-room for accusing someone of attempting to link-spam Wikipedia.— Preceding unsigned comment added by Tmbirkhead (talk • contribs)

I am not accusing of spamming - what I say is that popularity is not a reason to include. The reason to include would be whether the info is, or can be, included in the article. You point above to a lot of other cases, and I agree, many of these have to go as well. Our policies are WP:NOT vs. WP:ENC, and external links have a high bar to pass. — Preceding unsigned comment added by Beetstra (talk • contribs) 08:33, 14 December 2017 (UTC)

• Oppose. YouTube videos are generally not good in the external links section. Most articles with YouTube links should have them removed. Exceptions would be videos generated by official organisations that are somehow not hosted on their website. JFW | T@lk 10:35, 13 December 2017 (UTC)

can you provide a link to a guideline that specifically states that rule? If you can, I would remind you, as I have others (and in other places) that much lower quality YouTube videos have passed in the link section of youtube. I have continually requested that everyone simply follow the actual guidelines for external links, which is to judge two characteristics only. First the content, and second, the copyright. If you have not done that, then I encourage you to do so. Tmbirkhead (talk) 10:44, 13 December 2017 (UTC)

Tmbirkhead To be honest, when it comes to debates about these things it is actually consensus between editors that determines what happens. Here you have a big pool of experienced editors who don't think that we should be linking to your video. Your argument that other stuff exists is falacious. JFW | T@lk 18:47, 14 December 2017 (UTC)

I can see no rationality in the responses, so far. I will wait to see what replies come in from the rebuttals that I have posted, but without any request for my response, I am done trying. This was a fools errand. I tried to make Wikipedia a better place, but have, thus far, been prevented from doing that by a group that won’t even take the time to examine the content of my contribution. The contribution I didn’t have to make available to the public, a contribution that doesn’t bring me (nor ever will) great fame or wealth. And I have pointed out to at least some of you the obvious double standard where some YouTube videos are linked with very little (weak) relationship to a primary article, but they are allowed to stay. I honestly have nothing to gain from this other than the satisfaction of knowing that I made the worlds largest encyclopedia a little bit better. And when the historians judge; they will point to the few users above as individuals that (in this case) prevented that improvement. goodnight. Tmbirkhead (talk) 10:44, 13 December 2017 (UTC)

• Okay yes other "stuff" exists on Wikipedia and lots of poor quality work slips through especially on barely read articles like Mouse models of breast cancer metastasis. This article is heavily read and thus pushed to a higher standard.
• I agree with Jfd "videos generated by official organisations that are somehow not hosted on their website" would be appropriate as ELs.
• Please note that Wikipedia is NOT exclusively based on a reading of the "policies and guidelines". It is based on consensus. I have fixed a number of the issues you raised. Doc James (talk · contribs · email) 16:30, 13 December 2017 (UTC)
  • "videos generated by official organisations that are somehow not hosted on their website" appears to be exactly the case for the second video listed, so why are you still opposing inclusion of the second video? The second video is https://www.youtube.com/watch?v=LcNQdo15lF8 and it belongs to the Texas Liver Institute. WhatamIdoing (talk) 20:02, 13 December 2017 (UTC)
    • Sure so the question is do we consider the Texas Liver Institute to be a reliable source? Maybe it is. Would need to investigate the organization it is coming from further. Doc James (talk · contribs · email) 20:39, 13 December 2017 (UTC)
      • Whether it meets MEDRS irrelevant. External links do not have to be reliable sources. See WP:ELMAYBE #4: a site that is accurate, but not actually good enough to use as a reliable source is something that editors should be actively considering for inclusion. WhatamIdoing (talk) 22:53, 13 December 2017 (UTC)
        • Wikipedia:External links#Links normally to be avoidedthe site should not merely repeat information that is already or should be in the article...--Ozzie10aaaa (talk) 00:45, 14 December 2017 (UTC)
          • Unless you can find, to name only a single example, the word microglial somewhere in this article, then ELNO #1 (which I fully support) is irrelevant, because the first video contains more detailed information than the article does (or should). Would you mind stating whether you've actually watched any of either video? WhatamIdoing (talk) 06:43, 14 December 2017 (UTC)
            • Is there any reason why 'microglial' is not mentioned in the article? --Dirk Beetstra ^{T C} 08:33, 14 December 2017 (UTC)
              • It's a detail in pathogenesis, with some implications for treatment. A good summary doesn't need to include it; a highly detailed explanation definitely would. WhatamIdoing (talk) 06:35, 15 December 2017 (UTC)
              • Well user:WhatamIdoing, you obviously didn’t reply because you realize that the only reason he doesn’t know the answer to his own question is simple—-he didn’t investigate the source for “CONTENT” and “COPYRIGHT”, which is what the guidelines state should be done! Judge it on content and you’ll see that it adds a lot to the article. And it’s all my original work. But honestly, I gave up convincing users of that point. They obviously each have their own “pets” and pet-peeves. Plus, power is a bit blinding, and some people just enjoy rigidity because it’s “safer”. I’m not going to worry about trying to improve Wikipedia. I thought it would be fun, but a certain editor has actually made it a headache without reason.I appreciate your sole support (although I didn’t see you vote), but I think it’s pretty much impossible to change a Closed-mind. Tmbirkhead (talk) 00:46, 15 December 2017 (UTC)
                • I think we can give Ozzie more than a few hours to reply.
                  Part of the reason that I asked is that the objections here are rather strange for your video. I basically expect that anyone who actually watched the video would complain about other things (e.g., the sketch-on-the-whiteboard graphics – perfectly appropriate to your lecture, but with very little halo effect to endear it to average viewers). WhatamIdoing (talk) 06:35, 15 December 2017 (UTC)
                  • I had[1],saw before, during and after my opinion above...and its still the same opinion(WAID I am actually puzzled by your insistence on this topic, in any event, we'll agree to disagree...on a lighter note-Merry XMAS/Happy Holidays!)--Ozzie10aaaa (talk) 12:09, 15 December 2017 (UTC)
                    • I'm puzzled because it's out of character for you. The guideline says that you shouldn't worry about whether the creator might make a few cents off the link. It says that you should put readers first. You're not doing that. There are all kinds of arguments to be made for and against the content (Do we want something this advanced? this long? Is two videos too much?), and you've skipped over all of that to focus on a detail that the guideline says is irrelevant. I guess that I've gotten used to seeing policy-based responses from you, so it's weird to see the opposite. WhatamIdoing (talk) 17:51, 15 December 2017 (UTC)

• The HE video is very long, kind of rambles, and moves too carelessly between what is really accepted knowledge and what are emerging/possible explanations and treatments. I am not a big fan of video content in WP generally, but where we use them they should be crisp and ideally ad free. (I had to sit through an entirely "grammarly" ad to hear something a second time). am a bit concerned with the "tutoring" bit in Mike's about page. But his associated blog is all about giving people a free online biology/medical education.

Everything i do is aimed at high, high quality here, and these videos are not that. I encourage Mike to explore Wikiversity which might be the most appropriate wikimedia venue for what he wants to do. Jytdog (talk) 15:45, 16 December 2017 (UTC)

• • user:Jytdog, that was the fairest criticism I have seen, so far. I’m not disappointed at your response, as I was with many others because you followed the guidelines and based the conclusion on the actual content. As for emerging therapy, I was under the influence that external links are the most appropriate place—-for material that is related, but not appropriate for an actual WP. As for the ads, I google controls which ads, how long, and how often. And the reason I posted the request edit is for the sake of the ads. Had they not been added to the video, I would have felt no obligation to post it here. But the point of COI, is simply to make sure the content actually belongs in the EL rather than linking to spam that is barely related. There is an interest for people to subvert the EL solely for monetary gain, and COI-guidelines are in place to help prevent that. The guides do say that links are not to be denied solely due to perceived monetary gain. I agree with the rest of the critique. I attempt to teach in the best way shown by evidence-based-Education While also fulfilling the requirements of my degree AND within the constraints of my current budget. I do have plans for huge expansion and changes in the future (when my education is complete). My videos will be largely 3D graphics at that time, and scripted. They will be limited to 10-20 minutes and each video will be followed by vignette style questions with answer feedback (to name a few areas that I’m currently outside of evidence-base). When I finally make those changes, would you support a link to 3-separate professional videos covering the same content? Just probing. (Apologies: edit previously was unsigned) Tmbirkhead (talk) 04:48, 18 December 2017 (UTC)